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60,920
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37441
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Discharge summary
|
report
|
Admission Date: [**2173-1-5**] Discharge Date: [**2173-1-6**]
Date of Birth: [**2094-10-21**] Sex: F
Service: MEDICINE
Allergies:
Monosodium Glutamate
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
History of Present Illness:
Ms. [**Known lastname 1250**] is a 78 year old woman with a PMH significant for PAF,
MVP, DMII, & HTN who presents with hypotension during a
pulmonary vein isolation for PAF. Ms. [**Known lastname 1250**] was diagnosed with AF
in [**2166**]. She was initially placed on Rythmol with good control,
but over the past year episode of AF have increased in frequency
despite replacing Rythmol with Dronedarone earlier this year.
She endorses daily palpitations, increased fatigue, and dyspnea
on exertion over the past 3 months. Consequently, she was
referred for a therapeutic PVI. During the procedure, Ms. [**Known lastname 1250**]
became hypotensive & bradycardic with a junctional rhythm,
requiring Phenylephrine. Following administration of pressors,
she returned to a normal sinus rhythm with a hr in the 70's.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
PAF s/p pulmonary vein ablation
Diabetes Type 2
Hypertension
Hyperlipidemia
Mitral valve prolapse
s/p L2 vertebral fracture after falling down stairs c/b internal
bleeding requiring 7 units PRBC, [**2166**]
Social History:
Patient is widowed & lives alone. She has 6 children.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Non-contributory
Physical Exam:
VS: T 99.8 BP 115/58 HR 70 RR 20 O2 sat 96% RA on 5L NC
General Appearance: Well nourished, No acute distress, No(t)
Overweight / Obese, Thin, Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: Conjunctiva not pale, injected, or inflamed
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), No S3, No S4, No Rub
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, and time,
Movement: Purposeful, Sedated, Paralyzed, Tone: Normal
Pertinent Results:
WBC-9.8 RBC-3.40* Hgb-10.1* Hct-30.4* MCV-90 RDW-13.6 Plt Ct-187
PT-28.9* PTT-34.4 INR(PT)-2.9*
Glucose-155* UreaN-16 Creat-1.0 Na-138 K-4.6 Cl-108 HCO3-22
Calcium-7.9* Phos-3.8 Mg-1.8
Echocardiogram [**2173-1-5**]:
Findings
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes. Suboptimal image quality - ventilator. The patient
is in a ventricularly paced rhythm. Emergency study performed by
the cardiology fellow on call.
Conclusions
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade in suboptimal focused
views.
ECHO [**1-6**]
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Ms. [**Known lastname 1250**] is a 78 year old woman with a PMH significant for PAF,
MVP, DMII, & HTN who presents with hypotension & bradycardia
following pulmonary vein ablation for PAF. Despite briefly
requiring pressors, she did very well and was discharged the
following evening
By Problem
PAROXYSMAL AF
s/p PVI
Post-procedure Hypotension
The patient has a history of PAF that has been getting
progressively less feasible to manage medically. Due to this an
and her persistent symptomatology, she elected to proceed for
pulmonary vein isolation. This was achieved successfully with
reversion to sinus rhythm. This was complicated by some
hypotension and bradycardia post-procedurally requiring
phenylephrine and placement of a temporary pacing wire.
Overnight, her blood pressure improved and phenylephrine was
successfully stopped. The pacer wire was then removed and rate
remained stable in the 70's with hemodynamic stability. The
patient was discharged on propafenone and a smaller dose of
metoprolol succinate than previous. Coumadin was held during
her night in the hospital as INR was supratherapeutic at 3.3 and
had just had a procedure; it was restarted the following day.
2) Pericardial effusion: In the context of her hypotension after
procedure the patient had an echocardiogram that showed a small
pericardial effusion without signs of tamponade. She never had
a pulsus. The following morning repeat echocardiogram revealed
no evidence of tamponade
3)Diabetes Type 2: The patient was moderately well controlled on
an insulin sliding scale. She will be restarted on metformin at
discharge.
4)Hypertension: The patient's anti-hypertensives were held in
the hospital due to her hypotension. Prior to discharge she was
restarted on lower dose of metoprolol succinate as well as her
lisinopril and spironolactone.
5) Hyperlipidemia: The patient was continued on home
Omega-3-Fatty acid 1000 mg PO daily.
Medications on Admission:
DRONEDARONE 400 mg Tablet twice a day
LISINOPRIL - 20 mg Tablet twice a day
METFORMIN - 500 mg Tablet twice a day
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release twice a
day
SPIRONOLACTONE - 25 mg Tablet PO qAM
WARFARIN - 2.5mg PO qHS
ASCORBIC ACID - 500 mg Capsule, Sustained Release daily
CALCIUM CARBONATE-VITAMIN D3 - 600 mg/200 unit Tablet twice a
day
MAGNESIUM OXIDE 400 mg Tablet twice a day
MULTIVITAMIN 1 tablet PO daily
OMEGA-3 FATTY ACIDS - 1,000 mg by mouth daily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Propafenone 325 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2*
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation s/p PVI
Hypertension
Diabetes
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a pulmonary vein isolation for recurrent, refractory
atrial fibrilation. The procedure went well but you had some
slow heart rates and low blood pressures afterwards probably as
a result of the various medications you were on at home and
received during the procedure. Therefore, we monitored you
overnight in the intensive care unit with a temporary pacing
wire to help keep your heart rate from getting to slow. Your
blood pressures improved and you are doing much better so we are
sending you home to complete your recovery.
Your medications have been changed. You have been switched from
DRONADERONE back to RHYTHMOL (PROPAFENONE). Your METOPROLOL
dose has been decreased. Otherwise your medications have not
been changed. Please continue to take your medications as
previously prescribed.
Please continue your warfarin and check INR on Friday [**2173-1-8**].
Followup Instructions:
You should schedule a follow up appointment with your PCP Dr
[**Last Name (STitle) **] in [**2-4**] weeks to be evaluated. ([**Telephone/Fax (1) 62067**])
Please follow up with Dr. [**Last Name (STitle) **] in [**Location (un) 9101**] in four weeks to
discuss your procedure and see how you are doing.
Completed by:[**2173-1-6**]
|
[
"423.9",
"272.4",
"424.0",
"458.29",
"427.31",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
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300, 327
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8175, 8282
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|
2072, 2184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,779
| 126,393
|
54089+54090
|
Discharge summary
|
report+report
|
Admission Date: [**2170-5-21**] Discharge Date: [**2170-6-11**]
Date of Birth: [**2092-6-9**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
intubation and extubation
[**Last Name (NamePattern1) 282**] tube placement
History of Present Illness:
Ms. [**Known lastname 110862**] is a 77 yo W with h/o RA, AF on coumadin, who presents
with L frontal IPH s/p fall.
The patient was at her baseline until 8pm last night, when she
stood up from eating dinner, took [**4-15**] steps then suddenly
blacked
out and fell. She struck her L eye/forehead and landed
face-down.
Her husband could not awaken her at first, though she was
breathing, but in [**3-16**] minutes she moved her mouth and tried to
speak. Within 5-10 minutes, she was speaking normally, was not
confused or disoriented, but could not sit or stand despite
help.
Her husband brought her a blanket and pillow and let her rest on
the floor. After about 30 minutes, she was able to ambulate with
assistance to her bedroom, where she sat in a chair watching TV
then went to bed. Her husband sleeps in a different bedroom, and
typically hears her get up a few times per night to use the
bathroom. He did not hear her get up, so around 4am, went to
check on her. It appeared that she had attempted to get up but
could not, in that she was slumped sideways across the bed. She
awakens to his voice, opened her eyes, and was able to speak
normally. He did not think she was disoriented or confused, but
because she was sleepy and could not get up, he called 911.
The patient was brought to [**Hospital6 **]. Per ED notes, GCS
14, AOx3, nonfocal neuro exam. Head CT revealed L frontal IPH
with minimal intraventricular and subarachnoid spread. She was
also found to have L orbital and L wrist fractures. INR was 2.0.
She was given Keppra 500 mg IV, Vitamin K and bebulin (Factor IX
complex) and transferred to [**Hospital1 18**] for neurosurgery evaluation.
In [**Hospital1 18**], patient was somnolent, but able to follow commands,
oriented to hospital and month. She was intubated due to her
lethargy, and did have brief hypotension requiring pressor
post-sedation. She received FFP completed at 11:10am. Repeat
head
CT was stable.
Neurosurgery consult determined since head CT stable, no midline
shift, there was no acute indication for surgery. They agreed
with continued reversal of INR, BP control and repeat head CT
this evening.
Of note, the patient did fall 3 weeks ago upon going to bathroom
in middle of night. She fractured her shoulder. She has felt
"weak" since then but able to continue most of her usual
activities.
Past Medical History:
- atrial fibrillation, on coumadin
- HTN
- GERD
- depression
- RA, had been on Humira until 2 years ago when she developed
Legionella, on prednisone since, rheumatologist is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- no h/o stroke or TIA
Social History:
lives with husband. Retired special ed teacher. Has 1 son
(lives in [**Name (NI) **]) and 1 daughter (lives in [**Name (NI) 36413**]).
Independent in ADLs, drives. Smoked for a few years, quit in
[**2118**]. Drinks 2-4 whiskey sours/glasses of wine per day. Most
recent EtOH was last night at dinner. No illicits.
Family History:
negative for ICH
Physical Exam:
At admission:
VS: afebrile BP 119/82 HP 90-100s intubated
GEN: large hematoma involving L orbit, L eye is completely
bloodshot, L wrist hematoma.
HEENT: sclera anicteric
CV: irregular, no murmurs
PULM: crackles at bases
AB: ND/NT
EXT: no edema
SKIN: no rash
NEURO: off sedation 5 minutes
MSE: opens eyes to loud voice, does not consistently track
examiner. Follows midline and appendicular commands (L arm
limited by fracture/bandage)- including showing 2 fingers on R.
CN: PERRL 6 to 4mm but re-dilate quickly. Eyes midline, looks
toward left more easily than looks toward right. No facial
droop.
Tongue midline.
MOTOR: normal tone in upper extremities, increased tone in L
compared to R lower extremity. No tremor or myoclonus.
Able to squeeze hands and wiggles toes bilaterally. Cannot hold
limbs antigravity, but withdraws well antigravity with noxious
stimulation, this is symmetrical.
[**Last Name (un) **]: intact to noxious throughout
DTR: 2+ b/l biceps, triceps, 1+ brachiorad, trace patellar and
Achilles. Toes upgoing b/l.
At discharge:
Neurologic: Lethargic, arouses to voice, able to answer a few
simple questions with 1-2 word responses, oriented to [**Hospital 61**], does not know date. Does not consistently follow
commands. Pupils equal and reactive, extraocular movements
intact. Face is symmetric. Moves all extremities anti-gravity,
somewhat less in R lower extremity. Withdraws to noxious
stimulation throughout. L toe upgoing, R mute.
Pertinent Results:
[**2170-5-21**] 08:45AM BLOOD WBC-11.3* RBC-4.43 Hgb-12.7 Hct-39.2
MCV-89 MCH-28.7 MCHC-32.4 RDW-15.2 Plt Ct-202
[**2170-5-21**] 08:45AM BLOOD Neuts-76.1* Lymphs-18.6 Monos-4.6 Eos-0.3
Baso-0.5
[**2170-5-21**] 08:45AM BLOOD PT-16.5* PTT-26.3 INR(PT)-1.6*
[**2170-5-21**] 02:31PM BLOOD PT-13.5* PTT-24.0* INR(PT)-1.3*
[**2170-5-22**] 02:42AM BLOOD PT-12.0 PTT-24.5* INR(PT)-1.1
[**2170-5-21**] 08:45AM BLOOD Glucose-166* UreaN-15 Creat-0.5 Na-138
K-3.2* Cl-100 HCO3-28 AnGap-13
[**2170-5-22**] 02:42AM BLOOD Glucose-138* UreaN-10 Creat-0.5 Na-136
K-4.2 Cl-104 HCO3-26 AnGap-10
[**2170-5-25**] 12:58AM BLOOD ALT-31 AST-50* AlkPhos-78 TotBili-1.1
[**2170-5-22**] 02:42AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.6
[**2170-5-22**] 06:33PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2170-5-22**] 06:33PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-5-22**] 06:33PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Blood Cx on [**5-22**] x 2 and [**5-25**] x 2: No growth.
Urine Cx on [**5-22**] and [**5-25**]: No growth.
[**2170-5-23**] 5:26 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2170-5-28**]**
GRAM STAIN (Final [**2170-5-23**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2170-5-28**]):
THIS IS A CORRECTED REPORT [**2170-5-28**].
PREVIOUSLY REPORTED INCORECTLY WITH ERYTHROMYCIN MIC ON
[**2170-5-26**].
Reported to and read back by [**Last Name (un) **] [**Doctor Last Name 110863**] [**2170-5-28**] 1:24PM.
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2170-5-25**] 11:17 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2170-5-27**]**
GRAM STAIN (Final [**2170-5-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2170-5-27**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
C diff [**5-25**] negative
ECG:
Baseline artifact. Atrial fibrillation with rapid ventricular
response.
Vertical axis for age. Prominent precordial voltage. Consider
left
ventricular hypertrophy. ST-T wave abnormalities of
strain/ischemia.
No previous tracing available for comparison. Clinical
correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 0 88 354/445 0 81 -98
[**2170-5-21**] NCHCT:
Final Report
CLINICAL INFORMATION: 77-year-old female with intracranial
hemorrhage and
hypoxia.
COMPARISON: Images performed at [**Hospital6 2561**] at 0652
hours on
today's date.
TECHNIQUE: Axial CT images were acquired of the head without
contrast and
reformatted into coronal and sagittal planes.
FINDINGS: There is a left frontal intraparenchymal hemorrhage,
which is
unchanged in size compared with prior, measuring 3.1 x 1.8 cm.
Blood is seen
layering within the left sylvian fissure, and within the left
lateral
ventricle adherent to the septum. Minimal mass effect is seen
around the left
frontal hemorrhage, though the generalized enlargement of the
extra-axial
spaces allows for this, without shift of midline structures, or
evidence of
herniation. The ventricles are not enlarged, though there is ex
vacuo
dilatation of the right lateral ventricle adjacent to the
frontal [**Doctor Last Name 534**],
perhaps from prior ischemic insult. The periventricular white
matter is
generally hypodense, likely the result of chronic small vessel
ischemic
change. [**Doctor Last Name **] matter/white matter differentiation is preserved
throughout,
without evidence of acute infarction.
The orbits are unremarkable, though bilateral lens implants are
noted. There
is left periorbital hematoma extending into the left temporal
region. There
is no definite fracture. There is mucosal thickening within
multiple ethmoid
air cells. The maxillary and sphenoid sinuses are clear. The
mastoid air
cells are clear bilaterally.
IMPRESSION:
1. Stable appearance of intraparenchymal, intraventricular, and
subarachnoid
hemorrhage.
2. Left periorbital hematoma.
CTA chest/abd/pelvis:
Final Report
CLINICAL INFORMATION: 77-year-old female status post fall with
intracranial
hemorrhage, evaluate for traumatic injury to the chest, abdomen,
and pelvis.
COMPARISON: None.
TECHNIQUE: Helical MDCT images were acquired of the chest,
abdomen and pelvis
following the uneventful administration of 130 cc of Omnipaque.
Images were
reformatted into coronal and sagittal planes.
FINDINGS:
CHEST: There is left lower lobe collapse, with a small left
pleural effusion.
Subsegmental atelectasis is noted in the left upper lobe. There
is right
lower lobe subsegmental atelectasis, with a small right pleural
effusion.
Hypodense material in the left lower lobe airways suggests
aspiration. The
lungs are otherwise clear. The central airways appear patent.
The patient is
intubated, the tip of the endotracheal tube approaches the level
of the
carina. There is cardiac enlargement, with significant
enlargement of the
bilateral atria. There is calcification noted of the coronary
arteries, of
the mitral valve annulus, and of the aortic valve annulus and
leaflets. There
is no pericardial effusion. The aortic root is prominent,
measuring 3.4 cm.
The great vessels are unremarkable with some calcification noted
at their
origins. The central pulmonary arteries appear patent.
Nonspecific
calcifications are noted in the left breast, there is asymmetric
breast
tissue, with a 3.7 x 2.7 cm left breast mass resulting in nipple
retraction
(2; 38). There is no mediastinal, hilar, or axillary
lymphadenopathy.
ABDOMEN: The fatty liver, spleen, and pancreas are unremarkable.
There is a
left adrenal nodule which measures 1.3 cm. The right adrenal is
unremarkable.
The kidneys demonstrate brisk bilateral contrast enhancement,
and excretion.
The stomach contains an NG tube, the tip of which is in the
region of the
stomach body, and is collapsed. There is submucosal edema at the
gastric
antrum. Loops of small bowel are normal in caliber, and are
normally
opacified by ingested oral contrast. The small bowel mesentery
is normal in
appearance. The aorta is normal in caliber along its abdominal
course. There
is marked calcification at the origins of the celiac, and SMA,
which remain
patent. The [**Female First Name (un) 899**] is not well seen. There is no retroperitoneal,
or pelvic
side wall lymphadenopathy.
PELVIS: There is a Foley catheter seen within the bladder, which
is
collapsed. The uterus is retroverted, and enlarged. The rectum
is
unremarkable. There are innumerable diverticula seen throughout
the colon.
There is no evidence for acute diverticulitis. There is no
intraperitoneal
free air, or free fluid.
BONE WINDOWS: There are chronic right-sided rib fractures, some
of which have
not healed well including the right second, third, fourth,
fifth, sixth,
seventh, eighth, and ninth ribs. Likewise, there are fractures
of the left
seventh, eighth, ninth, and tenth ribs which are in stages of
healing. There
is a thoracic kyphosis. Vertebral body height and alignment are
maintained.
There is multilevel facet degenerative change, and Baastrup's
disease.
IMPRESSION:
1. Left lower lobe collapse, aspiration, and bilateral
subsegmental
atelectasis. The patient is intubated with the tip of the
endotracheal tube
approaching the level of the carina.
2. Biatrial enlargement, without pulmonary edema.
3. Multiple bilateral healing rib fractures, none of which
appear acute.
3. Left breast mass with nipple retraction, recommend
correlation with
mammography when clinically appropriate.
4. Bulky uterus, recommend further evaluation with pelvic
son[**Name (NI) 867**] when
clinically appropriate.
5. Severe diverticulosis, without evidence of acute
diverticulitis.
6. Gastric thickening of the gastric antrum, nonspecific,
suggests gastritis.
Left wrist/hand Xray:
WRIST(3 + VIEWS) LEFT; HAND (AP, LAT & OBLIQUE) LEFT Clip #
[**Clip Number (Radiology) 110864**]
Reason: please eval for fracture
Final Report
INDICATION: 77-year-old female with left hand and wrist
deformity of the
distal radius , evaluate for fracture.
COMPARISON: None available.
FINDINGS: Three views of the wrist and three views of the hand.
Diffuse
osteopenia slightly limits the examination. There are vascular
calcifications. There is sclerosis and joint space narrowing at
the first CMC
joint likely representing osteoarthritis. No fracture or
dislocation seen.
Possible subluxation of the second MCP joint.
IMPRESSION: No acute fracture or dislocation. Degenerative
changes most
prominent at the first CMC joint and osteopenia.
MRI brain with and without contrast:
FINDINGS: There is an acute intraparenchymal hematoma seen in
the left
frontal lobe measuring 3.2 x 2.1 x 3.4 cm with surrounding
edema, causing mass
effect on left lateral ventricle. There is no definite
enhancement seen. As
seen on the prior CT, there are blood products in the left
sylvian fissure and
within the lateral ventricles. There is no hydrocephalus or
midline shift.
There is ex vacuo dilatation of the right lateral ventricle
adjacent to the
frontal [**Doctor Last Name 534**], likely from prior ischemic insult. There are
extensive
confluent T2, FLAIR hyperintensities in bilateral
periventricular white matter
likely represent sequelae of small vessel ischemic disease.
There is no acute
intracranial infarction. Major intracranial flow voids are
preserved.
Visualized orbits and mastoid air cells appear unremarkable.
There is minimal
mucosal thickening along the inferior aspect of bilateral
maxillary and
bilateral ethmoid sinuses. There is no abnormal leptomeningeal
or parenchymal
enhancement seen.
IMPRESSION:
1. Intraparenchymal hematoma in the left frontal lobe with
surrounding edema, subarachnoid and intraventricular hemorrhage,
similar to that seen on the prior CT. There is no definite
underlying lesion seen. However, followup MRI should be obtained
once the hemorrhage resolves.
2. Small vessel ischemic disease.
[**2170-5-22**] NCHCT:
IMPRESSION:
1. Little change in comparison to prior study from [**2170-5-21**], roughly 32 hours earlier, with stable appearance of left
frontal parenchymal hemorrhage, as well as small
intraventricular and left-sided subarachnoid hemorrhage.
2. Stable appearance of left periorbital soft tissue hematoma.
[**5-25**] CXR:
FINDINGS:
Increased retrocardiac density reflecting left lower lung
consolidation and/or
atelectasis is unchanged, whereas right lower lung opacity,
which has
improved, is atelectasis. The orogastric tube has been
repositioned, and end
into the stomach.
[**2170-5-22**]- [**2170-5-27**] EEG - LTM:
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 14:23 on the afternoon of [**5-22**].
It showed a low voltage and mildly slow background with 6 Hz
frequencies
dominating posteriorly. There was also minimal additional focal
slowing
in the left hemisphere and occasional sharp waves in the same
region.
After 14:50, the background was of much lower voltage in all
areas.
They became even lower by 21:00 that evening but resumed a
moderate
voltage activity after 4 the next morning. Sharp waves were not
prominent after the afternoon of the 10th. There were no
electrographic
seizures.
SPIKE DETECTION PROGRAMS: Showed some of the same sharp waves,
most
with a generalized distribution, but all seen in isolation
rather than
repetitively.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There was a single activation at 15:36
on the
afternoon of [**5-22**]. There was no electrographic seizure on
EEG. The
patient was obscured on video.
SLEEP: No normal waking or sleeping patterns were evident.
CARDIAC MONITOR: Showed an irregularly irregular tachycardia
with a
rate of about 110.
IMPRESSION: This telemetry captured a single pushbutton
activation.
This showed no evidence of seizure. The background was a bit
slow and
of very low voltage throughout, especially in some periods,
likely
correlating with medication usage. There was minimal additional
slowing
on the left side but no area of persistent and prominent focal
slowing.
There were several isolated sharp waves, most with a generalized
distribution but some with a leftsided emphasis. These were all
seen in
isolation, and there were no electrographic seizures.
[**5-23**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of an
encephalopathy.
There were frequent bursts of slowing, some with sharp features,
and
there were some generalized blunted sharp waves, but there were
no
definitely epileptiform abnormalities. There were no
electrographic
seizures
[**5-24**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of a continuing
encephalopathy. There were no prominent focal features. There
were
very frequent generalized sharp wave discharges, especially at
the
beginning of the recording. They were not so rhythmic or
prolonged as
to suggest ongoing seizures, but they indicate some increased
potential for seizures.
[**5-25**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained slow throughout. There were very frequent
generalized blunt and sharp wave discharges, but they were never
rapid
or rhythmic enough to be considered electrographic seizure
activity.
While they were most likely part of the encephalopathy, they
suggest an
increased risk for seizures. There were no prominent focal
abnormalities. The sharp waves were a bit less frequent than on
the
previous day's recording.
[**5-26**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of a widespread
encephalopathy. In addition, there were generalized and left
hemisphere
blunted sharp wave discharges, almost always seen in isolation
rather
than repetitively. They diminished over the course of the
recording as
the background became slower, likely a medication effect. There
were no
rapid or rhythmic discharges to suggest an ongoing
electrographic
seizure.
[**5-27**]:
IMPRESSION: This telemetry captured one pushbutton activation.
It did
not show a seizure. The rest of the recording showed a
moderately slow
posterior background, indicative of an encephalopathy.
Nevertheless,
sharp waves evident on earlier recordings were no longer
present. The
recording suggests an improvement in the encephalopathy.
Routine EEG [**6-9**]:
Prelim read shows disorganized theta background, generalized
slow waves but no sharp waves or epileptiform activity. Final
read pending at time of discharge.
Brief Hospital Course:
77 yo W with h/o RA, AF on coumadin, who presents with L frontal
IPH and small SAH s/p fall. The mechanism of fall is unclear but
presumed to be mechanical with resultant traumatic IPH/SAH. The
patient was initially intubated in the ED for airway protection
and admitted to the neuroICU. Her admission exam initially
showed her to follow commands, moving all extremities. However
within a few hours she became obtunded and was no longer not
following commands with minimal movements of all extremities,
but otherwise nonfocal. Exam was intermittently concerning for
seizure activity given no responsiveness to voice, hippus, right
beating nystagmus, mouth movements and right hand tremors, for
which Keppra was increased. EEG [**2073-5-20**] showed occasional spikes
(left hemispheric and generalized) but no seizures. MRI brain
with and without contrast shows stable size of bleed with no
underlying mass or evidence for amyloid. The patient's alertness
gradually increased over the next week and she was extubated
[**2170-5-30**]. She remained somewhat lethargic for unclear reasons,
thought to be related to bleed, possible post-ictal state, drug
effects, and pneumonia. She was transferred to the neurology
floor on [**6-1**].
NEURO:
Upon transfer to the floor she continued to be largely nonverbal
but was following limited commands (wiggle toes). She was able
to move all extremities spontaneously although somewhat less in
the R leg. Keppra was decreased to 750mg IV BID and she was
started on amantadine 100mg daily on [**6-1**] with some improvement
in her level of alertness. Keppra was further decreased to 500mg
[**Hospital1 **] on [**6-8**]. A repeat EEG was performed on [**6-9**] which showed
disorganized theta background, generalized slow waves but no
sharp waves or epileptiform activity. She will need to remain on
Keppra until she follows up with Dr. [**Last Name (STitle) **]; it may be able to
be slowly weaned down at that point.
Due to persistent lethargy at toxic/metabolic work-up was
pursued, which was unremarkable except for TSH of 9.4. Free T4
was normal at 1.3.
She was restarted on subQ heparin for DVT prophylaxis on [**5-24**].
Aspirin 81mg was restarted on [**5-28**]. Coumadin was held during her
admission in light of her recent hemorrhage. The timing of
restarting her coumadin will be further discussed at her
follow-up visit with Dr. [**Last Name (STitle) **].
She will need a repeat MRI in 3 months to better assess for any
underlying lesions after resolution of her hemorrhage. She has a
follow up appointment scheduled with Dr. [**Last Name (STitle) **] on [**2170-7-23**].
A CT torso on [**5-21**] showed a left breast mass with nipple
retraction as well as a bulky uterus. This was discussed with
her PCP. [**Name10 (NameIs) **] is possible that the breast abnormality may have
been related to a hematoma in the setting of her fall but should
be followed up with a mammogram once medically stable. Pelvic
son[**Name (NI) 867**] was recommended for further evaluation of her uterus.
CV:
She was maintained on telemetry monitoring for her a fib. Her
home metoprolol 50mg [**Hospital1 **] and diltiazem 60mg QID were restarted.
Aspirin 81mg was restarted on [**5-28**].
ID:
Fevers and mental status improved while completing VAP protocol
[**Date range (1) 110865**] with Cefepime/Cipro/Vanc. Sputum cx grew coag positive
staph aureus. UA was negative. UCx and Blood Cx showed no
growth. She completed antibiotics on [**6-1**] and remained afebrile.
After her transfer to the floor she was noted to have persistent
leukocytosis to 14-15 although she remained afebrile with no
clinical signs of infection. This was thought to be related to
sinusitis / inflammation from her NGT. NGT was removed after [**Month/Year (2) 282**]
placement on [**6-8**]. WBC subsequently trended down and normalized.
PULM:
She was continued on lasix 20mg IV BID with improvement in her
volume overload.
HEME:
INR was reversed. Coumadin was held throughout her admission.
The timing of restarting coumadin will be further discussed at
her follow-up visit with Dr. [**Last Name (STitle) **].
GI:
After her transfer to the floor her BUN was noted to be
persistently high in the 40's. Stool guiac was positive. She had
no clinical signs of bleeding and Hct remained stable. Aspirin
was held. She was maintained on famotidine. This was thought to
be related to mild gastritis related to chronic prednisone use
and possibly irritation from NGT as well. BUN was monitored and
trended down. Hct remained stable. Aspirin was restarted on
[**2170-6-10**].
Due to her obtundation she was kept NPO and a NGT was placed for
tube feeds. She remained unable to swallow safely despite
multiple repeat swallow evaluations. After discussion with her
husband a [**Name2 (NI) 282**] tube was placed on [**6-7**]. She will need continued
monitoring by speech and swallow and nutrition.
ENDO:
She was maintained on ISS for blood glucose control during her
admission.
Musculoskeletal:
She was continued on her home prednisone 10mg daily for RA.
Ophtho:
She was found to have a L lateral non-displaced orbit fracture
and hematoma on admission. She was seen by ophthalmology who did
not recommend any acute intervention. She has a follow-up
appointment for a repeat exam scheduled on [**2170-6-27**] with Dr.
[**Last Name (STitle) **].
Code status: Full (discussed with husband [**Doctor First Name 3788**]
Dispo:
She was discharged to [**Hospital 100**] Rehab in good condition on [**2170-6-11**].
Transitional care issues:
She will need continued PT, OT, and speech therapy. Nutrition
should also be involved for management of her tube feeds.
She has a follow-up appointment scheduled with Dr. [**Last Name (STitle) **] in
ophthalmology clinic on [**2170-6-27**], and with Dr. [**Last Name (STitle) **] in
neurology clinic on [**2170-7-23**].
Medications on Admission:
ASA 81
coumadin
omeprazole 20 mg daily
prednisone 10 mg daily
Lopressor 50 mg [**Hospital1 **]
Cartia XL 240 mg daily
Lexapro 10 mg daily
Detrol LA 4 mg daily
Lasix 60 mg daily
fosamax 70 mg qSUN
MVI
iron
calcium
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. ferrous sulfate 300 mg (60 mg iron) 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 for rash in genital area.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
7. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): As per insulin sliding scale.
11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. amantadine 50 mg/5 mL Syrup Sig: Ten (10) ml PO QAM (once a
day (in the morning)): 100mg QAM.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
14. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Left frontal intraparenchymal hemorrhage
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic: Lethargic, arouses to voice, able to answer a few
simple questions with 1-2 word responses, oriented to [**Hospital 61**], does not know date. Does not consistently follow
commands. Pupils equal and reactive, extraocular movements
intact. Face is symmetric. Moves all extremities anti-gravity,
somewhat less in R lower extremity. Withdraws to noxious
stimulation throughout. L toe upgoing, R mute.
Discharge Instructions:
Dear Ms. [**Known lastname 110862**],
You were admitted to [**Hospital1 69**] on
[**2170-5-21**] after experiencing a fall at home. You were found to have
bleeding in the left front part of your brain. Your bleeding was
likely due to your fall in the setting of taking coumadin. An
MRI showed no evidence of any underlying abnormalities that
could have contributed to your bleeding. You should have a
repeat MRI in about 3 months once your bleeding has resolved to
take a better look. You had some activity concerning for
seizures when you were first admitted and were started on a
medication called Keppra to prevent further seizures. You will
need to remain on this medication until you follow up with Dr.
[**Last Name (STitle) **]; you may be able to be slowly weaned off it at that
point. You were also treated for pneumonia with IV antibiotics.
You continued to be quite lethargic during your admission and
had persistent difficulty swallowing. Because of this, a [**Last Name (STitle) 282**]
(percutaneous endoscopic gastrostomy) tube was placed to help
give you nutrition and medications. This can hopefully be
removed in the future once you are able to swallow on your own.
You will need physical and occupational therapy to help you
regain your strength.
During your fall you sustained a fracture of your left orbit
(the bone that encases your eye). You were seen by ophthalmology
during your hospitalization who did not feel that you needed any
surgical intervention. They would like you to be seen in their
clinic for a follow-up eye exam - your appointment is listed
below.
We made the following changes to your medications:
Started Keppra 500mg twice a day to prevent seizures
Started amantadine 100mg daily to help increase your alertness
Stopped coumadin
Increased metoprolol to 75mg three times a day to help control
your heart rate
Changed Diltiazem XL 240mg daily to Diltiazem 60mg four times a
day
Increased lasix to 40mg twice a day
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You have the following appointment scheduled with Dr. [**Last Name (STitle) **] in
our stroke clinic:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2170-7-23**] 3:30
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
You also have the following appointment with Dr. [**Last Name (STitle) **] in
ophthalmology clinic regarding your left orbital fracture:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2170-6-27**]
3:00
Admission Date: [**2170-5-21**] Discharge Date: [**2170-6-11**]
Date of Birth: [**2092-6-9**] Sex: F
Service: NME
ADDENDUM:
BRIEF HOSPITAL COURSE:
1. She did have encephalopathy during the admission.
2. She had acute systolic congestive heart failure
superimposed on chronic systolic congestive heart
failure.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 80146**]
Dictated By:[**Last Name (NamePattern4) 86982**]
MEDQUIST36
D: [**2170-7-10**] 17:08:43
T: [**2170-7-11**] 01:09:14
Job#: [**Job Number 110866**]
|
[
"427.31",
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
[]
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316, 394
|
28869, 28869
|
4919, 20814
|
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|
3399, 3418
|
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|
28795, 28848
|
26720, 26935
|
29460, 31070
|
3433, 4475
|
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|
31099, 31605
|
273, 278
|
26373, 26694
|
422, 2760
|
28884, 29436
|
2782, 3051
|
3067, 3383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,981
| 198,500
|
27508
|
Discharge summary
|
report
|
Admission Date: [**2159-12-3**] Discharge Date: [**2159-12-12**]
Date of Birth: [**2111-6-10**] Sex: M
Service: MEDICINE
Allergies:
Lasix
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Chief Complaint: Coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
History of Present Illness:
Patient is a 48 year old male with past medical history of
alcoholic cirrhosis who has transferred from [**Hospital3 **]
for coffee ground emesis. Patient relates that he has had nausea
and vomiting for about a week, and yesterday he had coffee
ground emesis, about 3-4 episodes. He also had a dark, black
colored bowel movement this morning as well, at which time he
began to feel dizzy and lightheaded, so he called the
paramedics.
He has had significant nausea and vomiting for several days, and
reports he has had virtually no PO intake. Relates he has had
several admissions to [**Hospital3 **] and [**Hospital1 18**] for nausea,
vomiting, and has had his esophageal varices banded in the
recent past, although he has a hard time recalling the time line
and dates of admissions and procedures.
.
ED course:
Patient transferred to [**Hospital1 18**] ED, where his vitals were T 100.2,
HR 120, BP 146/76, RR 18, and Oxygen Sat 98% on RA. He was given
4 L NS and 1 Banana bag, 2 large bore IV's were placed and he
was type and crossed. He was noted to have guaiac positive
stool. NG lavage had coffee-ground material that cleared.
.
Review of Systems:
Denies any fever, chills, chest pain, shortness of breath. Notes
he felt lightheaded this morning. No headache, numbness,
weakness. Reports abdominal pain, especially in right lower
quadrant, that resolved. No dyspnea, PND, orthopnea, leg edema,
no change in abdominal girth. Notes he has lost about 15 pounds
over unspecified amount of time. Reports very poor PO intake
over last week. Nausea and vomiting as noted in HPI. No changes
in diet or unusual food intake--patient states he's only had a
glass of milk over last few days. No travel or sick contacts.
Past Medical History:
Past Medical History:
-ETOH cirrhosis with known portal HTN and hx Grade I varices and
gastropathy
-partial portal vein thrombosis [**8-26**]
-hx alcoholic hepatitis
-hx upper GI bleed from distal esophagitis
-hx ascites with 2 large volume paracentesis (8 liters each time
per patient) in [**Month (only) 216**] and [**2157-9-22**]
-lower GI bleed from hemorrhoids
-iron deficiency anemia
-umbilical hernia with recent reduction in ED
-depression
-HTN
Social History:
Social History: Long history of EtOH abuse. He is currently not
drinking, reports last drink was three months ago, although OMR
note from [**2159-11-21**] notes he reported drinking whiskey daily at
that time. Denies any other ilicit drug use. Lives with his
mother. Divorced. Formerly employed as an electrician, however
currently unable to drive due to EtOH-related driving
suspension. No tobacco use.
Family History:
Family History: alcoholism in mother and aunt
Physical Exam:
PHYSICAL EXAM~
Vs- 142/91 99.8 113 18 97%ra
Gen- Well appearing middle aged male sitting up in bed, nad
Heent- MMdry, anicteric, NC/AT. PERRL, EOMI.
Neck- supple, JVP flat, no LAD, no thryomegaly or nodules
appreciated.
Cor- Tachycardic, S1, S2, no m/g/r appreciated
Chest- lungs CTAB, no w/r/r appreciated
Abd- soft NT, ND, no fluid wave appreciated, no HSM appreciated,
no dullness to percussion, no guarding/rebound tenderness
Ext- warm, well perfused, trace edema bilaterally at ankles, DP
2+ bilaterally, no cubbing or cyanosis, normal capillary refill
Neuro- A&Ox3, CNs grossly intact, strength 5/5 throughout, no
asterixis although + resting tremor bilaterally in arms, R>L.
Coordination intact.
Skin- Ruddy complexion, few cherry angiomas, no palmar erythema
or spider angiomas. No jaundice.
Msk- no joint swelling, full ROM.
Psych- appropriate
Pertinent Results:
ADMISSION LABS:
===============
8.3
3.7 >-----< 40
26.8
.
MCV 83
Neuts 82.3 Lymphs 11.4 Monos 5.9 Eos 0.2 Basos 0.1
PT 14.1 PTT 27.4 INR 1.2
.
138 96 5
-----|-----|-----< 126
3.3 17 0.8
.
ALT 46 AST 69 Alk Phos 183 Amylase 84 Total bili 2.5 Tot
protein 7.6
Ca 8.8 Phos 1.3
.
CK 34 Troponin <0.01
.
Serum Tox Screen: ASA negative, Ethanol negative, acetaminophen
negative, benzodiazepine negative, barbiturates negative, TCA
negative
Urine Tox Screen: negative
.
STUDIES:
=========
EKG [**2159-12-3**]
Baseline artifact
Sinus tachycardia
Q-Tc interval appears prolonged but is difficult to measure
Clinical correlation is suggested
Since previous tracing of [**2159-2-10**], sinus tachycardia now present
but otherwise
baseline artifact on both tracing makes comparison difficult
.
CHEST PORT. LINE PLACEMENT [**2159-12-6**]
FINDINGS: In comparison with the study of [**2158-4-27**], there is no
change in the appearance of the heart and lungs. Mild
cardiomegaly persists, but no acute pneumonia.
.
There has been placement of right subclavian PICC line that
extends to the lower portion of the superior vena cava. This
information was telephoned to the venous access nurse at her
request.
.
EKG [**2159-12-6**]
Sinus tachycardia with non-specific ST-T wave abnormalities.
Compared
to the prior tracing of [**2159-12-3**] no diagnostic interval change.
Brief Hospital Course:
# Hematemesis/Melena: Patient presented with coffee ground
emesis and melena in the setting of nausea, vomiting, and poor
PO intake for 1 week. Unclear what initiated N/V, possibly was
viral syndrome, or EtOH abuse. Hepatology was consulted, and
performed EGD which showed esophagitis and portal hypertensive
gastropathy. Presented with Hct 26.8 -> 23.7, up to 27.7 after
1 U PRBCs s/p 2 unit PRBCs with appropriate bump in HCT.
Patient was initially put on PPI IV bid, switched to PO bid and
sucralfate when tolerating PO. He continued taking nadolol for
his known esophageal varices. Diet was advance to clear, then
to regular as tolerated. Patient also underwent a flex
sigmoidoscopy on [**12-11**] to evalute for a lower source of GI
bleed. This showed evidence of hemorroids. NO further
intervention needed.
.
# Cirrhosis: Patient has a history of alcoholic cirrhosis. No
ascites appreciated on exam, no other stigmata of liver failure
noted (no asterixis, no palmar erythema, no ascites). U/S in
[**8-28**] did not reveal any HCC or visualize the portal vein, AFP
was 2.9. Liver enzymes slightly elevated on admission, but
trended down. Ammonia level elevated, but no evidence of
encephoalopathy. His lactulose was initially held as he was
agitated and not tolerating PO. He subsequently had evidence of
encephalopathy (positive asterixis) and his lactulose was
continued TID and Rifaxamin was started.
.
# Alcohol Withdrawal: Serum/urine tox were negative on
admission. Pt. developed acute delerium, confusion,
tremulousness, likely c/w alcohol withdrawal 48 hours into
hospitalization. He initially reported his last drink was three
months ago, although OMR note from [**2159-11-21**] notes he reported
drinking whiskey daily at that time. Patient was placed on CIWA
Protocol q15 minutes with Lorazepam 4 mg IV q15 min as needed.
As patient improved, CIWA changed to q3 hours with Diazepam 5 mg
PO q3 hours. He was supplemented with thiamine and folate. He
was put on 4 point restraints with a 1:1 sitter. His
Acamprosate was d/ced in the acute setting. Social work was
consulted.
.
# Hypophosphatemia: Hypophos noted in alcoholics often, 12 hours
after admission due to low reserve, shifting intracellularly.
Could also be secondary to re-feeding, as patient received D5
w/banana bag, and may have also received D5 at OSH. His
phosphate was 1.3 on admission and nadired at 0.8. Phosphate
was repleted with Neutra-Phos and K Phos.
.
# Hematuria: Patient self-d/ced Foley on [**12-6**] after an episode
of agitation/delerium leading to hematuria, a 3 way Foley placed
with CBI and urine clearing. Hct dropped from 27.2 -> 20.9 with
the hematuria, s/p 2 U PRBCs with Hct up to 27.1. Foley was
d/ced the next day.
.
# Borderline pancytopenia: Patient has WBC of 3.7, HCT of 26,
and platelet count of 40 on admission. Low platelet count could
be secondary to liver disease, while low HCT could be due to RBC
loss from GI tract or anemia of chronic disease. Stools were
guaiac positive, B12/folate WNL. Iron low at 22, so he was
continued on FeSO4. Triglycerides WNL, making Zieve syndrome
less likely (hemolytic anemia of alcoholics). However his
borderline pancytopenia may also represent systemic process,
such as malignancy or viral infection. More likely due to
overall chronic disease state and malnutrition, although patient
has fairly good albumin. An HIV test was sent and pending at
the time of discharge.
.
# AG Respiratory alkalosis: Patient with AG of 25 at time of
admission. HCO3 low, but likely respiratory alkalosis as patient
is likely overbreathing in the setting of alcohol withdrawal.
Complicated by acidosis: starvation ketosis with 150 ketones in
urine, also dehydration s/p episodes of emesis. This repiratory
alkalosis can contribute to the hypophosphatemia found on labs.
Checked serum Osm for unmeasured ions -> Osm gap is <4.
Continued to monitor AG, which was improved on discharge.
.
# HTN: Holding at present given potential for losses, low BP.
Can likely be re-started at at time of discharge.
.
# Depression: Continue home medications of seroquel and
fluxoetine.
Medications on Admission:
Medications:
- Campral 333 tid
- Fiber caps qd
- fluoxetine 20 qd
- Folbalin plus qd
- folic acid 0.4mg qd
- lactulose 20g tid
- lisinopril 5 qd
- MVI
- nadolol 20 qd
- omeprazole 40 qd
- Seroquel 25 qd
.
Allergies: Furosemide (rash)
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
11. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO three times a day.
12. Fiber-Caps 625 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 3 Esophagitis
Portal Gastropathy
Alcoholic Cirrhosis with encephalopathy
Hematuria [**2-23**] foley trauma
Hemorroids
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital because you were vomiting up
dark material. You had an EGD which showed evidence of
inflammation of your esophagus called esophagitis and portal
gastropathy. You received a total of 3 units of blood. You
were started on a medication called pantoprazole and sulcrafate.
Given your history of cirrhosis in your liver, you were started
on a medication called Rifaxamin.
You also had a few episodes of blood with your bowel movements.
You had a sigmoidoscopy which showed evidence of hemorroids that
are probably causing the blood in your bowels.
You had an HIV test which was pending at the time of discharge.
Your PCP will need to obtan records to follow up the result.
Your Lisinopril was held because you had some low blood
pressure. This was not restarted on discharge. Your Fobalin
Plus was held because you were started on thiamine and folic
acid vitamin supplements.
If you have any further episodes of nausea, vomiting, fever,
chills, abdominal pain, bloody stools, or any other concerning
symptoms, please call your PCP or return to the ED.
Please follow up with your PCP as below. An appointment has been
scheduled for you.
Followup Instructions:
Please follow up with your PCP Dr [**Last Name (STitle) 51969**] on Monday [**12-24**]
9:45am
.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] (Hepatology) Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2160-1-31**] 1:30
Completed by:[**2159-12-12**]
|
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|
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[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,219
| 105,442
|
43324
|
Discharge summary
|
report
|
Admission Date: [**2130-3-1**] Discharge Date: [**2130-3-7**]
Date of Birth: [**2081-7-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
PICC line placement
Upper endoscopy [**2130-3-1**]
History of Present Illness:
Ms. [**Name13 (STitle) 805**] is a 48-year-old F PMhx chronic HCV w Stage I
fibrosis, hypertension, Crohn's disease, rheumatoid arthritis,
and bipolar disorder who presented with with 3 days of
nausea/vomitting, and new onset hematemesis. Patient reports 10
episodes of about a cup full of vomiting dark, coffee ground
emesis following a binge on 40 ounces of malt liquor and a half
a fifth of Captain [**Doctor Last Name **] original spiced rum. Patient
reports that she often vomits after drinking (up to 3 times a
week). She denies taking any cocaine during this time. Patient
states that she has been having fevers (unmeasured) but no other
localizing symptoms. She states that she has been drinking
water, but not taking any of her home medications and not eating
due to the vomiting. She states that she may not have urinated
for the past 2 days and that she did pass a dark, oily stool
yesterday. Patient denies recent travel, strange foods, or
sick contacts. On the morning of admission, patient had 1
episode of hematemesis and called 911.
On initial presentation to the ED vital signs were not checked.
Patient was sitting up in bed and able to discuss her history.
Exam was significant for good mentation, nontender abdomen.
Initial labs were significant for Hct 34 (previously 29-36), WBC
18 (N67), Cr 6.4 (normal 1.4-1.7), ALT/AST 33/43 (previously
27/26), lactate 5.8. CXR demonstrated an elevated right
hemidiaphragm and no consolidation or pleural effusion seen on
the lateral view. She was bolused with IV NS (total 5L) with
blood pressure responsive and resolving to SBP 115-130s with HR
80bpm. Had clear NG lavage. Digital rectal exam showed dark
brown guaiac positive stool. Repeat labs showed lactate 3.8,
Hct 29. She received 1 dose zosyn and vancoymcin given concern
for infection, and 1 dose IV protonix given concern for GI
bleed. She was admitted to [**Hospital1 18**]
On arrival to the ICU patient had an initial blood pressure of
60s/20s, although this was in the context of her wiggling around
and not sitting still when the cuff was measuring. I checked
the pressure myself and got 120/50 on a manual cuff. Patient
did report some recent dizziness with standing, but denies frank
syncope. Bladder scan was done with 750cc in the bladder. A
foley was inserted.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1) Cardiomyopathy most likely secondary to hypertensive heart
disease and polysubstance abuse, LV systolic dysfunction,
EF 35-40%, NYHA class I-II.
2) Hypertension
3) Polysubstance abuse (cocaine, etoh)
4.) Crohn's disease since [**2099**] vs. ulcerative colitis (Chronic
active colitis with ulceration seen on biopsy in [**8-18**] and [**2-/2114**])
5.) hx abnormal mammogram with L breast biopsy in [**10-19**] -
sclerosing adenosis, Pseudoangiomatous stromal hyperplasia.
6.) Bipolar/Schizophrenia (per patient)
7.) Depression (per patient)
8.) Fibromyalgia (per patient)
9.) Brain aneurysm s/p surgery at [**Hospital1 112**] (per patient)
10.) Nicotine abuse
Social History:
Patient lives on SSI/disability and lives alone in an apartment
above her 25 year old daughter. + h/o cocaine and alcohol
abuse; + tobacco [**7-23**] cigarrettes a day since age 35
Family History:
Non contributory
Physical Exam:
Admission:
Vitals: T:98.9 BP:75/43 P:111 R: 18 O2: 100%
General: Alert, oriented, moving around alot/ psychomotor
agitation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to see, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur over precordium not on carotids, not radiating to left
axilla. No rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6* MCV-87 RDW-13.9 Plt
Ct-427
---Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7 Baso-0.6
Glucose-168* UreaN-72* Creat-6.4*# Na-136 K-3.4 Cl-86* HCO3-28
ALT-33 AST-43* AlkPhos-57 TotBili-0.6
Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Lactate-5.8*
UA: Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 Blood-SM Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-5.5 Leuks-NEG
RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 UreaN-447 Creat-99
Na-74 K-26 Cl-48 TotProt-23 Prot/Cr-0.2 bnzodzp-NEG barbitr-NEG
opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG
==============
OTHER STUDIES
==============
ECG [**2130-3-1**]:
Sinus tachycardia. It is difficult to determine the Q-T interval
secondary to underlying artifact and non-specific ST-T wave
changes. However, the Q-T interval may be slightly prolonged.
Compared to the previous tracing of [**2127-4-21**] artifact is not seen
on the current tracing and the Q-T interval may be prolonged.
Clinical correlation is suggested.
.
Chest Radiograph PA and Lateral [**2130-3-1**]:
IMPRESSION:
1. Elevated right hemidiaphragm.
2. Left base not well evaluated on the frontal view, although no
consolidation or pleural effusion seen on the lateral view.
.
EGD [**2130-3-1**]:
Impression: Severe esophagitis in the gastroesophageal junction
and lower third of the esophagus
Ulcer in the gastroesophageal junction
No blood was seen throughout the procedure
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue PPI 40mg [**Hospital1 **].
Restart ranitidine when renal function improves, if possible.
Consider sucralfate slurry 1gram QID.
Alcohol cessation counselling.
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Repeat endoscopy in [**8-27**] weeks to evaluate esophageal ulcer and
esophagitis for healing.
.
Renal U/S [**2130-3-2**]:
IMPRESSION:
No obstructing stones, masses or hydronephrosis.
[**2130-3-7**] 05:48AM BLOOD WBC-8.5 RBC-3.69* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.9 Plt Ct-291
[**2130-3-5**] 06:30AM BLOOD WBC-8.5 RBC-3.48* Hgb-10.1* Hct-30.4*
MCV-88 MCH-29.1 MCHC-33.3 RDW-14.6 Plt Ct-231
[**2130-3-4**] 06:00AM BLOOD WBC-7.1 RBC-3.34* Hgb-10.1* Hct-29.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.9 Plt Ct-224
[**2130-3-3**] 05:02AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.3* Hct-29.1*
MCV-88 MCH-30.9 MCHC-35.4* RDW-14.0 Plt Ct-247
[**2130-3-2**] 09:49PM BLOOD WBC-7.5 RBC-3.25*# Hgb-9.4*# Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.0 Plt Ct-231
[**2130-3-2**] 05:18AM BLOOD WBC-6.8 RBC-2.59* Hgb-7.4* Hct-22.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-260
[**2130-3-1**] 01:20PM BLOOD WBC-13.2* RBC-2.86* Hgb-8.4* Hct-25.4*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.8 Plt Ct-322
[**2130-3-1**] 08:40AM BLOOD WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6*
MCV-87 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-427
[**2130-3-4**] 06:00AM BLOOD Neuts-46.4* Lymphs-39.9 Monos-8.5
Eos-4.8* Baso-0.4
[**2130-3-1**] 08:40AM BLOOD Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7
Baso-0.6
[**2130-3-1**] 09:30AM BLOOD PT-12.2 PTT-23.3* INR(PT)-1.1
[**2130-3-7**] 12:47PM BLOOD Creat-1.7*
[**2130-3-7**] 05:48AM BLOOD Glucose-140* UreaN-21* Creat-1.8* Na-141
K-4.2 Cl-108 HCO3-26 AnGap-11
[**2130-3-6**] 06:30AM BLOOD Glucose-103* UreaN-15 Creat-1.6* Na-142
K-4.3 Cl-110* HCO3-29 AnGap-7*
[**2130-3-5**] 06:30AM BLOOD Glucose-152* UreaN-15 Creat-1.7* Na-141
K-3.9 Cl-108 HCO3-27 AnGap-10
[**2130-3-4**] 06:00AM BLOOD UreaN-18 Creat-1.8* Na-142 K-4.0 Cl-107
HCO3-29 AnGap-10
[**2130-3-3**] 05:02AM BLOOD Glucose-142* UreaN-18 Creat-1.9*# Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2130-3-2**] 05:18AM BLOOD Glucose-94 UreaN-38* Creat-3.1*# Na-145
K-3.4 Cl-108 HCO3-31 AnGap-9
[**2130-3-1**] 01:20PM BLOOD Glucose-95 UreaN-55* Creat-4.7*# Na-139
K-3.7 Cl-104 HCO3-25 AnGap-14
[**2130-3-1**] 08:40AM BLOOD Glucose-168* UreaN-72* Creat-6.4*# Na-136
K-3.4 Cl-86* HCO3-28 AnGap-25*
[**2130-3-4**] 06:00AM BLOOD ALT-34 AST-36 LD(LDH)-239 AlkPhos-50
TotBili-0.2
[**2130-3-1**] 08:40AM BLOOD ALT-33 AST-43* AlkPhos-57 TotBili-0.6
[**2130-3-1**] 08:40AM BLOOD Lipase-21
[**2130-3-7**] 05:48AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.7
[**2130-3-4**] 06:00AM BLOOD Mg-2.2
[**2130-3-3**] 05:02AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
[**2130-3-2**] 05:18AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7
[**2130-3-1**] 01:20PM BLOOD TotProt-5.8* Calcium-7.9* Phos-3.6#
Mg-1.7
[**2130-3-1**] 08:40AM BLOOD Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
[**2130-3-2**] 02:00PM BLOOD Cryoglb-NO CRYOGLO
[**2130-3-1**] 01:20PM BLOOD PEP-POLYCLONAL
[**2130-3-2**] 02:00PM BLOOD HIV Ab-NEGATIVE
[**2130-3-1**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-3-1**] 10:44AM BLOOD Lactate-3.8*
[**2130-3-1**] 08:53AM BLOOD Lactate-5.8*
.
Microbiology:
[**2130-3-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2130-3-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
48-year-old F PMhx chronic HCV w Stage I fibrosis, hypertension,
Crohn's disease, rheumatoid arthritis, and bipolar disorder who
presented with several days of nausea/vomiting, and new onset
hematemesis.
#Severe esophagitis causing hematemesis and acute blood loss
anemia in the context of alcohol abuse and history of candidal
esophagitis. Patient is on Protonix and ranitidine at home but
has questionable compliance. EGD [**2130-3-2**] demonstrated severe
esophagitis as well as an ulcer at the GE junction. We
initially started IV pantoprazole 40mg [**Hospital1 **], but switched to PO
after the first day. We also started sucralfate slurry 1gram
QID and recommended/ encouraged alcohol cessation counseling.
Per GI we also instituted an antireflux regimen: Avoid
chocolate, peppermint, alcohol, caffeine, onions, aspirin.
Elevate the head of the bed 3 inches. Go to bed with an empty
stomach. While in the ICU, we held patient's antihypertensive
regimen. Patient's hematocrit also decreased the day after
admission down to 22.8 and patient was transfused 2 units of
PRBCs. Hct was stable thereafter around 29. Pt was discharged
on sucralfate, pantoprazole [**Hospital1 **], and ranitidine. HCT was 32.7
upon discharge. She was discharged with an appointment with GI
for repeat evaluation and discussion of repeat endoscopy to
ensure ulcer healing. Pt can retrial ASA therapy upon discharge
if clinically indicated.
#Acute renal failure with anion gap acidosis: Question prerenal
from hypotension/ poor PO intake versus toxic injury/ cocaine
(positive u tox). Initial lactate 5.85, trended down to 3.8.
Also possible is retention as patient had 750cc in her bladder
when a foley was placed, perhaps from opioid use. Anion gap
closed rapidly, possibly starvation/EtOH due to poor PO and
alcohol use. Patient received 5L crystalloid in the ED. FeNa
2.53 and FeUrea 39 consistent with intrinsic renal disease.
Nephrology was consulted but Cr began to dramatically fall prior
to completion of work up ( showed no obstruction). HIV was
rechecked and was negative. Once Cr back down to 1.7 (near
baseline of 1.3-1.5) ranitidine was restarted first. Attempted
to restart HCTZ and lisinopril and creatinine bumped to 1.8.
Thus these were stopped and pt was advised not to restart these
medications upon discharge until further evaluation and repeat
labs by PCP. [**Name10 (NameIs) 17781**] negative. Pt's new baseline Cr may be
1.6-1.8. Follow up labs will help with determination. Creatinine
was 1.7 upon discharge.
#Leukocytosis: Unclear etiology: patient given vancomycin and
Zosyn in the ED but then stopped as no clear source. All
cultures remained negative and trended down without other
intervention. Likely leukemoid reaction due to vomiting and
acute GI bleeding.
#Tachycardia: Patient tachycardic during admission in the ICU.
Likely multifactorial including poor PO intake/ volume down
versus manic episode versus drug use. Patient was given 2 units
of blood. Tachycardia resolved by first night out of the ICU
and tele stopped.
.
#Chronic systolic CHF: Most recent TTE with marginally low EF of
50% (though previously as low as 35%). Pt appeared euvolemic
during admission and without lower extremity edema or pulmonary
edema. BB continued. Attempted to restart ACEI, however, pt had
a slight Cr bump and requested discharge. Lasix was also not
restarted given above. Pt did not report any SOB and was not
hypoxic.
#Psychomotor agitation and recent alcohol abuse/cocaine use-
Patient reported binge drinking up 3 times a week. Last drink
was 2/12 per report. Question side effects from benzotropine as
well. Cocaine + per urine. Patient was started on CIWA with
Ativan 1-2 mg PO q 2h CIWA>10 (initially IV). She did not
require any Ativan on [**3-2**]. On regular medical floor patient
without clear psychomotor retardation and received no further
BZD without signs of withdrawal.
#Nicotine abuse: Patient has been smoking up to a pack a day
for the past 10-20 years. We counseled on quitting and
continued a NICOTINE patch.
#Hypertension: Initially all anti-hypertensives were held in
setting of GI bleed. Labetalol was restarted prior to leaving
MICU as BPs trending high. Attempted to restart Lisinopril and
HCTZ on [**3-6**], however, pt had a slight Cr bump on [**3-7**] and these
medications were discontinued. Labetalol was increased to 600mg
[**Hospital1 **]. SHE WAS STRONGLY URGED NOT TO USE LABETALOL WHILE USING
COCAINE. Lasix was not restarted given recent GI bleeding and
[**Last Name (un) **].
#Crohn's disease since [**2099**] vs. ulcerative colitis: Pt on
sulfasalazine at baseline but this was held given acute renal
failure. This was restarted upon discharge as [**Last Name (un) **] resolved.
.
#Fibromyalgia (per patient): On chronic tramadol. This was
restarted at discharge.
.
#Depression/ Bipolar/Schizophrenia (per patient)/social issues:
She was continued on her quetiapine and ziprasidone at home
doses with pleasant (if odd) somewhat hypomanic behavior.
Continued benzotropine as well. Psychiatry was consulted and did
not feel as though pt had any psychiatric contraindications to
discharge. Pt was offered resources by SW and psychiatry for
assistance with stopping ETOH and drug use. However, she
declined. She was advised to follow up with her psychiatrist
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], [**Location (un) 669**] Comprehensive (per old records: cell
[**Telephone/Fax (1) 93299**], office [**Telephone/Fax (2) 93300**]). Pt told the psychiatry
team prior to discharge that she woiuld call to make an
appointment. Per report, SW attempted to file a 51A given pt's
reports of possible abuse involving her boyfriend and her
grandson's-reported to social work [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7839**]. However, pt
would not give her daugther's/grandson's address-stated she did
not know it and therefore report, per report, was unable to be
filed. Pt did not report this information to her attending. She
reported this to SW who attempted to file a 51A unsuccessfully
as the address could not be reportedly found.
-WOULD STRONGLY CONSIDER NEUROPSYCHIATRIC TESTING TO HELP IN
DETERMINING IF UNDERLYING COGNITIVE VS. PSYCHIATRIC STATE
IMPAIRING DECISION MAKING. PT UNABLE TO RECEIVE VNA SERVICES FOR
HOME SAFETY EVALUATION AS SHE IS AMBULATORY.
#COPD w/o exacerbation: Pt continued on chronic bronchodilators
#Transitional:
-Repeat endoscopy in [**8-27**] weeks ([**2130-4-20**]) to evaluate esophageal
ulcer and esophagitis for healing. Appointment made with GI
-BP check to determine if labetalol dosing should be changed
-chemistry panel check to determine if lasix, lisinopril, HCTZ
can be/should be restarted
-neuropsychiatric testing.
Medications on Admission:
BENZTROPINE 1mg qAM, 2mg qPM
Lasix 20mg daily prn lower extremity edema
HCTZ - 25mg daily
COMBIVENT 2 puffs QID
LABETALOL 400mg [**Hospital1 **]
LISINOPRIL 40mg daily
PANTOPRAZOLE 40mg Tablet [**Hospital1 **]
PREDNISOLONE ACETATE 1%Drops QID to R eye
QUETIAPINE 700mg qHS
RANITIDINE 300mg [**Hospital1 **]
SULFASALAZINE 1000mg [**Hospital1 **]
TRAMADOL 50mg [**1-16**] Tablet qid prn
ZIPRASIDONE 80mg [**Hospital1 **]
ASPIRIN 81mg daily
NICOTINE patch
Discharge Medications:
1. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. quetiapine 400 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)):
700mg total.
4. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO at bedtime: 700mg total.
5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO twice a
day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
14. benztropine 1 mg Tablet Sig: 1-2 Tablets PO twice a day:
take 1mg (1 tablet) in the morning and 2mg (2 tablets) in the
evening.
15. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
16. 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:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 249**]
Discharge Diagnosis:
Primary Diagnosis:
Hematemesis due to esophagitis
gastro-esophageal ulcer
Acute renal failure
Secondary Diagnoses:
Chronic systolic CHF
Hypertension
Bipolar affective disorder/shizophrenia
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to bleeding from your gastrointestinal
tract including your stomach. You were initially admitted to the
ICU and underwent an endoscopy that showed an ulcer and severe
irritation in your esophagus (the tube connecting your mouth to
your stomach). You were started on some new medications for
this. You will need to follow up with a gastroenterologist after
discharge to ensure that your ulcer is healing.
.
Please avoid alcohol as this will worsen your ulcer and
esophagitis. You have been seen by social work to help provide
you with resources.
.
Please stop using cocaine. If you take labetalol (medication for
blood pressure) with cocaine you could suffer a significant
heart attack and die. Please use the resources that were
provided to you by social work to stop using cocaine. If you
continue to use cocaine, please do not take your labetalol.
.
Your medications have been changed
1.Sucralfate has been started to help heal your esophagus
2.omeprazole has been started to help with ulcer healing
3.Hydrochlorothiazide, lasix, and lisinopril have been stopped
at this time due to your kidney function.
4.your labetalol was increased because your other blood pressure
medications were changed.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
.
We strongly recommend you stop using alcohol to excess and other
drugs to help protect your health.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2130-3-10**] at 1:45 PM
With:DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ( who works on Dr. [**Last Name (STitle) 93301**] team)
Phone:[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**], south
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2130-4-3**] at 4:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD
Phone:[**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"295.90",
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"729.1",
"288.60",
"404.91",
"305.1",
"428.0",
"714.0",
"496",
"305.00",
"530.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18990, 19040
|
9978, 16761
|
277, 329
|
19290, 19290
|
4678, 4737
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4002, 4021
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226, 239
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357, 2668
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19080, 19156
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4751, 9955
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19305, 19417
|
3110, 3786
|
3802, 3986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,955
| 154,963
|
51825
|
Discharge summary
|
report
|
Admission Date: [**2145-4-23**] Discharge Date: [**2145-5-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
[**Age over 90 **]M with hx of afib, hypertension, ?dCHF, recent aspiration
pneumonia, being treated with levofloxacin and flagyl,
presenting from home with increasing SOB since midnight,
increased secretions, decreased mental status overnight.
Patient has 24-hr caregivers at home who called EMS. Unclear if
patient has been having fevers at home. Patient currently on
levo/flagyl course for aspiration pneumonia.
.
In the ED, initial vs were: T 98.1 HR 125 BP 163/94 95% on ?L
O2. Patient was given a dose of vancomycin, levofloxacin, and
metronidazole due to likely aspiration. EKG showed AFib rate
131 with no ischemic changes. CXR showed increase in pleural
effusions and atelectasis bibasilar. Lactate not elevated at
2.0. Trop elevated at 0.13, increased past his baseline. He
was given a dose of aspirin 300mg rectally. BNP elevated to
4200. Patient was trialed with BiPap, which he did not tolerate
well due to altered mental status. Patient was initially not
given any IVFs but BPs started to drop to 80/44, for which he
was given 500cc bolus IVFs, to which BP reponded. Patient is
DNR/DNI and is being transfered to medical ICU for further
management. ED staff had conversation with HCP in [**State 2748**]
who understood that patient was not doing well. Vitals in ED
prior to transfer are as follows: 99/60 HR 90-126 (afib) RR 32
100% on NRB.
.
In the ICU, patient appears comfortable on non-rebreather. He
is able to squeeze hands to commands and answer some yes or no
questions. He denies pain.
Past Medical History:
- Atrial Fibrillation, on warfarin and diltiazem; followed by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
- Possible diastolic CHF (echo in [**2143**] showed EF of 50%)
- Chronic renal insufficiency (baseline Cr 1.4)
- Dementia (moderate to severe)
- Prostate Cancer (pt has elected to have no work-up or
treatment)
- Hypertension
- Hyperlipidemia
- Heel pressure ulcers
- Pneumonia, hospitalized [**5-/2144**], treated with levofloxacin
- Probable aspiration of thin liquids
Social History:
Occupation: Retired Lawyer, [**Name (NI) **] Alumnus
Religion: [**Hospital1 **]
Living situation: Lives in own apartment with 24 hour care
Key relationships: Nephew [**Name (NI) 3065**] [**Name (NI) 2405**] and Caretaker [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]-Giver stress level: Average
Smoking, EtOH: Non-smoker, [**12-27**] glass wine/month
Functional Baseline:
ADLS: dependent
IADLS: Dependent on all IADLs
Services at home: 24 hour caregiver
Assistive Device: [**Name (NI) 4886**] and wheelchair
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97 BP: 122/80 P: 110 R: 33 O2: 100% NRB
General: eyes closed, but awakens to voice and able to answer
some yes or no questions and squeeze hands to comman, difficult
to assess orientation, no acute distress with nonrebreather
HEENT: Sclera anicteric, PERRLA, difficult to assess oropharynx
with nonrebreather at this time, but mucus membranes appear
moist
Neck: supple, JVP estimated ~8cm
Lungs: poor air movement bilaterally, no crackles but decreased
breath sounds at bases
CV: irregular rhythm with rapid rate 110s, normal S1 + S2, no
murmurs appreciated at this rapid rate
Abdomen: soft but mildly distended, non-tender, bowel sounds
present
GU: foley in place with minimal urine output at this time
Ext: warm, well perfused, palpable pulses, 2+ edema lower
extremity edema; also has upper extremity edema R forearm and
hand greater than left ; nonstageable left heel ulcer
Pertinent Results:
ADMISSION LABS:
[**2145-4-23**] 05:49PM UREA N-15 CREAT-1.1 SODIUM-130*
POTASSIUM-5.3* CHLORIDE-92* TOTAL CO2-29 ANION GAP-14
[**2145-4-23**] 05:49PM CK(CPK)-114
[**2145-4-23**] 05:49PM CK-MB-17* MB INDX-14.9* cTropnT-0.44*
[**2145-4-23**] 05:49PM MAGNESIUM-2.1
[**2145-4-23**] 07:20AM URINE RBC-8* WBC-7* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2145-4-23**] 07:13AM PO2-83* PCO2-59* PH-7.32* TOTAL CO2-32* BASE
XS-1 COMMENTS-GREEN TOP
[**2145-4-23**] 07:00AM GLUCOSE-123* UREA N-15 CREAT-1.0 SODIUM-128*
POTASSIUM-6.2* CHLORIDE-92* TOTAL CO2-28 ANION GAP-14
[**2145-4-23**] 07:00AM CK(CPK)-63
[**2145-4-23**] 07:00AM cTropnT-0.13*
[**2145-4-23**] 07:00AM CK-MB-5 proBNP-4239*
[**2145-4-23**] 07:00AM TOT PROT-5.6* ALBUMIN-3.6 GLOBULIN-2.0
[**2145-4-23**] 07:00AM WBC-13.5* RBC-4.36* HGB-12.8* HCT-38.4*
MCV-88 MCH-29.4MCHC-33.4 RDW-15.3
[**2145-4-23**] 07:00AM NEUTS-85.2* LYMPHS-7.9* MONOS-6.0 EOS-0.8
BASOS-0.2
.
CHEST (PORTABLE AP) Study Date of [**2145-4-23**] 7:00 AM
1. Mild interval increase in bilateral pleural effusions and
associated basal atelectasis.
2. Mild pulmonary vascular congestion.
.
EKG [**4-23**]-Atrial fibrillation with rapid ventricular response.
There is a regularity which may represent atrial flutter. Low
amplitude QRS voltage in the limb leads. Indeterminate QRS axis.
Non-specific lateral ST-T wave changes. Compared to the previous
tracing of [**2145-2-4**] the venetricular response is now rapid. QRS
voltage in the precordial and limb leads is much lower. Clinical
correlation is suggested.
.
LENI [**4-23**]-
IMPRESSION: No deep venous thrombosis in right lower extremity.
.
[**4-24**] UENI-IMPRESSION: No deep venous thrombosis in right upper
extremity
.
CXR PICC-Portable AP chest radiograph was reviewed in comparison
to [**2145-4-23**].
Left PICC line tip is at the level of mid SVC. Bilateral pleural
effusions
are large. Interstitial pulmonary edema is unchanged. No
definitive
pneumothorax is noted on the current study. Mediastinal contours
are stable.
The study and the report were reviewed by the staff radiologist.
.
TTE ([**2145-4-27**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild septal hypokinesis.
The remaining segments contract normally (LVEF = 50%). The right
ventricular cavity is dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
[**5-1**] CXR-SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: The right
costophrenic angle
was beyond the field of view. Note is made of bilateral pleural
effusions,
which appear unchanged. These effusions as well as overlying
basal
subsegmental atelectasis result in partial obscuration of the
cardiac
silhouette which nevertheless appears minimally changed.
Mediastinal and
hilar contours are also unchanged, with note again being made of
atherosclerotic calcification along the aorta. A left PICC again
is seen to terminate at the upper portion of the superior vena
cava.
The study and the report were reviewed by the staff radiologist.
.
[**2145-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2145-4-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2145-4-23**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2145-4-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2145-4-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2145-4-23**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2145-4-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2145-5-4**] 06:15 10.7 4.67 13.2* 40.5 87 28.3 32.7 14.8 165
Source: Line-PICC
[**2145-5-3**] 06:50 9.9 4.60 13.0* 40.7 89 28.2 31.8 14.4 168
Source: Line-PICC
[**2145-5-2**] 06:13 7.9 4.45* 13.1* 38.8* 87 29.4 33.8 14.7 154
Source: Line-PICC
[**2145-5-1**] 05:40 9.1 4.59* 12.8* 40.7 89 27.9 31.4 14.4 155
Source: Line-PICC
[**2145-4-30**] 06:35 8.6 4.40* 12.4* 39.4* 90 28.2 31.5 14.4 136*
Source: Line-picc
[**2145-4-29**] 09:00 7.6 4.58* 13.0* 41.0 90 28.3 31.6 14.4 156
Source: Line-PICC
[**2145-4-28**] 03:54 7.7 4.34* 12.6* 38.5* 89 28.9 32.6 15.0 142*
Source: Line-PICC
[**2145-4-27**] 04:32 7.5 4.44* 12.9* 39.4* 89 29.0 32.7 14.5 151
Source: Line-PICC
[**2145-4-26**] 07:37 8.8 4.88 13.7* 43.0 88 28.1 31.9 15.0 172
[**2145-4-25**] 03:29 6.2 4.37* 12.5* 38.3* 88 28.7 32.7 14.9 166
Source: Line-PICC
[**2145-4-24**] 12:20 8.2 4.27* 12.3* 37.5* 88 28.7 32.6 15.0 166
[**2145-4-23**] 07:00 13.5* 4.36* 12.8* 38.4* 88 29.4 33.4 15.3
197
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2145-4-23**] 07:00 85.2* 7.9* 6.0 0.8 0.2
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2145-5-4**] 06:15 165
Source: Line-PICC
[**2145-5-4**] 06:15 20.4* 31.1 1.9*
Source: Line-PICC
[**2145-5-3**] 06:50 168
Source: Line-PICC
[**2145-5-3**] 06:50 21.1* 28.2 1.9*
Source: Line-PICC
[**2145-5-2**] 06:13 154
Source: Line-PICC
[**2145-5-2**] 06:13 28.6* 34.3 2.8*
Source: Line-PICC
[**2145-5-1**] 05:40 155
Source: Line-PICC
[**2145-5-1**] 05:40 31.3* 37.3* 3.1*
Source: Line-PICC
[**2145-4-30**] 06:35 136*
Source: Line-picc
[**2145-4-30**] 06:35 24.8* 29.5 2.3*
Source: Line-picc
[**2145-4-29**] 09:00 156
Source: Line-PICC
[**2145-4-29**] 09:00 27.5* 33.5 2.6*
Source: Line-PICC
[**2145-4-28**] 03:54 142*
Source: Line-PICC
[**2145-4-28**] 03:54 28.8* 32.8 2.8*
Source: Line-PICC
[**2145-4-27**] 04:32 151
Source: Line-PICC
[**2145-4-27**] 04:32 40.1* 46.1* 4.1*
Source: Line-PICC
[**2145-4-26**] 07:37 172
[**2145-4-26**] 07:37 34.1* 37.2* 3.4*
[**2145-4-25**] 03:29 166
Source: Line-PICC
[**2145-4-24**] 12:20 166
[**2145-4-24**] 12:20 24.5* 48.3* 2.3*
[**2145-4-23**] 07:00 197
[**2145-4-23**] 07:00 20.1* 27.5 1.8*
LAB USE ONLY
[**2145-5-4**] 06:15
Source: Line-PICC
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2145-5-4**] 06:15 17 1.0 139 3.9 97 36* 10
Source: Line-PICC
[**2145-5-3**] 06:50 15 0.9 139 4.0 98 34* 11
Source: Line-PICC
[**2145-5-2**] 06:13 851 16 1.0 142 3.6 99 36* 11
Source: Line-PICC
[**2145-5-1**] 05:40 981 16 1.0 141 3.5 98 38* 9
Source: Line-PICC
[**2145-4-30**] 06:35 [**Telephone/Fax (2) 107315**] 3.5 100 39* 8
Source: Line-picc
[**2145-4-29**] 09:00 112*1 16 1.0 142 3.6 99 38* 9
Source: Line-PICC
[**2145-4-28**] 03:54 [**Telephone/Fax (2) 107316**] 3.7 100 36* 11
Source: Line-PICC
[**2145-4-27**] 04:32 [**Telephone/Fax (2) 107317**] 3.9 100 35* 11
Source: Line-PICC
[**2145-4-26**] 07:37 [**Telephone/Fax (2) 107318**] 4.2 98 33* 13
[**2145-4-25**] 03:29 [**Telephone/Fax (2) 107319**] 4.2 98 32 13
Source: Line-PICC
[**2145-4-24**] 12:20 101*1 16 1.0 135 4.3 96 33* 10
[**2145-4-23**] 17:49 15 1.1 130* 5.3* 92* 29 14
CHEMS TE11-TE16 ADDED 10:10AM
[**2145-4-23**] 07:00 123*1 15 1.0 128* 6.2*2 92* 28 14
MODERATELY HEMOLYZED SPECIMEN
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
VERIFIED BY REPLICATE ANALYSIS
HEMOLYSIS FALSELY ELEVATES K
NOTIFIED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] AT 0800 [**2145-4-23**]
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2145-5-1**] 05:40 Using this1
Source: Line-PICC
Using this patient's age, gender, and serum creatinine value of
1.0,
Estimated GFR = 70 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2145-4-27**] 04:32 32*1
Source: Line-PICC
[**2145-4-24**] 12:20 601
[**2145-4-23**] 17:49 18 37 [**Telephone/Fax (1) 107320**] 0.5
CHEMS TE11-TE16 ADDED 10:10AM
[**2145-4-23**] 07:00 632
MODERATELY HEMOLYZED SPECIMEN
NEW REFERENCE INTERVAL AS OF [**2143-12-30**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
HEMOLYSIS FALSELY ELEVATES CK.
NEW REFERENCE INTERVAL AS OF [**2143-12-30**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
CPK ISOENZYMES CK-MB MB Indx cTropnT proBNP
[**2145-4-27**] 04:32 4 0.47*1
Source: Line-PICC
[**2145-4-26**] 07:37 0.41*1
[**2145-4-24**] 12:20 9 0.36*1
[**2145-4-23**] 17:49 17* 14.9* 0.44*1
CHEMS TE11-TE16 ADDED 10:10AM
[**2145-4-23**] 07:00 0.13*2
[**2145-4-23**] 07:00 5 4239*3
MODERATELY HEMOLYZED SPECIMEN
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
NOTIFIED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] AT 0835 [**2145-4-23**]
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION;AT 35%
PREVALENCE, NTPROBNP VALUES; < 450 HAVE 99% NEG PRED VALUE;
>1000 HAVE 78% POS PRED VALUE;SEE ONLINE LAB MANUAL FOR MORE
DETAILED INFORMATION
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2145-5-4**] 06:15 2.8 1.9
Source: Line-PICC
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc LDLmeas
[**2145-4-28**] 03:54 108 751 39 2.8 54 54
Source: Line-PICC
LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
PITUITARY TSH
[**2145-4-23**] 17:49 2.2
CHEMS TE11-TE16 ADDED 10:10AM
LAB USE ONLY RedHold
[**2145-4-24**] 12:20 HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Comment
[**2145-4-23**] 07:13 83* 59* 7.32* 32* 1 GREEN TOP
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2145-4-23**] 07:13 121* 2.0 129* 5.4* 89*
Brief Hospital Course:
[**Age over 90 **]M with atrial fibrillation, right-sided CHF, dementia, recent
aspiration pneumonia, who presented from home with increased
shortness of breath and altered mental status.
.
# Respiratory Distress: Shortness of breath and hypoxemia likely
[**1-27**] aspiration and flash pulmonary edema from diastolic heart
failure and afib with RVR. He was admitted to the ICU and
started on vanc, cefepime, and cipro; he received flagyl as
outpt which was not continued. His O2 status rapidly improved,
and it was thought that he unlikely had HAP, given that he lives
at home (with 24 hour care), and did not show signs of
infection. Vanc and cefepime were d/c'd, and ciprofloxacin was
continued for a 4 day course in house (given its uncertain
indication and course for him prior to hospitalization). He
remained afebrile without signs of infection throughout the rest
of his hospitalization. O2 was weaned off on [**5-1**]. He received a
speech and swallow evaluation that was largely unchanged from
previous. His aspiration diet was continued without changes. See
below for CHF.
.
# Diastolic CHF: He was admitted with flash pulmonary edema with
markedly elevated BNP, in the setting of rapid atrial
fibrillation. He was also total body volume overloaded with 3+
pitting edema throughout. He was on a minimal lasix regimen as
an outpatient, apparently because he had little to no edema, but
he was treated in the ICU with iv lasix, and this was continued
as iv and po on transfer to the floor. Although he is listed to
have chronic renal insufficiency, his creatinine tolerated
diuresis well with no elevation. He had a repeat TTE showing
good EF, hypertrophy, and possibly new RWMA (see below for
NSTEMI). On discharge, he required no O2, but he should
continue diuresis with daily weights and urine output monitoring
. BB and ACEI were started during this admission.
.
# Altered Mental Status: Likely toxic-metabolic etiology in
setting of hypoxia in the setting of underlying dementia.
Patient appears to be comfortable and responding well at this
time. Neuro exam nonfocal in ICU. His mental status is now back
to baseline, with A&Oxperson and intermittently place or month.
.
# Leukocytosis: Pt did have temp of 100.1 in ED which improved
with pr aspirin. He does have elevated WBC to 13, likely all
secondary to aspiration pneumonitis (now less likely pneumonia).
Pt did have loose stools on arrival to floor and has been on
antibiotics recently, though one of these antibiotics has been
flagyl. C diff toxin and stool culture were negative.
Leukocytosis resolved and pt remained afebrile on the regular
medical floor.
.
# Chronic renal insufficiency: Creatinine 1.0 on presentation,
actually lower than baseline, but urine output had been low
since arrival to ED and ICU. Likely in setting of fluid
overload. Urine electrolytes on admission c/w prerenal state.
His Cr remained normal/stable during admission
.
# Atrial Fibrillation: His rate was relatively well controlled
after 1-2 days with iv metoprolol, transitioned to po metoprolol
(he previously was not on metoprolol as outpt). now much better
controlled. Previously supratherapeutic on coumadin, now
therapeutic; originally bridged with lovenox. Pt's INR was 1.9
on day of discharge, but this was likely due to coumadin being
held 2 days ago. He will continue his coumadin and was
recommended to have INR checked in 2 days.
.
# Elevated troponins, thought to be demand ischemia vs. NSTEMI
in setting of RVR: Cardiac enzymes trended downward. Already on
ASA, statin. Added BB and ACEI as above. S/p lovenox bridge to
coumadin. He never complained of CP/SOB/palpitions.
.
# Hyponatremia: Patient with Na 128, which is likely in setting
of fluid overload. Resolved with diuresis.
.
# Right arm and Leg Swelling: He was ruled out for DVT in the
setting of initially R>L extremity swelling. His edema, later
more symmetrical on turning, likely represents dependent edema
along with full body anasarca.
.
# Dementia: Patient responding to commands, appears close to
baselilne now per his caretakers and family. Memantine was not
on formulary and was held while inpt.
.
FEN: Regular; Low sodium Consistency: Pureed (dysphagia); Nectar
prethickened liquids may take meds crushed in applesauce
.
Precautions: Aspiration
.
Prophylaxis: warfarin
.
Code: DNR/DNI (confirmed in ED with HCP)
.
Medications on Admission:
Diltiazem E.R. 120mg daily
Warfarin 2.5mg po every other day
furosemide 10mg Q M/W/F/Sat
aspirin 81mg daily
levaquin/flagyl
memantine 10 mg Tablet [**Hospital1 **]
atorvastatin 5 mg Tablet daily
Discharge Medications:
1. [**Doctor Last Name **] lift
for home use
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. 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:*2*
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,FR,SA).
6. atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs qs* Refills:*0*
10. Outpatient Lab Work
please have your INR/PT and chem 7 checked on [**2145-5-6**]. Please
fax results to:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Fax: [**Telephone/Fax (1) 8474**]
Discharge Disposition:
Home With Service
Facility:
caretenders
Discharge Diagnosis:
Aspiration pneumonitis
Atrial fibrillation
Acute diastolic heart failure
Non-ST-elevation myocardial infarction or demand ischemia
toxic metabolic encephalopathy
hyponatremia
Discharge Condition:
mental status: intermittently responsive to questions, oriented
to person and sometimes month
level of consciousness: intermittently responsive
activity status: out of bed with assist, ambulatory with assist
Discharge Instructions:
You were admitted with confusion and low oxygen levels due to an
aspiration event, fast heart rate, and congestive heart failure.
We have treated your heart rate and gave you medication to
remove some extra fluid. You should continue to be monitored
closely for your heart failure and your atrial fibrillation.
Specifically, your heart rate, oxygen status, fluid status
(inputs and outputs), and weights should be monitored daily. You
were evaluated for swallowing and found to be at risk for
aspiration; it is important that you follow dietary
recommendations below.
.
Medication changes:
1. Metoprolol for rate control of your atrial fibrillation.
Diltiazem stopped.
2. Increased lasix for diuresis to 40mg twice a day.
3. ACE inhibitor for your heart failure and given possible
injury to your heart
4.increased aspirin dosing.
.
Please take your medications as prescribed and keep your
appointments below. Weigh yourself daily.
.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Appointment: Thursday [**2145-5-13**] 2:45pm
Department: GERONTOLOGY
When: FRIDAY [**2145-5-14**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.7",
"428.0",
"349.82",
"272.4",
"403.90",
"707.07",
"294.8",
"411.89",
"185",
"507.0",
"428.33",
"707.25",
"276.1",
"410.71",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19984, 20026
|
14230, 16117
|
253, 276
|
20245, 20245
|
3892, 3892
|
21438, 22030
|
2946, 2950
|
18829, 19961
|
20047, 20224
|
18609, 18806
|
20479, 21049
|
2965, 3873
|
21069, 21415
|
210, 215
|
304, 1833
|
3909, 14207
|
20260, 20455
|
1855, 2359
|
2375, 2930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,552
| 116,827
|
21974
|
Discharge summary
|
report
|
Admission Date: [**2115-11-25**] Discharge Date: [**2115-11-28**]
Date of Birth: [**2073-6-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Latex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematemesis x 2 episodes
Major Surgical or Invasive Procedure:
EGD with gastric banding of esophageal varices.
History of Present Illness:
This is a 42 y.o lady w/ h/o cholangiocarcinoma (dx [**2112**]) s/p
wide resection in [**2112**], now w/ known metastatic disease,
presents after recent admit [**Date range (2) 57536**] for
hemoptysis/hematemesis w/ recurrence. Pt was feeling well since
discharge yesterday, until she felt nauseated this afternoon at
4 pm. She sat down and "knew I was going to have hematemesis."
She had two episodes in succession, one 60 cc of bright red
blood, the next of 80 cc bright red blood. She noted some clots
as well. Her appetite was "decent" today. Unsure what preceded
symptoms. Feeling less jaundiced that previous days. Biliary bag
draining well, approx 80 cc/hr per her report. No change in
drainage. Denies abd pain, denies increasing ascites.
On last admit, patient initially admitted to [**Hospital Unit Name 153**]. She underwent
EGD w/ finding of Grade III esophageal varices and was started
on octreotide/nadolol. Pt also had low grade temp during
admission w/ rising bili (max 17.8), w/ presumed cholangitis.
She was started on zosyn, then switched to
unasyn/flagyl/ceftriaxone for persistent fevers. She remained
afebrile for several days and was then switched to levofloxacin.
She had a 2nd EGD during that admission w/ sclerosing of
varices performed. Banding could not be done secondary to latex
allergy. She received a total 7 units of rpbc's, 8 units of
platelets w/ hemodynamic stability during admission. She had a
cholangiogram showing complete obstruction at
hepatacojejunostomy anastamosis w/ percutaneous drain placed w/o
complications. Pt's bili came down nicely to 7.8, she was
afebrile, and was discharged home in stable condition.
In ED, VSS, refused NG lavage. Seen by GI.
Past Medical History:
1. Ca Hx-Klatskin tumor originally diagnosed [**9-/2112**] after
presenting with painless jaundice. [**2112-10-21**] pt underwent ex. lap
with en bloc resection of L liver lobe, biliary tree, and portal
vein. Reconstructed portal vein followed by Roux-en-Y
hepaticojejunostomy. Per notes, pathology demonstrated biliary
ductal adenocarcinoma (T3N0M0) stage [**Doctor First Name **]. Since presentation,
patient had multiple episodes of cholangitis([**8-27**] in past 3
years with last on [**11-8**]), always short lived and treated with
antimicrobial therapy. She has been on ciprofloxacin proph for
about 1 year. Followed with yearly abdominal CT without
radiographic progression. CAT scan was performed on [**2115-10-11**] at
[**Hospital3 2358**], which revealed that she had a recurrence of the
tumor with occlusion of her portal vein occluding bile ducts,
hepatic artery nearly completely occluded, and much ascites and
was started on diuretics. She was was seen at [**Hospital1 18**] heme/on
clinic [**10-30**] and had repeat CT scan which revealed metastatic
cholangiocarcinoma with mets to the ovaries, with tremendous
increase in metastatic disease. There was there was obstructive
uropathy on the right side, as well as questionable gastric
outlet obstruction and peritoneal carcinomatosis.
2. cholecystectomy at age 25
3. MVA-multiple orthopedic procedures
4. Strabismus
Social History:
She is a nurse [**First Name (Titles) **] [**Hospital6 204**]. She denies any
alcohol, drugs or tobacco. She lives in [**Hospital1 487**] with her mom.
She is single, no children.
Family History:
Her maternal grandmother had breast cancer in
her 80s and her dad's grandmother had stomach cancer and died in
her 50s. On her mom's side is an extensive family cardiac
history.
Physical Exam:
T 99.4 HR 80 BP 90/59 RR 16 sat 100%RA
Exam limited as pt in ER hallway.
Gen: tired, jaundiced woman, no distress, visiting w/ family
HEENT: scleral icterus, subungal jaundice, MM dry, PERRL
Neck: supple, no LAD
CV: RRR no m/r/g
CHEST: BCTA
ABD: moderate ascites, soft, non tender even w/ deep palpation,
biliary drain in place draining green fluid
EXTRM: jaundiced, warm and well perfused, 2+ pulses DP and
radial bilaterally
NEURO: good historian, A + Ox 3, finger to nose intact, no
asterixis, good strength throughout
Pertinent Results:
[**2115-11-24**] 07:30AM PT-15.2* PTT-29.7 INR(PT)-1.5
[**2115-11-24**] 07:30AM WBC-2.2* RBC-3.09* HGB-9.6* HCT-28.7* MCV-93
MCH-31.2 MCHC-33.6 RDW-17.0*
[**2115-11-24**] 07:30AM PLT COUNT-89*
[**2115-11-24**] 07:30AM GLUCOSE-117* UREA N-11 CREAT-0.9 SODIUM-135
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14
[**2115-11-24**] 07:30AM ALK PHOS-431* TOT BILI-7.8*
[**2115-11-24**] 07:30AM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.9
[**2115-11-25**] 06:45PM WBC-3.9*# RBC-3.03* HGB-9.3* HCT-27.9* MCV-92
MCH-30.5 MCHC-33.1 RDW-17.4*
[**2115-11-25**] 06:45PM GLUCOSE-111* UREA N-10 CREAT-1.0 SODIUM-136
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12
[**2115-11-26**] 06:55AM BLOOD Hct-24.5*
[**2115-11-26**] 07:05AM BLOOD WBC-2.3* RBC-2.62* Hgb-8.0* Hct-24.6*
MCV-94 MCH-30.7 MCHC-32.6 RDW-18.3* Plt Ct-138*
[**2115-11-26**] 10:25PM BLOOD Hct-26.3*
[**2115-11-27**] 02:35AM BLOOD WBC-2.9* RBC-3.13* Hgb-9.8* Hct-28.8*
MCV-92 MCH-31.4 MCHC-34.0 RDW-17.4* Plt Ct-145*
[**2115-11-27**] 08:27AM BLOOD Hct-28.3*
.
[**2115-11-26**] EGD: "Varices at the middle third of the esophagus and
lower third of the esophagus, likely the source of bleeding
(ligation).
Diffuse congestion was seen, compatible with portal gastropathy.
Several large varices were seen in the fundus, with some cherry
red spots. These could have been a source of bleeding, but
overall did not appear as likely the source as the esophageal
varices.
Small hiatal hernia.
Otherwise normal egd to second part of the duodenum."
The esophageal varices were banded x3 with good hemostasis.
Brief Hospital Course:
42 y.o lady w/ metastatic cholangiocarcinoma complicated by
history of multiple episodes of cholangitis who now presents
with recurrent hemoptysis (pt previous admitted and discharged
from [**Hospital Unit Name 153**] s/p epinephrine injection of bleeding varices).
.
1. UGI bleed: Likely secondary to known Grade III varices. Not
banded on last admission, given allergy to latex and lack of
availability of latex-free bands. Pt banded with latex free
bands but gastirc varices seen on endoscopy which can not be
banded. Pt's hct remained stable through out admission. Will
have repeat EGD in 3 weeks.
2. Biliary obstruction: Drain in place which cont to drain green
translucent bile. Bili has cont to decrease. On levofloxacin
course from last admit for presumed cholangitis versus
obstruction. Will cont 4 days after admission. Restarted
nadolol and octreotide drip. Will d/c octreotide on discharge
and cont nadolol. Diuretics held while admitted. Will restart
home doses of lasix and aldactone on discharge.
3. Cholangiocarcinoma: Under care of Drs. [**Last Name (STitle) 57537**] and [**Name5 (PTitle) **]. Has
metastatic disease. Future chemo planned w/ cisplatinum and
gemzar per onc clinic notes. Symptoms management for nausea,
pain prn.
4. FEN: Started NPO but by discharge was tolerating a regular
diet well.
5. Code: DNR but will be intubated for procedure per onc fellow.
Medications on Admission:
1. Pantoprazole Sodium 40 mg twice daily
2. Furosemide 40 mg twice daily
3. Spironolactone 25 mg Tablet twice daily
4. Levofloxacin 500 mg Tablet once daily
5. Ursodiol 300 mg Capsule three times daily
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day: Swish and swallow.
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO twice a day.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hematemasis from Esophageal and Gastric Varices
Secondary: Biliary ductal adenocarcinoma
Discharge Condition:
Good.
Discharge Instructions:
Please take all of your medications.
Please follow up with your doctors.
If you have any further episodes of vomiting blood or any
excessive bleeding please call your PCP or come to the ED.
Followup Instructions:
Please follow up with your primary care doctor within two weeks
of discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"572.3",
"V10.09",
"198.6",
"197.6",
"197.7",
"456.20",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"42.33",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8460, 8466
|
6046, 7443
|
310, 360
|
8608, 8615
|
4454, 6023
|
8853, 9070
|
3713, 3894
|
7938, 8437
|
8487, 8587
|
7469, 7915
|
8639, 8830
|
3909, 4435
|
246, 272
|
388, 2091
|
2113, 3500
|
3516, 3697
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,237
| 197,562
|
6529
|
Discharge summary
|
report
|
Admission Date: [**2112-5-17**] Discharge Date: [**2112-5-25**]
Date of Birth: [**2034-7-19**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Levaquin / Nafcillin / ceftazidime
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
dyspnea on exertion, shortness of breath with speaking
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Hemodialysis Line Placement
Arterial Line Placement
History of Present Illness:
Mr. [**Known lastname **] is a 77yo M with severe diastolic HF (EF 55-60%, mild
AS, 3+TR/2+MR) with massive ascites, AF on coumadin, CKD stage
[**4-3**], severe PVD with multiple bypasses & procedures,
polymicrobial left foot osteo (h/o MSSA), DM, who presents with
worsening fluid overload and needing diuresis, from home.
.
Pt was hospitalized in [**2111-12-1**] for osteomyelitis and underwent
a left toe amputation. He was discharged to rehab for 8 weeks
of iv antibiotics, which he tolerated well. He was discharged
on 80 mg of po lasix. After coming home, his weight was 220 lbs
per his wife. [**Name (NI) **] was able to climb one flight of stairs, speak
comfortably at rest, and sleep with one pillow. In the past
month, pt noticed increasing weight, and abdominal girth. Pt
attributes that to dietary intake as wife cooks deliciously.
His wife reports strict low salt diet, and ~16 oz juice daily.
Pt was followed by Dr. [**First Name (STitle) 437**]. Three weeks ago, his lasix was
switched to torsemide 60 mg qd. He still continue to gain
weight. He started going to [**Hospital 25046**] clinic last week for iv
diuresis (getting 80 mg iv). Prior to coming to the hospital,
pt weighed 241 lbs at home, and 247 lbs here. Yesterday, pt was
found to be shortness of breath at rest, with ambulation
capacity less than 10 yards, and could not complete one
sentence. He denied chest pain in the past 6 weeks. There was
no fever, chill, nausea, vomiting, diarrhea. He does have dry
cough, and recently decreased appetite. Pt called [**Hospital 25046**]
clinic yesterday, and was recommend to come directly to the
hospital rather than to the clinic today.
.
On arrival to the floor, patient's VS were 98.0, 118/75, 100,
20, 94%2L.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Diabetes.
- Diastolic heart failure, Right ventricular dilatation, [**3-3**]
pulmonary htn, severe tricuspid regurgitation and
mild-to-moderate mitral regurgitation.
- Atrial fibrillation, on warfarin, rate control.
- Severe PVD with multiple bypasses and procedures.
- Multiple bilateral foot nonhealing ulcers.
- Recent second digit toe amputation on the right foot with
osteo.
- Chronic kidney disease, stage III/IV.
- Obesity, OSA.
- Hypothyroidism.
- Gout.
- BPH.
- Dieulafoy's lesion in duodenum with GI bleed, H. pylori, and
PUD with GI bleed.
- MSSA BSI associated with left foot osteomyelitis; culture
grew MSSA, CoNS.
- Left CEA in [**2108**].
- Status post radical prostatectomy.
Social History:
The patient lives with his wife, quit tobacco, has four
children. Owned his own business, retired.
-Tobacco history: smoked for 18yrs, 1.5ppd. Quit at 35yo
-ETOH: never
-Illicit drugs: never
Family History:
non-contributory
Physical Exam:
Admission Exam:
VS: 98.0, 118/75, 100, 20, 94%2L
FS 200
Weight: 246.2lbs, 111.8kg (weight was 226lbs on [**2112-4-11**])
GENERAL: The patient is an obese elderly man with bilateral
foot
dressings, pleasant, alert and oriented x3.
HEENT: Normocephalic and atraumatic. PERRL, EOMI. Oropharynx is
clear. Mucous membranes moist.
NECK: Supple, jugular venous pressure elevated to the jaw.
RESPIRATORY: Rales throughout lung fields, diminished breath
sounds at the bases. no rhonchi. Some abdominal muscle
recruitment.
CARDIAC: irreg irreg, normal S1 and normal S2 with systolic
ejection murmur along the left lower sternal border and apex.
ABDOMEN: Morbidly obese with significant ascites, firm.
Positive fluid wave and hepatojugular reflux. + hepatomegaly.
EXTREMITIES: With 2 to 3+ pitting edema from the ankles all the
way up to the thighs. + sacral edema/ 1+ pulses of DP b/l.
amputated toe on right.
SKIN: multiple superficial nonhealing ulcers of shins and feet
b/l as well as right knee.
Discharge Exam:
Patient Expired [**2112-5-25**] 1417
Pertinent Results:
Admission Labs:
[**2112-5-17**] 09:00PM BLOOD WBC-7.0 RBC-3.32* Hgb-10.2* Hct-35.2*
MCV-106* MCH-30.7 MCHC-29.1* RDW-21.2* Plt Ct-149*
[**2112-5-17**] 09:00PM BLOOD PT-20.9* PTT-35.7 INR(PT)-2.0*
[**2112-5-17**] 09:00PM BLOOD Glucose-162* UreaN-103* Creat-3.0* Na-144
K-3.5 Cl-98 HCO3-33* AnGap-17
[**2112-5-17**] 09:00PM BLOOD Calcium-10.3 Phos-4.2 Mg-2.0
UA:
[**2112-5-18**] 05:01AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.007
[**2112-5-18**] 05:01AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2112-5-18**] 05:01AM URINE RBC->182* WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
[**2112-5-18**] 05:01AM URINE CastHy-3*
Micro:
[**2112-5-17**] blood cultures: No growth
[**2112-5-18**] urine culture: No growth
Discharge Labs:
Patient Expired
Imaging:
ECG [**2112-5-17**]: Probable atrial fibrillation with ventricular
premature beats. Conducted complexes have right superior axis.
Right bundle-branch block. There are probably inferior Q waves.
Consider inferior myocardial infarction. Since the previous
tracing of [**2112-1-12**] the axis is more right superior. Otherwise,
probably unchanged. Clinical correlation is suggested. TRACING
#1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 0 180 388/451 0 -114 52
[**2112-5-17**] CXR: As compared to the previous radiograph, the
pre-existing right lung opacity has slightly increased in
extent. In addition, there is blunting of the right costophrenic
sinus, potentially suggestive of a new small pleural effusion.
The findings would be consistent with a combination of pulmonary
edema and pneumonia. The lung volumes remain low. Unchanged
massive cardiomegaly and mild-to-moderate pulmonary edema.
No left pleural effusion.
Change in the right humeral head could indicate chronic right
shoulder
subluxation.
[**2112-5-18**] Atrial fibrillation with controlled ventricular response
with ventricular premature beats including couplets. Since the
previous tracing the ventricular premature beats are more
frequent and include couplets. Otherwise, no significant change
from previously noted abnormalities. TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 0 180 424/466 0 0 -38
Echo [**2112-5-23**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. [Intrinsic function is likely more depressed
given the severity of tricuspid regurgitation.] There is
abnormal septal motion/position. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.2cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, inferolaterally directed jet of moderate
(2+) mitral regurgitation is seen. At least moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
IMPRESSION: Marked right ventricular cavity dilation with severe
free wall dysfunction. Pulmonary artery hypertension. At least
moderate tricuspid regurgitation. Mild-moderate mitral
regurgitation. Moderate aortic valve stenosis. Compared with the
prior study (images reviewed) of [**2112-1-14**], the findings are
similar.
Brief Hospital Course:
77 yo M with chronic diastolic CHF, PVD, AF, and stage III/IV
CKD who presents with acute on chronic diastolic CHF
exacerbation transferred to the CCU with hypotension, developed
hypoxic respiratory failure over requiring intubation. Patient's
right sided heart failure continued to deteriorate compensating
left ventricular filling. Unresponsive to diuretics, requiring
CVVH at bedisde though without improvement after aggressive
diuresis. Patient maintained on maximal pressors though
continued to deteriorate. Decision made to not pursue more
agressive measures and patient expired on [**2112-5-25**] at 1417 of
cardiogenic shock, acute on chronic diastolic heart failure and
hypoxic respiratory failure.
# Acute exacerbation of chronic diastolic CHF: Right sided heart
failure with dilated RA and RV with associated ascites and
dilated IVC indicating right sided volume overload. Elevated
right sided pressures causing interdependence and compromising
LVEDP. In addition elevated RA pressures causing poor pressure
gradient preventing venous return and causing passive
congestion. In addition atrial fibrillation with loss of atrial
kick likely exacerbation CHF. Patient initially refractory to
Lasix diuresis requiring RRT and CVVH for volume control. CVVH
removed about 2.5L of fluid from pt on [**5-24**] in attempt to
optimize pt on starling curve; however, pt continued to be in
afib with RVR, with occasional ectopy which drops BP??????s. Patient
maintained on maximal pressor requirment though hypotension
refractory and he continued to deteriorate. Cardiogenic shock
progressed until patient could not maintain adequate blood
pressure despite maximal pressors. After family discussion the
decision was made to make patient DNR/DNI and to not escalate
care, he expired [**2112-5-25**] at 1417.
# Goals of care: In speaking with family the patient expressed
not wanting heroic measures in the past. During CCU stay patient
exhibited 3 organ system failure and diffuclt to control volume
status. Renal failure necessitating renal replacement therapy
chronically if clinical status ever improved. His clinical
status in the CCU continued to deteriorate and very poor
prognosis was expressed to family. Additionally, his poor right
sided failure and likely chronic dialysis requirement also
indicates a poor prognosis even if patient were to be discharged
from CCU. Family meeting held [**2112-5-25**]: At the conclusion of the
meeting Mr. [**Known lastname **] was made DNR. The family asked that CVVH be
discontinued. They would like to keep him intubated for now in
the hopes that they can keep him alive long enough for family
members to come in.
#Respiratory distress/failure: Pt found by RN to be in
respiratory distress and altered with a dramatic decrease in his
HR and hypotension while in CCU weekend of [**5-21**]. The patient was
intubated as it was felt he was not able to keep up with the
work of breathing. His hemodynamics and mental status improved
with intubation. Barrier to respiratory distress includes
pulmonary edema and pleural effusisions. Unable to diurese
pharmacologically and will require CVVH for volume control. Low
lung volumes likely compression related to large ascites. In
addition aspiration event thought initial trigger to respiratory
distress requiring intubation.
# Atrial fibrillation: On Coumadin as an outpatient for CHADS2
of 4. INR on admission 2.0. Warfarin held during admission for
INR consistently >3.
# Chronic kidney disease: creatinine 2.2-3.0 at baseline.
Creatinine 3.0 on admission, which increased to 3.7 (GFR 15)
with attempted diuresis. Patient's kidneys did not respond
adequately (UOP 1150 in 24hrs, with 1030 in) to maximal diuresis
with lasix ggt at 25 and metolazone 5mg [**Hospital1 **]. Given aggressive
diuresis without sufficient urine output and worsening fluid
overload, patient was started on ultrafiltration. After family
meeting decision was made to discontinue CVVH.
# Superficial wounds/status post left toe amputation: wounds
did not appear grossly infected. Wound consult was obtained and
appropriate wound care was provided. Podiatry was additionally
consulted and ulcer at the base of the previous toe amputation
was packed. Right lower extremity was nonweight bearing and left
lower extremity was partially weight bearing (on the heel only).
# Macrocyctic anemia: Chronic issue, Hct 35 on admission. Vit
B12 736 on [**2112-5-4**]. Folate WNL in [**1-10**]. No history of ETOH
intake. Mild hematuria with foley placement, but hct remained
stable in the mid-high 30s. Multivitamin was continued.
# Diabetes: HISS inhouse with good glucose control. HgbA1c 6.3%
on [**2112-5-4**].
# Hypothyroidism: TSH mildly elevated at 9 on [**2112-5-4**], but free
T4 wnl. Continued home levothyroxine.
# Gout: Continued home allopurinol. No active issues.
# HL: Continued home rosuvastatin.
# OSA: Continued home CPAP.
Transitional Issues:
Patient expired with Family members at bedside: Wife [**Name (NI) **],
#[**Telephone/Fax (1) 24999**], cell: [**Telephone/Fax (1) 25047**]
Medications on Admission:
ALLOPURINOL 300 mg Tablet every other day
CALCITRIOL - 0.25 mcg Capsule daily
DILTIAZEM HCL 120 mg Capsule, Extended Release daily
GLYBURIDE 5 mg daily
LEVOTHYROXINE [SYNTHROID] 100 mcg daily but 2 tablets tues and
fri
METOPROLOL SUCCINATE - 100 mg Tablet ER daily
OMEPRAZOLE 40 mg Capsule daily
POTASSIUM CHLORIDE - 10 mEq Capsule, Extended Release - 2 caps
daily
ROSUVASTATIN [CRESTOR] 5 mg daily
TORSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth daily
WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth QOD and 1.25mg QOD
ASPIRIN - 81 mg Tablet, Chewable daily
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] daily
FERROUS SULFATE 325 [**Hospital1 **]
MULTIVITAMIN 1 tab daily
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Primary:
Acute on chronic diastolic heart failure
Acute on chronic renal failure
Cardiogenic Shock
Hypoxic Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.95",
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"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14057, 14066
|
8190, 13099
|
359, 436
|
14254, 14264
|
4465, 4465
|
14328, 14347
|
3359, 3377
|
14017, 14034
|
14087, 14233
|
13286, 13994
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14288, 14305
|
5266, 8167
|
3392, 4392
|
2324, 2393
|
4408, 4446
|
13120, 13260
|
265, 321
|
464, 2214
|
4481, 5250
|
2424, 3133
|
2236, 2304
|
3149, 3343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,103
| 105,540
|
33094
|
Discharge summary
|
report
|
Admission Date: [**2127-7-30**] Discharge Date: [**2127-8-6**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Naprosyn
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABGx4 (LIMA>LAD, SVG>RAMUS, SVG>OM, SVG>PDA) [**2127-8-1**]
History of Present Illness:
84M with CAD s/p PTCA in [**2115**], positive stress test in [**Month (only) 956**]
at OSH, cath showing 3VD in [**Month (only) 116**], who was scheduled to undergo
CABG next week, presented to OSH Tuesday evening with substernal
chest pain. He was sitting in his living room, watching the
Celtics game, when he experienced onset of crushing substernal
pain, similar to previous episodes of angina, that was not
relieved by NTG.
At OSH, received NTG SL and then IV, and morphine, and was then
chest pain free. He was transferred here on heparin and NTG gtt.
NTG was d/c'd in [**Hospital1 18**] ED to change over lines/pumps, and not
restarted because pt remained CP free. Additionally given
aspirin, metoprolol, and admitted for further management. CT
surgery was notified of his admission
Past Medical History:
acute on chronic diastolic heart failure
HTN, DJD of knees b/l, AF, PVD, hyperlipidemia, PE, CAD, R
popliteal artery aneurism s/p bypass grafting with saphenous
vein, hemerhoids, hernia
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
Social History:
He is divorced and lives with his daughter who is also his
primary caregiver. [**Name (NI) **] does not smoke and drinks minimally.
Family History:
N/C
Physical Exam:
VS - 96.0 162/85 68 18 100% 2L
Gen: thin elderly 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 [**10-22**] cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI midsystolic murmur at LLSB. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Palpable cord on L antecubital
vein, non erythematous, nontender
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous SKs esp around neck
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:
[**2127-8-5**] 05:50AM BLOOD WBC-9.0 RBC-3.38* Hgb-9.7* Hct-29.0*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.6* Plt Ct-158
[**2127-8-6**] 05:50AM BLOOD PT-13.2 INR(PT)-1.1
[**2127-8-5**] 05:50AM BLOOD PT-14.9* INR(PT)-1.3*
[**2127-8-1**] 01:40PM BLOOD PT-13.7* PTT-62.5* INR(PT)-1.2*
[**2127-8-6**] 05:50AM BLOOD Glucose-101 UreaN-23* Creat-1.1 Na-131*
K-4.1 Cl-95* HCO3-28 AnGap-12
Radiology Report CHEST (PA & LAT) Study Date of [**2127-8-6**] 9:32 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2127-8-6**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 76925**]
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
Final Report
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**8-4**], there is
evidence of
bilateral pleural effusions, more marked on the left. Streaks of
atelectasis
are seen in the left mid and lower lung zones. Intact sternal
sutures
persist.
IMPRESSION: Bilateral pleural effusions, more prominent on the
left.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76926**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76927**] (Complete)
Done [**2127-8-1**] at 11:28:14 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-2-14**]
Age (years): 84 M Hgt (in): 68
BP (mm Hg): 137/87 Wgt (lb): 78
HR (bpm): 72 BSA (m2): 1.37 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 427.31, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2127-8-1**] at 11:28 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 35981**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. See Conclusions for post-bypass
data The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. Aymmetric hypertrophy of the Septum near the LVOT is seen.
However no gradient across the LVOT is seen.The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Mild (1+) aortic regurgitation is
seen. Aortic sclerosis is seen with a valve area of about 2.2
cm2
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. Two jets are seen, one extremely
anterior directed and a second smaller central jet. Prolapse of
the P3 scallop is seen. Mild [**Male First Name (un) **] is seen with no gradient across
the LVOT and valve.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being V paced.
1. Biventricular function is preserved.
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**].
3. Aorta is intact post decannulation.
4. Other findings are [**Last Name (Titles) 1506**]
Brief Hospital Course:
He ruled out for MI with CEs and had No ECG changes. His
surgery was moved up because of his symptoms and on [**8-1**] he was
taken to the operating room where he underwent a CABG x 4. He
was transferred to the ICU in stable condition. He was extubated
later that same day. He was started on vasopressin for ? of
SIRS. He was weaned from his vasoactive drips on POD#2. He was
transferred to the floor on POD #3. He required aggressive
diuresis. He was restarted on coumadin with a lovenox bridge for
his recent history of PE. He was ready for discharge to rehab on
POD #5,
Medications on Admission:
Aspirin 81mg
metoprolol succinate 50mg daily
atorvastatin 80mg daily
lisinopril 5mg daily
MVI
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses: then check INR daily and continue lovenox until INR > 2,
then check PRN. Dose coumadin accordingly.
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): until INR > 2.0.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: then please reassess need for diuresis.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours): while on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
CAD s/p CABG
acute on chronic diastolic heart failure
PMH: HTN, hyperlipidemia, PVD, postop PE (coumadin), L popliteal
aneurysm, AF/flutter, arthritis, DJD, ? old MI, wide complex
tachycardia
PSH: s/p R fem-tib bypass [**3-/2127**], appendectomy, R hernia repair,
umbilical hernia repair, hemorrhoidectomy + rectal polyp
removed, L cataract surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-8-21**]
1:45
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2127-8-21**] 2:15
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6699**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 2 weeks
Completed by:[**2127-8-6**]
|
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"428.33",
"424.0",
"272.4",
"564.00",
"V45.82",
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] |
icd9cm
|
[
[
[]
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] |
[
"36.13",
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] |
icd9pcs
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[
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,256
| 155,356
|
12443
|
Discharge summary
|
report
|
Admission Date: [**2162-10-18**] Discharge Date: [**2162-11-14**]
Date of Birth: [**2123-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever and leukocytosis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname 38598**] is a 39 year-old male with hx of non-Hodgkin's
lymphoma s/p allsoSCT s/p DLI, complicated by PTLD treated with
rituxan, GVHD of the gut, liver, and lung with BOOP/pulmonary
fibrosis with chronic trach and vent admitted from [**Hospital1 **]
with fever and leukocytosis.
Mr. [**Known lastname 38598**] is well known to the [**Hospital Unit Name 153**] and ID with multiple stays
here for BOOP exacerbations and pseudomonal pneumonia. Per the
patient he has had increased green sputum production and cough
for the past 5-6 days with overall malaise. He has felt febrile
in addition to having measured fevers at [**Hospital1 **]. He has also
had some occasional nausea and reports dry mouth but denies
abdominal pain, vomiting, diarrhea, dysuria, sinus pain, rash,
nasal congestion, chest pain. Of note, he was recently admitted
at the beginning of [**Month (only) 359**] with tachycardia and leukocytosis.
He has not had any recent hanges in vent settings and has been
on AC 500 x 16 PEEP 5 FiO2 40%. PIP 27-30. Per discussion with
Dr. [**Last Name (STitle) 724**] on [**10-13**], abx were changed from doripenem to Ceftaz
with downtrending WBC and sputum cx from [**10-17**] revealed 2
strains Pseudomonas [**Last Name (un) 36**] to Ceftaz. Of note, he also received 1
units PRBCs on evening prior to transfer.
Past Medical History:
Past Oncologic History:
- [**4-/2154**] p/w fevers, night sweats, and weight loss in the
setting of a left inguinal lymph node.
- CT scan: 15x14x10cm mass in the LUQ.
- Bx grade II/III follicular lymphoma.
- Treated with six cycles of CHOP/Rituxan with good response,
but showed evidence for relapse in [**12/2154**] and was treated with
MINE chemotherapy for two cycles.
- [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed
by autologous stem cell transplant in
- [**7-/2155**]: Noted for disease recurrence. He was initially treated
with a course of Rituxan without response followed by Zevalin
- [**3-/2156**]: Noted progression of his disease. He was treated with
one cycle of [**Hospital1 **] followed by one cycle of ESHAP.
- [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant
with a [**5-30**] HLA-matched unrelated donor with Campath conditioning
- Six-month follow-up CT noted for disease progression.
- [**1-/2157**]: Received donor lymphocyte infusion in , complicated by
acute liver/GI GVHD grade IV, for which [**Known firstname **] required a
prolonged hospitalization in the summer of [**2156**].
- Multiple GI bleeds requiring ICU admissions and multiple
transfusions and embolization of his bleeding.
- Noted to have CNS lesions felt consistent with PTLD and this
was treated with a course of Rituxan. No evidence for recurrence
of the PTLD.
- Acute liver GVHD, on CellCept, prednisone, and photophoresis.
- [**2157-12-28**] Photophoresis was d/c'd due to episodes of
bacteremia and eventual removal of his apheresis catheter.
- [**2158-6-13**] restarted photopheresis on a weekly basis on, but
then discontinued this again on [**2158-9-7**] as this was felt not
to be making any impact on his liver function tests.
- undergone phlebotomy due to iron overload with corresponding
drop in his ferritin. He has continued with transient rises in
his transaminases and bilirubin and has remained on varying
doses of CellCept and prednisone which has been slowly tapered
over the time.
- [**2160-1-10**] CellCept discontinued.
- [**2159-1-19**] admission due to increasing right hip pain. MRI
revealed edema and infiltrating process in the psoas muscle
bilaterally. After extensive workup, this was felt related to an
infection and required several admissions with completion of
antibiotics in 03/[**2158**].
- [**7-/2160**]: Last scans showed no evidence for lymphoma and he has
remained in remission.
- [**2160-10-20**]: URI and treatment with course of Levaquin.
- [**2160-11-13**] completed a 4 week course of Rituxan to treat his
GVHD.
-In [**5-/2161**], noted to have tiny echogenic nodule on abdominal
[**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not
as concerning on review and he is due to have a repeat MRI
imaging in early [**Month (only) **].
-- GI varices and attempts at banding have been unsuccessful due
to difficulty with passing the necessary instruments. He has
been on a low dose beta blocker as well as simvastatin, which
was started on [**2161-7-7**] to help with medical management of his
varices.
-On [**2161-8-3**], worsening cough and was noted to have a small
new pneumothorax in the left apical area. This has essentially
resolved over time
- Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]);
multiple tests done with no etiology found; question
malabsorption related to GVHD
- Has on and off respiratory infections and has been treated
with antibiotics (now colistin inhaled and IV) for resistant
pseudomonas. Question underlying exacerbations of pulmonary GVHD
in setting of his URIs.
- Currently receives IVIG every month.
.
Other Past Medical History:
1. Non-Hodgkin's lymphoma s/p allo SCT
2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed,
chronic transaminitis, portal HTN with esophageal varices (not
able to band)
3. History of intracranial lesions felt consistent with PTLD.
4. Extensinve chronic GVHD of lung, liver, skin, mucous
membranes.
5. Grade II esophageal varices, intollerant to beta blockade.
6. HSV in nasal washing [**11/2159**](completed course of Valtrex)
7. Hypothyroidism
8. hx of Psoas muscle infection
9. Recurrent resistant Pseudomonal PNAs on long term inhaled
Colistin
Social History:
Smoke: never
EtOH: none currently; occassional use prior to NHL dx
Drugs: never
Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]).
Married in [**2160-8-25**] and lives in [**Location **]. has newborn at
home. Writer. Currently living at [**Hospital1 **].
Family History:
No lymphoma or other cancers in the family. Father had CAD s/p
PCI.
Physical Exam:
Physical Exam on Admission to [**Hospital Unit Name 153**]:
GEN: Middle-aged Caucasian male comfortable appearing at rest
but in distress with coughing.
VS: T 100.5, HR 123, BP 109/77, RR 28, O2 sat 100% on AC 500x16
FiO2 40% PEEP 5.
HEENT: MM dry, no OP lesions, dobhoff tube in place. No sinus
tenderness.
NECK: Supple, JVP not elevated. No LAD.
CV: Tachycardic, regular rhythm, NL S1S2, no m/r/g
PULM: Coarse BS throughout, anteriorly and R>L base. No
wheezes.
ABD: BS+, soft, NTND, no masses or HSM
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown
NEURO: A&O. CNII-XII intact. Nonfocal.
Pertinent Results:
[**2162-10-18**] 12:45PM BLOOD WBC-16.3* RBC-3.13* Hgb-8.9* Hct-26.7*
MCV-85 MCH-28.5 MCHC-33.5 RDW-16.3* Plt Ct-342
[**2162-10-19**] 02:52PM BLOOD Hct-23.7*
[**2162-10-21**] 04:32AM BLOOD WBC-21.8* RBC-3.04* Hgb-8.7* Hct-26.9*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.9* Plt Ct-325
[**2162-10-24**] 01:44AM BLOOD WBC-23.6* RBC-2.78* Hgb-8.1* Hct-23.7*
MCV-85 MCH-29.0 MCHC-34.1 RDW-17.6* Plt Ct-339
[**2162-11-1**] 04:11AM BLOOD WBC-17.4* RBC-3.59* Hgb-10.1* Hct-31.6*
MCV-88 MCH-28.2 MCHC-32.0 RDW-17.5* Plt Ct-221
[**2162-11-10**] 04:00AM BLOOD WBC-24.4* RBC-2.82* Hgb-8.2* Hct-25.9*
MCV-92 MCH-28.9 MCHC-31.5 RDW-18.2* Plt Ct-173
[**2162-11-12**] 04:34AM BLOOD WBC-16.8* RBC-2.73* Hgb-8.0* Hct-24.4*
MCV-89 MCH-29.3 MCHC-32.8 RDW-18.6* Plt Ct-132*
[**2162-11-14**] 05:51AM BLOOD WBC-20.4* RBC-2.61* Hgb-7.4* Hct-23.8*
MCV-91 MCH-28.3 MCHC-31.1 RDW-19.1* Plt Ct-100*
[**2162-10-18**] 12:45PM BLOOD Neuts-74* Bands-2 Lymphs-16* Monos-3
Eos-3 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2162-11-3**] 04:23AM BLOOD Neuts-82* Bands-2 Lymphs-6* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-6* Myelos-1*
[**2162-11-13**] 02:23AM BLOOD Neuts-74* Bands-8* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-8* Myelos-5* NRBC-7*
[**2162-11-14**] 05:51AM BLOOD Neuts-73* Bands-9* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-5* Myelos-5*
[**2162-10-31**] 04:33AM BLOOD PT-15.7* PTT-36.5* INR(PT)-1.4*
[**2162-10-31**] 11:30AM BLOOD PT-14.7* PTT-35.8* INR(PT)-1.3*
[**2162-11-13**] 02:23AM BLOOD PT-13.7* PTT-35.6* INR(PT)-1.2*
[**2162-10-18**] 12:45PM BLOOD Glucose-73 UreaN-29* Creat-0.8 Na-137
K-3.5 Cl-100 HCO3-26 AnGap-15
[**2162-10-20**] 04:38AM BLOOD Glucose-132* UreaN-29* Creat-0.8 Na-135
K-3.7 Cl-101 HCO3-22 AnGap-16
[**2162-10-24**] 01:44AM BLOOD Glucose-125* UreaN-23* Creat-0.7 Na-141
K-2.7* Cl-105 HCO3-23 AnGap-16
[**2162-10-28**] 05:59AM BLOOD Glucose-137* UreaN-26* Creat-0.6 Na-141
K-3.8 Cl-105 HCO3-24 AnGap-16
[**2162-10-30**] 05:39AM BLOOD Glucose-98 UreaN-23* Creat-0.5 Na-136
K-3.6 Cl-101 HCO3-24 AnGap-15
[**2162-11-7**] 04:41AM BLOOD Glucose-197* UreaN-29* Creat-0.7 Na-144
K-3.9 Cl-104 HCO3-25 AnGap-19
[**2162-11-13**] 02:23AM BLOOD Glucose-66* UreaN-46* Creat-0.9 Na-141
K-4.2 Cl-101 HCO3-30 AnGap-14
[**2162-11-14**] 05:51AM BLOOD Glucose-182* UreaN-54* Creat-0.9 Na-144
K-4.6 Cl-108 HCO3-30 AnGap-11
[**2162-10-18**] 12:45PM BLOOD ALT-68* AST-124* LD(LDH)-359*
AlkPhos-999* TotBili-1.5
[**2162-10-20**] 04:38AM BLOOD ALT-65* AST-119* LD(LDH)-378*
AlkPhos-1075* Amylase-96 TotBili-1.0
[**2162-10-24**] 01:44AM BLOOD ALT-67* AST-101* LD(LDH)-345*
AlkPhos-915* Amylase-93 TotBili-1.8*
[**2162-11-7**] 04:41AM BLOOD ALT-184* AST-184* AlkPhos-929*
TotBili-2.9*
[**2162-11-9**] 05:41AM BLOOD ALT-92* AST-71* AlkPhos-686* TotBili-2.0*
[**2162-11-13**] 02:23AM BLOOD ALT-102* AST-152* LD(LDH)-530*
AlkPhos-982* TotBili-2.4*
[**2162-10-29**] 05:41AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8
[**2162-10-31**] 10:22PM BLOOD Calcium-7.2* Phos-3.4 Mg-2.0
[**2162-11-3**] 04:23AM BLOOD Albumin-2.5* Calcium-8.1* Phos-5.0*
Mg-2.1
[**2162-11-5**] 06:13AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.7
[**2162-11-14**] 05:51AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.1
[**2162-10-31**] 11:30AM BLOOD Hapto-330*
[**2162-10-24**] 01:19PM BLOOD Vanco-20.9*
[**2162-10-26**] 01:03PM BLOOD Vanco-31.7*
[**2162-10-28**] 05:59AM BLOOD Vanco-20.5*
[**2162-10-28**] 08:43PM BLOOD Vanco-8.0*
[**2162-10-30**] 06:32PM BLOOD Vanco-23.0*
[**2162-11-1**] 06:00AM BLOOD Vanco-20.6*
[**2162-11-4**] 03:29PM BLOOD Amkacin-1.4*
[**2162-11-5**] 07:15PM BLOOD Amkacin-5.1*
[**2162-11-8**] 03:18PM BLOOD Amkacin-8.5*
[**2162-11-11**] 02:40PM BLOOD Amkacin-10.1*
[**2162-10-18**] 08:03PM BLOOD Type-MIX Temp-37.5 pH-7.45
[**2162-10-19**] 04:26AM BLOOD Type-MIX pH-7.47*
[**2162-10-21**] 04:53AM BLOOD Type-[**Last Name (un) **] Temp-36.4 Rates-17/ Tidal V-500
PEEP-5 FiO2-40 pO2-52* pCO2-50* pH-7.31* calTCO2-26 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2162-10-22**] 06:12AM BLOOD Type-MIX Temp-37.6 pH-7.28*
[**2162-10-31**] 11:46AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-49* pH-7.34*
calTCO2-28 Base XS-0
[**2162-11-13**] 02:30AM BLOOD Type-ART Temp-36.7 PEEP-8 FiO2-50 pO2-93
pCO2-59* pH-7.33* calTCO2-33* Base XS-2 Intubat-INTUBATED
[**2162-10-23**] 05:00AM BLOOD B-GLUCAN-Test
[**2162-10-23**] 05:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
[**2162-11-5**] 06:13AM BLOOD VORICONAZOLE-Test
Brief Hospital Course:
39M with non-Hodgkin's lymphoma s/p alloSCT s/p DLI, complicated
by PTLD, GVHD of the gut, liver, and lung with BOOP/pulmonary
fibrosis with chronic trach and vent admitted from [**Hospital1 **]
with fever and leukocytosis and respiratory symptoms. Pt
presented with known pseudomonas respiratory infections.
Sensitivities were done and the patient was started on amikacin
and colistin therapy. He was monitored closely and seemingly
was improving during the initial days of his hospitalization,
but then began to have increasingly thickened sputum production
and was have more frequent episodes of respiratory distress.
Mucolytics, chest PT, and hypertonic saline were administered to
thin out patients sputum and make him more comfortable. Sputum
was also collected to look for new sensitivities and whether the
patient had developed resistance to the Abx. Pt also had
bronchoscopy done to re-evaluate underlying infection and also
attempt to clear up some underlying thickened mucous. Sputum
samples continued to grow psuedomonas with sensitivities to
colistin and amikacin. It was also sensitive to ceftazidime and
this was restarted later on in the [**Hospital 228**] hospital course as
his bronchopneumonia seemed to have worsened. Despite adequate
antibiotic treatment the patient was unable to clear his
infection and repeated sputum samples continued to grow
pseudomonas.
As his pneumonia persisted, he began to be persistently
tachycardic. Evaluation of the tachycardia showed it was sinus
and his underlying respiratory distress and anxiety was treated
with mucolytics, frequent suctioning, morphine for air hunger
and chest PT. The patient began to have baseline heart rate in
the 120's even during periods when he was not in respiratory
distress. His WBC count fluctuated. rising and falling day to
day, never truly normalizing. The patient also began to become
increasingly weak, likely secondary to medications he was taking
as well as deconditioning as he had been in the hospital for an
extended period of time and rarely got out of bed. He
progressively worsened over the last week of his hospital stay
and on [**2162-11-14**] his health care proxy decided that the Mr. [**Known lastname 38598**]
was to be made CMO. He was started on a morphine drip and his
tracheal tube was disconnected from the ventilator. The patient
passed away on [**2162-11-14**] at 5:05pm.
Medications on Admission:
Ceftaz 2g IV q8 Day 1 [**10-13**]
Colistin 125mg IV q12 Day 1 [**10-13**]
Acyclovir 400 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every 12
hours): per NGT.
Acetaminophen 650 mg/20.3 mL Solution [**Month/Year (2) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Age over 90 **]: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
Pantoprazole 40mg IV q24
Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) MG
PO BID (2 times a day) prn.
DiphenhydrAMINE 12.5 mg IV Q6H:PRN itching
Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Age over 90 **]: Three
Hundred (300) MG PO once a day.
Guaifenesin 100 mg/5 mL Syrup [**Age over 90 **]: Ten (10) ML PO Q6H (every
6 hours).
Levothyroxine 125 mcg Tablet [**Age over 90 **]: One (1) Tablet PO Daily
[**Age over 90 766**] through Saturday.
Lorazepam 0.5 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Per NGT. .
Lorazepam 1 mg Tablet [**Age over 90 **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety: Per NGT.
Prednisone 5 mg Tablet [**Age over 90 **]: two Tablet PO DAILY
(Daily): Per NGT.
Senna 8.6 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Per NGT.
Sulfamethoxazole-Trimethoprim 200-40 mg/5 mL Suspension [**Age over 90 **]:
Twenty (20) ML PO M/W/F ().
Doxycyline 100mg [**Hospital1 **]
Voriconazole 200mg q12h
Ergocalciferol [**Numeric Identifier 1871**] q sunday
carafate 1g PO BID
Trazodone 12/5mg PO qhs
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
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"707.03",
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"518.84",
"244.9",
"V85.0",
"456.1",
"V44.0",
"263.9",
"799.4",
"E849.8",
"780.79",
"279.53"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
15549, 15558
|
11460, 13860
|
347, 361
|
15605, 15610
|
7098, 11437
|
15662, 15804
|
6359, 6428
|
15521, 15526
|
15579, 15584
|
13886, 15498
|
15634, 15639
|
6443, 7079
|
285, 309
|
389, 1735
|
5487, 6045
|
6061, 6343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,283
| 107,928
|
6392
|
Discharge summary
|
report
|
Admission Date: [**2110-5-9**] Discharge Date: [**2110-5-13**]
Date of Birth: [**2054-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 yo M with history of DM, HTN, high cholesterol presented to
the ED with sevedral days of nausea and vomiting. The patient
reports being in his USOH until Monday, 5 days prior to admssion
when he developed malaise, rigors, and myalgias. He did not
check his temperature. He then developed nausea, vomiting,
non-bilious, non-bloody. He reports not being able to tolerate
any po's since Monday. He reports 5-6 episodes of emesis daily.
He said he stopped taking all of his usual medications,
including insulin on Monday because he was not sure what was
going on. He had been taking Advil with relief in symptoms. He
denies diarrhea, abdominal pain, cough, chest pain before coming
to the ED (developed non-productive cough in the ED). No sick
contacts.
.
ED course: VS on admission T 100.7; HR 119; BP 184/77; RR 30; O2
98% RA. Labs were significant for WBC of 17, Cr 2.5, K 3.2,
serum glucose 474, presence of urine glucose 1000; urine ketones
15. AG =19 initially. Lactate 1.6. Trop 0.12; CK [**2049**]; MB 9 on
presentation (with Cr 2.5. Trop went up to 0.38. EKG sinus rate
104; new ST depression in aVL on this am's EKG.
.
Patient resuscitated with 2L NS. In the ED the paitent was also
given:
Acetaminophen 1000 mg x 2, Insulin Human Regular 6 units IV and
8 units SC; Ondansetron 4 mg IV x 2; Levofloxacin 750mg; Aspirin
325mg.
.
By the time the patient arrived to the floor, he felt improved.
Continues to have nausea. Denies CP or any other symptpoms. He
has nver had DKA before.
Past Medical History:
1. HTN
2. DM type 2
3. Hypercholesterolemia
4. Hepatitis C
5. PUD
6. R cranial nerve palsy
7. Erectile dysfunction
8. Prostatitis
9. BPH
10. L renal cell carcinoma
11. LLL radiculopathy
12. Microalbuminuria
Social History:
Lives with wife. [**Name (NI) **] children. Quit smoking 20 y ago. No alcohol
Family History:
Noncontributory
Physical Exam:
VS: 100.9 95 156/94 27 97% RA
General: resting in bed; pleasant; alert and oriented x 3; NAD;
breathing comfortably
HEENT: OP clear; no scleral icterus; MM sl dry
Neck: no JVD, no bruits
Heart: regular, nl S1S2, no m/rubs/gallops
Lungs: soft crackles at left base
Abd: + BS, soft, NT, ND
Ext: no edema, palp pulses throughout
Pertinent Results:
[**2110-5-8**] 11:00PM URINE GRANULAR-0-2
[**2110-5-8**] 11:00PM URINE RBC-[**1-27**]* WBC-[**5-4**]* BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2110-5-8**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-5-8**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2110-5-8**] 11:30PM PT-11.1 PTT-27.2 INR(PT)-0.9
[**2110-5-8**] 11:30PM PLT SMR-NORMAL PLT COUNT-337
[**2110-5-8**] 11:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2110-5-8**] 11:30PM NEUTS-94.9* BANDS-0 LYMPHS-3.2* MONOS-1.9*
EOS-0.1 BASOS-0
[**2110-5-8**] 11:30PM WBC-17.3*# RBC-3.50* HGB-10.7* HCT-29.6*
MCV-85 MCH-30.5 MCHC-36.0* RDW-14.4
[**2110-5-8**] 11:30PM CK-MB-9 cTropnT-0.12*
[**2110-5-8**] 11:30PM CK(CPK)-[**2049**]*
[**2110-5-8**] 11:30PM estGFR-Using this
[**2110-5-8**] 11:30PM GLUCOSE-474* UREA N-41* CREAT-2.8* SODIUM-134
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-22 ANION GAP-23
[**2110-5-8**] 11:48PM GLUCOSE-446* LACTATE-2.0 K+-3.6
[**2110-5-9**] 01:44AM LACTATE-1.6 K+-3.2*
[**2110-5-9**] 01:44AM COMMENTS-GREEN TOP
[**2110-5-9**] 04:00AM CK-MB-11* MB INDX-0.6 cTropnT-0.33*
[**2110-5-9**] 04:00AM LIPASE-41
[**2110-5-9**] 04:00AM ALT(SGPT)-37 AST(SGOT)-73* CK(CPK)-1705* ALK
PHOS-64 TOT BILI-0.4
[**2110-5-9**] 04:00AM GLUCOSE-298* UREA N-39* CREAT-2.5* SODIUM-133
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-24 ANION GAP-14
[**2110-5-9**] 05:45AM CK-MB-10 MB INDX-0.5 cTropnT-0.38*
[**2110-5-9**] 05:45AM CK(CPK)-1828*
[**2110-5-9**] 10:29AM PLT COUNT-291
[**2110-5-9**] 10:29AM WBC-14.1* RBC-3.01* HGB-9.0* HCT-26.1* MCV-87
MCH-29.8 MCHC-34.3 RDW-14.4
[**2110-5-9**] 10:29AM CALCIUM-8.0* PHOSPHATE-2.6*
[**2110-5-9**] 10:29AM CK-MB-12* MB INDX-0.7 cTropnT-0.58*
[**2110-5-9**] 10:29AM ALT(SGPT)-39 AST(SGOT)-87* CK(CPK)-1776* ALK
PHOS-64 TOT BILI-0.5
[**2110-5-9**] 10:29AM GLUCOSE-303* UREA N-35* CREAT-2.3* SODIUM-135
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
[**2110-5-9**] 11:15AM URINE OSMOLAL-430
[**2110-5-9**] 11:15AM URINE HOURS-RANDOM CREAT-63 SODIUM-23
[**2110-5-9**] 06:30PM PLT COUNT-321
[**2110-5-9**] 06:30PM WBC-14.5* RBC-2.36* HGB-7.1* HCT-19.5*#
MCV-83 MCH-30.0 MCHC-36.3* RDW-14.5
[**2110-5-9**] 06:30PM CALCIUM-7.8* PHOSPHATE-1.5* MAGNESIUM-1.8
[**2110-5-9**] 06:30PM CK-MB-9 cTropnT-1.14*
[**2110-5-9**] 06:30PM GLUCOSE-113* UREA N-32* CREAT-2.2*
SODIUM-131* POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION
GAP-12
[**2110-5-9**] 10:00PM PLT COUNT-269
[**2110-5-9**] 10:00PM WBC-11.4* RBC-2.67* HGB-7.9* HCT-22.4* MCV-84
MCH-29.6 MCHC-35.2* RDW-14.7
[**2110-5-9**] 10:00PM CALCIUM-7.7* PHOSPHATE-2.3* MAGNESIUM-1.8
[**2110-5-9**] 10:00PM GLUCOSE-113* UREA N-32* CREAT-2.2* SODIUM-133
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-11
.
[**2110-5-9**]: Sinus tachycardia. There is a late transition with tiny
R waves in the anterior leads consistent with possible prior
anterior wall myocardial infarction. Minimal ST segment
elevation in the inferior leads consistent with possible
ischemia or infarction. Clinical correlation is suggested.
Compared to the previous tracing left ventricular hypertrophy is
no longer apparent and ST segment elevation is new.
.
[**2110-5-9**] AXR: Fidnings suggestive of mild partial or early small
bowel obstruction. If clinically indicated, continued monitoring
is advised.
.
[**2110-5-9**] CXR: Left lower lobe pneumonia.
.
[**2110-5-10**] Echo: Mild left ventricular cavity enlargement with
moderate global hypokinesis suggestive of a diffuse process
(toxin, metabolic, etc. - though cannot fully exclude
multivessel CAD).
.
[**2110-5-9**] EKG: Sinus tachycardia. Left axis deviation. Late
transition with tiny R waves in the anterior leads consistent
with possible prior anterior wall myocardial infarction. Minimal
ST segment elevation in the inferior leads with diffuse ST-T
wave changes consistent with possible ischemia or infarction.
Clinical correlation is suggested.
.
[**2110-5-9**] EKG: Sinus tachycardia. Probable left ventricular
hypertrophy. Non-specific ST-T wave changes. Compared to the
previous tracing of [**2110-5-9**] no change.
.
[**2110-5-10**] EKG: Sinus rhythm. Compared to the previous tracing the
rate is slower.
.
[**2110-5-11**] CXR: Sinus rhythm. Compared to the previous tracing the
rate is slower.
.
[**2110-5-11**] EKG: Sinus rhythm. Occasional atrial premature beats.
Leftward axis. Intraventricular conduction delay. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2110-5-10**]
atrial ectopy is new. The QRS duration is similar.
.
[**2110-5-12**] CXR: Consolidation in the left lower lobe, not
significantly changed since the prior radiographs.
Brief Hospital Course:
Mr. [**Known lastname **] is a 55 year old man with diabetes, hypertension,
and hyperlipidemia, who presented with fever, nausea, and
vomiting, and who was found to be in DKA with infiltrate on CXR,
now positive for Legionella. His brief hospital course, by
problem:
.
#) Pneumonia. Urinary Legionella antigen positive, treated
empirically for CAP for 3 days with levofloxacin. Afebrile,
leukocytosis resolved, satting well on room air. CXR showed that
pneumonia unchanged. He was given a total 14-day course of
levofloxacin.
.
#) NSTEMI. Subendocardial ischemia in the setting of acute
demand from difficult-to-control hypertension/fever/pneumonia.
Non-specific EKG changes. Enzymes trending down. He will get a
P-MIBI once pneumonia has resolved and blood pressure is better
controlled; it was scheduled for [**6-4**]. Continued aspirin,
statin, beta blocker, [**Last Name (un) **]. Blood pressure was aggressively
controlled, and the patient was discharged on many blood
pressure medications (see med list).
.
#) Anemia. Received 2 units of pRBC's in MICU. Hematocrit
remained stable.
.
#) Hypertension. Has been difficult to control, requiring
esmolol and nitro drip for control. Blood pressure on floor has
been 142-180 systolic. Titrated medications to max dose; the
patient has follow up appointment with his PCP next week for
further titration of blood pressure medications.
.
#) Elevated blood glucose. Likely high in the setting of
infection. Initial anion gap closed quickly. Blood sugars have
been well controlled since transfer. He was continued on Lantus
while inpatient, and his outpatient oral hypoglycemic
medications were restarted at the time of discharge.
.
#) Nausea. Resolved.
.
#) Metabolic acidosis/resp alkalosis. Anion gap is 12. [**Month (only) 116**] have
respiratory alkalosis from pneumonia, with compensatory renal
acidosis. Mildly elevated anion gap (12) was concerning given no
clear source (lactate WNL, blood glucose has been well
controlled, ? renal failure). It resolved by the time of
discharge.
.
#) Renal failure. s/p left nephrectomy with rising creatinine
over the past few months (appears baseline is 1.6-2.0 or so).
MRI in [**12/2109**] showed widely patent R kidney vasculature.
Creatinine was monitored and remained stable.
Medications on Admission:
Aspirin 81mg daily
Neurontin 300mg [**Hospital1 **]
Vytorin 10-40mg daily
Glipizide 10mg [**Hospital1 **]
Metoprolol 50mg [**Hospital1 **]
Prilosec daily
Glucophage 1000mg [**Hospital1 **]
Levirmir Pen 10mL at bedtime
Norvasc 5mg daily
Doxazosin 2mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Disp:*180 Tablet(s)* Refills:*2*
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 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. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Levemir Flexpen 100 unit/mL Insulin Pen Subcutaneous
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Type 2 diabetes
Hypertension
Demand ischemia
Discharge Condition:
Stable, blood pressures improved,
Discharge Instructions:
You were admitted with high blood pressure, high blood sugars,
and pneumonia. You are being treated with many new blood
pressure medications and antibiotics for the pneumonia. Please
take all of the new medications as prescribed, and complete the
entire course of the antibiotics.
.
If you develop nausea, vomiting, dizziness, chest pain,
shortness of breath, high fevers, or other concerning symptoms,
please seek medical attention immediately.
Followup Instructions:
You have been
Chest X-ray: To be scheduled by Dr. [**Last Name (STitle) 5717**]
Stress Test: Tuesday, [**2110-5-27**], at 10am. [**Location (un) **] of
[**Hospital Ward Name 23**] Building on [**Hospital Ward Name 516**] of [**Hospital1 18**].
- No smoking or eating for 2 hours prior to the test
- No caffeine or decaffeinated products for 12 hours prior to
the test
- They will send a letter
Please follow up with Dr. [**Last Name (STitle) 5717**] as previously scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-5-22**] 9:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2110-5-23**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-6-10**] 9:10
|
[
"276.3",
"272.0",
"410.71",
"600.00",
"584.9",
"585.9",
"486",
"285.21",
"070.54",
"250.12",
"V10.52",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11214, 11220
|
7385, 9657
|
332, 338
|
11331, 11367
|
2584, 7362
|
11861, 12742
|
2197, 2214
|
9964, 11191
|
11241, 11310
|
9683, 9941
|
11391, 11838
|
2229, 2565
|
276, 294
|
366, 1856
|
1878, 2086
|
2102, 2181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,297
| 116,946
|
7333
|
Discharge summary
|
report
|
Admission Date: [**2124-5-10**] Discharge Date: [**2124-5-18**]
Date of Birth: [**2043-5-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 yo M w/h/o CHF w/EF 22%, CAD, CABG x2, complete AV block with
DDD Pacer presented to his Cardiologist's office, Dr. [**Last Name (STitle) **]
on [**5-9**] with increasing DOE. His lasix was increased from 40mg
daily to 80mg daily without improvement in DOE. Over the past 2
days PTA pt noticed increasing DOE with limitation in
ambulating. At baseline pt can walk ~1block and can go up 5-7
stairs without SOB or having to stop secondary to fatigue or
SOB. Pt denies any CP/Palpitations or SOB at rest. Pt also
denies PND, and orthopnea.
.
Pt presented to ED with increasing DOE. In [**Name (NI) **], pt was hypoxic
with O2Sats 86%RA, BNP [**Numeric Identifier 27074**], CXR c/w mild pulmonary edema. Pt's
O2 Sats did not improve on 4LNC-sats remained 86% on 4LNC. Pt
was then started on BIPAP, O2 sats improved to 100%.
Approximately 1 hour after presenting to ED received 80mg IV
Lasix x1, and ASA 600mg PR. Pt's VSS at that time 112/66 88 RR
36 100%Sats on BIPAP, with 400cc UOP. Pt was to be started on
Nitro gtt but due to BP 94/50 was held. Pt's SOB improved, BIPAP
removed and placed on NRB with 100%sats, comfortable breathing,
and transferred to CCU for closer monitoring.
.
On further ROS: Pt denied any constitutional symptoms, no
F/C/Cough. No dysuria, no hematuria, no diarrhea, no BRBPR. No
LH/Dizziness-had 1 episode 2 weeks ago of LH and fatigue while
gardening. Has not had any recent recurrence of LH/Dizziness.
Denies any testicular pain, no penile discharge, itchiness or
discomfort (completed course of levofloxacin for testicular
infection)
Past Medical History:
-CAD s/p MI and CABGx2(last CABG-[**2111**])-->Subsequent EF 22%
-Complete AV Block s/p DDD Pacer-Atrial sensed, V paced
-CHF
-HTN
-CRI (Baseline Cr 1.7-2.0)
-SAH ([**2120**])
-Testicular infection (levofloxacin last week)
Social History:
-Pt is retired, lives with wife in [**Name (NI) **].
-Denies any h/o TOB use and no ETOH use. No h/o IVDU.
Family History:
NC
Physical Exam:
-Afebrile, BP 94/50 HR 74 RR 18 100%NRB
-GEN: NAD, pleasant elderly male speaking in full sentences
-HEENT: Cataract surgery b/l, EOMI, Anicteric sclera, MMM
-RESP: Crackles 2/3 up b/l, no wheezing
-CV: Reg Nml S1, S2, 2/6 SEM at LLSB, elevated JVP up to
mandible, sternotomy scar, pacer SC-L sided
-ABD: Soft ND/NT +BS
-EXT: 2+pitting edema b/l up to knees, warm, 1+DP pulses B/L
-NEURO: A&OX3, no confusion
Pertinent Results:
[**2124-5-10**] CXR:
IMPRESSION: Cardiomegaly and findings consistent with mild
congestive heart failure
.
[**2124-5-11**] ECHO:
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
The inferior vena cava is dilated (>2.5 cm). Left ventricular
wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe
global left ventricular hypokinesis (ejection fraction [**10-6**]
percent). No
masses or thrombi are seen in the left ventricle. There is no
ventricular
septal defect. The right ventricular cavity is dilated. Right
ventricular
systolic function appears depressed. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.
Tissue velocity imaging and tissue synchrony imaging
demonstrates < 50 msec opposing wall delay to peak velocity in
all apical windows (dyssynchrony not present).
.
Brief Hospital Course:
AP: 81 yo M w/CAD, s/p CABG, HTN, CHF p/w CHF exacerbation and
respiratory distress
.
#. CHF exacerbation: Pt's CHF exacerbation most likely in
setting of increased fluid intake due to testicular infection.
Pt presented with worsening SOB with recently increased Lasix 80
mg PO daily without improvement in symptoms. EF 22% on P-MIBI,
no recent ECHO. Received 80 mg IV Lasix in ED with good UOP >800
cc UOP, off BIPAP on NRB w/100% O2 sats. In CCU he received
another 80IVLasix x1 with his cardiac meds, including Carvedilol
12.5, lisinopril 5mg and Dig 0.125. His SBP dropped in to the
70s. Pt was asymptomatic, however MAPs dropped to 40s. SBP
minimally improved with 100cc IVF bolus. Pt was started on Dopa
gtt and subsequently started on lasix gtt for better perfusion
and diuresis. Pt diuresed well with -1L per day. He was noted to
have severely depressed EF on ECHO 10-20% with 3+TR, 2+MR,
Moderate Pulmonary Regurg. He was also noted to have elevated
PAD pressures, elevated PCWP 26. With lasix gtt, Wedge decreased
to 18, Dopa was weaned off on [**5-13**] as well as lasix gtt. His
BB/ACE-I/Dig were held while on Dopa gtt. He was further
diuresed on furosemide 80 mg po qd. Eventually his dose was
further decreased to 40 mg po qd with ins and outs remaining
roughly even. He will be discharged on furosemide 40 mg qd. His
respiratory status improved during his hospitalization. He was
encouraged to use BiPAP at night to augment his respiratory
status.
.
#. CAD: Pt denies any CP/palpitation. No indication of ischemia
on ECG or with CE. CE remained Negative. He was continued on low
dose ASA, and statin. Patient needs to have follow-up with
cardiology. Would have PCP recommend [**Name Initial (PRE) **] local out-patient
cardiologist to follow the patient. He should see cardiology in
[**1-21**] weeks.
.
#. Rhythm: NSR, v-paced. Had an episode of VT on Tele. On ECHO
no dy synchrony noted. Pt with DDD Pacer. No further episodes.
.
#. RESP: Pt with persistent respiratory acidosis with initial
ABG 7.27/70S/90S. Noted to have elevated PaCO2. Upon arrival to
CCU remained on NRB while diuresing. Pt was started on BIPAP the
following morning for the above notable ABG. A respiratory
consult was obtained for his respiratory hypercarbia. Per PCP pt
noted to have empyema as child with restructured R-sided
pulmonary anatomy. R-sided parenchyma with pleural thickening.
He was aggressively diuresed with improvement of respiratory
status ABG improved 7.40/56/121, the Lasix gtt was turned off
and continued on Lasix IV. Patient developed metabolic alkalosis
in response to his ongoing respiratory acidosis. Patient was
encouraged to wear his BiPAP at night and while napping,
however, he often refused as he does not like the machine. Would
continue to encourage use of BiPAP. Patient should follow-up
with Dr. [**Last Name (STitle) 575**] in the pulmonary clinic. He has an
appointment for [**2124-7-17**] but the clinic will call him if an
earlier appointment becomes available. A sleep study can be
arranged to evaluate for sleep apnea after he has been
officially seen in the pulmonary clinic.
.
#. HTN: Baseline SBP low 100s. Reinitiated BB, ACE-I and
titrated as BP tolerated once off the dopamine drip. Patient
had SBPs in low 100s during most of his stay. He was discharged
on carvedilol 6.25 mg [**Hospital1 **] and lisinopril 7.5 mg QD. Meds,
particularly the ace inhibitor, should be titrated up if blood
pressure tolerates.
.
# Testicular infection: Pt had recently completed 1 week course
levofloxacin for testicular infection. He remained afebrile,
normal WBC, testicular exam normal. Spoke with PCP which
confirmed the 1 week course of ABX. Urine culture was negative.
No additional antibiotics were administered during his stay.
.
#. CRI: Cr baseline 1.7-2.0, currently at 1.8. Renally dose
meds, avoid nephrotoxins
Follow UOP and Cr and electrolytes weekly while taking
furosemide.
.
# Gout: Had been allopurinol as an out-patient, which was not
continued during his admission. Developed some R great toe pain
on [**5-17**] and was started on colchicine for symptom control ([**Hospital1 **]
dosing). Would plan to restart allopurinol in the future after
acute symptoms have subsided. Renal function should be followed
on colchicine and allopurinol. Allopurinol should be renally
dosed. If flare does not improve with colchicine, could use
NSAID like sulindac, steroids, or intra-articular steroids.
.
#. Thrombocytopenia: Plts in low 100s during admission. On
review of records, PLTs 100 in [**3-22**], etiology is unclear. HIT
(PF4) ab was negative. Would follow in out-patient setting.
Consider evaluation by out-patient hematology.
.
Medications on Admission:
MEDS (at home):
-Lasix 40mg daily
-Lisinopril 5mg daily
-Dig 0.125mg daily
-Carvedilol 12.5mg [**Hospital1 **]
-Lipitor 20mg daily
-ASA 81mg
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: for acute gouty flare.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
CHF exacerbation
Pulm HTN
CO2 retention
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 Liter
*
Call your doctor or return to the emergency department if you
develop shortness of breath, chest pain, you cannot eat, drink
or take your medications or you develop any other symptoms that
are concerning to you.
Followup Instructions:
Please follow-up in pulmonary clinic with Dr. [**Last Name (STitle) 9504**].
*
Provider: [**Name10 (NameIs) 2052**],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLGY PPS (SB)
Date/Time:[**2124-7-4**] 2:00
|
[
"287.4",
"416.8",
"274.9",
"V45.81",
"428.0",
"403.91",
"276.2",
"799.02",
"414.00",
"V45.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9912, 9984
|
4076, 8753
|
291, 298
|
10068, 10077
|
2726, 4053
|
10466, 10684
|
2278, 2282
|
8944, 9889
|
10005, 10047
|
8779, 8921
|
10101, 10443
|
2297, 2707
|
232, 253
|
326, 1892
|
1914, 2138
|
2154, 2262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,825
| 103,843
|
32836
|
Discharge summary
|
report
|
Admission Date: [**2195-12-13**] Discharge Date: [**2195-12-20**]
Date of Birth: [**2123-1-12**] Sex: F
Service: SURGERY
Allergies:
Codeine / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 yo F presents BIBA from OSH s/p fall down [**1-3**] steps. X-rays
at OSH showed posterior left rib fractures, and a left clavicle
fracture. No LOC. Tetanus given 1 week ago. At OSH, glucose
450, WBC 16.3, ceftriaxone x1 dose, 10 units of insulin.
Past Medical History:
1. IDDM
2. s/p AAA repair
3. ureteral stent with atrophic R kidney
4. s/p TAH/BSO
Social History:
lives at home with her husband, [**Name (NI) **] [**Name (NI) 28211**], [**Telephone/Fax (1) 76452**].
Family History:
non-contributory
Physical Exam:
on admission:
101.4 F (rectal) 110 140/90 24 97%
General: NAD, appears mildly confused
Eyes: 3-->2 bilaterally
ENT: airway patent
Neck: c-collar in place, trachea midline
Respiratory: CTAB
CV: nl rate, regular rhythm
Chest: left amteropr cjest wa;; temder to palpation
GI: soft, NTND, guaiac negative, good rectal tone
Foley in place, no gross blood
Spine: non-tender
Neuro: A&O x2, following commands, MAEW
Pertinent Results:
admission labs:
[**2195-12-13**] 04:51PM GLUCOSE-241* LACTATE-2.5* NA+-143 K+-4.3
CL--104 TCO2-24
[**2195-12-13**] 04:15PM CK(CPK)-483* AMYLASE-19
[**2195-12-13**] 04:15PM CK-MB-7 cTropnT-<0.01
[**2195-12-13**] 04:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-12-13**] 04:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2195-12-13**] 04:15PM WBC-16.4* RBC-4.30 HGB-12.7 HCT-36.5 MCV-85
MCH-29.6 MCHC-34.8 RDW-17.5*
[**2195-12-13**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2195-12-13**] 04:15PM URINE RBC-[**10-20**]* WBC-[**10-20**]* BACTERIA-FEW
YEAST-MOD EPI-0-2
pertinent imaging:
[**12-13**] CT head (OSH): large left hematoma soft tissue. No SAH or
SDH, no fracture, sinuses clear, no acute intracranial process.
[**12-13**]: CT chest: L lateral ribs 3->6 rib fx's. posterior [**1-4**] rib
fx's
[**12-13**]: CT c-spine: degenerative changes, no fx or dislocation
[**12-13**]: CT torso: neg for acute intra-abdominal process, s/p AAA
repair. R adrenal mass 3.6x1.8cm c/w adenoma. R ureteral stent
with atrophic R kidney. s/p TAH/BSO.
[**12-14**]: CXR: As compared to [**2195-12-13**], slight left
suprabasal
atelectasis has developed. Small left-sided pleural effusion,
no
pneumothorax. Rib fractures and clavicular fracture are
unchanged.
[**12-17**]: CXR: (prelim) Moderate left pleural effusion, slightly
increased. Adjacent L retrocardiac opacity likely represents
atelectasis but coexisting infxn is not excluded. No definite
pneumonia.
Brief Hospital Course:
Upon arrival to the [**Hospital1 18**] ED, a trauma basic was called. The
patient had multiple radiographic studies, as detailed above.
The patient was admitted to the TICU, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
attending. Her pain was controlled with dilaudid, and she was
placed on insulin sliding scale for her high glucose. She was
additionally started on ciprofloxacin for her UTI. Her
pulmonary function was closely monitored because of her multiple
rib fractures. Incentive spirometry was encouraged. She was
seen by the inpatient geriatrics service, and the physical
therapy and occupational therapy services. It was felt that she
would be best served in a rehab facility upon discharge. The
Acute Pain Service was contact[**Name (NI) **] regarding placement of an
epidural, and an epidural was placed on HD 3. The patient was
transferred to the floor, and continued to work with physical
therapy. She tolerated a regular home diet, and continued on
her home medications. The patient continued to improve, and her
epidural was removed on HD 6.
She was placed on an insulin sliding scale in addition to her
home oral diabetic medications, and this was titrated as needed
for improved blood sugar control. She will continue her diabetic
medications and insulin sliding scale at her Rehab facility. On
HD 6, a Foley was placed for urinary retention, and 1250 cc were
emptied. Her Foley was d/c'd the next day, and she failed a
voiding trial, so it was replaced. It was then d/c'd, and she
was voiding, though incontinent at times. She was bladder
scanned for only 66cc - negative for overflow incontinence.
Early in her hospital course, the urology service was consulted
regarding her UTI given her stent and renal issues - per their
recommendations, the stent was left in place ,and she completed
her 7 day course of ciprofloxacin for complicated UTI on HD 7.
Medications on Admission:
advair
oxycontin
albuterol/ventolin HFA 90 mcg
lorazepam 1 [**Hospital1 **]
buproprion (wellbutrin xl) 150 qhs
trazodone 300 qhs
gemfibrozil 600
glyburide 5 [**Hospital1 **]
ibuprofen 800 [**Hospital1 **]
atenolol 100
premarin 0.625
lipitor 40 mg
effexor 150 mg
detrol 4 mg qhs
aspirin 325 mg qd
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain: Hold for sedation or RR <12.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain: Hold for sedation or RR
<12.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Insulin Sliding Scale
Please keep patient on a tight Humalog insulin sliding scale.
Titrate as needed to keep blood sugars between 120 and 140 if
possible.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
1.s/p fall
2. Left lateral ribs 3->6 rib fractures. Posterior [**1-4**] rib
fractures
Discharge Condition:
stable
Discharge Instructions:
You have been admitted to [**Hospital1 69**]
after a fall. You have been cared for by the trauma team. The
acute pain service has also followed you.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Redness around your wounds or drainage from your wounds.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic in [**12-2**] weeks.
Please call [**Telephone/Fax (1) 6429**] to make an appointment.
Please call your primary care physician to schedule an
appointment in 1 week for monitoring of blood sugar management.
Please call your Urologist to schedule an appointment for 1 week
for f/u of complicated UTI and renal f/u.
|
[
"250.00",
"V58.67",
"E880.9",
"807.05",
"293.0",
"788.20",
"810.02",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6794, 6837
|
2951, 4865
|
306, 313
|
6968, 6977
|
1299, 1299
|
8279, 8664
|
838, 856
|
5211, 6771
|
6858, 6947
|
4891, 5188
|
7001, 8256
|
871, 871
|
258, 268
|
341, 597
|
1315, 2928
|
885, 1280
|
619, 702
|
718, 822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,990
| 189,592
|
41392
|
Discharge summary
|
report
|
Admission Date: [**2165-2-27**] Discharge Date: [**2165-3-8**]
Date of Birth: [**2120-7-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vicodin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Transfer from OSH for IVC filter placement and management of
hemorrhagic cyst
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
The patient is a 41 year old woman with a PMHx significant for
DM2, SLE, antiphospholipid AB, and prior PEs; who was recently
discharged from [**Hospital1 **] [**2165-2-9**] with a saddle PE and a recommendation
for lifelong anticoagulation. After discharge, she had more
arthralgias, so her prednisone dose was increased to 20 mg po
bid. She went to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital with LLQ pain and was
found to have a hemorrhagic ovarian cyst. She was seen by GYN
there and they advised conservative management. Her hemoglobin
trended down from 9's to 8's. Her SBP, which is normally in
100s, drifted down to the 90s. Her last bp 98/56. She is not
tachycardic and patient not symptomatic. On [**2165-2-26**], she
developed right lower quadrant pain. An U/S showed a NEW right
ovarian cyst, but also enlargement of her left ovarian cyst from
3.7 to 4.8 cm and development of large adjacent hematoma 13x11x7
cm. Her last warfarin dose of 6mg was given last night. Her AM
hct was 25.5, AM INR 2.5, serum creatinine 0.8 and BUN 18. She
was transferred here for further management of her hemorrhagic
cysts and
hematoma, which developed while on anticoagulation for recently
diagnosed saddle
PE.
She reports having two LE u/s, which were negative for DVT at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5678**] (last was 2 days ago).
Upon review of OMR, on her last admission here on [**2165-2-9**], her
urine grew pan-sensitive Klebsiella pneumoniae for which she was
sent out with a prescription of macrobid for 2 more days at
discharge.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia. Denies chest pain, palpitations, orthopnea,
dyspnea on exertion. Denies shortness of breath, cough or
wheezes. Denies nausea, vomiting, heartburn, diarrhea, BRBPR,
melena. No dysuria, urinary frequency. Denies arthralgias or
myalgias. Denies rashes. No increasing lower extremity swelling.
No numbness/tingling or muscle weakness in extremities. No
feelings of depression or anxiety. All other review of systems
negative.
Past Medical History:
systemic lupus erythematosus [**2161**]
diabetes mellitus type II
headaches
two hemorrhagic strokes in [**2161**]
dyslipidemia
PTSD
depression
ADHD
bipolar disorder
asthma
multiple pulmonary embolisms
ALLERGIES: pcn (angioedema) and vicodin (headache)
Social History:
Retired hair dresser - on disability now. Takes care of her
mother in [**Name (NI) **]. Identifies as lesbian and recently split
from her partner of 14 years (former HCP). Not close to brother
or mother (does not want to share medical issues with them).
No smoking, no alcohol ingestion. Denies any recreational drug
use.
Per further history, patient did binge drink in past (bottle of
Hennesey at a time), has been sober for 14 years (since [**2151**])
Family History:
As per her, she has nine siblings, five of which are females,
and all the five females were tested positive for blood in the
urine per her mother. [**Name (NI) **] mother has been diagnosed with colon
cancer at the age of 86. Her father passed away with prostate
cancer. She also has a history of diabetes and coronary
disease in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 147/77 85 18 98% RA, glu 436; pain 0/10
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**5-25**] motor function globally
DERM: multiple abdominal echymoses present
Pertinent Results:
[**Hospital3 26615**] Hospital labs:
[**2165-2-27**]:
wbc 7.6, hct 30.7 (repeat was 25 just prior to transfer), plt
208, inr 1.5
HCG neg
Na 135, K 4.2, Cl 99, CO2 99, Glu 225, sCr 0.7, Ca 9.2
[**2165-2-28**] 07:09AM BLOOD WBC-7.8# RBC-2.74*# Hgb-8.1*# Hct-23.6*
MCV-86 MCH-29.6 MCHC-34.4 RDW-16.1* Plt Ct-244#
[**2165-3-4**] 02:22AM BLOOD WBC-8.4 RBC-4.10* Hgb-12.3 Hct-36.0
MCV-88 MCH-30.0 MCHC-34.1 RDW-16.3* Plt Ct-259
[**2165-3-4**] 11:15AM BLOOD WBC-3.6*# RBC-3.13* Hgb-9.5* Hct-29.5*
MCV-94 MCH-30.5 MCHC-32.3 RDW-15.8* Plt Ct-139*
[**2165-3-5**] 08:28AM BLOOD WBC-3.5* RBC-3.13* Hgb-9.3* Hct-27.8*
MCV-89 MCH-29.6 MCHC-33.3 RDW-15.6* Plt Ct-149*
[**2165-2-28**] 02:00AM BLOOD PT-25.6* PTT-33.7 INR(PT)-2.5*
[**2165-3-5**] 08:28AM BLOOD PT-21.9* PTT-66.6* INR(PT)-2.1*
[**2165-2-28**] 07:09AM BLOOD ESR-76*
[**2165-2-28**] 02:00AM BLOOD Glucose-317* UreaN-27* Creat-0.7 Na-131*
K-4.7 Cl-95* HCO3-26 AnGap-15
[**2165-3-3**] 07:00AM BLOOD Glucose-209* UreaN-23* Creat-0.8 Na-138
K-3.6 Cl-100 HCO3-27 AnGap-15
[**2165-3-5**] 04:17AM BLOOD Glucose-242* UreaN-10 Creat-0.6 Na-136
K-3.6 Cl-105 HCO3-23 AnGap-12
[**2165-2-28**] 07:09AM BLOOD ALT-20 AST-8 LD(LDH)-143 AlkPhos-61
TotBili-0.8
[**2165-3-5**] 04:17AM BLOOD ALT-17 AST-10 LD(LDH)-198 AlkPhos-47
TotBili-0.7
[**2165-3-4**] 12:50PM BLOOD Lipase-123*
[**2165-3-1**] 07:50PM BLOOD CK-MB-1 cTropnT-<0.01
[**2165-3-2**] 03:20AM BLOOD CK-MB-1 cTropnT-<0.01
[**2165-2-28**] 07:09AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.6* Mg-2.0
[**2165-3-5**] 04:17AM BLOOD Calcium-8.0* Phos-3.7 Mg-3.1*
[**2165-3-4**] 03:31AM BLOOD Type-ART pO2-73* pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2165-3-5**] 12:28AM BLOOD freeCa-1.27
[**2165-3-4**] 11:46AM BLOOD Lactate-2.1*
[**2165-3-4**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2165-3-4**] 12:00PM URINE Blood-TR Nitrite-POS Protein-NEG
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2165-3-4**] 12:00PM URINE RBC-4* WBC-2 Bacteri-MANY Yeast-NONE
Epi-1
MICRO:
**FINAL REPORT [**2165-3-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-3-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
GRAM STAIN (Final [**2165-3-4**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
Blood culture ([**3-4**]): ngtd
urine culture ([**3-4**]): ngtd
[**2165-2-22**]: Pelvic U/S:
Findings: A 13 x 11 x 7 cm hematoma of mixed echogenicity has
appeared in the left addnexal region immediately adjacent to the
left ovary which contains an enlarging hemorrhagic cyst
measuring up to 4.8 cm. The transvaginal view demonstgrate a 2.5
cm complex right ovarian cyst, likely containing hemorrhagic
material, not demonstrable on current and past transabdominal
views. There is intact color and spectral Doppler flow within
each ovary.
The uterus is unremarkable with a length of 7.7 cm and an
endometrial stripe thickness of 4.3 mm.
Impression:
1. New 13 cm organizing hematoma in the left adnexal region
immediately adjacent to an enlarging 4.8 cm hemorrhagic left
ovarian cyst.
2. 2.5 cm complex right ovarian cyst, likely containing
hemorrhagic material.
3. Unremarkable uterus.
[**2165-2-28**]: Pelvic U/S:
IMPRESSION: Large pelvic mass posterior to uterus extending
towards the left greater than the right. This is felt to
represent hematoma/clot rather than an ovarian lesion. The
ovaries not seen. If clinically warranted, cross-sectional
imaging may be considered to evaluate extent of blood in the
abdomen/pelvis and possible acute source of bleeding.
CTA abdomen ([**2165-2-28**]):
1. Hemoperitoneum with the densest clot in the pelvis consistent
with a
pelvic bleeding source. However, there is no evidence for active
extravasation at this point in time.
EKG ([**3-1**]): Sinus rhythm. Normal tracing. Compared to the
previous tracing of [**2165-2-7**] the findings are similar.
EKG ([**3-4**]): Sinus tachycardia. Compared to tracing #2 there are
non-specific inferior and anterior ST-T wave changes throughout.
Otherwise, there is no change.
CXR ([**3-4**]):
There are large bands of atelectasis at both lung bases and on
the right a
wedge-shaped region of consolidation which could be either more
atelectasis or an early pneumonia. There is no evidence of
pneumonia elsewhere in the lungs.
Pleural effusions are small if any. Heart size is normal,
exaggerated by low lung volumes. No pneumothorax.
CXR ([**3-4**]): WET READ: Right picc with tip in the lower svc.
Otherwise, bilateral areas of bandlike atelectasis are again
noted along with a more focal opacity in the right lower lobe
suggestive of atelectasis/developing pneumonia.
Brief Hospital Course:
ACUTE PE WITH HEMORRHAGIC OVARIAN CYSTS:
Gynecology was involved and reviewed outside imaging as well as
transvaginal ultrasound and CTA abdomen performed here that
showed pelvic hematoma, stable in size, and no evidence of
active extravasation. She was transfused 2 U pRBC on admission
with response in hct from 23 to 33. Hematocrit then stable.
INR below 2.0 as her Coumadin was held prior to transfer.
Coumadin resumed [**3-2**] and heparin drip started [**3-2**], given
presence of recent hematoma. Heparin drip was discontinued when
INR therapeutic on Coumadin. Dr. [**Last Name (STitle) 1492**] feels that he can take
over anticoagulation management.
.
Although she was transferred here for consideration of IVC
filter, a filter does not remove the both intermediate and long
term need to anticoagulate this patient because of the
proximal/large and recent PEs along with her suspected
hypercoagulable state. Since she was hemodynamically stable
without evidence of active bleeding clinically, or on imaging,
gynecology and medicine agreed not to pursue operative
management which would carry significant morbidity.
Lupron given [**3-1**] to cause cessation of menses and diminish risk
of future hemorrhagic cysts. This avoided thrombotic risks of
progesterone (albiet low risk)
- Warfarin goal [**2-22**], indefinite. Settled on home dose of 3 mg
daily. Check INR 2 days post discharge
- Follow up with Dr. [**Last Name (STitle) 1492**], hematologist, and PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] up with [**Hospital1 18**] Gyn given her ovarian cysts
DM2, UNCONTROLLED:
She needed nearly 51 units of SS Humalog coverage in the initial
24h. Basal insulin was started, and her AM glucose improved.
[**Last Name (un) **] was consulted for assistance in management. Her steroids
were likely driving her hyperglycemia. She was initiated on
Lantus with HISS. Her FSBG came under better control once her
steroids were tapered down. [**First Name8 (NamePattern2) **] [**Last Name (un) **], we restarted her
Glipizide at 5mg [**Hospital1 **]. Final lantus insulin dose is 26U QHS [**First Name8 (NamePattern2) **]
[**Last Name (un) **] without sliding scale. VNA was arranged to help her with
insulin mgmt & diabetes education.
SLE:
For her lupus she was continued on azathioprine and plaquinel.
Her prednisone dose was reduced because of hyperglycemia to 10mg
daily after initial stress doses, this will require further dose
reduction as directed by her rheumatologist on follow up.
- Questions were raised regarding her history of DVT or APL
syndrome. It was confirmed with her outpatient providers that
she did NOT have either previous DVT, OR APL syndrome. Thus, we
should assume that she does NOT have these prior diagnoses.
- She will follow up closely with her rheumatologist
# HYPOTENION WITH FEVER:
Likely related to hypovolemia in the setting of GI losses. The
patient is particularly volume-sensitive due to her recent PE.
DDx includes bleeding, sepsis, recurrent PE, adrenal
insufficiency (on chronic steroids). Unclear infectious source:
CXR with right sided ? Pneumonia given clear productive cough,
although clear lung exam and no leukocytosis or fevers while in
the ICU. Also possible is urinary tract infection given UA with
many bacteria (Urine culture pending). Also possible is
norovirus. Patient is immunosuppressed with azathioprine and
prednisone. Patient was started broadly on IV antibiotics
(meropenem, ciprofloxacin and vancomycin.) The following day,
patient had no further episodes of diarrhea or vomiting and was
feeling much better. Her abdominal exam also improved although
she had persistent cough. CXR was negative when repeated on the
medical floor, and cultures remained negative, so meropenem and
vancomycin were discontinued. She was continued on Cipro for
possible early UTI/cystitis and finished a short course. Patient
was also given hydrocortisone stress dose but switched back to
10mg PO prednisone daily (patient on 3mg at home). Patient
maintained stable blood pressures on the medical floor.
-
# ANEMIA, NOS: Ddx includes hemodilution, GI bleeding (guaiac
negative overnight), bleeding into abdomen/pelvis. We checked
Hct q12h which were stable following initial dilutional drop
(although in context of 7 liters of crystalloid). Patient was
not transfused and not reimaged while in the ICU or on the floor
# HA: noted on [**3-7**]. Given high risk of bleed, CT Head
performed and was unremarkable. Headache improved with Tylenol.
Medications on Admission:
Home:
1. warfarin 2.5 mg Two Tablets PO once a day
2. azathioprine 75 mg Two Tablets PO DAILY
3. prednisone 1 mg Three Tablet PO DAILY
4. aspirin 81 mg One Tablet PO DAILY
5. Vitamin D 1,000 unit One Tablet PO once a day.
6. lorazepam 1 mg One Tablet PO BID
7. iron 325 mg (65 mg iron) One Tablet PO once a day.
8. Tylenol 325 mg One Tablet PO twice a day as needed for fever
or pain.
9. glipizide 5 mg One Tablet PO DAILY
10. Calcium 600 600 mg (1,500 mg) Two Tablets PO once a day.
11. nystatin 100,000 unit/mL Suspension Five ML PO QID prn
thrush.
12. hydroxychloroquine 200 mg Two Tablets PO HS
[**Hospital3 26615**] Hospital:
Tylenol 650 mg q4 prn pain/fever
Calcium 1500 mg daily
vitamin D [**2153**] IU dialy
colace 100 mg [**Hospital1 **] prn constipation
Coumadin (last dose 6 mg last night)
heparin discontinued this am
Ferrous Gluconate 325 mg TID
Plaquenil 200 mg qhs
sliding scale insulin
morphine prn for hemorrhage cyst pain
protonix 40 mg daily
prednisone 15 mg po bid
glucotrol 5 mg daily
robitussin 10 mg q4h prn cough
roxicodone 5-10 mg q4h prn pain
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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
3. azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) for 3 days.
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. iron 325 mg (65 mg iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
11. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO once a day.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: do NOT use with alcohol or driving.
Disp:*60 Tablet(s)* Refills:*0*
13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day: while on opiates.
Disp:*60 packets* Refills:*1*
14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*90 Tablet(s)* Refills:*0*
15. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
16. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
Six (26) units Subcutaneous at bedtime.
Disp:*3 pens* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ACUTE BLOOD LOSS ANEMIA
PULMONARY EMBOLISM
PELVIC HEMATOMA/OVARIAN CYSTS
SLE
DIABETES MELLITUS TYPE II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
YOU WERE HOSPITALIZED FOR BLEEDING FROM HEMORRHAGIC OVARIAN
CYSTS THAT WAS MORE SIGNIFICANT BECAUSE YOU ARE ON COUMADIN FOR
RECENT PE. YOU ALSO SUFFERED FEVER AND LOW BLOOD PRESSURE
LIKELY CAUSED BY A VIRAL GASTROENTERITIS.
TRANSITIONAL ISSUES
You will need continued Warfarin dosing and INR monitoring by
your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1661**]. Additionally, you will need to follow up
with Gynecology at [**Hospital1 18**] for your ovarian cysts.
Additionally, please follow up with your rheumatologist as
scheduled for ongoing care and testing. Please continue your
home doses of prednisone.
Finally, you were found to have high blood sugars in the
hospital. You were restarted on insulin therapy, specifically
Lantus. Please take as prescribed and follow up closely with
your physicians. We restarted your Glipizide 5 mg twice daily
on [**3-7**].
Followup Instructions:
SCHEDULE F/U WITH YOUR PCP AND YOUR HEMATOLOGIST AS SOON AS
POSSIBLE AFTER DISCHARGE
Department: RHEUMATOLOGY
When: THURSDAY [**2165-3-28**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: OBSTETRICS AND GYNECOLOGY
When: WEDNESDAY [**2165-4-3**] at 2:15 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90092**], MD [**Telephone/Fax (1) 2664**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2165-3-12**]
|
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"276.50",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
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406, 2006
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2678, 2932
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2948, 3404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,912
| 133,351
|
32425
|
Discharge summary
|
report
|
Admission Date: [**2109-10-23**] Discharge Date: [**2109-11-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
HCT drop and abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year-old female with recently diagnosis of acquired Factor
VIII inhibitor, who presents with a hematocrit drop and LLQ pain
x 1 day. She was transferred from [**Hospital6 33**] on the
day of admission with a finding of a hematocrit drop from 8
points since discharge the day prior. She stateed that she
first experienced pain in her LLQ pain the evening prior to
admission. She also reported a "large amount" of hematuria x 1
episode yesterday. She denied any hematochezia, black stools or
hematemesis.
.
Per patient's history, she initially presented her PCP's office
last week with a large ecchymoses and hematoma of her left leg.
She was found to have a prolonged PTT and a drop in her
hematocrit from 30 to 25 two days earlier. On [**2109-10-18**] she was
transported to [**Hospital1 18**] for bloodwork including inhibitor screen
and factor levels. Per patient's request, she was then
transferred back to [**Hospital6 33**] for admission. She was
transfused 2 units PRBC's. With a finding of severe Factor VIII
deficiency and a strongly positive inhibitor screen, she was
started on prednisone 60 mg daily and cyclophosphamide 50 mg
daily. She was felt to be hemodynamically stable and was
discharged home on [**2109-10-21**]. On the day following discharge, she
developed abdominal pain and returned to the [**Hospital3 **] ED.
.
In the ED she received 3000 units recombinant Factor VIII. CT
abdomen/pelvis showed a large hematoma in the left rectus muscle
with high density within it, suggestive of active extravasation.
She was admitted for futher care and management.
Past Medical History:
1. Acquired Factor VIII deficiency
2. Rheumatoid arthritis
3. Hypercholesterolemia
4. Hypertension
5. Question cardiac arrhythmia
6. s/p enucleation of right eye as a child
Social History:
Rare alcohol use. Denies any history of tobacco use.
Family History:
No known family history of bleeding disorders. Parents with
hypertension.
Physical Exam:
Admission
VS: 99.4 98 146/58 24 98%RA
Gen: Elderly white female, pale, in NAD
HEENT: Left sclera anicteric, right prostetic eye, left eye
reactive, OP clear without lesions, MM dry
CV: RRR, no MRG
Resp: CTAB
Abd: Soft, + 6 cm tender LLQ mass, no reboung
Ext: No CCE, large ecchymoses over medial aspect of left thigh
without induration; bilateral distal lower extremities with
ecchymoses to the knees
Neuro: AAOx3, CN II-XII intact (left eye), strength 5/5 BUE/LE
Pertinent Results:
CT abdomen [**2109-10-23**]:
IMPRESSION:
1. Large hematoma in the left rectus muscle with high density
within it, suggestive of active extravasation. Close follow up
with laboratory correlation advised.
2. High-density fluid within the pelvis, also concerning for
blood.
3. Partial obscuration of fat planes in the right groin and
apparant
asymmetry of the right psoas muscle. Please correlate with
patient's clinical symptoms, as these could be areas of prior
bleeding.
4. Peripherally enhancing collection in the posterior right
lobe of the liver, with surrounding stranding and thickening of
the right lateral conal fascia as well as a small amount of
fluid at the liver tip. The etiology of this is not clear, and
it may represent an area of focal hemorrhage, although abscess
cannot be excluded.
.
Admit labs:
[**2109-10-23**] 02:40PM BLOOD WBC-9.2 RBC-2.62* Hgb-8.4* Hct-24.4*
MCV-93 MCH-32.0 MCHC-34.2 RDW-15.3 Plt Ct-416
[**2109-10-23**] 07:40PM BLOOD Hct-21.2*
[**2109-10-23**] 02:40PM BLOOD PT-13.4 PTT-57.2* INR(PT)-1.1
[**2109-10-23**] 02:40PM BLOOD FacVIII-1.8*
[**2109-10-23**] 02:40PM BLOOD Glucose-194* UreaN-22* Creat-0.7 Na-140
K-4.0 Cl-105 HCO3-23 AnGap-16
Factor VIII inhibitor 56.7
Discharge labs:
[**2109-11-10**] 06:05AM BLOOD WBC-2.5* RBC-3.29* Hgb-10.7* Hct-32.1*
MCV-98 MCH-32.4* MCHC-33.3 RDW-20.6* Plt Ct-228
[**2109-11-9**] 06:20AM BLOOD Neuts-82.8* Lymphs-11.9* Monos-5.0
Eos-0.4 Baso-0
[**2109-11-10**] 06:05AM BLOOD PT-12.3 PTT-37.1* INR(PT)-1.0
[**2109-11-3**] 01:00PM BLOOD FacVIII-14*
[**2109-11-9**] 06:20AM BLOOD Glucose-70 UreaN-15 Creat-0.6 Na-138
K-3.5 Cl-103 HCO3-26 AnGap-13
[**2109-11-3**] 07:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.4
[**2109-11-7**] 03:30PM URINE Color-LtAmb Appear-SlHazy Sp [**Last Name (un) **]-1.021
[**2109-11-7**] 03:30PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-MOD
[**2109-11-7**] 03:30PM URINE RBC-3* WBC-111* Bacteri-FEW Yeast-NONE
Epi-5 TransE-<1
Factor VIII inhibitor 1.0
Brief Hospital Course:
1. acquired factor VIII inhibitor with rectus sheath hematoma
and acute blood loss anemia -- The patient was recently
diagnosised with Factor VIII inhibitor on last admission
approximately 2-3 weeks ago. She now presented with abdominal
pain and worsening anemia and was found to have a left rectus
muscle bleed and a likely retroperitoneal bleed with fluid in
the pelvis. She intially received Factor VIII but her PTT did
not trend down. She was then transfused and placed on Factor
VIIa q6. HCT bumped from 21->27 with 2units PRBC's. She was also
started on cytoxin 150mg daily and Prednisone 80mg daily as well
as calcium carbonate and Vit D as well as bactrim for PCP
[**Name Initial (PRE) 1102**]. On [**2109-10-26**], she was switched from q6 hours Factor
VIIa to q8hrs Factor VIIa but unintentionally received one dose
2 hours late making the interval between one dose and the next
10hrs. She was then noted to have a HCT drop from 30->26 and new
bruising along the right flank, but maintained hemodynamic
stability. She was immediately given VIIa and transfused 2 units
pRBC's. Since then has been maintained on Factor VIIa q6hrs with
no further HCT drop. Per Hematology request, she was kept in the
ICU for monitoring. After several days of stable HCT and a
rising VIII level (from less than 1->9), the hematology team
determined that the patient was stable and less likely to bleed
again. On [**11-1**], she was once again transitioned from q6H dosing
to q8hrs dosing of VIIa, switched to q12 HCT's and daily
coagulation panels. As hematocrits remained stable, the
frequency of factor VII infusions were decreased. Her factor
levels increased and inhibitor level decreased, with the last
coming back in the normal range. Factor VII infusions were
discontinued, and no further evidence of bleeding was noted.
She was discharged on prednisone 80 mg po qday and Cytoxan 100
mg po qday to follow up in heme clinic on Friday [**2109-11-15**].
2. UTI -- assymptomatic, treated with 10 days ciprofloxacin
given immunosuppresion.
3. microscopic hematuria -- She should have a surveillance
urinalysis to assure this has resolved.
4. hyperglycemia on prednisone -- Required daytime NPH and
prandial insulin. Received glucometer and insulin teaching
prior to discharge. She was counseled that her insulin needs
should diminish as she tapers off prednisone.
5. immunosuppression on Cytoxan and prednisone -- She will need
daily SS Bactrim for PCP prophylaxis while on the meds, as well
as Vit D/Calcium for bone protection.
Medications on Admission:
1. Prednisone 60 mg daily (day 6)
2. Cyclophosphamide 50 mg daily
3. Propanolol 20 mg daily
4. Protonix 40 mg daily
5. Lipitor 20 mg daily
6. Lisinopril 20 mg daily
7. Tylenol 650 mg q 4hours PRN pain
.
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*10 Tablet(s)* Refills:*0*
2. Cyclophosphamide 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
10 Subcutaneous q breakfast.
Disp:*1 bottle* Refills:*2*
12. Insulin Syringe 1 mL 28 x [**12-11**] Syringe Sig: One (1) 1
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
13. Humalog 100 unit/mL Solution Sig: One (1) 8 Subcutaneous q
lunch and q dinner.
Disp:*1 bottle* Refills:*2*
14. Lancets,Thin Misc Sig: One (1) Miscellaneous four times
a day.
Disp:*1 box* Refills:*2*
15. Insulin Needles (Disposable) Needle Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
16. med
Please see attached sliding scale to be used with Humalog. you
will need to take your blood glucose 4 times daily.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 75696**] Homecare
Discharge Diagnosis:
Primary:
Acute blood loss anemia secondary to rectus sheath hematoma
Acquired Factor VIII inhibitor
Discharge Condition:
stable
Discharge Instructions:
You were admitted with anemia secondary to your acquired Factor
VIII inhibitor and found to have a rectus sheath hematoma. You
were treated with cytoxan and prednisone and required several
blood product transfusions. You will need hematology follow up
as listed below.
Followup Instructions:
Hematology:Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 26384**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-11-15**] 12:00
Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2109-11-15**]
12:00
Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2109-11-29**]
12:00
|
[
"728.89",
"599.0",
"286.0",
"401.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9340, 9400
|
4797, 7330
|
286, 292
|
9544, 9553
|
2767, 3977
|
9872, 10337
|
2193, 2268
|
7583, 9317
|
9421, 9523
|
7356, 7560
|
9577, 9849
|
3993, 4774
|
2283, 2748
|
225, 248
|
320, 1911
|
1933, 2107
|
2123, 2177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,209
| 122,588
|
40810
|
Discharge summary
|
report
|
Admission Date: [**2175-8-18**] Discharge Date: [**2175-8-29**]
Service: MEDICINE
Allergies:
doxycycline / Erythromycin Base / ibuprofen / indomethacin /
lovastatin / Pravastatin / brilliant blue FCF / Penicillins /
Latex / tetracyclines / NSAIDS / HMG-CoA-R Inhibitors /
macrolides / Statins-Hmg-Coa Reductase Inhibitors / ketolides
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
s/p NSTEMI
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Patient is an 87 year old woman with PMH of DM, HTN, and AFib
s/p PPM admitted to [**Hospital3 4107**] on [**2175-8-15**] with non-healing
gangreonous right fourth toe for consult regarding amputation.
Patient was started empirically on vancomycin, levofloxacin, and
flagyl until wound culture grew MRSA, and levofloxacin and
metronidazole were D/C'd.
.
The morning prior to admission, at [**Hospital1 **], patient developed SOB
without CP or EKG changes and was diuresed with relief of SOB.
Later in the day, she developed chest tightness and troponins
bumped 1.2/1.26/1.04. The patient was placed on heparin drip
along with plavix and aspirin. TTE showed possible anterior wall
dysmotility. The morning of admission she developed recurrent
left shoulder pain relieved with NTG and morphine and TWI on
EKG. It was decided to transfer patient to [**Hospital1 18**] for cardiac
catheterization.
.
VS on transfer: 132/68 HR 78 R 18 sat 97% 2Lnc. 0/10 pain. In
the cath lab, patient was noted to have 3 vessel disease.
Cardiac surgery was consulted and recommended CABG on Monday.
Patient was transferred to the floor in good condition,
complains of a mild headache, denies any chest pain or SOB.
.
On review of systems, she complains of chronic nonproductive
cough, decreased sensation in her feet, claudication, and
chronic diarrhea self treated with lometil, and increased
urinary frequency. She denies any prior history of stroke, TIA,
deep venous thrombosis, or pulmonary embolism. She denies recent
fever or chills.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, ?Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: Afib s/p PPM [**2165**]
3. OTHER PAST MEDICAL HISTORY:
Retinopathy
Neuropathy
LVH
AFib s/p PPM for sick sinus syndrome
GERD
DJD
Anxiety
Osteoporosis
Pernicious anemia
s/p C-section x2 and Hysterectomy
Cataracts
Vulvar condylomata
Diverticulosis
Social History:
-Lives at [**Location 89168**] senior living.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: Never
-Herbal Medications: None
Family History:
Father and 2 brothers with MI. Otherwise noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=98.7 BP=134/49 HR=61 RR=16O2 sat=98%
GENERAL: Thin elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Anicteric sclerae. PERRL, EOMI. Dry mucus membranes.
Nares and oropharnxy clear.
NECK: Supple without LAD, thyromegaly or JVD.
CARDIAC: normal S1, S2. II/VI systolic murmur over left sternal
border. No S3 or S4.
LUNGS: Resp were unlabored, patient lying on back post cath.
Auscultation of anterior chest was clear.
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive BS
EXTREMITIES: Right foot dressed up to ankle. Bandage clean. No
CCE noted on left foot
SKIN:Stasis dermatitis noted over left foot, well healed midline
abdominal scar. No ulcers or scars noted.
PULSES:
Right: Radial 2+
Left: Radial 2+ DP 0 PT 0
.
DISCHARGE EXAM:
GEN: NAD
NECK: JVP flat
CV: Irregular rate and rhythm, no m/r/g appreciated
PULM: no crackles, good air movement, resp unlaboured
ABD: NABS, soft, non-tender even with deep palpation.
EXT: No edema. Wound on right foot largely unchanged, lambs
wool between toes at site of kissing ulcer sticking to ulcer
site this am. Eschar material coming loose from toe with minimal
drainage. Toe much less TTP. Feet warm. Dopplerable pulses.
NEURO: A/Ox3, non-focal
Pertinent Results:
ADMISSION LABS
[**2175-8-18**] 01:42PM BLOOD WBC-10.1 RBC-3.31* Hgb-10.4* Hct-29.5*
MCV-89 MCH-31.3 MCHC-35.1* RDW-13.2 Plt Ct-165
[**2175-8-18**] 01:42PM BLOOD Neuts-75.6* Lymphs-16.6* Monos-3.5
Eos-3.8 Baso-0.5
[**2175-8-18**] 01:42PM BLOOD PT-14.8* INR(PT)-1.3*
[**2175-8-18**] 01:42PM BLOOD Glucose-133* UreaN-20 Creat-0.9 Na-140
K-3.5 Cl-103 HCO3-28 AnGap-13
[**2175-8-18**] 01:42PM BLOOD ALT-15 AST-32 CK(CPK)-65 AlkPhos-77
Amylase-27
[**2175-8-18**] 01:42PM BLOOD CK-MB-5 cTropnT-0.11*
[**2175-8-18**] 01:42PM BLOOD Albumin-3.1*
[**2175-8-18**] 01:42PM BLOOD %HbA1c-7.9* eAG-180*
PERTINENT LABS
[**2175-8-19**] 04:10AM BLOOD ESR-46*
[**2175-8-18**] 01:42PM BLOOD CK-MB-5 cTropnT-0.11*
[**2175-8-19**] 04:10AM BLOOD CK-MB-4 cTropnT-0.08*
[**2175-8-19**] 04:10AM BLOOD CRP-78.5*
[**2175-8-19**] 04:10AM BLOOD %HbA1c-8.2* eAG-189*
[**2175-8-19**] 02:42PM BLOOD Lactate-2.4*
[**2175-8-19**] 09:17PM BLOOD Lactate-1.2
[**2175-8-20**] 05:46AM BLOOD Lactate-0.8
DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-8-29**] 06:30 9.3 3.66* 11.2* 33.7* 92 30.7 33.4 14.3 207
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-8-29**] 06:30 183*1 16 0.9 139 4.8 104 26 14
PERTINENT STUDIES
# [**8-18**] Cardiac Cath
1. Selective coronary angiography of this co-dominant system
revealed
three vessel coronary disease. The LMCA had a 20% distal lesion.
The LAD
had 70% proximal stenosis with a very tortuous mid-distal vessel
with
mid 70 and 60% stenoses. There was moderate stenosis of major
branching
S2 and apical collaterals to the RPDA with retrograde filling of
the
distal RCA upstream of the RPDA. The LCX had a 65% proximal
lesion and
an 80% complex mid-vessel lesion at the bifurcation of the major
OM1.
There was mild-moderate diffuse disease in the AV groove LCX
after Om1
to 50%. Ther ewas a modest caliber LPL1 and LP2, a small PDA and
collaterals to the RPDA. The RCA had a proximal 50% lesion and a
mid
occlusion.
2. Resting hemodynamics revealed mild pulmonary arterial
hypertension,
mild elevation of the LVEDP, no end diastolic gradient. The Peak
to peak
gradient across the aortic valve was 4mmHg (mean of 14mmHg) on
simultaneous recording of the LV and Ao, confirmed on left heart
pullback. The patient had a low calculated cardiac output with
calculated [**Location (un) 109**] 1.2cm2 by [**Last Name (un) 55965**] and 0.9cm2 by Haki, but
dobutamine was
not administered given recent myocardial infarction and history
of
atrial fibrillation.
3. Left Ventriculography was not performed. Heavy mitral annular
calcification and calcification of the aortic knob were noted.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systolic ventricular dysfunction.
3. Mild pulmonary arterial hypertension.
# [**8-19**] ECHO
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is 5-10 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the distal ventricle and apex. The remaining
segments are hyperdynamic (LVEF = 40-45 %). A left ventricular
thrombus was not seen but cannot be excluded given poor apical
windows. Right ventricular chamber size and free wall motion are
normal. There is an elongated echodense structure in the right
ventricular apex (0.8 x 1.7 cm, clip [**Clip Number (Radiology) **]). This most likely
represents a prominent moderator band and less likely a mural
thrombus given preserved RV function. In addition, a mass
attached to the RV lead cannot be excluded. The aortic valve
leaflets (3) are mildly thickened with mild aortic stenosis ([**Location (un) 109**]
1.2-1.9 cm2). No aortic regurgitation is seen. There is severe
mitral annular calcification. There is mild functional mitral
stenosis (mean gradient 7mmHg) due to mitral annular
calcification. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild-moderate focal dysfunction c/w CAD. Severe MAC with at
least moderate mitral regurgitation. Mild aortic stenosis based
on visual assessment and continuity equation (transvalvular
aortic velocities and gradients are not increased). Right
ventricular echodensity as described above. Moderate pulmonary
artery systolic hypertension.
# [**8-19**] CXR
The tip of the Swan-Ganz catheter is in the proximal part of the
right main pulmonary artery. There is no evidence of a
pneumothorax. The heart is enlarged, but there is no failure. A
dual-chamber pacemaker is present.
IMPRESSION: Tip of Swan-Ganz catheter in proximal right main
pulmonary
artery. No pneumothorax.
# [**8-20**] CXR
In comparison with the study of [**8-19**], there is evidence for
increased pulmonary venous pressure, consistent with the
clinical impression of pulmonary edema. There has been
development of right and probably a small left pleural effusion.
Pacemaker device remains in place and the right IJ Swan-Ganz
catheter tip is in the right pulmonary artery.
# [**8-20**] CXR (portable)
The lungs are well expanded and show mild bilateral interstitial
and focal
airspace opacities. In addition, there are more confluent
opacities in both lower lobes. The cardiac silhouette is
enlarged, unchanged. The mediastinal silhouette and hilar
contours are normal. A sheath is noted in the right internal
jugular, terminating in the proximal SVC. A left-sided pacer
terminates with its leads in the right atrium and right
ventricle. There is a moderate right and small left pleural
effusion. No pneumothorax is present.
IMPRESSION: Interval improvement in now mild pulmonary edema.
Unchanged right moderate and small left pleural effusion.
# [**8-19**] Foot
FINDINGS: No prior images. Calcification in small vessels is
consistent with diabetes. There is soft tissue swelling about
the fourth digit, though no definite evidence of erosions or
lucencies on this limited study. If there is a high clinical
suspicion for osteomyelitis, MRI could be helpful.
# [**8-23**] Lower extremity arterial studies
RIGHT: The right ABI is 0.55/0.33 at PT and DP respectively. The
right
femoral, superficial femoral, popliteal, posterior tibial
waveforms are all monophasic. The dorsalis pedis waveform is
nearly aphasic. PVRs show a
significant dampening between the thigh and calf and again in
the distal areas with aphasic metatarsal tracing. The digital
pleth waveforms are flat.
LEFT: The left ABI is 0.34/0.35 at PT and DP respectively.
Doppler waveforms are monophasic at all levels with severe
dampening at the dorsalis pedis. The PVRs show severe dampening
at ankle and flat tracing at the metatarsal level. Digital
plethysmography is flat.
IMPRESSION: Multilevel occlusive disease involving inflow and
tibial vessels bilaterally. Forefoot ischemia is severe
bilaterally.
# [**8-25**] Lower extremity catheterization
FINAL DIAGNOSIS:
1. Severe right lower extremily multilevel disease with
re-occlusion of
the previously angioplastied right dSFA-Popliteal segment,
severe right
TPT disease and severe diffuse right PT disease with occlusion
of the
right AT and Peroneal arteries with minimal flow to the right
foot.
2. Successful PTA and stenting of the right dSFA-Popliteal with
deployment of three overlapping Zilver stents.
3. Successful PTA of the PT and TPT with a 2.0mm balloon.
# [**8-28**] Lower extremity arterial studies
FINDINGS: Monophasic Doppler waveforms were seen bilaterally at
the femoral, popliteal, posterior tibial and dorsalis pedis
arteries. The right ABI was 0.98 and the left ABI was 0.42.
Pulsed volume recordings showed markedly decreased amplitudes on
the left
side, with flat tracing at the left ankle, metatarsal, and
digits.
COMPARISON: Compared to the noninvasive arterial study obtained
on [**2175-8-23**], there has been improvement in the right ABI
and right ankle and
metatarsal pulsed volume recordings.
IMPRESSION:
1. Bilateral inflow arterial disease to the lower extremities.
2. Mild outflow arterial disease in the right lower extremity,
which has
significantly improved since the last study of [**2175-8-23**].
3. Severe outflow arterial disease component in the left lower
extremity.
Brief Hospital Course:
87 y.o woman with history of afib, sick sinus s/p pacemaker
placement, hypertension transferred from outside hospital for
cardiac cath, and was found to have three vessel coronary artery
disease and gangrenous R 4th toe.
.
ACTIVE ISSUES
# Coronary artery disease
Patient was transferred from outside hospital for concerns of
NSTEMI. Cardiac catheterization was performed immediately upon
arrival and showed three vessel coronary artery disease with
moderate systolic ventricular dysfunctionn and mild pulmonary
arterial hypertension. The definitive treatment for her
condition is either CABG or high risk angioplasty. However, her
condition was unstable to pursue either modality. Per
discussion with patient herself and family, a decision of
medical management was made. Patient was treated with aspirin
325 mg daily, metoprolol succinate XL 200 mg daily and
fondaparinux 2.5 mg for 8 days. There were no increase in CK-MB,
but troponin remained marginally positive throughout this
hospitalization. Patient was briefly treated for chest pain
initially, but remainly asymptomatic afterwards.
OUTPATIENT ISSUES
- STARTED Plavix, not on coumadin, s/p stenting of peripheral
artery
.
# Atrial fibrillation:
During the first night, patient developed atrial fibrillation
with RVR and chest pain. She was given her home dose of
verapermil, po metoprolol, two sublingual nitroglycerine as well
as an additional 5 mg iv metoprolol for rate control. Shortly
afterwards patient developed hypotension with SBP in 60s. She
was then transferred to CCU for treatment of cardiogenic shock
(see below). She returned to sinus rhythm on the second day.
Her atrial fibrillation recurred again later during the
hospitalization, but she remained hemodynamically stable. We
held her verapermil, but continued her on 100 mg metoprolol XL
daily for rate control.
.
# Cardiogenic shock:
Patient was found to be in cardiogenic shock on the second
hospital day. This potentially could have been precipitated by
patient's atrial fibrillation and her likely markeded dependence
on her atrial kick due to significant mitral stenosis from her
mitral annulus calcification as well as decreased contractility
from NSTEMI. She was treated in CCU with fluid, and
dopamine/levophed drip. Patient was successfully weaned off
pressor within 24 hours, and remained hemodynamically stable
aftewards. ECHO on [**8-19**] showed mild symmetric left ventricular
hypertrophy with mild-moderate focal dysfunction c/w CAD, with
LVEF 40-45%.
.
# Pulmonary edema
Patient developed acute shortness of breath with a drop of O2
saturation to 80s on the next morning after successful treatment
of cardiogenic shock. A stat chest X-ray showed pulmonary
edema. She received iv lasix, and responded well to the
diuresis. Her Losartan was not continued during her hospital
stay because of uptitration of the metoprolol. Please restart at
25 mg daily in a few days. Furosemide 20 mg daily was started
during this hospitalization. Her discharge weight was 56.9kg.
.
# Gangrenous right foot
Patient has a nonhealing ganrenous ulcer in her right foot,
which started about nine month ago, and was evaluated at the OSH
prior to admission at our hospital. Culture from OSH grew MRSA
which was sensitive to genatmycin, tetracycline, bactrim and
vancomycin. A foot X-ray showed tracking to the bones
consistent with osteomyelitis. Given the high likelihood of
polymicrobial infection in the setting diabetic foot ulcer,
patient was received triple coverage of vancomycin,
ciprofloxacin and flagyl during this hospitalization per ID
consult. Patient had an arterial study, which showed severe
outflow arterial disease component in the left lower extremity.
Patient underwent popliteal catheterization with three stents
placed. Her DP pulses were dopplerable all the way to the
distal toe, and vessel patency was confirmed on a repeat
arterial study. Patient was reevalauted by ID, who recommend
finishing a 6 week course of vancomycin, ciprofloxacin and
flagyl. A PICC line was placed on the day of discharge.
OUTPATIENT ISSUES:
- START vancomycin 1250 mg iv qd for 6 weeks
- START Ciprofloxacin 500 mg po bid for 6 weeks
- START Metroniadazole 500 mg po tid for 6 weeks
- Patient will be followed by ID in two weeks.
.
CHROINIC ISSUES
# Diabetes mellitus
Patient has a documented history of type 2 diabetes, and was
treated with sliding scale insulin during this hospitalization.
Her hemoglobin A1c was 8.2.
.
TRANSITIONAL ISSUES
- Patient declared a code status of DNR/DNI
- Lenthy discussion was made with both the patient and her
family regarding the the goal of care. Patient apppears to
value quality of life, and independence; and therefore may not
want invasive therapy. Palliative care team was involved in her
care this hospitalization. The goal of care is expected to
change as patient's condition changes.
Medications on Admission:
TRANSFER MEDICATIONS:
.
NTG 0.4 SL prn
ASA 325 daily
Vicodin q4 prn
Heparin gtt
Lexapro 10 daily
Latanoprost eyedrops
Bactrim DS [**Hospital1 **]
Tylenol 650 q6 prn
Verapemil 240 daily
metoprolol XL 25 daily
Losartan HCT 50/12.5 [**2-5**] pill daily
Glimepiride 4 mg [**Hospital1 **]
Zetia 10mg daily
Colace 100 daily
Digoxin 0.125 daily
Plavix 75 daily
Humalog sliding scale
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for Chest pain: no more
than 3 tablets for each episode.
3. 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.
4. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for Pain >6: do not exceed 4 grams
of acetaminophen per day.
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
8. glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Humalog 100 unit/mL Solution Sig: 0-14 units Subcutaneous
four times a day: before meals and qhs as per sliding scale.
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take daily until Dr. [**First Name (STitle) **] tells you to stop.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 weeks: Stop on [**2175-10-7**].
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 weeks: Last day [**2175-10-7**].
14. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): to necrotic area on toe.
15. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 24H (Every 24 Hours) for 6 weeks: Last day [**2175-10-7**]. Please
check trough before dose on [**2175-8-31**] and adjust vanco dose as
needed.
18. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Cardiogenic shock
Acute systolic dysfunction
Severe coronary artery disease
Diabetes mellitus
Right toe ulcer with osteomyolitis and gangrene
Peripheral artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for your at [**Hospital1 18**].
You were transferred from [**Hospital3 **] for a cardiac
catheterization which showed severe blockages in your heart
arteries. The decision was made by the team, you and your family
to treat these blockages with medicines instead of surgery. You
developed a rapid heart rhythm called atrial fibrillation that
caused a low blood pressure and shock. In this setting you also
had fluid overload and needed to take diuretics to remove the
fluid. Your right toe ulcer was more painful and you underwent a
peripheral catheterization and received 3 stents to open the
artery in your leg to increase the blood flow to your toe. This
seems to be working and your circulation to the foot is much
improved. You will need daily dressing changes and intravenous
antibiotics to treat the infection in your toe bone until
[**2175-10-7**]. A PICC line was placed on [**8-29**] for the antibiotics. You
will need to be seen by the infectiious disease team and Dr.
[**First Name (STitle) **] in a few weeks.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 45513**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop taking Verapamil, Losartan HCT, Colace and Digoxin.
2. Start taking Ciprofloxacin, Flagyl and Vancomycin for the
infection in your toe bone, you will need these intravenously
for 6 weeks.
3. Start taking pantoprazole for your stomach
4. Start taking Lomotil for the diarrhea
5. Use Collagenase on your toe to remove dead tissue
6. Start Lasix to prevent fluid from accumulating
7. Increase metoprolol to 200 mg daily to prevent a rapid heart
rate.
Followup Instructions:
ID:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2175-9-15**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2175-9-29**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: FRIDAY [**2175-9-15**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
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"427.31",
"250.80",
"731.8",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.48",
"00.41",
"39.50",
"39.90",
"38.93",
"88.42",
"37.23",
"89.64",
"00.47"
] |
icd9pcs
|
[
[
[]
]
] |
20060, 20157
|
12624, 17500
|
459, 484
|
20421, 20421
|
4130, 6772
|
22319, 23436
|
2797, 2855
|
17927, 20037
|
20178, 20400
|
17526, 17526
|
11305, 12601
|
20604, 22296
|
2870, 3638
|
2318, 2410
|
3654, 4111
|
409, 421
|
17548, 17904
|
512, 2210
|
20436, 20580
|
2441, 2633
|
2232, 2298
|
2649, 2781
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,400
| 184,852
|
42059
|
Discharge summary
|
report
|
Admission Date: [**2131-10-8**] Discharge Date: [**2131-10-24**]
Date of Birth: [**2053-12-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Nasogastric tube ([**2131-10-10**])
ERCP / Endoscopic Ultrasound
History of Present Illness:
77 year old woman with PMH of DM and AFib on coumadin s/p open
cholecystectomy [**2131-7-18**]. Post op course complicated by
pancreatitis requiring extended hospital stay at OSH. Discharged
to NH on TPN, where patient was found to have worsening RUQ
abdominal pain, nausea, vomiting and subjective fevers leading
to admission OSH on [**2131-10-2**]. Patient was found to have
symptomatic pseudocysts, and underwent unsuccessful ERCP on
[**10-5**]. Post-ERCP course was c/b increased abdominal pain and
LFT's, lipase. Also with atrial fibrillation with RVR controlled
with diltiazem gtt on transfer and per nursing report at OSH
bloody bowel movement with Hgb drop from 9.0 to 7.9. Patient is
transferred for further evaluation and treatment for pancreatic
pseudocysts. VS prior to transfer were BP 119/52, HR 82 in A
fib. 98% on RA.
.
On the floor, patient appears comfortable and in NAD distress.
She is Creole only speaking and her son is at bedside who
provides much of history. She complains of persistent RUQ
abdominal pain worse with eating to [**10-1**] since her surgery in
[**Month (only) 205**]. She also notes persistent nausea and vomiting as well.
Last emesis yesterday x1 without blood. Denies blood in stool
despite OSH report, with last bowel movement 2 days prior. Also
endorsed approximately 50 lb weight loss over the last several
months.
.
Review of systems, somewhat limited:
(+) Per HPI
(-) Denies Denies headache or recent URI symptoms. Denies cough
and SOB. Denies chest pain. Denies dysuria.
.
Past Medical History:
-Diabetes
-HLD
-HTN
-AFib
-S/p open CCY [**2131-7-18**] c/b pancreatitis and pancreatic pseudocyst
Social History:
[**Location 7979**]. Moved here 19 years ago. Lived with son prior to
moving into [**Name (NI) **].
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Unremarkable
Physical Exam:
Admission Physical Exam:
Vitals: T:98.5 BP:134/75 P:100 R:22 O2:99%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, PERLL, EOMI, MMM, thick white plaque
over tongue
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic with irregular rate, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Soft, distended, TTP diffusely but most prominent over
RUQ. Soft bowel sounds present, no rebound tenderness or
guarding, difficult to appreciate for HSM. Well healed surgical
scars c/w prior surgery.
Ext: warm, well perfused, 1+ DP 2+ radial pulses. No clubbing,
cyanosis or edema
Neuro: CNII-XII grossly intact. Able to lift both legs off bed
with ease. Good strength upper extremities bilaterally. No gross
sensory loss.
Pertinent Results:
CXR [**10-9**]:
FINDINGS: No previous images. The tip of the right-sided PICC
line lies in
the upper portion of the SVC. Cardiac silhouette is somewhat
prominent,
though this may merely reflect the portable positioning. Lungs
are clear
without evidence of vascular congestion.
.
KUB [**10-10**]:
IMPRESSION: No evidence of obstruction. No oral contrast is seen
within the abdomen.
.
Reports:
CT a/p [**10-9**]
IMPRESSION:
1. Persistent pancreatic pseudocyst within the head of the
pancreas with no evidence of necrotizing pancreatitis. There may
be some superimposed active inflammation, but the majority of
the changes are consistent with a chronic inflammatory process,
especially given the pancreatic ductal dilation. In a patient
without a clear history of acute pancreatitis, intraductal
papillary mucinous neoplasm would enter into differential
diagnosis. If further evaluation of the pseudocyst is required,
the recommended next studies would be endoscopic ultrasound or
MRCP.
2. Delayed transit of p.o. contrast into the small bowel. This
is most
likely caused by inadequate time given for transit of contrast.
With a
gastric outlet obstruction, one would expect more marked gastric
dilation.
3. Cardiomegaly.
4. Multiple large bilateral simple cysts of the kidneys.
5. Degenerative changes of the spine and hips.
.
EUS [**10-11**]
Impression: EGD: The mucosa at the pylorus and duodenal bulb and
the sweep was edematous with mild to moderate narrowing of the
lumen. It was traversed with the scope.
EUS: Large ill-defined heterogenous mass / expansion of the head
of pancreas. There were hyperechoic areas within the mass. There
was edema surrounding the mass that involved the duodenal wall.
This was suggestive of an inflammatory mass.
The main PD was dilated and contained multiple stones in the
head of the pancreas.
The PD of the body and tail was mildly dilated to 3.4mm.
There were multiple small peripancreatic lymph nodes. FNA was
performed.
CBD was normal. There was no dilation or stones.
.
Recommendations: Follow-up cytology results. If it is benign,
repeat CT in 2 - 3 months to reassess the pancreas.
Restart heparin drip in [**3-28**] hours.
Continue current antibiotic.
Return to hospital [**Hospital1 **] and f/u with pancreas team.
.
.
.
Biopsy:
DIAGNOSIS: FNA, Peripancreatic Lymph Node:
NEGATIVE FOR MALIGNANT CELLS.
[**10-15**] CT abd/pelvis IMPRESSION:
1. Markedly decreased size of cyst in the pancreatic head.
Differential
diagnosis includes ruptured pseudocyst or interval draining of
pancreatic cyst through the ampulla.
2. Mucosal enhancement of fluid-filled ascending colon, likely
secondary to adjacent right-sided inflammation. However, primary
colonic inflammation cannot be excluded. There is no evidence
for intestinal perforation or ischemia.
3. Soft tissue density in the left retroareolar region.
Underlying mass
cannot be excluded. Correlation with mammography is recommended.
.
KUB [**10-15**]
IMPRESSION: No evidence of obstruction. No free air. No evidence
of
pneumatosis.
.
KUB [**10-19**]:
Preliminary Report !! WET READ !!
No evidence of obstruction or free air.
.
Microbiology:
[**2131-10-17**] 9:33 pm URINE Source: CVS.
**FINAL REPORT [**2131-10-19**]**
URINE CULTURE (Final [**2131-10-19**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
[**2131-10-17**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
INPATIENT
[**2131-10-14**] URINE URINE CULTURE-FINAL INPATIENT
[**2131-10-9**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2131-10-9**] URINE URINE CULTURE-FINAL INPATIENT
[**2131-10-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2131-10-8**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
.
[**2131-10-19**] 07:35AM BLOOD WBC-5.7 RBC-3.97* Hgb-11.1* Hct-33.9*
MCV-85 MCH-27.9 MCHC-32.8 RDW-16.1* Plt Ct-438
[**2131-10-18**] 03:56AM BLOOD WBC-8.8# RBC-3.82* Hgb-10.1* Hct-32.5*
MCV-85 MCH-26.5* MCHC-31.1 RDW-17.1* Plt Ct-449*
[**2131-10-17**] 06:00AM BLOOD WBC-5.8 RBC-3.61* Hgb-9.6* Hct-31.1*
MCV-86 MCH-26.5* MCHC-30.7* RDW-17.0* Plt Ct-461*
[**2131-10-16**] 11:46AM BLOOD WBC-5.4 RBC-3.60* Hgb-9.8* Hct-30.7*
MCV-85 MCH-27.3 MCHC-32.0 RDW-16.1* Plt Ct-485*
[**2131-10-16**] 04:33AM BLOOD WBC-5.5 RBC-3.59* Hgb-9.7* Hct-31.4*
MCV-87 MCH-27.0 MCHC-30.9* RDW-17.0* Plt Ct-447*
[**2131-10-15**] 05:31AM BLOOD WBC-6.6 RBC-3.59* Hgb-9.8* Hct-30.6*
MCV-85 MCH-27.3 MCHC-32.1 RDW-16.1* Plt Ct-535*
[**2131-10-14**] 06:00AM BLOOD WBC-7.3 RBC-3.37* Hgb-8.9* Hct-28.9*
MCV-86 MCH-26.5* MCHC-30.9* RDW-16.7* Plt Ct-499*
[**2131-10-13**] 02:59AM BLOOD WBC-7.5 RBC-3.11* Hgb-8.4* Hct-26.6*
MCV-85 MCH-27.0 MCHC-31.6 RDW-15.5 Plt Ct-467*
[**2131-10-12**] 12:19AM BLOOD WBC-8.0 RBC-3.24* Hgb-8.5* Hct-27.3*
MCV-84 MCH-26.2* MCHC-31.1 RDW-15.2 Plt Ct-421
[**2131-10-11**] 05:27AM BLOOD WBC-6.9 RBC-3.11* Hgb-8.3* Hct-26.4*
MCV-85 MCH-26.8* MCHC-31.7 RDW-15.3 Plt Ct-407
[**2131-10-10**] 11:56AM BLOOD Hct-25.3*
[**2131-10-10**] 04:37AM BLOOD WBC-13.0*# RBC-2.93* Hgb-7.7* Hct-25.4*
MCV-87 MCH-26.3* MCHC-30.4* RDW-15.1 Plt Ct-373
[**2131-10-9**] 05:17AM BLOOD WBC-8.6 RBC-2.97* Hgb-7.9* Hct-25.4*
MCV-85 MCH-26.6* MCHC-31.1 RDW-15.4 Plt Ct-362
[**2131-10-8**] 10:54PM BLOOD WBC-10.0 RBC-3.14* Hgb-8.4* Hct-26.5*
MCV-84 MCH-26.8* MCHC-31.8 RDW-16.2* Plt Ct-340
[**2131-10-13**] 02:59AM BLOOD Neuts-67 Bands-0 Lymphs-26 Monos-6 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2131-10-11**] 05:27AM BLOOD Neuts-62.7 Lymphs-26.5 Monos-9.2 Eos-1.3
Baso-0.2
[**2131-10-19**] 07:35AM BLOOD Plt Ct-438
[**2131-10-18**] 03:56AM BLOOD Plt Ct-449*
[**2131-10-19**] 07:35AM BLOOD Glucose-255* UreaN-20 Creat-0.6 Na-134
K-3.9 Cl-101 HCO3-24 AnGap-13
[**2131-10-18**] 03:56AM BLOOD Glucose-131* UreaN-18 Creat-0.6 Na-137
K-4.5 Cl-105 HCO3-27 AnGap-10
[**2131-10-17**] 06:00AM BLOOD Glucose-119* UreaN-15 Creat-0.5 Na-139
K-4.5 Cl-107 HCO3-24 AnGap-13
[**2131-10-16**] 11:46AM BLOOD Glucose-130* UreaN-16 Creat-0.6 Na-137
K-4.7 Cl-105 HCO3-24 AnGap-13
[**2131-10-16**] 04:33AM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-139
K-4.4 Cl-104 HCO3-24 AnGap-15
[**2131-10-15**] 05:31AM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-137
K-4.8 Cl-102 HCO3-27 AnGap-13
[**2131-10-14**] 06:00AM BLOOD Glucose-108* UreaN-11 Creat-0.5 Na-139
K-4.9 Cl-104 HCO3-28 AnGap-12
[**2131-10-13**] 02:59AM BLOOD Glucose-127* UreaN-13 Creat-0.5 Na-138
K-4.1 Cl-105 HCO3-26 AnGap-11
[**2131-10-19**] 07:35AM BLOOD ALT-20 AST-30 AlkPhos-125* TotBili-0.4
[**2131-10-14**] 06:00AM BLOOD ALT-39 AST-19 LD(LDH)-197 AlkPhos-173*
TotBili-0.4
[**2131-10-15**] 05:31AM BLOOD ALT-34 AST-22 TotBili-0.5
[**2131-10-13**] 02:59AM BLOOD ALT-49* AST-18 LD(LDH)-206 AlkPhos-183*
TotBili-0.4
[**2131-10-12**] 12:19AM BLOOD ALT-70* AST-24 LD(LDH)-218 AlkPhos-228*
TotBili-0.7
[**2131-10-11**] 08:11PM BLOOD Amylase-127*
[**2131-10-11**] 05:27AM BLOOD ALT-96* AST-37 LD(LDH)-181 AlkPhos-257*
TotBili-0.6
[**2131-10-10**] 04:37AM BLOOD ALT-131* AST-110* LD(LDH)-211
AlkPhos-305* TotBili-0.9
[**2131-10-9**] 05:17AM BLOOD ALT-162* AST-103* LD(LDH)-227
AlkPhos-271* TotBili-1.0
[**2131-10-8**] 10:54PM BLOOD ALT-190* AST-134* AlkPhos-301*
Amylase-112* TotBili-1.2
[**2131-10-19**] 07:35AM BLOOD Lipase-17
[**2131-10-15**] 05:31AM BLOOD Lipase-14
[**2131-10-14**] 06:00AM BLOOD Lipase-13
[**2131-10-13**] 02:59AM BLOOD Lipase-13
[**2131-10-11**] 08:11PM BLOOD Lipase-10
[**2131-10-8**] 10:54PM BLOOD Lipase-42
[**2131-10-8**] 10:54PM BLOOD calTIBC-243* Ferritn-285* TRF-187*
[**2131-10-15**] 01:43PM BLOOD Lactate-1.5
.
[**2131-10-24**] 09:08AM BLOOD WBC-4.6 RBC-3.88* Hgb-10.6* Hct-32.9*
MCV-85# MCH-27.4 MCHC-32.3# RDW-17.3* Plt Ct-321
[**2131-10-24**] 09:08AM BLOOD Glucose-125* UreaN-18 Creat-0.6 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
[**2131-10-24**] 09:08AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
.
Microbiology:
[**2131-10-20**] 3:53 pm URINE Source: CVS.
**FINAL REPORT [**2131-10-21**]**
URINE CULTURE (Final [**2131-10-21**]): <10,000 organisms/ml.
.
.
[**10-19**] KUB:
INDICATION: Severe abdominal pain with nausea and vomiting,
evaluate for
obstruction or free air.
.
COMPARISON: [**2131-10-15**].
.
FINDINGS: Two frontal views of the abdomen were obtained. There
is no free
air. There is air seen throughout the small and large bowel with
a few
scattered air-fluid levels, but no evidence of dilatation. There
are
degenerative changes of the lumbar spine and bilateral hips.
There are clips in the right upper quadrant. The visualized lung
bases are clear.
.
IMPRESSION: No evidence of obstruction or free air.
.
Brief Hospital Course:
77 year old woman with DM and AFib s/p open cholecystectomy for
gallstone pancreatitis in [**Month (only) 205**] with post op course c/b recurrent
pancreatitis and subsequent pseudocysts admitted to OSH with
persistent pain and nausea who failed ERCP transferred for
further evaluation and treatment. Course complicated by afib
with RVR and periods of continued pain with nausea and vomiting.
.
#Abdominal pain/pseudocysts/chronic pancreatitis/pancreatic duct
stones- Given recent history of recurrent pancreatitis and
enlarging pseudocysts on OSH CT, suspected that symptomatic
psueudocyst was causing intermittent biliary obstruction. As pt
was afebrile there was less suspicion for spontaneous infection
or cholangitis. HCT was stable, lowering suspicion for
spontaneous bleed into pseudocyst. Given increased pain and
lipase following ERCP on [**10-5**] at OSH, acute exacerbation of
pain could be explained by recent ERCP pancreatitis although
lipase was normal. Given recent surgery and abdominal
distension, considered bowel obstruction but BS present on exam
and patient's bowel habits have been normal per history. KUB
without obstruction or free air. EUS performed this admission
finding edematous pylorus, large ill-defined heterogenous mass
in the head of the pancrea, dilated PD with multiple stones.
Small peripancreatic lymph nodes. CBD not dilated. Despite
NPO/TPN status, pt continued to have bouts of significant
abdominal pain and repeat KUB and CT were performed. KUB was
negative for obstruction. CT scan showed "decrease in size of
pseudocyst". Pt's episodes of intermittent pain, likely due to
known stones in pancreatic duct as well as recurrent
pancreatitis. ERCP followed the patient. ERCP's recommendations
were for no plans for any additional ERCP/EUS intervention this
admission. Pt did have evidence of chronic pancreatitis and
pancreatic duct stones on recent ERCP. Plan is for NPO an TPN
x4wks, improvement of recent acute pancreatitis and then repeat
ERCP to attempt and extract PD stones and further evaluate
"pseudocyst" that ERCP feels could be a phlegmon vs. mass. Pt
was given 7 days of empiric cipro/flagyl as well as a bowel
regimen. At this time, patient continues to experience daily
bouts of abdominal pain, felt to be likely due to the pancreatic
duct stones. The episodes are acute in nature, but respond well
to IV opiates, as well as anti-emetic medications.
PT WILL NEED REPEAT EUS/ERCP IN 4 WKS TIME TO EVALUATE FOR
POSSIBILITY OF MASS/IMPN RATHER THAN PSEUDOCYST. She will
follow-up with ERCP, and may need additional Surgical follow-up
as well, pending repeat ERCP/EUS evaluation.
.
# Atrial Fibrillation. Chronic. Pt on coumadin as an outpt. She
was transferred on a diltiazem gtt given inability to tolerate
any PO. She was eventually transitioned to 90mg QID dilt.
However, given increased pain/n/v she was briefly on IV
metoprolol, but was transitioned back to oral diltiazem. She
was placed on lovenox [**Hospital1 **] and coumadin was held given the
possibility of upcoming procedures and inability to tolerate
reliable PO.
.
# ? enterococcal UTI- Was initially started on IV unasyn while
awaiting culture results, however final culture results grew
multiple bacterial organisms consistent with contamination with
skin/genital flora. The antibiotic was discontinued and the the
UA/Urine culture was repeated. The repeat urine culture grew
<10K organisms. She denied any dysuria, suprapubic tenderness
or flank pain.
.
# oral thrush - the patient was noted to have oral thrush on
exam, although she denied any pain. She was started on Nystatin
swish/swallow, and should continue on this for 7 additional days
once her symptoms resolve. If the symptoms persist, consider a
course of oral fluconazole.
.
# ? GIB: Per OSH nursing report, possible bloody bowel movement.
Patient denied. No further reported episodes. Stools were
ordered for guaiac. HCT remained stable.
.
# normocytic Anemia: Iron studies and hx appeared c/w AOCD given
elevated ferritin with low serum iron and TIBC. No further
episodes of GIB see above. Stable. HCT on discharge was 32.9.
.
# Transaminitis: LST's wnl on admission to OSH on [**10-2**].
Increased during admission, thought to be due to transient
obstruction from pseudocyst vs. recent ERCP. This trended
downward and normalized.
.
# HTN, benign: Currently normotensive. Will continue home
regimen of doxazosin 4mg [**Hospital1 **] and enalapril 5 daily. Is also on
diltiazem for atrial fibrillation.
.
# Diabetes: On metformin at home. Currently NPO on TPN.
-Continued enalapril
-Humalog sliding scale while on TPN.
.
INCIDENTAL RADIOGRAPHIC FINDING:
#*********Soft tissue density in the left retroareolar region.
Underlying mass
cannot be excluded. Correlation with mammography is recommended.
Will need outpt mammography*********
.
# FEN: TPNx 4wks per ERCP consult. Will allow sips with pills.
Should have Chem-10, LFT's, and trigylcerides monitored 3 times
per week to monitor her TPN.
# Prophylaxis: Lovenox [**Hospital1 **]
# Access: peripherals, PICC
# Code: Full
# Disposition: Pt will need 4 total weeks of TPN-bowel rest with
only sips/pills. Then will need repeat ERCP/EUS eval to attempt
to extract stones and evalauate "pseudocyst" to r/o mass.
.
Medications on Admission:
Home medications, per OSH records and patient unable to
reconcile:
- Doxazosin 4mg [**Hospital1 **]
- Coumadin 7.5mg daily
- Enalapril 5mg daily
- Lopressor 75mg daily
- Lovenox 60mg SC bid
- Metformin 500 mg [**Hospital1 **]
- Protonix 40mg [**Hospital1 **]
.
Medications on transfer:
-Cipro 400 mg [**Hospital1 **]
-Dilaudid 0.5-2mg q4 hrs prn pain
-Diltiazem 30mg q6hrs
-Diltiazem gtt
-Metoclopramide 5mg IV q6hrs prn nausea
-ISS
-ZOfran 4mg IV q4hrs prn nausea
-Doxazosin 4mg [**Hospital1 **]
-Enalapril 5mg daily
-Lovenox 60mg SQ [**Hospital1 **]
-Protonix 40mg po bid
Discharge Medications:
1. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous [**Hospital1 **] (2 times a day).
3. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. hydromorphone 2 mg/mL Syringe Sig: Two (2) mg Injection Q3H
(every 3 hours) as needed for pain: hold for RR<10, sedation.
10. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
12. Humalog 100 unit/mL Solution Sig: see below for sliding
scale instructions Subcutaneous four times a day: please check
finger sticks q6hours.
for BS <70, [**Name8 (MD) 138**] MD, give juice
for BS 71 - 150, give zero units.
for BS 151 - 200, give 2 units humalog SQ,
for BS 201 - 250, give 4 units humalog SQ,
for BS 251 - 300, give 6 units humalog SQ,
for BS 301 - 350, give 8 units SQ,
for BS >350, give 10 units humalog SQ and notify MD.
13. finger sticks
check finger sticks every 6 hours and administer sliding scale
insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
acute on chronic pancreatitis
pancreatic duct stones
atrial fibrillation with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for further evaluation of abdominal pain,
nausea, vomiting. This is likely due to recurrent pancreatitis
and presence of cysts in your pancreas as well as stones. For
this, you were given bowel rest, IV fluids and started on TPN
(IV nutrition). It will be important that you do not have
anything to eat and drink other than sips of liquids with pills
for 4 week's total time. After, your body has had time to
recover from pancreatitis, you will need to be reevaluated by
the ERCP/GI and pancreatic surgical teams. You will need a
repeat ERCP.
.
In addition, you had many episodes of atrial fibrillation and
were started on diltiazem. You will continue on lovenox
injections for blood thinning (anticoagulation).
Medication changes:
1. diltiazem was STARTED
2. IV dilaudid was STARTED
3. Famotidine was STARTED
4. Nystatin was STARTED
5. Colace was STARTED
6. Insulin was STARTED
.
Please STOP the following medications that you were previously
taking:
METFORMIN
PROTONIX
COUMADIN
LOPRESSOR
.
Followup Instructions:
Department: GASTROENTEROLOGY
When: TUESDAY [**2131-11-27**] at 1:40 PM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
You will be discharged to a rehab facility and will be followed
by a doctor at the facility while you are there. Once you are
discharged, you should call your PCP (Dr. [**Last Name (STitle) 91285**] at
[**Telephone/Fax (1) 91286**] to be seen in follow-up.
.
|
[
"427.31",
"288.60",
"112.0",
"285.29",
"272.4",
"250.00",
"577.0",
"577.1",
"276.8",
"537.0",
"348.31",
"577.8",
"V58.61",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"88.74",
"45.13",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
19243, 19325
|
11806, 17066
|
321, 387
|
19451, 19451
|
3096, 11783
|
20637, 21246
|
2249, 2263
|
17691, 19220
|
19346, 19430
|
17092, 17353
|
19602, 20333
|
2303, 3077
|
20353, 20614
|
267, 283
|
415, 1936
|
19466, 19578
|
17378, 17668
|
1958, 2060
|
2076, 2233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,617
| 141,217
|
11483
|
Discharge summary
|
report
|
Admission Date: [**2108-2-17**] Discharge Date: [**2108-2-21**]
Date of Birth: [**2036-1-3**] Sex: M
Service: Medicine
CHIEF COMPLAINT: GI bleed.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
Jesuit priest who presents with upper GI bleed. He describes
several days of bright red blood in his vomitus, nausea and
vomiting. He has also had melena for several days as well.
He has had some lightheadedness and dizziness.
PAST MEDICAL HISTORY: Alcoholic cirrhosis originally
diagnosed by liver biopsy, questionable esophageal varices,
paroxysmal atrial fibrillation, type 2 diabetes, BPH,
hypothyroidism.
MEDICATIONS: On admission, Aldactone 25 mg po q d, Cardizem
CD 120 mg po q d, Levoxyl 50 mcg po q d, Lopressor 12.5 mg po
bid, change to Propranolol at recent GI visit, NPH 30 units
subcu q a.m., Colace 100 mg po bid and Trazodone at night for
sleep.
ALLERGIES: Muscle relaxants.
SOCIAL HISTORY: Remote history of alcohol abuse, none
recently. No tobacco, no other drug use. He is a Jesuit
priest, Fr. [**Name2 (NI) **] is his health care proxy.
PHYSICAL EXAMINATION: On admission revealed normal vital
signs, normal blood pressure and no fever. In general, he is
an elderly white male in no acute distress. Lungs are clear
to auscultation. Heart is regular, S1 and S2, 2/6 systolic
murmur at the right upper sternal border. Abdomen soft, non
distended, nontender. Rectal is with frank melena, 2+ edema
bilaterally. Neurologically is intact.
LABORATORY DATA: On admission revealed an initial hematocrit
of 31.2 that dropped to 25.6 after hydration. White count 7,
platelet count 120,000. Chem 7, sodium 137, potassium 5.0,
chloride 104, CO2 25, BUN 26, creatinine 0.8, glucose 202.
He ruled out for MI by CK. Calcium and phosphorus were
within normal limits. Chest x-ray was unremarkable. EKG
showed sinus rhythm at 70, borderline first degree AV block
and minor diffuse ST-T abnormalities, no change since [**11-25**].
HOSPITAL COURSE:
1. GI bleed: Given the patient's cirrhotic history and
questionable esophageal varices, the patient was monitored
very carefully in the ICU for possible esophageal variceal
bleed. His hematocrit was followed serially. His
hemodynamics remained normal throughout his initial stay in
the ICU. He was transfused with four units of red cells
initially with good response. He underwent upper endoscopy
which at first was unrevealing. He was noted to have a
slight drop in hematocrit over the next few days and was
re-endoscoped. At that time bleeding gastric varices were
seen although no esophageal varices were noted. The patient
underwent banding of this gastric varices and was treated
with Propranolol as well as Octreotide. He remained
hemodynamically stable after this procedure. The next day he
was hungry and requesting foods. He was able to tolerate
clear liquids and after 24 hours of observation after his
gastric variceal banding he was transferred out of the MICU.
The patient did well with a stable hematocrit and normal
vital signs. On the next day he decompensated. At that time
he was found unresponsive in his chair. A code was called
and resuscitation was begun. Initially the patient was
pulseless, had no blood pressure. CPR was begun and patient
was noted to vomit up large amounts of blood. The patient
was intubated and venous access was obtained. He received
aggressive blood resuscitation and with intubation and
institution of CPR quickly gained his pulse and blood
pressure. As his blood pressure remained low and he was
intubated, he was transferred back to the MICU. With
surgical assistance as well as GI assistance, aggressive
management was initiated for this gastric variceal bleed. The
patient received aggressive blood transfusions approximately
16 units as well as several units of FFP. Gastroenterology
came and with surgical assistance [**Last Name (un) **] tube was placed.
The patient's blood pressure was noted to be declining and
pressor therapy was begun. Upon the initial decompensation
and the code, the [**Hospital 228**] health care proxy, Fr. [**Name2 (NI) **],
was contact[**Name (NI) **]. Fr. [**Location (un) **] and patient's other family
members/friends did come to the scene. After large volumes
of blood had been given and patient's hemodynamics remained
poor as well as evidence of active bleeding, so discussion
was held with Fr. [**Location (un) **]. At that time we had been hopeful
that he would be able to go down for emergent TIPS but
patient was too unstable. After discussion with Fr. [**Location (un) **]
it was deemed that the patient would not have wanted these
heroic measures taken. Transfusion of blood products
stopped. Pressor support was stopped. At this time patient
was breathing on his own although still intubated. The
family members and friends were allowed to stay good-bye and
the patient expired at 8 p.m. on [**2108-2-21**].
DISCHARGE MEDICATIONS: None.
DISCHARGE DIAGNOSIS:
1. Massive gastric variceal bleed secondary to alcoholic
cirrhosis.
Dr. [**Last Name (STitle) **], patient's PCP, [**Name10 (NameIs) **] notified as was attending of
record, Dr. [**Last Name (STitle) **] [**Name (STitle) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 36649**]
MEDQUIST36
D: [**2108-3-26**] 11:55
T: [**2108-3-27**] 09:19
JOB#: [**Job Number 36650**]
|
[
"571.2",
"244.9",
"456.21",
"401.9",
"427.31",
"456.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.44",
"45.13",
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4959, 4966
|
4987, 5506
|
1998, 4935
|
1115, 1981
|
154, 165
|
194, 453
|
476, 922
|
939, 1092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,397
| 194,826
|
21704
|
Discharge summary
|
report
|
Admission Date: [**2189-11-3**] Discharge Date: [**2189-11-9**]
Date of Birth: [**2135-3-12**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Alcohol Isopropyl
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
54 yo female with cirrhosis, hepatic encephalopathy admitted on
[**2189-11-3**] for hepatic encephalopathy and hyponatremia. The patient
was enrolled in the SALT-2 trial (vasopressin antagonist v
placebo). On day of admission, she was noted to have a 7 point
hematocrit drop and had one episod of coffee ground emesis . She
was hemodynamically stable. GI recommended urgent transfer to
ICU for upper endoscopy.
Past Medical History:
Cirrhosis with ascites (thought to be due to methotrexate
toxicity), hepatic encephalopathy, hyponatremia, portal
gastropathy, psoriasis, psoriatic arthritis, multiple hand
surgeries
Social History:
Denies ETOh, +tobacco, 3 children
Family History:
No history of liver or colon cancer
Physical Exam:
99, 132/65, 114, 18, 100%RA, 58.2 kg
GEn: fatigued, pale, NAD
HEENT: PERRLA, anicteric, dry MM
CV: Tachy, no M/R/G,
Lungs: CTA
Abd: soft, NT, +ascites, +BS, guaiaic +
Ext: no cyanosis or edema, + psoriatic rash involving arms,
trunk
Neuro: A&Ox3, however somnolent, +asterixis
Pertinent Results:
[**2189-11-3**] 09:35AM BLOOD WBC-5.6# RBC-2.75* Hgb-9.5* Hct-29.0*
MCV-105* MCH-34.5* MCHC-32.8 RDW-15.7* Plt Ct-72*
[**2189-11-9**] 06:20AM BLOOD WBC-6.2 RBC-2.85* Hgb-9.6* Hct-28.5*
MCV-100* MCH-33.5* MCHC-33.5 RDW-18.5* Plt Ct-79*
[**2189-11-3**] 09:35AM BLOOD Neuts-75* Bands-1 Lymphs-12* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2189-11-3**] 09:35AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Target-1+ Burr-1+
[**2189-11-3**] 09:35AM BLOOD PT-14.5* PTT-32.8 INR(PT)-1.3
[**2189-11-3**] 09:35AM BLOOD Plt Smr-VERY LOW Plt Ct-72*
[**2189-11-8**] 06:40AM BLOOD PT-15.9* PTT-34.5 INR(PT)-1.6
[**2189-11-9**] 06:20AM BLOOD Plt Ct-79*
[**2189-11-5**] 12:52AM BLOOD Fibrino-144*
[**2189-11-3**] 09:35AM BLOOD UreaN-12 Creat-0.8 K-3.7 Cl-100 HCO3-20*
[**2189-11-4**] 06:30AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-132*
K-4.0 Cl-104 HCO3-21* AnGap-11
[**2189-11-9**] 06:20AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-132*
K-4.4 Cl-104 HCO3-22 AnGap-10
[**2189-11-3**] 09:35AM BLOOD ALT-34 AST-46* AlkPhos-119* TotBili-2.7*
[**2189-11-4**] 06:30AM BLOOD ALT-29 AST-35 AlkPhos-103 TotBili-2.2*
[**2189-11-3**] 09:35AM BLOOD Albumin-3.3* Calcium-8.8 Phos-2.7 Mg-1.6
[**2189-11-9**] 06:20AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
[**2189-11-5**] 03:30PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.023
[**2189-11-5**] 03:30PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2189-11-5**] 03:30PM URINE RBC-[**5-7**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2189-11-4**] 03:03PM ASCITES WBC-48* RBC-1305* Polys-15* Lymphs-11*
Monos-38* Mesothe-13* Macroph-21* Other-2*
[**2189-11-4**] 03:03PM ASCITES TotPro-1.2 Glucose-118 LD(LDH)-57
Albumin-<1.0
Micro:
[**2189-11-4**] URINE no growth
[**2189-11-4**] SEROLOGY/BLOOD no growth
[**2189-11-4**] FLUID no growth
[**2189-11-4**] no growth, no organisms or WBCs seen on Gram stain
Rads:
[**2189-11-6**] Radiology CHEST (PORTABLE AP) No acute
cardiopulmonary disease.
[**2189-11-6**] Radiology CTA ABD 1) Cirrhotic liver, with conventional
hepatic arterial anatomy, as described. Small accessory right
hepatic vein noted.
2) Marked wall thickening within the splenic flexure and rectum,
suggestive of colitis, probably inflammatory. Ischemia is felt
to be less likely, given the involvement of the rectum.
[**2189-11-4**] Cardiology ECHO The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. 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. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2189-11-3**] Radiology CHEST (PA & LAT) The heart size, mediastinal
and hilar contours are normal, and the lungs appear clear. There
are no pleural effusions. Minimal degenerative changes are noted
in the spine.
[**2189-11-3**] Radiology US ABD LIMIT, SINGLE ORGAN Limited
four-quadrant ultrasound was performed to identify suitable spot
for paracenteis. There is a large amount of ascites distributed
throughout the abdomen. A suitable spot for paracentesis was
marked in the left lower quadrant to be performed by the
referring clinical team.
Brief Hospital Course:
She was admitted to the ICU for urgent upper endoscopy.
1. UGIB: She remained hemodynamically stable and was transferred
one unit of blood. She was started on IV protonix [**Hospital1 **]. She was
also started on octreotide per Hepatology team for 48 hours. EGD
showed >10 ulcers, no esophageal varices and portal gastropathy
versus GAVE (gastric antral vascular ectasia). Serial
hematocrits and coags were tested. She was transfused one unit
of PRBC on [**2189-11-4**] with her UGIB and one unit of PRBC on
[**2189-11-6**] for a slowly decreasing hematocrit.
2. Cirrhosis: secondary to MTX hepatotoxicity, being followed by
Liver team and is to have complete liver transplant workup while
inpatient, including CT abdomen.
3. Hyponatremia: This is felt to be due to her cirrhosis. We
continued fluid restriction. She was maintained on the SALT-2
trial drug (tolvaptan vs placebo)(vasopressin antagonist).
4. Mental status: Initially her mental status waxed and waned.
Her mental status improved quickly while in the ICU. We
continued lactulose. Paracentesis was negative for SBP.
Maintained on Levaquin for ppx.
5. ID: Paracentesis was negative for SBP, however, she was
started on levofloxacin for SBP prophylaxis given her increased
risk for developing SBP with a UGIB.
6. GI: She was made NPO after the UGIB. Her diet was advanced
slowly and she was tolerating a regualar low protein diet upon
discharge.
Medications on Admission:
Lactulose 30 ml TID
protonix 40 mg daily
Aldactone 200 mg daily
Prochloperazine 0 mg QID PRN
Folate 1 mg daily
Tolvaptan/placebo
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Etanercept 25 mg Kit Sig: Twenty Five (25) mg injection
Subcutaneous Twice weekly (): patient may be instructed to take
more by her Rheumatologist.
4. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO QID (4
times a day).
Disp:*1 bottle* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
TID (3 times a day).
8. Tolvaptan Sig: One (1) tablet QD ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hepatic encephalopathy
Gastric Antrum Vascular Ectasia (GAVE)
Discharge Condition:
Stable with no complaints, no evid of hepatic encephalopathy
Discharge Instructions:
Please continue to take all medications as prescribed and to
follow up with your liver doctors [**First Name (Titles) **] [**Last Name (Titles) 20212**] of this week.
If you or your family members feel that you are becoming
confused, or if you develop abdominal pain, chest pain,
shortness of breath, dizziness or lightheadedness, please go to
the nearest Emergency Room or call 911 to have an ambulance
bring you.
Followup Instructions:
Please keep all of your scheduled appointments, including with
Dr. [**Last Name (STitle) **] (or potentially another Liver Fellow) this
[**Last Name (STitle) 20212**] [**2189-11-11**] at the [**Hospital Ward Name **] Liver Center on the [**Location (un) 861**] of
the [**Hospital Ward Name **] Bldg, 9am or as instructed by your liver doctors. They
will try to arrange your pulmonary function tests for the same
day.
|
[
"572.2",
"571.2",
"531.40",
"789.5",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7356, 7407
|
4874, 5785
|
336, 353
|
7513, 7575
|
1415, 4851
|
8039, 8459
|
1066, 1103
|
6467, 7333
|
7428, 7492
|
6314, 6444
|
7599, 8016
|
1118, 1396
|
276, 298
|
381, 793
|
5800, 6288
|
815, 999
|
1015, 1050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,953
| 102,143
|
48694
|
Discharge summary
|
report
|
Admission Date: [**2112-9-9**] Discharge Date: [**2112-9-13**]
Date of Birth: [**2060-8-8**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfonamides / Tigan /
Meperidine / Iodine; Iodine Containing / Prednisone / Cefotaxime
/ Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Ciprofloxacin / Heparin Agents / Fluconazole /
Meropenem / Tizanidine
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SVC syndrome/abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 52 female with h.o Crohn's disease with multiple
complications, SVC syndrome s/p angioplasty,
depression/anxiety/PTSD, HIT + who presents with acute on
chronic abdominal pain and facial swelling. Pt reports DOE for
the last month, and orthopnea for the last week. Facial swelling
x1wk. [**First Name3 (LF) 5283**] pain xseveral days. Pt reports that when flushing her
port she experienced [**First Name3 (LF) 5283**] pain that radiated up to her eye. Pt
also reports mild headache for ~1wk which she reports she
usually gets before she's "septic". Otherwise, pt denies
LH/Dizziness, fevers/chills, dysphagia, CP/palp, joint
pain/rash. Pt reports she's had an increase in her [**First Name3 (LF) 5283**] pain with
slight nausea, 1 episode of vomiting this am, no
hematemesis/non-bilious, no diarrhea/constipation/melena/brbpr,
pt able to tolerate meals. Denies LE edema.
.
On review of symptoms, including cardiac, she denies any prior
history of stroke, TIA, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. However, pt
has had SVC clot in the past.
.
Additionally, pt reports that due to her PTSD, she requires 3mg
IV dilaudid Q3hrs, valium 5mg IV prn, 10mg QHS, benedryl 50mg IV
Q3-4hrs.
Past Medical History:
1) Crohn's disease dx [**2079**], s/p ~13 surgeries, including
transverse/ascending colectomy
- rectovaginal fistula
2) h/o multiple SBOs
3) SVC syndrome s/p angioplasty(had prior episode of facial and
neck swelling 11 years ago, when work-up revealed stenoses of R
subclavian and SVC,which were angioplastied by IR in [**2101**]. In
the intervening time period, pt reports only episode of facial
swelling occurred
during work-up and diagnosis of symptomatic parathyroid
adenoma).
4) h/o line/portocath infections (partic w/ coag neg staph)
5) Depression & Anxiety
6) Fatty liver with mildly elevated LFTs at baseline
7) s/p TAH BSO
8) s/p ccy
9) Gastric dysmotility - on TPN over last yr, though recently
tolerating POs
10) Short bowel syndrome
11) Parathyroid adenoma s/p removal
12) Fibromyalgia
13) hypothyroidism
14) HIT+ Ab: s/p 30 days treatment with Fondaparinux
15) Fe deficiency anemia
16) Mediastinal lymphadenopathy NOS: followed by Dr. [**Last Name (STitle) 575**]
17) Pulmonary nodules -- in process of being evaluated
18) PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
Social History:
Patient lives with husband. [**Name (NI) **] 5 children (3 biologic 2
step).Currently disabled. Used to work as teacher. Denies hx of
tobacco, etoh, illicit drugs
.
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
VS: T , BP121/67 , HR107 RR19 , O2 99% on RA
Gen: NAD, able to speak in full sentences, perseverating on
doses of narcotics, benzos, benedryl.
HEENT: NC/AT, perrla, EOMI, anicteric, facial plethora/swelling.
No oropharyngeal lesions/exudates.
Neck: Supple, unable to assess for JVP. +swelling, diffuse,
non-pitting, +multiple well healed scars c/w line insertions.
+well healed line c/w parathyroidectomy.
CV: Port C/D/I, s1s2 tachycardic, RRR, no m/r/g
Chest: B/L AE no w/c/r
Abd: +bs, soft, TTP [**Name (NI) 5283**], no guarding/no rebound/no skin rash, no
dullness to percussion
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2112-9-9**] 08:50AM BLOOD WBC-5.6 RBC-4.02* Hgb-11.1* Hct-32.8*
MCV-82 MCH-27.6 MCHC-33.8 RDW-14.9 Plt Ct-176
[**2112-9-9**] 08:50AM BLOOD Neuts-75.2* Lymphs-19.0 Monos-4.4 Eos-1.3
Baso-0.2
[**2112-9-9**] 08:50AM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2112-9-9**] 08:50AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-140
K-3.3 Cl-108 HCO3-22 AnGap-13
[**2112-9-9**] 08:50AM BLOOD ALT-24 AST-22 LD(LDH)-203 AlkPhos-114
Amylase-19 TotBili-0.5
[**2112-9-9**] 08:50AM BLOOD Lipase-26
[**2112-9-9**] 08:50AM BLOOD Albumin-4.3 Calcium-8.8 Phos-2.7 Mg-1.4*
PERTINENT LABS/STUDIES:
Hct: 32.8 -> 30.8 -> 29.2 -> 28.3 -> 28.6
WBC: 7.1 -> 5.0 -> 3.1
INR: ([**9-9**]) 2.8 -> 2.9 -> 3.5 -> 2.1 -> 3.2 ([**9-13**])
TSH: 7.6
U/A ([**9-10**]): 30 Protein, small leukocytes, 20 RBCs, 12 WBCs, few
bacteria
UCx: Negative x2
EKG [**2112-9-7**]: Sinus tachycardia. Otherwise, within normal limits.
Compared to the previous tracing of [**2112-1-5**] diffuse T wave
flattening, which was previously seen, has largely resolved.
Heart rate is faster. The other findings are similar.
.
CT neck/abdomen [**2112-9-9**]: 1)SVC occlusion w/ possible thrombus
extending to rt atrium. Extensive collaterals and prominent
azygous/hemiazygous. 2) stable appearance of small bowel/colon
without evidence of obstruction. 3) stable mediastinal/hilar
adenopathy 4) bilat axillary lymph nodes w/ haziness of
surrounding fat, uncertain etiology.
.
CXR [**2112-9-9**]: No pneumothorax. No new air space consolidation or
effusion. The patient will be undergoing CTA of the chest.
.
KUB [**2112-9-7**]: No obstructive bowel gas pattern.
ECHO ([**2112-9-10**]): The left atrium and right atrium are normal in
cavity size. No mass or thrombus is seen in the right atrium
(best excluded by TEE). Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
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 normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is an anterior space which most likely
represents a fat pad. Compared with the prior study (images
reviewed) of [**2112-4-13**], the aortic valve leaflets now appear
mildly thickened (non-specific).
DISCHARGE LABS:
[**2112-9-13**] 06:23AM BLOOD WBC-3.1* RBC-3.46* Hgb-9.6* Hct-28.6*
MCV-83 MCH-27.8 MCHC-33.7 RDW-15.6* Plt Ct-211
[**2112-9-10**] 04:22AM BLOOD Neuts-62.0 Lymphs-29.6 Monos-5.6 Eos-2.3
Baso-0.6
[**2112-9-13**] 06:23AM BLOOD PT-31.4* PTT-37.5* INR(PT)-3.2*
[**2112-9-13**] 06:23AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-138
K-4.5 Cl-106 HCO3-22 AnGap-15
[**2112-9-10**] 04:22AM BLOOD ALT-22 AST-22 LD(LDH)-219 AlkPhos-112
Amylase-15 TotBili-0.6
[**2112-9-13**] 06:23AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.4
Brief Hospital Course:
Pt is a 52 y.o female with h/o Crohn's dx s/p multiple
complications, and h/o SVC syndrome who presents with facial
swelling and acute on chronic abdominal pain.
.
#. SVC syndrome: Pt has a h/o SVC syndrome in [**2101**] and presented
with facial swelling for one day and pain upon flushing her
port. Chest CT on [**2112-9-9**] revealed SVC clot to R.atrium with
extensive collaterals to the azygous vein. Patient was
evaluated by vascular surgery and Cardiothoracic surgery in the
ED, and both felt that she was not a surgical candidate at this
time, as her collaterals suggested a non-acute nature. The
patient has a history of [**Last Name (LF) **], [**First Name3 (LF) **] she was started on Argatroban
in the ED. This was discontinued on [**9-11**]. Patient was started
on Coumadin on [**9-11**], and her INR was 3.1 at discharge (on 5 mg
daily). Patient has a follow-up appointment with the [**Hospital 197**]
clinic on [**2112-9-15**], and her port may now be used again, per Dr.
[**Last Name (STitle) **].
.
#. Crohn's Disease: Pt has a h/o Crohn's, diagnosed in [**2079**], s/p
multiple complications including fistula, SBO. Pt has had
multiple episodes of abdominal pain requiring high doses of
narcotics. She had an acute exacerbation of her abdominal pain
on [**9-7**]. CT at the time and today showing unchanged stable mild
bowel thickening and distention in the area of anastamosis in
the [**Month/Day (4) 5283**]. GI was consulted and recommended starting her on Cipro
for an acute Crohn's flare. Patient's pain was controlled
during this hospital stay with Dilaudid, Benadryl, and
Anti-emetics. She will complete a two-week course of Cipro, and
she will follow up in clinic with Dr. [**Last Name (STitle) 79**].
.
# Psychiatric: Pt has a history of PTSD, depression, and
anxiety. Pt has extreme distress in the hospital setting. During
this hospital stay, she was given Citalopram, Dilaudid,
Oxazepam, and Benadryl to alleviate her anxiety. She did not
have any acute events during this hospital stay.
#. Code: full
.
# Communication: with patient.
.
Medications on Admission:
ALLERGIES:
Reglan / Compazine / Gentamicin / Sulfonamides / Tigan /
Meperidine / Iodine; Iodine Containing / Prednisone / Cefotaxime
/ Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Ciprofloxacin / Heparin Agents / Fluconazole /
Meropenem / Tizanidine
MEDS ON ADMISSION:
Celexa 40mg daily
nascobal 500mcg/0.1mg 1 spray 1 nare 1xwk
ergocalciferol 50,000 units 1 cap 2x wk
ethanol 10% port
dilaudid 2mg 1-2tab TID prn
IVF
levoxyl 50mcg daily
oxazepam 15mg [**Hospital1 **]
phenergan 1mg IV QID
ultram 50mg [**2-3**] tapbs TID up to 300mg
saccharomyces 250mg daily
slomag 250mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO TWICE WEEKLY ().
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day) as needed.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 11 days: To complete course [**9-23**] or as
instructed by your [**Month/Year (2) **]. Thank you.
[**Month/Year (2) **]:*44 Tablet(s)* Refills:*0*
10. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for nausea.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
Dose to be changed by [**Company 191**] coumadin clinic.
[**Company **]:*90 Tablet(s)* Refills:*2*
12. ethanol flush Sig: 10% ethanol 2.5cc in each chamber of the
port for a one hour once a day: etoh should then be flushed
through and port locked
with normal saline. The dwell coudl be done daily if port used
daily or if port not used once weekly when port flushed and
locked in usual care.
.
[**Company **]:*qs qs* Refills:*2*
13. Nascobal 500 mcg Spray, Non-Aerosol Sig: One (1) spray Nasal
once a week: One spray in one nare weekly.
14. Promethazine 25 mg/mL Solution Sig: One (1) Injection every
eight (8) hours as needed for nausea.
[**Company **]:*qs qs* Refills:*0*
15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
for 5 days.
[**Company **]:*20 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
SVC clot
Crohn's flare
Secondary:
Depression
Anxiety
Discharge Condition:
Good. Patient's vital signs are stable, and she is able to
ambulate without difficulty.
Discharge Instructions:
You were admitted to the hospital because you experienced
swelling in your face, and you had pain in your abdomen. While
you were here, you were found to have a blood clot in your
superior vena cava. We started you on a blood thinner,
coumadin, to prevent any complications from this clot. While
you were here, we also started you on Cipro for your abdominal
pain. It was thought that this pain may represent a Crohn's
flare. You should continue this medication for a total duration
of two weeks.
While you were here, we made the following changes to your
medications:
1.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience recurrence of your face swelling, fevers, chills,
bloody diarrhea, confusion, chest pain, shortness of breath, or
any other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2112-9-20**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2112-10-10**] 11:20
Please call Dr.[**Name (NI) 18707**] gastroenterology clinic for a follow-up
appointment within the next 1 week.
You have an appointment with [**Company 191**] coumadin clinic on [**9-15**] -
please call [**Telephone/Fax (1) 2756**].
Completed by:[**2112-9-14**]
|
[
"414.01",
"V45.82",
"459.2",
"309.81",
"518.89",
"429.89",
"579.3",
"244.9",
"729.1",
"300.4",
"996.74",
"555.9",
"453.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11903, 11909
|
7288, 9369
|
552, 560
|
12016, 12107
|
4287, 4287
|
13045, 13587
|
3323, 3436
|
10039, 11880
|
11930, 11995
|
9395, 9679
|
12131, 13022
|
6760, 7265
|
3451, 4268
|
485, 514
|
588, 1955
|
4304, 6743
|
9693, 10016
|
1977, 3124
|
3140, 3307
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,247
| 126,143
|
34744
|
Discharge summary
|
report
|
Admission Date: [**2167-6-27**] Discharge Date: [**2167-7-9**]
Date of Birth: [**2143-3-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
1. Emergent left craniectomy for SDH and bolt placement
2. Emergent Right crani for EDH
3. IVC filter placement
4. G tube placement
History of Present Illness:
24 year-old gentleman with no known past medical history who is
s/p fall. Per available records and the trauma team, pt was out
with friends drinking alcohol. He slipped and fell down
approximately 15 stairs, striking his head. GCS was 3 on the
scene. He was intubated in the field and transferred to [**Hospital1 18**] ED
for further evaluation. He received no more than 5mg IV versed
en route and in the ED. He was unable to offer complaints at the
time of my encounter.
Past Medical History:
unknown
Social History:
social ETOH; otherwise unknown
Family History:
non-contributory
Physical Exam:
On Admission:
O: T: NR BP: 130/70 HR: 60 R 14 O2Sats 98%RA
Gen: Intubated, sedated.
HEENT: Lacerations over posterior skull.
Neck: In hard collar.
Lungs: Transmitted sounds bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
Mental Status: No response to voice or noxious stimuli.
Cranial Nerves: Pupils 5mm and not reactive to light. EOM could
not be assessed due to hard collar (could not visualize TM and
therefore deferred calorics). Corneal weak on left, present on
right. No response to supraorbital pressure. Facial symmetry
could not be adequately assessed due to intubation but no overt
droop. Gag present.
Motor: No motor response to noxious stimuli throughout.
Sensation: No grimace to noxious stimuli throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes mute bilaterally
Pertinent Results:
Head CT([**6-26**]):
NON-CONTRAST CT HEAD: There is a left convexity left subdural
hematoma
measuring up to 8 mm from the left inner table. There is a right
occipital
cephalohematoma with associated contrecoup injury in the left
frontal lobe
with edema noted diffusely through the brain parenchyma although
more
prominent in the left frontal lobe. There is a 10-mm
left-to-right midline
shift. There is subarachnoid blood in the basal cisterns.
Bone windows demonstrate no evidence of acute fracture.
Head CT([**6-27**]):
NON-CONTRAST CT HEAD: There is a new right convexity epidural
hematoma
extending up to 2.1 cm from the inner table. There is associated
right uncal herniation with the uncus abutting and exerting mass
effect on the brainstem. Diffuse brain edema is again noted with
areas of subarachnoid blood, unchanged. Post-craniectomy changes
are noted in the left convexity with subcutaneous air that is
within the spectrum of post-surgical change. There is a 7-mm
leftward midline shift noted.
Head CT [**6-28**]:
Since the prior study, there appears to be essentially complete
evacuation of the right middle cranial fossa epidural hematoma,
with resolution of previously noted leftward subfalcine
herniation. The large left-sided craniectomy defect is again
noted. There is no hydrocephalus. The right calvarial craniotomy
flap is now apparent, as are overlying surgical staples. Lastly,
there is a probable minimal degree of pneumocephalus within the
former site of the right epidural hematoma.
Head CT [**6-29**]
1. Overall stable post-surgical changes from prior right
craniotomy and
epidural hematoma evacuation, and left craniectomy. No new
intracranial
hemorrhage.
2. Subtle area of focal hypodensity in the right thalamus could
possibly
represent an area of evolving infarction.
CT HEAD [**7-6**]
FINDINGS: Post-surgical changes from prior right craniotomy,
with evacuation of right middle cranial fossa epidural hematoma
and large left craniectomy are similar. No new intracranial
hemorrhage or infarct. There has been interval resolution of the
pneumocephalus.
IMPRESSION: Overall similar post-surgical changes from prior
right craniotomy and left craniectomy. New intracranial
hemorrhage.
NOTE ON ATTENDING REVIEW:
There is a change in the configuration of the left cerebral
hemisphere part of which is protruding contour but likely within
the confines of the flap and can relate to herniation or
expansion of the brain. Hypodense areas are noted between the
brain and the flap (series 2, im 21) and between the flap and
the subcutaneous tissues of the flap measuing about -1 to 2.5HU
and may represent fat or less likely fluid. There is interval
resolution of the previously noted hemorrhage in the extra-axial
location at the sit eof craniotomy.
As before, there is some degree of cerebral edema. Hypodense
areas noted in the bifrontal and left occipital lobes related to
previously noted acute infarcts. To correlate if this is
expected appearance of brain post
craniotomy. Thin right sided subdural hemorrhage is unchanged.
[**7-6**] BILAT LOWER EXT VEINS
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.
Labs on discharge [**2167-7-7**]
WBC 7.5, Hgb, 10.5*, Hct 30.4*, Plt 679*
Brief Hospital Course:
Patient was admitted for head trauma with left subdural and
subarachnoid bleeds with left hemispheric edema and uncal
herniation. Patient was emergently taken to the OR for caminio
bolt placement and left craniectomy for relief of high ICP and
evacuation of a small SDH. Patient tolerated the procedure well
and was transfered to the trauma SICU for Q1hr neuro checks. A
post-operative head CT showed the development of a new right
epidural hematoma. He emergently returned to the OR and
underwent a craniectomy for evacuation of the right epidural
hematoma. He tolerated the procedure well and was again
transferred to the trauma SICU. Patient was monitored closely
with neuro checks Q1hr. A post-op head CT showed essentially
complete evacuation of the right middle cranial fossa epidural
hematoma, with resolution of previously noted leftward
subfalcine herniation. Post-operatively he was able to
intermitently squeeze his hands to commands, but did not open
his eyes. His neuro exam continued to improve daily, with R>L
withdrawal progressing to purposeful movement on the right. His
left upper and lower extremity was largely plegic, but at times
he moved his RUE spontaneously and with withdrawal to pain. He
ran a fever form most of his post-operative course, with no
clear source. His urine and blood cultures have been negative,
and there was no clear evidence of an aspiration PNA. We
suspected a dilantin-induced fever and was therefore switched to
keppra on [**2167-7-2**]. On [**7-1**] patient was successfully extubated,
and on [**7-2**] was able to mumble a few intelligible words, such as
"hi mom" and "I'm nauseous." He was transferredto neuro stepdown
and continued to improve. He was spiking fevers but no source
wasfound via CXR, urine cultures, blood cultures and lower
extremity dopplers. he was switched from dilantin to keppra and
temperatures dropped. His incision is well healing with all
staples/sutures removed. He had IVC filter and g tube placed.
Tube feedings are at goal. Neuro exam [**7-9**] is eyes open,
attending examiner, said "good morning". Moves upper
extremities purposefully and withdraws lowers to pain.
Intermittenetly follows commands. Pupils reactive with minimal
subconjunctival hemmorrhages laterally bilaterally. Due to the
patients improving activity and ability to move his upper
extemities and to manipulate his incision/head, use of a helmet
was started at all times.
Medications on Admission:
None
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
8. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for [**Female First Name (un) **].
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed.
13. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Ondansetron 4 mg IV Q8H:PRN
15. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Left SDH, s/p emerg evac
2. Right EDH s/p emerg evac
3. Elevated ICP s/p bolt placement
Discharge Condition:
stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? 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 have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 14074**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2167-7-9**]
|
[
"873.0",
"801.16",
"305.00",
"276.2",
"780.6",
"958.4",
"348.5",
"434.91",
"348.4",
"E880.9",
"518.5",
"861.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.24",
"38.7",
"01.31",
"01.10",
"86.59",
"96.72",
"43.11",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9050, 9120
|
5243, 7685
|
336, 469
|
9255, 9264
|
1980, 2014
|
10779, 11138
|
1067, 1085
|
7740, 9027
|
9141, 9234
|
7711, 7717
|
9288, 10756
|
1100, 1100
|
279, 298
|
497, 972
|
1436, 1961
|
2525, 5220
|
1114, 1363
|
1378, 1420
|
994, 1003
|
1019, 1051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,895
| 162,439
|
37611
|
Discharge summary
|
report
|
Admission Date: [**2192-10-25**] Discharge Date: [**2192-11-11**]
Date of Birth: [**2108-9-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatgiue
Major Surgical or Invasive Procedure:
[**2192-11-5**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] tissue),Coronary
Artery Bypass Graft x 1 (Left internal mammary artery to left
anterior descending)
History of Present Illness:
84 yo female with PMHX significantfor chronic Afib on coumadin,
HTN, high cholesterol, celiac sprue, right BKA secondary to
peripheral vascular disease and recent anorexia and weight loss
presented to OSH with lethargy, SOB and shaking chills. Pt was
found to have an E coli UTI and started on ceftriaxone on
[**2192-10-17**]. Echo done revealed EF 50% and severe Aortic stenosis.
Pt has CT head, chest, abdomen as part of preop work up which
was unrevealing with the exception of benign pelvic mass. Cath
performed [**10-24**] showed 80% LAD stenosis. Pt
transferred to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Hypertension
Hypercholesterolemia
Atrial Fibrillation
Peripheral vascular disease s/p left below knee amputation
Celiac Sprue
Hypothyroidism
s/p B/L breast implants 20 yrs ago
Social History:
Last Dental Exam: years?
Lives with: daughter
[**Name (NI) 1139**]:1 PPD x5 years- quit 30 years ago
ETOH: rare
Family History:
non-contributory
Physical Exam:
Skin: Dry [x] intact [stage one on coccyx]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur- LSB II/VI radiating to
carotids bilat and left axilla
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [doppler pulses :DP/PT;
palapable femoral and popliteal.] Edema Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: BKA Left: doppler
PT [**Name (NI) 167**]: BKA Left: doppler
Radial Right: Left:
Carotid Bruit Right/Left: +2 -radiating from Aorta
Pertinent Results:
[**2192-10-26**] Echo: The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2192-11-10**] 06:45AM BLOOD WBC-6.2 RBC-3.26* Hgb-9.3* Hct-28.7*
MCV-88 MCH-28.5 MCHC-32.3 RDW-16.1* Plt Ct-246
[**2192-11-11**] 07:40AM BLOOD PT-16.3* INR(PT)-1.4*
[**2192-11-10**] 06:45AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-101 HCO3-27 AnGap-12
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname **] was transferred to [**Hospital1 18**] for
surgical intervention. She underwent appropriate surgical
work-up which included an echocardiogram and dental clearance.
Heparin gtt was started d/t Atrial fibrillation history. She was
treated for her E coli urosepsis with completion of 10 days of
ceftriaxone therapy and was then noted to have minimal pyuria
and VRE in urine. ID was consulted and appropriate antibiotics
were given based on there recommendations. She was eventually
brought to the operating room on [**11-5**] where she underwent a
aortic valve replacement and coronary artery bypass graft x 1.
Please see operative report for surgical details. Following
surgery she was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours she was weaned from
sedation, awoke neurologically intact and extubated. She was
tranferred to the floor and continued to progress well. Chest
tubes and pacing wires were removed per cardiac surgery
protocol. She was started on coumadin for atrial fibrillation
and INR was monitored daily. She was seen by ophthamology for
left eye pain and was found to have inflammation of her eye lid.
She was treated with warm compresses. She worked with
physicial therapy and was fitted with a prosthetic shrinker.
Repeat urinalysis was done which was negative and the patient
was off antibiotics at the time of discharge. Her heart rate in
atrial fibrillation elevated and her lopressor was uptitrated.
She was discharged on post op day # 6 in stable condition to
rehab.
Medications on Admission:
At Home: coumadin 3 mg on M, W, Thurs, Fri, Sat, Sun; 2 mg on
Tues, Fri. Gabapentin 300 mg (unsure of times) simvastatin 20',
atenolol 25", digoxin 0.125', diltiazem 30 QID, levothyroxine 88
mcg', omeprazole 20', oxycontin 5" (for phantom leg pain),
ambien PRN, lorazepam 0.5-1 mg q 8 hrs PRN, advair
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. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: for
goal INR of [**3-20**] for atrial fibrillation.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] health care center
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1
PMH: Hypertension, Hypercholesterolemia, Atrial Fibrillation,
Peripheral vascular disease s/p left below knee amputation,
Celiac Sprue, Hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**3-20**] weeks
Dr. [**Last Name (STitle) **] in [**2-17**] weeks
Completed by:[**2192-11-11**]
|
[
"579.0",
"424.2",
"V85.0",
"424.1",
"041.19",
"620.2",
"599.0",
"041.04",
"V58.61",
"414.01",
"416.8",
"427.31",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6701, 6767
|
3432, 5019
|
331, 514
|
7067, 7073
|
2228, 3409
|
7871, 8043
|
1508, 1526
|
5371, 6678
|
6788, 7046
|
5045, 5348
|
7097, 7848
|
1541, 2209
|
284, 293
|
542, 1164
|
1186, 1363
|
1379, 1492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,080
| 113,019
|
53498
|
Discharge summary
|
report
|
Admission Date: [**2183-1-6**] Discharge Date: [**2183-1-15**]
Date of Birth: [**2110-10-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
L sided neglect and confusion, R parietal hemorrhage seen on
Head CT
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
The pt is a 72 year-old right-handed man with a PMH of advanced
PD. Per his wife, he was more sleepy over the weekend and
yesterday she noticed that he did not eat the L half of his
plate. She had put muffins out for him and he only at the ones
on the R, complaining of the fact that there were only crumbs on
the plate, despite the fact that there was a half of a muffin on
the L. Then over the course of the day he seemed to have a
little difficulty navigating space and finding the stairs. He
was however able to walk without greater trouble than his
baseline. He was still not at baseline today so she brought him
here.
.
In the ED he was given 1 gm of CTX, 1 gm of dilantin and 2mg of
Zofran after having an episode of emesis. He remained
hypertensive in the 200/99-> 170's/80's.
.
ROS: sleepy over the weekend per his wife; HA and nausea
Past Medical History:
- Advance Parkinson's disease, dx in [**2179**] vs [**Last Name (un) 309**] Body dementia
with Parkinsonism
- Orthostatic hypotension
- Parotid benign tumor
Social History:
Dr. [**Known lastname 1683**] obtained a doctorate degree in physics from the
[**State 109986**], Berkeley and worked as a physicist for
ten years. Then he obtained a medical degree from [**University/College **]
[**Location (un) **]. He worked as an internist for [**Hospital1 18**] for 21 years.
He retired in [**2181-1-8**]
Family History:
Dr. [**Known lastname 1683**]?????? father died at age 75. His mother died at age 71
with probable Alzheimer??????s disease. A brother died at age 75.
Dr. [**Known lastname 1683**] has one adopted daughter, aged 22, who attends Gibbs
College. His wife is reportedly healthy and recently returned
to work as a psychiatric social worker.
Physical Exam:
Vitals: T: 96.2 P: 71 R: 20 BP: 200/99-> 171/87 SaO2: 97% 2L
General: Awake, but keeps eyes closed, NAD but initally
tachypneic, cachectic
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: difficult to move neck in any direction, no carotid bruits
appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ LE edema with erythema; Pain at R IV site but no
erythema or edema; R wrist healing ecchymoses and abrasion
.
Neurologic:
-Mental Status: awake, oriented to person, hospital and year.
Unable to provide details about his history or symptoms.
Inattentive, but with brief fluent speech (max 5 words); intact
comprehension, does not repeat. Speech was not dysarthric. Pt
does not attend to examiner on the L side of the bed. Masked
face; Further testing deferred as pt states he is not feeling
well
.
CN
I: not tested
II,III: does not cooperate with formal VF testing; does not
blink to threat consistently bilaterally, pupils 2mm->1mm
bilaterally, fundi normal w/ sharp discs
III,IV,V: able to cross the midline on the L but does not fully
abduct, no ptosis. No nystagmus
V: + corneals and nasal tickle
VII: masked face but no clear facial droop
VIII: hears voice bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-13**] bilaterally
XII: tongue protrudes midline, no dysarthria
.
Motor: limited exam as pt does not cooperate with formal
testing; diffusely increased tone and rigidity w/ cogwheeling;
intermittent R hand tremmor; antigravity throughout
.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 1 Up
R 2 2 2 2 1 Flexor
.
-Sensory: unreliable testing to light touch
.
-Coordination: deferred
.
-Gait: deferred
Pertinent Results:
Admission Labs:
[**2183-1-6**] 08:35AM PT-12.3 PTT-29.0 INR(PT)-1.0
[**2183-1-6**] 08:35AM PLT COUNT-204
[**2183-1-6**] 08:35AM NEUTS-81.7* LYMPHS-11.9* MONOS-3.4 EOS-2.7
BASOS-0.2
[**2183-1-6**] 08:35AM WBC-7.5 RBC-4.44* HGB-13.7* HCT-38.5* MCV-87
MCH-30.8 MCHC-35.5* RDW-12.8
[**2183-1-6**] 08:35AM cTropnT-<0.01
[**2183-1-6**] 08:35AM CK(CPK)-72
[**2183-1-6**] 08:35AM GLUCOSE-117* UREA N-24* CREAT-0.8 SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10
[**2183-1-6**] 08:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-1-6**] 01:34PM PT-12.8 PTT-27.1 INR(PT)-1.1
[**2183-1-6**] 01:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-1-6**] 01:34PM TSH-1.6
[**2183-1-6**] 01:34PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2183-1-6**] 01:34PM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-155
CK(CPK)-64 ALK PHOS-121* TOT BILI-0.3
.
EEG: This is an abnormal portable EEG due to the slow
background
and additional bursts of generalized slowing. This abnormality
suggests
a moderate encephalopathy. Medications, metabolic disturbances,
and
infection are the most common causes. Of note is that focal
abnormalities could be obscured by the diffuse generalized
slowing.
However, there were no focal findings in this recording and no
epileptiform features
.
Head CT [**1-6**]:
FINDINGS: There is 2.9 x 6.1 cm right parietotemporal
hemorrhage, which
dissects into the right lateral ventricle. Moderate surrounding
vasogenic
edema is noted. There is also another focus of intraparenchymal
hemorrhage
within the right temporal lobe measuring 13 mm. No hydrocephalus
is
visualized. There is subarachnoid hemorrhage within the right
frontoparietal and temporal lobes. 5-mm left [**Hospital1 **] subfalcine
herniation is noted. No fracture is identified. The paranasal
sinuses and mastoid air cells are clear. Calcification of the
cavernosal internal carotid arteries is noted.
.
IMPRESSION:
1. Right temporoparietal hemorrhage associated with surrounding
vasogenic
edema and 5-mm subfalcine herniation. Considering the presence
of small foci of hemorrhage on prior MR of the head of [**2182-4-9**], the most likely etiology is amyloid angiopathy.
2. Small focus of hemorrhage within the right temporal lobe may
be the
extension of the right temporal lobe bleeding in extraxial space
or a new
focus of hemorrhage. Another possibility is a small subarachnoid
hemorrhage.
3. Right intraventricular hemorrhage with no hydrocephalus and
right
hemispheric subarachnoid hemorrhage.
.
Repeat Head CT [**12-28**]:
1. Essentially stable appearance of parenchymal and subarachnoid
hemorrhage.
2. Decreased intraventricular hemorrhage. Stable ventricular
size with
partial effacement of the posterior right lateral ventricle.
3. Stable mild right subfalcine herniation
Brief Hospital Course:
Pt was admitted for his presenting symptoms. Pt was initially
admitted to the ICU for monitoring. Pt completed a Head CT which
showed Right parietal and temporal hemorrhage. Pt continued to
show cognitive decline. Pt was transferred to the floor.
Pallatative Care was consulted. A family meeting was conducted
with neurology-stroke division, pallatative care team and the
family including wife and daughter. The decision was made to
make the patient CMO. CMO measures were taken. Medications were
withdrawn. Case management and family decided on a hospice
facility for 24hrs supervision and healthcare.
Pt was trf to the hospice facility of the families choice,
[**Hospital1 3894**].
Medications on Admission:
- Exelon 9.5 mg/24 hour Transderm 24 hr Patch Apply one patch
daily
- Sertraline 50 mg Tab Oral 1 Tablet(s) , at bedtime
- Carbidopa-Levodopa 25 mg-250 mg Tab, Rapid Dissolve Oral 2
Tablet, Rapid Dissolve(s) Three times daily
- Fludrocortisone 0.1 mg Tab Oral 1 Tablet(s) Twice Daily
- Omeprazole 20 mg Cap, Delayed Release Oral
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Ativan 0.5 mg Tablet Sig: 2-4 Tablets PO q4 PRN discomfort as
needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO q2
PRN pain as needed: Please give 5mg to 20mg q1-2 hrs SL PRN
pain/dyspnea.
Disp:*20 ml* Refills:*0*
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours as needed: Give as needed for
congestion.
Disp:*5 patches* Refills:*0*
5. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [**1-10**] Sublingual q4
PRN congestion as needed: Give as need for congestion .
Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] health hospice
Discharge Diagnosis:
Primary: Right Parietal and temporal hemorrhage secondary to
amyloid angiopathy
Secondary: Parkinson's Disease
Discharge Condition:
Stable. Increased symptoms of Parkinsonism symptoms including
cogwheel rigidity, masked facies, Left facial paresis and unable
to follow commands. Pt currently has audible yet comfortable
respiratory rhythm.
Discharge Instructions:
You were admitted for evaluation of confusion and left sided
neglect. You were found to have hemorrhages in the right
parietal and temporal lobes and cognitive deficits due to
progression of your Parkinson's Disease and dementia in the
setting of this hemorrhage.
Your family elected to focus your care on comfort based on your
previously stated wishes, and we therefore stopped your Sinemet
and Exelon, and consulted with the Palliative Care team about
how best to make you comfortable.
Followup Instructions:
NONE
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"348.4",
"294.10",
"430",
"331.82",
"277.39",
"781.8",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8741, 8807
|
6978, 7665
|
383, 390
|
8963, 9173
|
4069, 4069
|
9710, 9810
|
1806, 2147
|
8045, 8718
|
8828, 8942
|
7691, 8022
|
9197, 9687
|
2162, 2740
|
275, 345
|
418, 1263
|
4086, 6955
|
2755, 4050
|
1285, 1443
|
1459, 1790
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,105
| 157,720
|
45951
|
Discharge summary
|
report
|
Admission Date: [**2195-9-2**] Discharge Date: [**2195-9-10**]
Date of Birth: [**2132-11-18**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nifedipine / Premarin / Morphine / Crestor /
Atorvastatin / Codeine
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
s/p fall, w/ GI bleed, MI, DKA
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
62 y/o F with PMH of HTN, HL, DMII, CVA, CAD s/p MI and stent
'[**86**] and '[**89**], on Plavix (no ASA), who presented to ER s/p fall,
with coffee ground emesis x 2 days. She reports that she was at
home in her wheelchair 1 day PTA when she became
lightheaded/dizzy and fell. Unwitnessed. Apparently lost
consciousness and awoke the next day. Called paramedics and
brought to [**Hospital1 18**]. Reports no preceding chest pain, palpitations,
shortness of breath. +nausea and dark emesis over last couple
days. denies black stools or BRBPR.
.
In ER, BP 203/106, HR 103, T97.4, FSBG >500. NG lavage coffee
ground cleared w/ 200 cc, rectal brown strongly G+, Hct 37
baseline. EKG with STEMI (1mm III/aVF, CK/Tn neg x1) and DKA
(Glu 800's, HCO3 18, AG 33, BUN/Cr 40/1.7). Seen by GI in ER. No
scope given MI. Seen by Cards. No cath given GI bleed. Given
Anzemet 12.5 IV, Protonix, Regular Insulin 10 IV x 1, followed
by Insulin drip at 7U/hr. 3L NS IVF. Lopressor 5mg IV x 1.
Past Medical History:
HTN
DMII
Hyperlipidemia
h/o CVA w/ residual L sided hemiparesis
CAD- w/ stent '[**86**] and '[**89**]
Asthma
Rheumatic fever
Femoral Bypass - [**1-15**] complication of most recent cath
Asthma - last hospitalization mult years ago, uses rescue
albuterol inhaler 1-2 times per week
migraine headaches - tx with vicodin or tylenol
Breast Cancer - node negative (surgery only, no chemo, no rad)
Degenerative Disk Disease
Osteoarthritis
Osteoporosis
GERD
Social History:
lives alone at home [**Location (un) 6409**]; wheelchair bound s/p CVA; no
h/o ETOH or tobacco use
Family History:
non-contributory
Physical Exam:
vitals- 96.3, 90, 156/90, 23, 100% RA
gen- nauseated, no acute distress, chest pain free
neck- b/l EJ lines, no noticeable JVD
heent- EOMI. non-icteric sclera. MM dry
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND. mild RUQ tenderness w/o rebound or guarding
ext- cool LE's. 1+ pulses b/l. no edema
neuro- sleepy but arousable, oriented x 3. LUE/LLE 0/5; RLE/RUE
[**4-17**] motor strength
rect- dark brown, guaiac +; no bright red blood.
Pertinent Results:
ADMIT EKG:
=========
NSR. borderline left axis. 1mm ST elev III, 0.5mm AVF, w/ 1mm ST
dep I, 1mm AVL. QIII, AVF (old) , TWI anterolaterally
.
ADMIT Labs:
==========
[**2195-9-2**] 06:00PM WBC-10.1# RBC-4.28 HGB-12.6 HCT-36.6 MCV-86
[**2195-9-2**] 06:00PM NEUTS-88.1* LYMPHS-8.5* MONOS-3.2 EOS-0.2
BASOS-0
[**2195-9-2**] 06:00PM ALBUMIN-3.6
[**2195-9-2**] 06:00PM ALT(SGPT)-11 AST(SGOT)-17 CK(CPK)-49 ALK
PHOS-120* AMYLASE-42 TOT BILI-0.5
[**2195-9-2**] 06:00PM LIPASE-25
[**2195-9-2**] 06:00PM GLUCOSE-883* UREA N-40* CREAT-1.7* SODIUM-140
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-18* ANION GAP-33*
[**2195-9-2**] 06:00PM PT-11.0 PTT-20.8* INR(PT)-0.9
.
Cardiac Enzymes:
===============
[**2195-9-2**] 09:41PM BLOOD CK(CPK)-48
[**2195-9-3**] 04:10AM BLOOD CK(CPK)-62
[**2195-9-3**] 12:00PM BLOOD CK(CPK)-86
[**2195-9-2**] 09:41PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2195-9-3**] 04:10AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2195-9-3**] 12:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
.
ECHO [**2195-9-3**]:
============
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to hypokinesis of the inferior septum and
inferior free wall (basal segments). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion
.
Compared with the findings of the prior study (images reviewed)
of [**2191-12-23**], inferior hypokinesis is now present
.
ABDOMINAL U/S [**2195-9-3**]:
=====================
COMPLETE ABDOMINAL ULTRASOUND:
.
The liver is normal in echotexture with no focal lesions
identified. There is appropriate forward portal venous flow.
There is no intra- or extra-hepatic ductal dilatation. There are
a few small gallstones with no evidence of cholecystitis. The
spleen is small measuring 8 cm. The right kidney measures 9.0
cm. The left kidney measures 9.1 cm. There is no hydronephrosis
or stones. There is no ascites.
.
IMPRESSION:
1. Cholelithiasis with no evidence for cholecystitis.
2. Patent portal veins with appropriate forward flow.
.
EGD [**2195-9-4**]:
============
Esophagus:
Mucosa: Esophagitis with contact bleeding was seen in the lower
third of the esophagus, most likely associated with [**Female First Name (un) **].
Diffuse candidiasis was seen in the upper third of the
esophagus, middle third of the esophagus and lower third of the
esophagus. Samples were obtained for microbiology using a brush.
Stomach: Excavated Lesions Multiple erosions were noted in the
stomach body, antrum and fundus. Most were in a linear
distribution. [**Month (only) 116**] or may not be related to NG tube (if placed
earlier).
Duodenum: Normal duodenum.
.
Colonoscopy [**2195-9-10**]: aborted secondary to inadequate preparation
Brief Hospital Course:
62 yo female with h/o DMII, CAD, CVA, who presents with GI
bleed, found to be in DKA, c/b UGIB likely [**1-15**] esophageal
candidiasis, currently stable.
.
# ? SEIZURE- Had question of hypoglycemic seizure [**9-6**] with BG
38 and confusion, aphasia. CT of the head was negative for
bleed. EEG performed [**9-6**] showed diffusely slow and disorganized
background and bursts of frequent slowing suggestive of moderate
to severe encephalopathy. Also occasional delta frequency
slowing in temporal region bilaterally suggestive of subcortical
dysfunction. No clear epileptiform seizures were seen. She
continued to have brief intermittent episodes of agitation. She
always quickly returned back to her alert, oriented, pleasant
baseline on each occasion. These episodes lasted for 2 days and
then resolved. Toxic metabolic workup was unremarkable.
Non-motor seizures were still on the differential so a
sphenoidal EEG was performed which was also unremarkable. At the
time of discharge, patient had been alert, oriented, and
pleasant for the 48 hours prior to discharge. She was set up
with follow up in the neurology epilepsy clinic on discharge.
.
# Diabetes - Her DKA resolved and gap closed with IVF and
insulin. Unclear precipitating factor of DKA but thought
possibly due to UTI or esophageal candidiasis. She had
relatively well controlled BGs during admission with only
occasional late evening elevations thought likely secondary to
overeating at dinner. She was changed from NPH to lantus with
the help of [**Last Name (un) **] recommendations. At the time of discharge,
the majority of her fingersticks were in the low 100s and she
was sent out on lantus and humalog insulin sliding scale [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommendations.
.
# GIB - She was initially seen by GI with coffee ground emesis
and a positive NG lavage in ER. She initially recieved 1 unit of
pRBCs for hct of 28.9 with concern for STEMI which was
eventually ruled out. EGD performed on HD# 3 which demonstrated
esophagitis with contact bleeding in the lower third of the
esophagus, most likely associated with [**Female First Name (un) **]. Diffuse
candidiasis was seen in the upper third of the esophagus, middle
third of the esophagus and lower third of the esophagus. She was
treated with fluconazole, to complete a 14 day course.
Esophageal candidiasis believed likely secondary to poorly
controlled diabetes. Her HIV test was negative. Her hematocrit
fluctuated over course of admission but remained relatively
stable. She required no further transfusions. However, given
concern for a possible lower GI source with stable hematocrit
significantly below prior baseline, she was prepped for a
colonoscopy. However, at colonoscopy, her bowel preparation was
inadequate and the procedure was aborted. There was urgent need
for acute colonoscopy so she was discharged for outpatient
colonoscopy per GI recommendations.
.
# hypernatremia- The etiology of her hypernatremia was unclear.
It slowly responded to 1/2 NS but then quickly rebounded to 150
after her bowel preparation. Seemed to be euvolemic
hypernatremia on exam. It was as high as 152 on admission. Serum
osmolality and urine osmolality was normal. BGs were not high
enough to suggest an osmotic diuresis. DI was not suggested by
urine osmolality. Patient has had excellent po intake but
unclear whether thirst and osmoreceptor function was intact.
With history of CVA, there was some question of hypothalamic
dysfunction. However, there was no evidence of new changes on
head CT, which would have been expected as patient presented
with hypernatremia. Also possible that when volume recessated
for her DKA she was treated with hypertonic sodium bicarbonate
to treat her metabolic acidosis which can cause hypernatremia
but should have resolved after resusitation was stopped. She
had no neurologic symptoms of her hypernatremia at the time of
discharge and was encouraged to take in free water. She was
scheduled for follow up wiht her PCP to have labs drawn prior to
her visit.
.
# hypertension- Patient had elevated BPs, especially overnight,
without clear cause. Her beta blocker was increased to 50 mg TID
of metoprolol. Her lisinopril was increased to 30 mg QD. At the
time of discharge, her metoprolol was changed to 150 mg QD of
atenolol.
.
# CAD- Initial EKG with inferior ST elevations (1mm III, 0.5mm
AVF), w/ reciprocal ST depressions in I,AVL. Cardiac enzymes
cycled and were negative x 3. Patient remained chest pain free
throughout. Cardiology reviewed EKGs and did not feel that
changes were consistent with a STEMI. Recommended [**Hospital **] medical
management only. Was continued on her clopedigrel, lisinopril,
and beta blocker. She was not given aspirin or a statin given
her documented allergy.
.
# UTI - Culture [**2195-9-2**] grew a pansensitive E-coli. Unclear
whether this was the cause of her DKA. She was started on Cipro
and was treated for a 7 day course to be completed as an
outpatient.
.
Medications on Admission:
prilosec 40mg/day
plavix 75mg/day
albuterol inh
insulin 40NPH/20Reg qam, 20NPH qpm
atenolol 25mg/day
lisinopril 20mg/day
sl Ntg prn
neurontin 600mg TID
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
6. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
7. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous asdir: For BG<80, no insulin.
For BG 81-120 mg/dL give 4 Units.
For BG 121-160 mg/dL give 5 Units. For BG 161-200 mg/dL give 6
Units For BG 201-240 mg/dL, give 7 Units For BG 241-280 mg/dL
give 8 Units.
For BG 281-320 mg/dL, give 9 units
For BG 321-360 mg/dL give 10 Units For BG 361-400 mg/dL, give 11
Units .
8. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual Q5minutes as needed for chest pain: x 4 doses. If
chest pain persistent after 4 doses, [**Name8 (MD) 138**] MD or go to Emergency
Room.
10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Atenolol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please have bloodwork done in 1 week and have the results faxed
to your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at fax: [**Telephone/Fax (1) 16587**].
Check CBC, SMA-7
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Diabetic Ketoacidosis
2. esophageal candidiasis
3. urinary tract infection
.
Secondary:
1. Diabetes Mellitus
2. hypertension
3. hyperlipidemia
4. coronary artery disease
5. gastroesophageal reflux disease
Discharge Condition:
stable
Discharge Instructions:
Please continue to take all medications as prescribed. Please
note that you must continue to take your Cipro to complete a 7
day course for a urinary tract infection. You will also need to
continue to take fluconazole for your esophageal yeast infection
to complete a 14 day course. Please note that your atenolol and
lisinopril doses have been increased. Your NPH insulin has been
changed to Lantus (insulin glargine) which you will now only
have to take once a day.
.
Please try to drink water as much as possible as your lab
results suggest that you are dehydrated.
.
Please follow up with Nurse [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as below.
You should have blood work drawn in 1 week and have the results
faxed to Dr. [**Last Name (STitle) **]. You have been given a prescription for
bloodwork.
.
Your colonoscopy could not be performed while in the hospital
because your bowel preparation was inadequate. You will need to
follow up as an outpatient to repeat the colonscopy. See below.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fever, chills,
nausea, vomiting, abdominal pain, bloody stools, dark tarry
stools, or any other concerns.
Followup Instructions:
Please follow up with Nurse [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2195-9-25**] at 10 am at [**Hospital3 **]. Phone [**Telephone/Fax (1) 1247**]
.
Please follow up with Neurology with Dr. [**First Name (STitle) **] [**Name (STitle) 4253**]. The
office will be calling you to let you know the date and time of
your appointment.
.
Please follow up with Gastroenterology to repeat your
colonoscopy on [**2195-9-23**] at 8am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**]. Phone: [**Telephone/Fax (1) 97842**]. You will need to complete a bowel preparation the day
prior to your procedure. This will be mailed to you prior to
that date. If you have not received your preparation before
[**2195-9-18**], please call [**Telephone/Fax (1) 9557**].
.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2195-11-18**] 1:00
.
Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2195-11-18**]
1:00
|
[
"412",
"438.20",
"584.9",
"250.82",
"599.0",
"272.4",
"112.84",
"V58.67",
"414.01",
"530.81",
"E884.4",
"V64.1",
"250.12",
"794.31",
"V45.82",
"401.9",
"530.82",
"280.0",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12698, 12756
|
5759, 10763
|
369, 374
|
13017, 13026
|
2488, 3152
|
14342, 15424
|
1985, 2003
|
10965, 12675
|
12777, 12996
|
10789, 10942
|
13050, 14319
|
2018, 2469
|
3169, 5736
|
299, 331
|
402, 1379
|
1401, 1853
|
1869, 1969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,811
| 183,795
|
44421
|
Discharge summary
|
report
|
Admission Date: [**2119-3-25**] Discharge Date: [**2119-3-31**]
Date of Birth: [**2047-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
presyncope
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
72 y/o M w/hyperlipidemia who presents with presyncope. He
notes that he has been feeling increasingly fatigued over the
past few weeks. He was visiting another priest at BC today and
walked up the stairs, after which he felt very weak and short of
breath. He then vomited brown liquid (no blood). He felt
presyncopal but did not pass out. He also notes he had two
black bowel movements today. He denies any abd pain. On review
of systems, he does note a weight loss of 25 pounds over the
past year - he was trying to lose weight but feels that he lost
too much. He notes that he now has early satiety. He denies
any NSAID use.
.
In the ED, his vitals were 97.6, 125/65, 98, 14, 99%RA. NG
lavage was positive for blood which didn't clear. Stool was
melena, guaiac positive. His hematocrit was found to be 18,
down from 44 on [**3-16**].
Past Medical History:
-hyperlipidemia
-"mitral valve problem" (told this by cardiologist, is followed
by serial TTE)
Social History:
Lives in [**Location (un) 3844**]. Is a Jesuit priest, retired chaplain at
[**Hospital3 27447**] Center.
Family History:
Brother died of pancreatic cancer.
Brief Hospital Course:
A/P: 72 y/o M w/hyperlipidemia, who presented with melena,
fatigue, and Hct 18. The following issues were investigated
during this hospitalization:
.
# GI bleed: Pt was admitted to the MICU for BP/HCT monitoring
overnight while awaiting EGD by GI. On EGD there was not
significant bleeding noted but a large, fungating mass
w/ulceration was found at the superior portion of the stomach
and was thought to be the source of the bleeding. A biopsy was
not sent given the concern for bleeding. He was given 3 units of
pRBCs and his hct remained stable without further evidence of
gross bleeding. Subsequent CT scan of torso on [**2119-3-26**] revealed a
large 7cm mass involving head/tail of pancreas, invading the
posterior portion of the stomach and encasing the splenic
artery. There were also hypodense nodules noted in the left
lower lobe of the lung and the liver, suspicious for mets. GI
recommended an IR guided biopsy of liver/lung masses to
determine staging of presumed pancreatic cancer. However, the
questionable mets were considered too small for percutaneous
biopsy. At this point, the patient was called out to the floor
since his hematocrit was stable. While on the floor, he was
followed by GI who decided to attemped an EUS-guided biopsy of
the gastric lesion, since biopsy of the liver and lung lesions
was not possible. However, the EUS scope could not be passed
down the oropharynx, so the biopsy was then deferred again to
IR. IR performed a RUQ US which showed that what was previously
thought to be a metastatic lesion was actually a simple cyst,
making metastasis unlikely, but also not yielding a tissue
biopsy. As a result, a repeat EUS-guided biopsy was attempted
and was successful, with FNA of the gastric mass.
Per report, the appearance of the mass was suggestive of a GIST,
though pancreatic malignancy couldn't be ruled out. The patient
received one additional unit of PRBCs before discharge for a
slowly decreasing hematocrit and was discharged with follow-up
with Dr. [**Last Name (STitle) **], who performed the EUS-guided biopsy, for
results and appropriate triage to surgery and or heme/onc.
.
# Hyperlipidemia: Patient was maintained on the constituents of
Vytorin - Ezetimibe and Simvastatin as Vytorin was not on
formulary. He was discharged on Vytorin.
Medications on Admission:
vytorin
fish oil
calcium
multivitamin
baby aspirin
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Vytorin [**11-1**] 10-10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Gastric Mass
Upper GI Bleed
.
Secondary
Hypercholesterolemia
Discharge Condition:
Hemodynamically stable, afebrile, able to tolerate PO, with
appropriate follow-up.
Discharge Instructions:
You were seen and evaluated for bleeding in your digestive
tract. This was later found to be due to a mass in your stomach.
This mass was eventually biopsied and the results of this biopsy
are currently pending. A follow-up appointment has been
scheduled for you (see below) to go over the results of this
biopsy and then determine what needs to be done next for your
continued treatment and care.
Take all of your medications as directed.
Keep all of your follow-up appointments.
Call your doctor or go to the ER for any of the following:
bleeding from your rectum, persistent, dark/black stools, if you
vomit blood or anything that is black or looks like coffee
grounds, lightheadedness/dizziness, palpitations, fevers/chills
or any other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2119-4-7**] 10:20 - [**Hospital Unit Name 1825**], [**Location (un) 453**] on the [**Hospital Ward Name **] of [**Hospital1 69**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"272.4",
"197.7",
"285.1",
"578.9",
"197.0",
"424.0",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"52.11",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4232, 4238
|
1526, 3821
|
325, 330
|
4351, 4436
|
5249, 5627
|
1467, 1503
|
3923, 4209
|
4259, 4330
|
3847, 3900
|
4460, 5226
|
275, 287
|
358, 1208
|
1230, 1327
|
1343, 1451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,238
| 148,934
|
41693
|
Discharge summary
|
report
|
Admission Date: [**2150-10-23**] Discharge Date: [**2150-10-28**]
Date of Birth: [**2073-6-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percodan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Lightheadness and fatigue
Major Surgical or Invasive Procedure:
[**2150-10-23**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] Epic Supra
Porcine)
History of Present Illness:
77 year old female with a history of aortic stenosis and has
been followed by serial echocardiograms. Her most recent echo
done on [**2150-9-21**] demonstrates severe aortic stenosis with peak
gradient of 100mmHg/mean gradient of 60mmHg, EF 60%. She has
been experiencing intermittent episodes of lightheadedness over
the last 6 months. She denies any syncope. She also has chronic
lower extremity edema and fatigue. She denies any dyspnea or
chest pain. Due to the progression of her symptomatic aortic
stenosis, she was for cardiac catheterization. She is now being
referred to cardiac surgery for evaluation of an aortic valve
replacement.
Past Medical History:
Hypertension
Dyslipidemia; treated with diet
Trauma to both legs from a remote rope injury
Aortic stenosis
Osteoporosis
s/p total hip replacement bilaterally [**2144**], [**2146**]
Social History:
Race:Caucasian
Last Dental Exam:[**2150-5-24**]
Lives with:Husband
Contact:[**Name (NI) 429**] (husband) Phone #[**Telephone/Fax (1) 90617**]
Occupation:retired
Cigarettes: Smoked no [] yes [x]Hx:remote smoker, quit [**2109**]
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-2**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
No premature coronary artery disease
Physical Exam:
Pulse:62 Resp:16 O2 sat:98/RA
B/P Right:143/59 Left:147/61
Height:5'4" Weight:170 lbs
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade II/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [] minimal
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2150-10-27**] CXR: 1. Opacification of left costophrenic recess,
compatible with small effusion. In the appropriate clinical
setting, however, superimposed pneumonia should be considered.
2. Improvement of right pleural effusion and atelectasis.
[**2150-10-23**] 11:58AM BLOOD WBC-12.8*# RBC-3.39* Hgb-10.7* Hct-31.3*
MCV-92 MCH-31.5 MCHC-34.1 RDW-15.0 Plt Ct-144*
[**2150-10-28**] 05:45AM BLOOD WBC-6.4 RBC-3.66* Hgb-11.0* Hct-34.6*
MCV-95 MCH-30.1 MCHC-31.8# RDW-14.4 Plt Ct-293#
[**2150-10-23**] 11:58AM BLOOD PT-13.2 PTT-30.9 INR(PT)-1.1
[**2150-10-25**] 04:07AM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.1
[**2150-10-23**] 11:58AM BLOOD UreaN-13 Creat-0.7 Na-138 K-3.7 Cl-108
HCO3-22 AnGap-12
[**2150-10-28**] 05:45AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-139
K-4.3 Cl-101 HCO3-29 AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up at the time of her cardiac cath on previous admission.
On [**10-23**] she was brought to the operating room where she
underwent an aortic valve replacement. Please see operative
report for surgical details. Of note, she had atrial
fibrillation in the operating room that required multiple
cardioversions without effect and then Amiodarone infusion with
conversion to sinus rhythm. Following surgery she was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one she was
started on beta-blockers and diuretics and diuresed towards her
pre-op weight. Had post-op anemia and was transfused with
appropriate effect. She remained in the CVICU for hemodynamic
monitoring until post-op day three when she was transferred to
the step-down floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol. She worked with physical
therapy for strength and mobility. She remained in sinus rhythm
for the rest of her hospital course while receiving Amiodarone
(will receive 200 mg daily for 1 month) and didn't require
Coumadin. The remainder of her hospital course was uneventful
and was ready for discharge home with VNA services on post-op
day five. She was able to walk with assistance and required use
of a gait belt to help stand. Appropriate medications and
follow-up appointments were made.
Medications on Admission:
ATENOLOL 50 mg Tablet 1.5 Tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE 25 mg Tablet 1 Tablet(s) by mouth daily
NIFEDIPINE 90 mg Tablet Extended Rel 24 hr 1 Tablet(s) by mouth
daily
ACETAMINOPHEN 325 mg Tablet [**1-25**] Tablet(s) by mouth once a day as
needed for pain
ASCORBIC ACID 500 mg Tablet one Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] 600 mg
calcium (1,500 mg)-400 unit Tablet - one Tablet(s) by mouth
twice daily
CARBOXYMETHYLCELLULOSE SODIUM [REFRESH TEARS] 0.5 % Drops - one
in each eye twice daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] 1,000 unit Capsule -
one Capsule(s) by mouth daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis, s/p Aortic Valve Replacement
Past medical history:
Hypertension
Dyslipidemia
Trauma to both legs from a remote rope injury
Osteoporosis
s/p total hip replacement bilaterally [**2144**], [**2146**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance and gait belt
Incisional pain managed with Tylenol/Oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - Trace
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
Wound Care: [**Telephone/Fax (1) 170**] Date/Time:[**2150-11-5**] 10:15
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2150-12-2**] 1:00
Cardiologist: Dr. [**Last Name (STitle) 90618**], [**First Name3 (LF) **]/ [**Last Name (LF) **], [**First Name3 (LF) **] [**11-17**] at
1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21136**] [**Telephone/Fax (1) 21640**] in [**4-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2150-10-28**]
|
[
"401.9",
"424.1",
"288.60",
"E849.7",
"733.00",
"V43.64",
"E878.1",
"272.4",
"V15.82",
"285.9",
"997.1",
"251.2",
"458.29",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
6725, 6774
|
3164, 4688
|
303, 407
|
7031, 7230
|
2349, 3141
|
8153, 8202
|
1663, 1701
|
5377, 6702
|
6795, 6841
|
4714, 5354
|
7254, 8130
|
1716, 2330
|
238, 265
|
8214, 8896
|
435, 1079
|
6863, 7010
|
1299, 1647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,050
| 181,699
|
4122
|
Discharge summary
|
report
|
Admission Date: [**2167-3-29**] Discharge Date: [**2167-4-29**]
Date of Birth: [**2098-8-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Novocain / Lidocaine / Propofol
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
TAH BSO 3 weeks prior ([**2167-3-5**])
History of Present Illness:
68 yo F w/recent TAH BSO [**2167-3-5**] who presents c/o fever,
RUQ/epigastric pain. In ED, noted to have low grade temperature
(Tm 100.5), otherwise normotensive, not tachycardic, tachypneic
or hypoxic. Initial labwork revealed nl CBC, chem-7 (except for
low potassium), but elevated LFTs - ALT 184, AST 217, alk phos
323, nl bilirubin, LDH 3000. Amylase/lipase wnl. RUQ u/s was
done to further evaluate which showed thickening of GB wall
w/edema without frank cholecystitis; it also revealed multiple
hypoechoic rounded liver lesions worrisome for metastases. A CTA
confirmed LAD but did not show evidence of pulmonary embolus.A
HIDA scan was obtained, preliminary result negative per ED
resident. Blood cx, urine cx were obtained.
.
Of note, an abdominal CT was done as an outpatient for
evaluation of abdominal pain which showed:
.
IMPRESSION:
1) Diffuse enlarged lymphadenopathy throughout the hilar,
paracardiac,
paraesophageal, paragastric, porta hepatis, mesenteric,
retroperitoneal,
iliac, inguinal, and deep pelvic regions. The greatest
concentration of these
abnormal nodes is superiorly in the paraesophageal and
paragastric region.
This nodal burden taken in conjunction with the ring-enhancing
lesions
throughout the liver and the findings in the spleen, are
extremely concerning
for malignancy. A primary is not definitively identified.
There may be a
mass in the proximal stomach, though this may also represent an
artifactual
pseudotumor due to underdistension. Diagnostic considerations
include
lymphoma and metastatic spread from primary esophageal or
gastric tumor.
2) Multiple ring-enhancing hypodensities throughout the liver,
concerning for
metastases.
3) Multiple wedge-shaped hypodensities throughout the spleen,
consistent with
infarct versus metastases. The splenic artery is patent.
4) No evidence of acute postoperative complication; no evidence
of bowel
obstruction, significant hematoma, or active arterial bleeding.
Post-surgical
changes at the site of the previous hysterectomy.
5) No suspicious lesions seen throughout the lung bases or
osseous structures,
though dedicated chest CT and bone scan is recommended if
clinically
warranted.
.
Additional hx from the patient noted that the patient has had a
colonoscopy in [**2163**] with non-malignant polyps and her last
mammogram was at an outside institution, reportedly normal one
year ago.
.
The patient was informed of the concern for possible malignancy
given these findings.
Past Medical History:
PMH: asthma, hypertension, hypothyroid
PSH: Appy '[**26**]
Gyn: fibroids, nl [**Last Name (un) 3907**]
OB: G12 P2
Social History:
no tobacco or alcohol
Family History:
no breast, ovarian, colon ca
Physical Exam:
Gen: ill appearing, somewhat sweaty but not frankly diaphoretic
HEENT: mucous membranes somewhat dry, PERRL, EOMI
Neck: posterior cervical lymph nodes palpable on L, about 1cm
each; biopsy site on R posterior neck appears intact
CV: RRR, nl S1/S2, 2/6 systolic murmur loudest at LLSB
Pulm: trace crackles, no wheezes
Abd: soft, NT/ND, wound vac in place medially, intact; no HSM
appreciated
Ext: no edema, 2+ distal pulses
Pertinent Results:
CBC:
[**2167-3-29**] 12:00PM BLOOD WBC-9.7 RBC-4.55 Hgb-12.8 Hct-37.1 MCV-82
MCH-28.2 MCHC-34.6 RDW-14.8 Plt Ct-150
[**2167-3-29**] 12:00PM BLOOD Neuts-62 Bands-4 Lymphs-21 Monos-8 Eos-4
Baso-0 Atyps-0 Metas-1* Myelos-0
---
Coags/DIC workup:
[**2167-3-30**] 09:05AM BLOOD PT-14.7* PTT-25.8 INR(PT)-1.4
[**2167-3-31**] 08:29AM BLOOD Fibrino-435* D-Dimer-7162*
[**2167-4-1**] 11:53AM BLOOD FDP-10-40
---
Lytes/LFTs:
[**2167-3-29**] 12:00PM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-138
K-3.2* Cl-98 HCO3-24 AnGap-19
[**2167-3-29**] 12:00PM BLOOD ALT-184* AST-217* LD(LDH)-3000*
AlkPhos-323* Amylase-20 TotBili-0.9
[**2167-4-2**] 04:11AM BLOOD LD(LDH)-6290*
[**2167-3-31**] 08:29AM BLOOD Calcium-8.8 Phos-1.9*# Mg-1.8
UricAcd-10.3*
[**2167-3-30**] 03:45PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.8 Mg-1.6
----
Lactate:
[**2167-3-29**] 12:02PM BLOOD Lactate-3.6*
[**2167-4-2**] 12:11AM BLOOD Lactate-14.4(peak)*
----
Urine:
[**2167-3-29**] 03:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.027
[**2167-3-29**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2167-3-31**] 02:00PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
----
Micro:
BCx neg throughout stay (10+ sets)
Urine Cx neg x4
Multiple sputum cxs with only sparse OP flora
----
RUQ U/S ([**3-29**])
IMPRESSION:
1) Numerous hypoechoic foci within the liver that are worrisome
for metastatic disease. These were further characterized on a
recent CT scan.
2) Gallbladder wall thickening and edema. The gallbladder is not
distended, however, without stones, pericholecystic fluid or
[**Doctor Last Name **] sign. The gallbladder wall thickening and edema could be
related to inflammatory processes within the right upper
quadrant, including hepatitis, duodenitis or pancreatitis. Also
the etiology could be related to lymphatic obstruction due to
lymphadenopathy within the porta hepatis. There is no definite
evidence of cholecystitis, though to completely exclude
cholecystitis, a HIDA scan could be considered.
----
[**3-30**]:CTA CHest:IMPRESSION:
1) No evidence of pulmonary embolus.
2) Extensive lymphadenopathy within the mediastinum, hila,
axillae, epiphrenic and periaortic regions. Given the calcified
hilar lymph nodes, sarcoidosis could be a diagnostic
consideration. Lymphoma is less likely, unless it was previously
treated. Other infectious or inflammatory etiologies could be
considered, such as old TB infection. In reviewing the findings
of the recent abdominal CT, metastatic disease is a
consideration.
3) Small nodular opacities along the bronchovascular bundle
likely represent additional small lymph nodes.
----
[**3-30**]:CXR:IMPRESSION: New bilateral hilar and right mediastinal
lymphadenopathy, concerning for metastases.
----
[**4-6**]:CXR:IMPRESSION: Worsening left retrocardiac opacity, most
likely due to atelectasis and adjacent pleural effusion.
Interval extubation.
----
[**4-8**]:CXR:Unchanged appearance of left lower lobe
consolidation/collapse. Malpositioned endotracheal tube
terminating within the cervical esophagus. This should be
advanced.
---
[**4-9**]:CT abd/pelvis:IMPRESSION:
1) No evidence of retroperitoneal hematoma.
2) The patient's NG tube is positioned with its distal tip
within the second portion of the duodenum causing significant
mass effect upon the posterolateral wall of the duodenum. This
tube should be withdrawn approximately 5 cm to avoid iatrogenic
lesion of the duodenal mucosa.
3) New anasarca as well as free fluid within the pelvis and
small bilateral pleural effusions.
4) Atelectasis versus consolidation within the left lower lobe
that is new when compared to [**2167-3-26**].
5) Large spleen with areas of focal hypodensity better assessed
on the recent contrast CT from [**2167-3-26**]. Low attenuation
lesions within the liver as well as retroperitoneal and
periportal lymph node enlargement are also better assessed on
this prior study.
Brief Hospital Course:
# Lymphoma: Pt was found to have physical exam c/w lymphoma/LAD,
as well as elevated LFTs, LDH >3000, diffuse LAD on chest/abd
CT. She had also been having low grade fevers at home. Given
this, concern for malignancy was high. Pt had biopsy of
cervical LN which returned as non-Hodgkin lymphoma, diffuse
large B-cell type. She was also having a rapid rise in her
lactic acid, uric acid, and LDH levels. At this point, she was
transferred from the BMT unit to the ICU for closer
monitoring and for initiation of chemotherapy. She was very
high risk for tumor lysis syndrome, so she initially had ABGs
and electrolytes/lactate monitored every 2 hours. Allopurinol
was also started and continued throughout. The BMT team
continued to consult on the pt, and she was staretd on a 6 day
continuous infusion of chemo ([**Hospital1 **] regimen). This was done to
minimize tumor lysis. With treatment, her LDH, uric acid, and
lactate levels all fell to acceptable levels. Her electrolytes
were monitored closely, and she required phos binders for much
of her stay. Her urine was also alkalizinized initially due to
high levels of uric acid. This was stopped when her levels
dropped to normal range. She was placed on steroids during her
chemo regimen as well. After her chemo was completed, her tumor
lysis labs were measured daily and remained stable.
Her LDH continued to trend down and while intubated, BMT started
the patient on rituxan. Her counts recovered and her filgastrim
was discontinued. She was continued on allopurinol. BMT believed
she had a good prognosis to recover from her lymphoma, however,
overall, her prognosis including her active infections,
respiratory failure, and ultimate unresponsiveness precluded any
chance of full recovery.
.
# Respiratory distress/Resp compensation for met acidosis:
On presentation, she was breathing fairly rapidly and deeply to
compensate for her severe metabolic acidosis. Based on pH
measurements, she was actually doing well with this. However,
as she was appearing to become tired, and also as a precaution,
she was intubated 1 day after entering ICU. She was intubated
for several days, but required minimal ventilatory support. She
was in fact overbreathing the ventilator most of the time. The
only concern was the large amt of fluids she had received in the
face of severe distress and low UOP in her first few days in the
ICU. Given the fact that her acidosis resolved with chemo
though, and her ability to easily breathe on no vent support,
she was extubated on [**4-5**].
However, she developed respiratory distress on [**4-6**] and was
re-intubated with unclear etiology with the development of
stridor and likely CHF exacerbation. She was grossly 19 liters
positive and was aggressively diuresed with lasix and
metalazone. She had a diaphragm bedside study on [**4-10**] which
showed no paradoxical movement of the diaphragm. NIF= -25.
She remained intubated with failure to wean for 2 weeks despite
diuresis and treatment of a LLL consolidation on CXR and
confirmed by CT. Thus, the patient was bronched on [**4-18**] which
showed evidence of tracheo-bronchitis, so voriconazole was added
to her course in addition to IV acyclovir with oral HSV lesions.
Viral Ag not detected with negative AFB, viral cultures also
negative. No evidence of PCP. [**Name10 (NameIs) **] patient had a repeat bronch on
[**4-22**] which showed significant bronchitis only mildly improved
since Friday and the patient was kept on caspofungin with fungal
cultures negative as her airways resembled "rotting ground beef"
and appeared fungal in nature.
After much diuresis and continued antimicrobial treatment, the
patient had a RSBI of 27 on [**4-24**] and was successfully extubated.
However, she developed [**Last Name (un) 6055**]-[**Doctor Last Name 6056**] like ventilation(but
without apnea) soon after and her daughter decided against
re-intubation.
.
# Lactic acidosis: This is a typical finding in lymphoma. With
treatment, her levels fell back to normal ranges. They were
checked frequently for the remainder of her stay.
.
# ID:Pt was started on levo/flagyl on admission for concern of
possible cholecystitis. This did not turn out to be the case.
In the BMT unit, she was changed to vancomycin/levofloxacin as
she was acutely ill, and team was concerned about possible
continued infection/or possibility of re-infection of her
abdominal wound(followed by surgery, vac dressing). Continued
these initially in ICU, but then the levofloxacin was stopped,
as main concern was for infection of abd wound with gram + skin
organisms. She was having interemittent fevers, initially
believed to be due to her disease process. Multiple urine and
blood cultures (as well as sputum) were sent which showed no
growth.
She was continued on cefepime/caspofungin x [**6-14**] d from last
bronch(flagyl d/c'd on [**4-16**], voriconazole and acyclovir also
d/c'd, vanco d/'c 5.22). Her antibiotic coverage was empiric in
the setting of febrile neutropenia and LLL consolidation which
resolved on CXR.
- A CT torso showed splenic lesions c/w infarct, w/ no clear
evidence of infectious source. BMT felt these were related to
necrosing lymphomatous tissue.
- BAL negative for viral Ag, AFB, PCP and fungal. All other
cultures negative to date.
- changed CVL on [**4-14**]
- Had been persistently febrile up to few days ago, Likely cause
was secondary to her LLL consolidation/pneumonia + suspected
HSV/candidal bronchitis or even her lymphoma.
.
# Abdominal Wound:She had a vac dressing in place which was
followed and changed as needed by surgical service. They did
not believe that this wound was currently infected, but it was
watched closely and ppx vancomycin was administered and
continued as empiric coverage with no positive blood cultures in
the setting of her febrile neutropenia. The vanc was
discontinued. The vac dressing was removed by surgery and
dressings were wet to dry [**Hospital1 **].
.
# .Low UOP/Renal:Pt initially had a low urine output. Concern
was for shock, as well as for possible of urate crystals forming
in kidneys causing obstruction. For this reason, a large amt of
fluid was administered in first several days that pt was in ICU.
Her renal function did improve, and her fluids were decreased
as tolerated. An echo was done which showed hyperdynamic EF and
a mildly hypertrophic LV. Concern was for possible diastolic
CHF.
#hypertension
- on IV lopressor and hydralazine titrate to BP <160
#fluid status/diastolic heart failure:clinically euvolemic
- will aim for goal even for now since she had metabolic
alkalosis from contraction after she was diuresed 19 liters over
3 weeks.
- A repeat echo was performed on [**4-9**] which showed an EF of >55%
but it was suboptimal.
# mental status: unresponsive post extubation. At first, the
patient opened her eyes to voice and squeezed her right hand and
weakly with her left. She was able to communicate with her
daughter in [**Name (NI) 595**] and was aware per daughter that she was in
the ICU and recognized her daughter and husband. However, the
following day, her mental status rapidly deteriorated as did her
breathing pattern. As a result, a CT of the head was obtained
which showed a small subdural hematoma.
# Family meeting on [**4-17**] with daughter [**Name (NI) 13762**] and Dr. [**First Name (STitle) **]
that decided to continue with plans for further chemo and plan
to extubate as tolerated. Daughter met with team on [**4-23**] and
asked for extubation on [**4-24**]. If the patient does not succeed
with extubation, the daughter would want her to re-intubated.
She developed declining mental status on [**4-27**] and goals of care
were re-addressed. Family opted for comfort measures only. The
pt. passed away peacefully on [**2167-4-29**].
Medications on Admission:
None
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
-non-Hodgkin's lymphoma
Discharge Condition:
Deceased.
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"428.31",
"995.92",
"584.9",
"486",
"466.0",
"276.2",
"284.8",
"599.0",
"432.1",
"038.9",
"998.32",
"289.59",
"627.3",
"401.9",
"202.80",
"054.2",
"518.84",
"054.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"99.05",
"96.72",
"96.04",
"93.59",
"33.24",
"86.05",
"99.28",
"99.25",
"96.6",
"40.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15422, 15431
|
7532, 14307
|
338, 378
|
15498, 15509
|
3557, 7509
|
15561, 15567
|
3067, 3097
|
15394, 15399
|
15452, 15477
|
15365, 15371
|
15533, 15538
|
3112, 3538
|
277, 300
|
406, 2875
|
14322, 15339
|
2897, 3012
|
3028, 3051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,814
| 162,981
|
30057
|
Discharge summary
|
report
|
Admission Date: [**2111-2-11**] Discharge Date: [**2111-2-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
on admission to hospital [**2-11**]: weakness, labs with hyperK,
hypoNa, ARF
cc on tramsfer to [**Hospital Unit Name 153**] [**2-13**]: AF with RVR, pulmonary edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 85yoW with pmh sig for laryngeal ca now with trach > 10
years, transferred from OSH on [**2111-2-12**], where she has been for 3
weeks for evaluation of weakness and lethargy, diagnoses PMR and
started prednisone. MD's at OSH felt PMR with deconditioning,
and considered paraneoplastic syndrome. Course complicated by
hyponatremia which MD thought may be in the setting of
overdiuresis. Diuresis was held, and she was transferred to
[**Hospital1 18**] for further evaluation of this weakness. On transfer, she
was seen by rheumatology who felt that course, symptoms were not
consistent with PMR. They recommended that steroids be tapered
quickly to off. On [**2111-2-13**] pt became acutely sob, CXR was
consistent with pulmonary edema, and she was found to be in afib
with ventricular rate in 150s. HR responded to to IV lopressor,
po digoxin, and diltiazem with minimal response of symptoms, and
IV lasix was given with resultant hypotension.
Past Medical History:
1. Laryngeal ca s/p laryngectomy and trach (years ago); uses
voice box
2. CABG x4 [**2105**], ?MI [**2106**]
3. CHF, EF=30% by report (ischemic cardiomyopathy, b/l wt
108-110 lb)
4. COPD
Primary cardiologust Dr. [**Last Name (STitle) 17204**], Dr. [**Last Name (STitle) 24630**]
Social History:
+tob, lives with family now (recent)
Family History:
NC
Physical Exam:
Last vitals T 98 60 100/53 92% on trach mask
Gen: no response to voice or pain, agonal breathing
HEENT: PERRL, OP clear, with metal trach
Neck: no JVD (difficult to assess neck)
Lungs: diffuse crackles throughout all lung fields with diffuse
wheezing
CV: RRR, nl s1/s1, no m/r/g
Abd: mildly distended but soft, nt, nabs
Ext: warm
Neuro: unable to assess fully, family at bedside
Brief Hospital Course:
85yo female, h/o ischemic CM (EF=30%), new onset weakness and
?PMR, p/w pulmonary edema, SOB, and afib with RVR, admitted to
ICU for further monitoring, there pt with minimal urine output
to lasix, after discussion with family, made CMO. Patient
maintained on IV morphine drip and remained comfortable prior to
death.
Medications on Admission:
Synthroid 100 mcg
ASA 162 mg
Dig 0.125 mg
Lasix 80 mg qam, 40 mg qhs
Allopurinol 150 mg
ATrovent/Albuterol nebs
Pulmicort neb
Pravastatin 10 mg
Omeprazole
Spironolactone 25 mg
Actoenl q xk
Pred 10 mg/5 mg
Discharge Medications:
Died
Discharge Disposition:
Expired
Discharge Diagnosis:
Died
Discharge Condition:
Dead
|
[
"V44.0",
"799.02",
"427.31",
"V10.21",
"428.0",
"331.4",
"584.9",
"V45.81",
"414.00",
"496",
"428.20",
"425.4",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2817, 2826
|
2212, 2532
|
428, 434
|
2874, 2881
|
1789, 1793
|
2788, 2794
|
2847, 2853
|
2558, 2765
|
1808, 2189
|
223, 390
|
462, 1417
|
1439, 1719
|
1735, 1773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,236
| 121,957
|
19042
|
Discharge summary
|
report
|
Admission Date: [**2149-9-5**] Discharge Date: [**2149-9-15**]
Date of Birth: [**2072-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76M h/o pancreatic CA (s/p Whipple), upper GI bleed and liver
abscesses with recent admission to [**Hospital1 **] on [**2149-8-9**], d/c'ed on
[**2149-9-2**] on antibiotic therapy with vancomycin, meropenam, and
caspofungin. He was discharged to New [**Hospital3 105**] for IV
antibiotic therapy after he had improved for a few days before
discharge. He had been feeling well after discharge, but
returned to the ED today after he began experiencing shortness
of breath. His wife also noted that his abdomen, which has known
ascites, began looking larger, and that his legs were becoming
increasingly swollen.
.
Of note, during his last hospitalization he was found to be
bacteremic, with various blood cultures growing out E.coli,
Klebsiella (sensitive only to the penems), and Enterococcus
(Vanc sensitive). He was also found to have expanding liver
absesses; absess fluid grew out E. coli, strep viridans, [**Female First Name (un) **]
[**Female First Name (un) 17939**], enterococcus, and bacteroides. A tap of his peritoneal
fluid grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 17939**]. He was then started on
vancomycin, meropenam, and caspofungin. He also had waxing and
[**Doctor Last Name 688**] mental status throughout his hospitalization with
persistent word finding difficulties.
.
Throughout his last admission, he remained in positive fluid
status, per discharge summary. He received 1 paracentesis for
fluid culture and at the time had 6 L of peritoneal fluid
removed which reaccumulated rapidly. The volume overload was
attributed to low albumin secondary to liver dysfunction from
his large abscesses.
.
He had persistent pleural effusions during his admission, noted
on CT on [**8-9**], moderate on the right and small on the left.
There were also two areas of opacity in the left midlung region.
Per conversation with primary team from last admission, a
pleural tap was considered but deferred due to its stable
nature. It did, however, increase after the liver abscesses were
drained.
.
In the ED, he had a temperature of 100 degrees per rectum. His
heart rate was 92, BP 124/54, RR 14, and his O2 Sat was 100% on
room air. A chest x-ray and EKG were ordered and he had a RUQ
ultra-sound. He was started on O2 via nasal cannula. Full labs
and blood cultures were drawn. He was given Percocet 5/325 mg
per NGT.
.
On the floor, he desatted to mid 80's on 4L NC, was hypoglycemic
to 50's and had multiple runs of VTach. His hypoxia improved
without any intervention. His BS improved after D50. He was
always hemodynamically stable with Vtach runs. ABG showed
7.32/32/102 with lactate of 2.1. He was transferred to MICU for
more intensive monitoring.
Past Medical History:
1. Pancreatic adenocarcinoma- s/p Whipple [**9-28**] and chemo/XRT
2. Liver abscess ([**3-3**]) Has recurred multiple times. In [**5-31**]-
Abscess composed of E. coli, Morganella morganii, and
enterococcus-Rx w/ cefipime, vancomycin, Fungizone
3. Acute Renal Failure at OSH in DC [**5-/2149**] (thought [**2-27**]
vanc/ampho)
4. Anemia secondary to bleeding duodenal ulcers ([**5-/2149**])
5. E. coli bacteremia ([**5-31**])
6. Chronic diarrhea-secondary to pancreatic insufficiency
7. Hypertension-no longer on Rx
8. GERD
9. Sigmoid diverticulosis ([**2146**])
10. Abdominal aortic aneurysm ([**2146**])
11. Pancreatitis
12. Ascites-3L removed ([**5-/2149**])
13. DM- well controlled w/ Prandin
14. E. coli bacteremia [**7-/2149**]
15: RUE DVT [**7-/2149**]
16. RUQ U/S on [**8-12**] showed multiple liver nodules concerning for
abcesses vs. metastases. He received a CT guided drainage of one
liver abscess and drain placement on [**8-15**] -> growing klebsiella
resistant to cetriaxone, enterococcus and yeast. No malignant
cells were found on abscess biopsy. He also received a
paracentesis and peritoneal fluid grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 17939**] and
fluid analysis showed elevated WBCs c/w SBP. Meropenem and
vanco were started on [**8-17**] due to ceftriaxone and methacillin
resistance profiles. Caspofungin started [**8-19**] for [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 17939**] coverage. He had two other liver nodules also drained
by IR, last on [**8-19**]. Attempted to replace percutaneous drains on
[**8-27**] after drainage slowed but abscesses were not amenable to
drainage by IR. Planning for antibiotics will need to be
continued for 6 weeks with serial imaging to monitor for
resolution of absecesses.
Social History:
Lives with wife in [**Hospital3 4298**]. Of Argentinian decent,
travelled to [**Country 32814**] earlier this year, where his liver abcess
was diagnosed. Used tobacco for >10 yrs as youth. Denies EtOH,
drugs. Recently transferred to [**Hospital1 **] for IV antibiotics on
[**2149-9-2**].
Family History:
non-contributory
Physical Exam:
General- Sick-appearing man in some distress. Did not want to be
examined; moaning.
HEENT- PERRL, NC.
Neck- JVD
Pulm- Decreased breath sounds at the bases bilaterally.
CV- Irregular rhythm; nl S1 and S2.
Abd- Large distended abdomen with hernia above the umbilicus.
Bowel sounds present. Firm, nontender.
Rectal- Deferred
Extrem- 3+ pitting edema in bilateral lower extremities
including both thighs
Neuro- Somnolent. Oriented to person. Did not know the date or
where he was
Brief Hospital Course:
Patient was transferred to the floor out of the MICU. His MICU
stay was complicated by an upper [**Hospital1 **] bleed secondary to peptic
and duodenal ulcers. He developed acute on chronic renal
failure secondary to aggressive diuresis, but remained otherwise
stable of the course.
.
#)SOB
Pt has known pleural effusion and left lower lobe opacities.
Effusion had increased during last hospitalization after
drainage of his liver abscesses. Pt had clinically been doing
better pre-discharge. Now has shortness of breath in bed. Also
has 3+ pitting edema up to thighs bilaterally and large,
protrudent abdomen with increased ascites, and increased JVD.
SOB likely related to fluid overload from increasing liver
dysfunction. Patient refused further invasive interventions
including thoracentesis. Effusions were not responsive to
aggressive diuresis.
.
# Upper GIB- peptic ulcers found on EGD. Per GI, not treatable
via EGD. Recommended carafate and PPI IV BID. Hct remained
stable after bleed post transfusions. No need for repeat
transfusions after repeat episode.
.
#A fib: Rate controlled with metoprolol. Episodes of
tachycardia treated with IV lopressor prn. Standing metoprolol
dose gradually increased. Could not anticoagulate given upper GI
bleed and possible intracranial septic emboli.
.
#)Liver abscesses and Bacteremia - Continued vancomycin,
caspofungin, and meropenem. Were not amenable to further
percutaneous drainage on last admission. Would have needed long
term antibiotics with serial imaging to assess responsiveness.
.
# Mental status changes- patient was believed to be
encephalopathic secondary to his multisystem dysfunction and
severe illness as his mental status waxed and waned greatly. He
never had focal neurologic deficits except for a persistent word
finding difficulty noted on his prior admission. The utility of
repeating head imaging to reevaluate his possible septic emboli
was believed to be low without further intervention options. In
his final days in the hospital, his mental status improved such
that he was able to participate in decisions regarding his
treatment.
.
#)Ascites- persistent ascites with low albumin minimally
responsive to aggressive tube feeds. Patient refused repeat
paracentesis.
.
#)Pancreatic insufficiency - Was given viokase per NG while he
was getting tube feeds to assist in breakdown and absorbtion of
nutrients.
.
# Renal failure: Creatinine elevationa after aggressive diuresis
for pleural effusions. Slowly declined after discontinuation of
diuresis, then stabilized. UOP remained consistently at 30-40
cc/hr.
.
# DM2- controlled with insulin sliding scale.
.
#)HTN- controlled with increasing doses of metoprolol
.
#)FEN- frequent high residuals over this admission. Patient
switched to TPN given the need for nutrition to increase his
albumin.
.
#)Prophylaxis- Heparin SC 5000 units
.
Patient pulled out his NG tube on [**9-13**] and refused replacement.
He explained that he was tired of aggressive treatment. A
family meeting was held which included the patient, and it was
decided to make Mr. [**Known lastname 52006**] [**Last Name (Titles) **] measures only. His
therapeutic medications were stopped and he was started on a
morphine drip. He passed away peacefully 2 days after beginning
[**Last Name (Titles) **] care.
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
|
[
"427.31",
"530.81",
"261",
"577.8",
"572.0",
"427.1",
"790.7",
"V10.09",
"584.9",
"789.5",
"511.9",
"585.9",
"531.40",
"250.80",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9074, 9083
|
5732, 9051
|
333, 339
|
9134, 9144
|
5198, 5216
|
9104, 9113
|
5231, 5709
|
274, 295
|
367, 3061
|
3083, 4877
|
4893, 5182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,714
| 198,634
|
26832
|
Discharge summary
|
report
|
Admission Date: [**2193-11-14**] Discharge Date: [**2193-12-6**]
Date of Birth: [**2142-3-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
51M unrestrained driver s/o MVA, initially unresponsive,
intubated at OSH, SDH, SAH, T11/T12 burst fracture, bilateral
open ankle fractures, and orbital hematoma.
Major Surgical or Invasive Procedure:
-Left craniotomy for evacuation of large subdural hematoma on
the left. Craniectomy for decompression of ICP
-Multilayer closure of right forehead/scalp laceration
-Bilateral serial irrigation and debridement of open
bilateral talus fracture/dislocation
-Adjustment of bilateral external fixators of the
tibiotalar joints
-Posterior thoracic instrumentation, T8 to L2
-Posterior arthrodesis with lateral mass screws from T8 to
L2
-Use of allograft for arthrodesis
-Inferior vena cava filter placement
History of Present Illness:
51M unrestrained driver s/o MVA, initially unresponsive,
intubated at OSH, SDH, SAH, T11/T12 burst fracture, bilateral
open ankle fractures, and orbital hematoma.
Past Medical History:
s/p CABG
CAD
s/p [**First Name3 (LF) 1291**]
Family History:
non-contributory
Physical Exam:
98.4 69 130/60
intubated
no sedation - moves bilateral upper extremity, partially moves L
toes and L hip flexion
pupils 3-4mm OU and sluggish
facial lacs- closed by plastics
equal BS bilaterally
+BS
abd soft
lower extremity deformity.
Pertinent Results:
[**2193-11-14**] 11:10AM URINE RBC-21-50* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0
[**2193-11-14**] 11:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2193-11-14**] 11:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2193-11-14**] 11:10AM FIBRINOGE-205
[**2193-11-14**] 11:10AM PT-26.5* PTT-38.2* INR(PT)-5.2
[**2193-11-14**] 11:10AM PLT SMR-VERY LOW PLT COUNT-55*
[**2193-11-14**] 11:10AM WBC-8.8 RBC-3.07* HGB-10.6* HCT-30.9*
MCV-101* MCH-34.4* MCHC-34.2 RDW-15.8*
[**2193-11-14**] 11:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2193-11-14**] 11:10AM URINE GR HOLD-HOLD
[**2193-11-14**] 11:10AM URINE HOURS-RANDOM
[**2193-11-14**] 11:10AM URINE HOURS-RANDOM
[**2193-11-14**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-11-14**] 11:10AM AMYLASE-59
[**2193-11-14**] 11:10AM UREA N-11 CREAT-1.1
[**2193-11-14**] 11:19AM GLUCOSE-243* LACTATE-9.1* NA+-138 K+-4.6
CL--102 TCO2-18*
[**2193-11-14**] 12:45PM FIBRINOGE-159
[**2193-11-14**] 12:45PM PT-11.8 PTT-37.8* INR(PT)-0.9
[**2193-11-14**] 12:45PM PLT SMR-VERY LOW PLT COUNT-33*
Brief Hospital Course:
[**12-6**] HD 23
POD 22, 14, 11
Abx: Unasyn d6, flagyl d11, (optho polysporin gtts)
proph: coumadin, hep gtt (PTT 50 for [**Month/Year (2) 1291**]), prevacid, IVC filter
TLD: LUE picc
51M s/p ex fix ([**11-14**]) & washout ([**11-17**]) unrestrained driver s/p
MVA, unresponsive, intubated at OSH, SDH, SAH, T11,T12 burst
fracture, B open ankle fracture, orbital hematoma, fx of R 7,8
ribs.
PMH: CABG, CAD [**First Name9 (NamePattern2) 1291**]
[**Last Name (un) 1724**]: Atenolol 50 QD, omeprozole 20 QD, warfarin 8, colchicine
.6, cyclobenzapr 10 TID, gemfibrozol, 600, mephyton 5, Dig .25,
relafen 500
micro: [**12-3**] rare GNRs, strep viridians rare, rare staph aureus.
[**11-28**] cath tip neg. [**11-27**] R eye MRSA [**11-24**] Cdiff neg. [**11-19**]
sputum neg. U/Bld Cx's neg. swabs of b/l feet and craniotomy
neg.
RADS: [**12-1**] CT abd: L rectus abd small fluid collection likely
due to inflammation/infection. No definite abscess; CXR patchy
opacity R perihilar region.
[**11-14**] - s/p L craniotomy, s/p closure of R frontal laceration,
s/p R eye lateral canthotomy, s/p ex-fix of B tib fib fx
[**11-20**] washout w/ KRod, call plastics intern when going
-d/w plastics re repeat washout, flap
[**11-22**]- IVC filter
[**11-25**] - Peg [**11-26**]-OR w/ ortho ORIF/ex fix L knee tibial plateau
[**11-29**]- wound vac changed by ortho, erythematous wounds,
augmentin added, PICC placed
[**12-1**]-CP/SOB-->CXR/EKG/[**Last Name (un) **] ok; purulent d/c from PEG site-->hold
TF, CT abd small inflam/infxn L rectus, no definited
collections, no intraperitoneal involvement; PTT 33 @2400
Hep-->incr 2500
[**12-2**]-PPT 42 @0030-->incr Hep 2600, PPT 48.0 inc to 2650. wicks
TID to PEG, MRSA optho, vac change [**12-3**], plastics no STSG till
exfix off, started TPN (TG 197: 2L/304dex/110AA/40fat today),
CXR on 25th patchy opacity. fx of R 7,8 ribs on CT.
[**12-3**]- full TPN, vac changed by ortho-plans pending, NTD per
neuro f/u with NSG Dr. [**Last Name (STitle) 66042**] 4 weeks. [**Hospital1 **] screening.
d/c'd cipro and erytho gtts per ophtho. only on gent x 48h and
polysporin.
[**12-4**]- started coumadin, TPN, bowel regimen, GNR/GP on swab
[**12-5**]- daughter wants guardianship to aid in placement,
antifungal aloe to perineum, swab cx rare growth.
[**12-6**] hep gtt [**Month (only) **] to 2600 from 2800 for PTT > 60. Tropic tube
feeds per PEG started as PEG site improving. another dose of
coumadin ordered.
labs as of [**2193-12-6**]
07:06a
heparin dose: 2800
PT: 14.4 PTT: 91.5 INR: 1.4
[**2193-12-6**]
04:50a
Na 127 Cl 97 BUN 13 Glu 129 AGap=16
K 3.7 HCO3 18 Cr 0.4
Comments: Note Updated Reference Range As Of [**2193-6-7**]
Ca: 8.4 Mg: 1.4 P: 3.4
WBC 12.0 Hb 7.9 HCT 23.9 Plt 87
Medications on Admission:
Atenolol 50 QD, omeprozole 20 QD, warfarin 8, colchicine .6,
cyclobenzapr 10 TID, gemfibrozol 600, mephyton 5, Dig .25,
relafen 500
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: [**12-10**]
Injection ASDIR (AS DIRECTED) as needed for hyperglycemia.
2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Acetaminophen 160 mg/5 mL Solution Sig: [**12-9**] PO Q4-6H (every
4 to 6 hours) as needed.
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
10. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q4H (every 4 hours): OU.
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: as
needed to keep INR 2.0 - 2.5.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Morphine Sulfate 2-4 mg IV Q4H:PRN
14. Unasyn 3 gm IV Q6H
15. Metronidazole 500 mg IV Q8H
16. HydrALAZINE HCl 10 mg IV Q8H:PRN SBP > 160
17. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 2600 (2600) Intravenous ASDIR (AS DIRECTED): rate was
2600 units/hr to keep PTT goal 50 - 60 sec until INR
therapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p MVA
subdural hematoma
subarachnoid hematoma
complex laceration right forehead
bilateral talus fracture/dislocation
T11 and T12 burst fractures
left knee tibial plateau fracture
Discharge Condition:
Stable
Discharge Instructions:
Please take prescribed medications as instructed.
TPN x 1d more. Impact with fiber per PEG with goal of 70cc/hr.
Vacuum dressings on RLE and LLE to be changed q3 days.
Duoderm to back incision q3 days.
Dressing and wound care per page 2.
Sponge bathe only.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Reddness/swelling/discharge from wounds
* Anything that concerns you.
Followup Instructions:
Call [**Telephone/Fax (1) 1669**] for appointment with Dr. [**Last Name (STitle) 739**] in 3
weeks, inform the office that you will need a head CT scan for
this appointment. This is for Neurosurgery.
Call [**Telephone/Fax (1) 6439**] for an apppointment with Trauma Clinic in [**1-10**]
weeks
Call [**Telephone/Fax (1) 1228**] for a follow up appointment with Orthopedics
in 2 weeks.
Call [**Telephone/Fax (1) 253**] for any concerns for redness/discharge of the
right eye. This is the ophthamology office.
Call [**Telephone/Fax (1) 66043**] for follow up with the Plastic surgeons in
next Tuesday.
Completed by:[**2193-12-6**]
|
[
"305.00",
"401.9",
"824.1",
"E816.0",
"801.26",
"806.25",
"348.4",
"837.1",
"V43.3",
"414.00",
"371.40",
"427.31",
"873.59",
"V45.81",
"825.31",
"823.00",
"873.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.51",
"38.7",
"86.59",
"96.6",
"79.17",
"03.53",
"43.11",
"79.36",
"01.31",
"79.67",
"78.18",
"81.63",
"81.05",
"78.17",
"79.87"
] |
icd9pcs
|
[
[
[]
]
] |
7167, 7246
|
2806, 5547
|
477, 980
|
7471, 7480
|
1547, 2783
|
7938, 8573
|
1257, 1275
|
5729, 7144
|
7267, 7450
|
5573, 5706
|
7504, 7915
|
1290, 1528
|
275, 439
|
1008, 1172
|
1194, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,803
| 178,451
|
30380
|
Discharge summary
|
report
|
Admission Date: [**2116-1-20**] Discharge Date: [**2116-1-24**]
Date of Birth: [**2088-7-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
[**Known firstname **] [**Known lastname 6164**] is a 27 year-old female referred for the
evaluation of gastric restrictive surgery in the treatment and
management of morbid obesity.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 304.1 lbs
as
of [**2115-9-5**] (initial screen weight [**2115-6-24**] was 305.1 lbs), height
of 64.75 inches and BMI of 51. Her previous weight loss efforts
have included Weight Watchers in [**2113**]/[**2114**] losing 13 lbs, [**First Name8 (NamePattern2) 1446**]
[**Last Name (NamePattern1) **] in [**2108**]/[**2109**] losing 30 lbs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] Loss with little
results, prescription weight loss medication Meridia for one
month with no weight loss, Slim-Fast for 2 weeks losing 4 lbs,
[**Doctor Last Name 1729**] Diet for weeks with no weight loss and over-the-counter
Ephedra-containing supplement for 4 weeks losing 10 lbs. She
cannot maintain her lost weight for no more than one month. Her
weight at age 21 was 200 lbs with her lowest adult weight 180
lbs
and her highest being her initial screen weight of 305 lbs. She
weighed 250 lbs in [**2114**]. She stated she developed significant
[**Last Name 4977**] problem in childhood. Factors contributing to her excess
weight include large portions, too many fats and carbohydrates,
inconsistent meal schedules, stress, emotional and nervous
eating, compulsive eating and lack of exercise. She denied
history of eating disorders - no bulimia, anorexia, laxative or
diuretic abuse. She has situational depression centered around
her weight.
Past Medical History:
Her medical history is noted for cardiac arrhythmias (SVT) on
beta-blocker for control, occasional weight-related back pain
and
iron deficiency buy recent blood work. Review of systems is
relatively unremarkable except for palpitations. She denied
chest
pain, shortness of breath, dizziness or lightheadedness,
abdominal pain, nausea/vomiting, diarrhea or constipation. She
has menstrual irregularities. She denied heart disease,
hypertension, diabetes, asthma, sleep breathing disorder, GERD,
dyslipidemia, thromboembolism, polycystic ovary syndrome,
osteoarthritis, thyroid or gallbladder disease. She has no
surgical history.
Social History:
She smokes 3 cigarettes a week, no
recreational drugs, [**4-16**] glasses of Bicardi/Budweiser a week and
has one cup of coffee 5 days a week as well as glass of diet
caffeine-free soda a day. She is a homemaker and
CNA, single with one child age 6.
Family History:
Family history is noted for both parents living father age 58
with obesity; mother age 55 with hyperlipidemia, arthritis and
obesity.
Physical Exam:
Per Dr. [**Last Name (STitle) 28349**] on [**2115-9-23**]
Her blood pressure was 118/72 and pulse 82. On physical
examination [**Known firstname **] was casually dressed in no distress. Her
skin was warm and dry with mild acne and very mild hirsutism.
Sclerae were anicteric, conjunctiva clear,pupils were equal
round
and reactive to light, fundi were normal, mucous membranes were
moist, tongue was smooth and pink, oropharynx was without
exudates or hyperemia. Trachea was in the midline and the neck
was supple without adenopathy, thyromegaly or carotid bruits,
there was no JVD. Chest was symmetric and the lungs were clear
to
auscultation bilaterally. Cardiac exam was regular rate and
rhythm with normal S1 and S2, no murmurs, rubs or gallops.
Abdomen was obese but soft, non-tender, non-distended with
normal
bowel sounds and no masses, hernias, no incision scars. There
was
no spinal tenderness or flank pain. Extremities were without
edema, venous insufficiency or clubbing. There was no evidence
of
joint swelling or inflammation. There were no focal neurological
deficits.
Pertinent Results:
[**2116-1-20**] 06:00PM BLOOD Hct-33.5*
[**2116-1-23**] 08:31AM BLOOD WBC-9.8 RBC-3.57* Hgb-10.1* Hct-29.5*
MCV-83 MCH-28.2 MCHC-34.1 RDW-14.5 Plt Ct-278
[**2116-1-22**] 07:30AM BLOOD Plt Ct-454*
[**2116-1-23**] 04:50AM BLOOD Glucose-81 UreaN-8 Creat-0.5 Na-138 K-3.7
Cl-102 HCO3-25 AnGap-15
[**2116-1-23**] 04:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
[**2116-1-22**] 04:55AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9
[**2116-1-22**] 07:23AM BLOOD Type-ART pO2-125* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
Brief Hospital Course:
27 year old female admitted for weight reduction surgery. On
[**2116-1-20**] underwent a laparoscopic gastric bypass without
complications.
Postoperative day 1 - Patient had UGI showing post Roux- en- Y
gastric bypass without evidence of leak. There is delay of
passage of contrast into the distal jejunum at the expected
region of jejunjejonostomy, likely related to postsurgical
adynamic ileus. Nasogastric tube discontinued and she was
started on bariatric stage one and tolerated well.
Postoperative day 2 - Patient went into rapid svt, lopressor 5mg
given x 3 without effect. Adensoine 6mg given resulting in
conversion of sinus rhythm. ABG obtained which was normal.
Denies shortness of breath. Patient transferred to Intensive
care unit to monitor heart rate. Cardiology consult called.
Patient placed on verapamil 40mg q6 hours. Progressed to
Bariatric stage 2 diet.
Postoperative day 3 - Patient feels well. Continues to be in
sinus rhythm on verapamil. Transferred back to floor. Progressed
to stage 3 diet. Patient out of bed and ambulating. Very little
pain.
Postoperative day 4 - Patient had good night and continues to be
in sinus rhythm. One event this morning of transient sinus
bradycardia noted on telemetry. When questioned patient was
trying to move bowels at this time. EKG obtained with no change
and cardiology called. They have seen her and feel that she is
ready to go home.
Discharge plans
1. Cardiac - Patient will take verapamil 40mg every 8 hours per
cardiology. She is to follow up with Dr. [**Last Name (STitle) **] in 4 weeks
regarding further treatment of her SVT. Contact information has
been given to patient.
2. Gastric bypass - Patient will be discharged on bariatric
stage 3. She is to follow up with Dr. [**Last Name (STitle) **] on [**2115-2-12**]
Medications on Admission:
Metoprolol 50mg po daily
Vicodin PRN for back pain
Discharge Medications:
1. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*600 ML(s)* Refills:*0*
3. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Verapamil 40 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Status Post Laparoscopic Gastric Bypass
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet:
Stay in Stage III diet until your follow up appointment. Do not
self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You will be given a prescription for pain medication, which
may make you drowsy. Do not drive while taking pain medication.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. Thismedicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**11-25**] 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.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2116-2-12**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2116-2-12**] 10:30
Completed by:[**2116-1-24**]
|
[
"311",
"427.89",
"560.1",
"V85.4",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.38"
] |
icd9pcs
|
[
[
[]
]
] |
7027, 7033
|
4693, 6488
|
496, 538
|
7117, 7126
|
4173, 4670
|
8727, 9093
|
2917, 3052
|
6589, 7004
|
7054, 7096
|
6514, 6566
|
7150, 7716
|
3067, 4154
|
274, 458
|
8584, 8704
|
566, 1980
|
7742, 8572
|
2002, 2633
|
2649, 2901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,716
| 140,696
|
35691
|
Discharge summary
|
report
|
Admission Date: [**2156-4-23**] Discharge Date: [**2156-5-2**]
Date of Birth: [**2102-11-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2156-4-27**] Coronary Artery Bypass Graft x 5 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, Saphenous vein graft to obtuse marginal, Saphenous
vein graft to posterior descending artery to posterior lateral
branch)
[**2156-4-23**] Cardiac Cath
History of Present Illness:
This active 53 year old gentleman has a history of chest pain
for the past year which he describes as occurring intermittently
with exertion such as running with his dog or playing
volleyball. He had a stress test done last year, in [**2155-3-8**]
which demonstrated a mild apical reperfusion defect. He was
started on a medication regimen and continues to have symptoms.
He denies symptoms occurring at rest.
He was seen by Dr. [**Last Name (STitle) 5310**] earlier this month. The stress
test was reviewed by Dr. [**Last Name (STitle) 5310**] and given the patient??????s
continued symptoms, he has been referred for outpatient cardiac
catheterization.
Past Medical History:
Hypertension
Hyperlipidemia
Hepatitis C diagnosed in [**2149**] status post 20 month interferon
therapy
Social History:
Married, 2 children (35, 28)
-Tobacco history: 30 pack years quit 4-5 years ago
-ETOH: 1-2 beers/day
-Illicit drugs: Denies
Family History:
Notable for a brother with heart disease.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: 56 18 161/107 5'5" 165lbs
General: No acute distress, alert and oriented x 3
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm with no murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact
Pertinent Results:
[**4-23**] Cardiac Cath: 1. Coronary angiography of this right
dominant system revealed three vessel coronary artery disease.
The LMCA had a long 90% stenosis. The LAD had minimal disease.
The LCx was a small vessel without significant stenoses. The
proximal RCA had an ostial 60% lesion with catheter damping and
partial spasm. The distal RCA had a 70% lesion before the crux.
2. Resting hemodynamics revealed mildly elevated systemic
arterial blood pressure (SBP 140 mm Hg). 3. Left
ventriculography was deferred.
[**4-23**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**4-27**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). 3.
Right ventricular chamber size and free wall motion are normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. 5. There are
three aortic valve leaflets. There is no aortic valve stenosis.
No aortic regurgitation is seen. 6. Physiologic mitral
regurgitation is seen (within normal limits). 7. There is a
small pericardial effusion. Dr. [**Last Name (STitle) 65203**] was notified in person
of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
Sinus rhythm 1. Biventricular function is normal 2.Aorta is
intact post decannulation 3. Other findings are unchanged
[**2156-5-1**] 07:10AM BLOOD WBC-12.3* RBC-2.76* Hgb-8.5* Hct-24.5*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.5 Plt Ct-331
[**2156-4-23**] 05:34PM BLOOD WBC-11.2* RBC-4.93 Hgb-14.6 Hct-42.9
MCV-87 MCH-29.6 MCHC-34.0 RDW-12.9 Plt Ct-327
[**2156-5-1**] 07:10AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
[**2156-4-23**] 05:34PM BLOOD Glucose-105 UreaN-13 Creat-0.8 Na-143
K-3.8 Cl-106 HCO3-28 AnGap-13
[**2156-4-23**] 09:00AM BLOOD ALT-32 AST-26 CK(CPK)-199* AlkPhos-45
Amylase-65 TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2156-4-23**] 09:00AM BLOOD %HbA1c-5.7
[**2156-4-23**] 05:34PM BLOOD Triglyc-82 HDL-50 CHOL/HD-3.2 LDLcalc-96
[**2156-4-23**] 05:34PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2156-4-23**] 05:34PM BLOOD HCV Ab-POSITIVE*
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname 81204**] [**Last Name (Titles) 21110**] cardiac cath on [**4-23**] which revealed left main and
severe three vessel disease. Due to the severity of his disease,
he was admitted following his cath and awaited surgical
intervention. Prior to surgery he was medically managed and
underwent a comprehensive work-up. On [**4-27**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 5. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On
post-operative day one he appeared to be doing well and was
transferred to the telemetry floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol.
He was transferred to the step down unit on post-operative day 2
and physical therapy was consulted to work on strength and
balance. He continued to progress well and was ready for
discharge to home on post-operative day 5.
Medications on Admission:
HCTZ 12.5mg daily, Lisinopril 10mg daily, Atenolol 25mg daily,
Simvastatin 20mg daily, Wellbutrin 150mg daily, Aspirin 81mg
daily
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime for 1 months.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA,
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Hepatitis C status post Interferon therapy
status post right hand 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:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 5310**] in [**2-10**] weeks
Dr. [**Last Name (STitle) **] in [**1-9**] weeks
Completed by:[**2156-5-2**]
|
[
"788.20",
"600.01",
"788.5",
"413.9",
"997.5",
"070.54",
"530.81",
"E878.2",
"V15.82",
"327.23",
"401.9",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"37.22",
"39.61",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7020, 7072
|
4440, 5570
|
330, 624
|
7241, 7247
|
2138, 4417
|
7758, 7934
|
1593, 1750
|
5750, 6997
|
7093, 7220
|
5596, 5727
|
7271, 7735
|
1765, 2119
|
280, 292
|
652, 1309
|
1331, 1436
|
1452, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,095
| 144,510
|
48600
|
Discharge summary
|
report
|
Admission Date: [**2121-3-8**] Discharge Date: [**2121-3-15**]
Date of Birth: [**2054-11-17**] Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
abdominal pain and cramping
Major Surgical or Invasive Procedure:
Central line insertion
PICC insertion
Packed red blood cell transfusion
Thoracentesis x2
History of Present Illness:
66-year-old female with history of EtOH vs heterozygous
hemochromatosis cirrhosis c/b chronic hyponatremia, ascites,
hepatic hydrothorax with twice weekly thoracentesis, and
encephalopathy presents from the [**First Name4 (NamePattern1) 8125**] [**Last Name (NamePattern1) **] with pain and weakness
following a therapeutic [**Female First Name (un) 576**] today. She states that the pain
and weakness have been on going for 5 days, and that she should
have forgone her procedure. She states that after she had a 3
liter thoracentesis that she had absolutely no energy and was
falling asleep in the car on the way home with her daughter.
She denies fevers, chills, vomitting, rigors, or dysuria.
.
At [**Hospital3 6592**] she noted that after returning home she felt
chills, worsening abdominal pain, "cramps", diffuse, no fever,
no n/v. Labs at [**Hospital1 **] Na 119, K 5.6, BP 80/40 where she received
Levaquin and 3L IVF and was transferred here for further
evaluation.
.
In the ED, initial vs were 98.1 81 94/34 18 98%. Bedside
ultrasound was performed and did not reveal large ascites
pockets. She got 6L IVF, a R. IJ was placed and levofed was
started. Hepatology was contact[**Name (NI) **] and [**Name2 (NI) 24816**] an infectious
work-up and hepatorenal challenge with albumin. The patient
was given Vancomycin and Zosyn.
.
Of note the patient had a potassium of 6.1 and received calcium
gluconate and insulin with D50. EKG was checked and revealed no
peaked T waves.
.
On arrival to the ICU, the patient states that she feels much
better than she has all week.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
--Alcoholic cirrhosis with stage 4 fibrosis
c/b: jaundice, hyponatremia (on Tolvaptan), coagulopathy,
hepatic encephalopathy, recurrent ascites, and recurrent
hepatic hydrothorax s/p pig tail catheter drainage in [**11-1**] and
multiple thoracenteses
(has not had variceal bleeding, and had no varices seen on EGD
on [**2120-9-10**])
-- Taken off of transplant list in MA due to noncompliance with
diet and medications
--Thrombocytopenia/anemia
--Alcohol abuse
--H/o Hypertension
--Heterozygotic hemochromatosis (clinically silent genotype)
--Depression
Social History:
Patient lives at home with her daughter. She worked as a
staffing manager for the [**Location (un) 86**] public school system until 2
years ago. Last drink was in [**2120-7-24**]. She denies any
tobacco
or illicit drug use.
Family History:
Daughter with hemachromatosis. Denies other family history of
liver disease.
Physical Exam:
Vitals: T:97.0 BP:110/34 P:81 R: 18 O2: 100%
General: Alert, oriented, no acute distress
HEENT: icteric sclera, Dry MM, oropharynx clear
Neck: supple, JV flat, no LAD
Lungs: decreased at the bases bilaterally, atelectatic crackles
half way up. no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2,SEM heard best at
LUSB
Abdomen: large, distended, soft, non-tender, bowel sounds
present, no rebound tenderness or guarding, no palpable
organomegaly, no fluid wave
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing
Pertinent Results:
[**2121-3-8**] 04:33PM GLUCOSE-182* UREA N-37* CREAT-1.2*
SODIUM-127* POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-20* ANION GAP-14
[**2121-3-8**] 04:33PM WBC-20.3* RBC-1.76* HGB-6.8* HCT-19.2*
MCV-109* MCH-38.8* MCHC-35.5* RDW-20.5*
[**2121-3-8**] 10:45AM CK-MB-4 cTropnT-0.01
[**2121-3-8**] 06:11AM LACTATE-1.9
[**2121-3-8**] 02:10AM LACTATE-2.8* K+-5.9*
[**2121-3-8**] 01:45AM cTropnT-0.01
[**2121-3-8**] 01:45AM WBC-24.8*# RBC-2.25* HGB-8.7* HCT-24.4*
MCV-108* MCH-38.7* MCHC-35.7* RDW-20.7*
[**2121-3-8**] 01:45AM NEUTS-88* BANDS-2 LYMPHS-2* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-3-8**] 01:15AM GLUCOSE-101* UREA N-40* CREAT-1.4*
SODIUM-120* POTASSIUM-6.1* CHLORIDE-94* TOTAL CO2-19* ANION
GAP-13
[**2121-3-8**] 01:45AM NEUTS-88* BANDS-2 LYMPHS-2* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-3-8**] 01:45AM WBC-24.8*# RBC-2.25* HGB-8.7* HCT-24.4*
MCV-108* MCH-38.7* MCHC-35.7* RDW-20.7*
MICROBIOLOGY:
Pleural fluid:
GRAM STAIN (Final [**2121-3-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2121-3-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
GRAM STAIN (Final [**2121-3-10**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2121-3-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2121-3-16**]): NO GROWTH.
Blood cultures - no growth x2
Urine culture - no growth
RADIOLOGY:
IMPRESSION: Uncomplicated ultrasound-guided right thoracentesis
yielding 1.8 liters of clear serous pleural fluid. Samples sent
for cytology and
microbiology
CXR:
FINDINGS: As compared to the previous radiograph, there is a
minimal decrease
in extent of a pre-existing right pleural effusion. However, the
effusion
still occupies approximately the 50% of the right hemithorax.
Presence of a
minimal left pleural effusion cannot be excluded. Borderline
size of the
cardiac silhouette with signs of minimal overhydration.
A PICC line on the left has been advanced, the tip of the line
is now in
correct position. There is no evidence of pneumothorax.
U/S:
FINDINGS: Limited four-quadrant ultrasound of the abdomen
reveals a small
amount of ascites in the lower abdomen. Given the small amount
of ascites,
this is deemed unsafe for a blind paracentesis. Also noted is a
moderate-sized right pleural effusion.
Liver U/S:
IMPRESSION: Limited examination as noted above. Within this
limitation the
liver appears cirrhotic and the main portal vein is patent with
pulsatile
flow.
Discharge Labs:
[**2121-3-15**] 05:32AM BLOOD WBC-7.0 RBC-2.02* Hgb-7.6* Hct-21.9*
MCV-108* MCH-37.7* MCHC-34.8 RDW-20.8* Plt Ct-65*
[**2121-3-15**] 05:32AM BLOOD PT-27.3* PTT-47.4* INR(PT)-2.6*
[**2121-3-15**] 05:32AM BLOOD Glucose-129* UreaN-16 Creat-0.6 Na-129*
K-4.2 Cl-95* HCO3-27 AnGap-11
[**2121-3-13**] 07:27AM BLOOD ALT-15 AST-23 AlkPhos-95 TotBili-8.6*
[**2121-3-15**] 05:32AM BLOOD TotBili-7.1*
[**2121-3-15**] 05:32AM BLOOD Calcium-9.4 Phos-2.4* Mg-1.4*
Brief Hospital Course:
66F with cirrhosis s/p thoracentesis [**3-8**] returning with
abdominal cramping, leukocytosis, and hypotension.
.
# Sepsis: Etiology of the sepsis was unknown. Based on the
first pleural fluid studies, there was an elevated neutrophil
count concerning for spontaneous bacterial empyema, which is the
most likely etiology of her sepsis. The patient had a benign
abdominal exam so it was thought she did not have SBP. The
patient was treated with albumin, vanco, and zosyn and she
became hemodynamically stable. The patient had a PICC line
placed for long term antibiotics, however she ended up finishing
her antibiotics (8 day course) as an inpatient and the PICC line
was removed.
.
# Anemia - The patient was overall close to her baseline Hct of
24-26. She did experience a drop in Hct after her first
thoracentesis for which she was transfused 1 unit PRBC. She did
have a small drop in Hct after her second thoracentesis, however
the patient was asymptomatic. She was instructed to have a CBC
drawn prior to her PCP [**Name9 (PRE) 702**] appointment.
.
# Hepatic hydrothorax - The patient had her first thoracentesis
on [**3-10**]. Pleural fluid did show elevated neutrophils concerning
for Spontaneous bacterial empyema, however cultures were
negative. The patient had a second thoracentesis on [**3-14**] which
showed marked improvement in WBC and neutrophil count. Cultures
were negative to date. The patient was discharged on
ciprofloxacin for SBP/SBE prophylaxis.
.
#Acute renal faillure: Pre-renal, her renal failure resolved
with albumin and improved blood pressures. Her home diuretics
were restarted prior to discharge with no change in renal
function.
.
Acute on Chronic hyponatremia: Initial sodium 120 which is the
low end of her common range. Her sodium improved after
rehydration. She was initially kept off of her tolvaptan,
however this was restarted on discharge. Sodium was stable
between 129-133 for 3 days before discharge. The patient was
instructed to hold to 1500L fluid restriction as well as less
than 2 gm sodium for day diet.
.
Cirrhosis: Patient is chronically decompensated with jaundice,
hyponatremia, ascites and hepatic hydrothorax. She was
continued on her home regimen.
.
# Inactive issues included depression and GERD - continued on
home regimen
.
# Transitional Issues:
- f/u of Hematocrit
- continued thoracentesis as needed
- f/u of pending pleural fluid cultures
- salt and fluid compliance
Medications on Admission:
citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
tolvaptan 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tolvaptan 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day.
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Outpatient Lab Work
Please draw CBC on [**Last Name (LF) 766**], [**3-17**]. Please have the results
faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30613**] office at:
Fax: [**Telephone/Fax (1) 102200**]
14. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary: Sepsis, hepatic hydrothorax, spontaneous bacterial
empyema
cirrhosis
Secondary: Depression, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
Please have a CBC checked on [**Hospital3 766**] [**3-17**] prior to this
appointment.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R
Address: [**Location (un) 102195**], [**Location (un) **],[**Numeric Identifier 102196**]
Phone: [**Telephone/Fax (1) 75222**]
Appointment: Tuesday [**3-18**] at 1PM
Department: RADIOLOGY CARE UNIT
When: FRIDAY [**2121-3-21**] at 11:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2121-3-17**]
|
[
"571.2",
"995.92",
"311",
"584.9",
"572.2",
"V49.83",
"276.7",
"401.9",
"537.89",
"288.60",
"789.59",
"530.81",
"511.89",
"276.1",
"038.9",
"V15.82",
"599.0",
"567.23",
"285.9",
"V11.3",
"510.9",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.97",
"34.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11901, 11962
|
7316, 9623
|
299, 389
|
12116, 12116
|
3952, 5245
|
12266, 12994
|
3301, 3379
|
10662, 11878
|
11983, 12095
|
9797, 10639
|
6842, 7293
|
3394, 3933
|
2019, 2466
|
231, 261
|
417, 2000
|
5281, 6825
|
12131, 12243
|
9646, 9771
|
2488, 3043
|
3059, 3285
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,180
| 120,102
|
13023
|
Discharge summary
|
report
|
Admission Date: [**2110-7-23**] Discharge Date: [**2110-8-13**]
Date of Birth: [**2055-7-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Severe bilateral foot gangrene requiring prior bilateral
guillotine below-knee amputations
Major Surgical or Invasive Procedure:
Right above-the-knee amputation and a left below-
the-knee amputation
History of Present Illness:
Mr. [**Known lastname 29179**] presented on the [**1-23**] at [**Hospital1 **] with severe bilateral foot gangrene. He has had a
history of long standing bilateral foot infection and gangrene
(wet and dry) extending to his ankle
bilaterally. He now presents for revision of his prior
below-the-knee guillotine amputations. The remainder of the
right BKA was non-viable and necessitated above
knee amputation.
Past Medical History:
CAD s/p cardiac cath [**2105-1-21**] with diffuse, minor LAD disease,
OM1 80% and RCA 70-99%.
PVD with 90% right femoral lesion, stented and right posterior
tibial s/p PTCA.
Tobacco abuse
ESRD on dialysis
Diabetes Mellitus
Chronic Hepatitis C (unknown genotype)
Social History:
approx 50 pack year smoking history, currently does not
smoke, heavy alcohol use in past but denies current use, denies
illicit drug use.
Family History:
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory. Siblings with CABG in
their 40s.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS - Temp 98.5, BP 119/82, HR 65 BPM, RR 18,
O2-sat 100/RA
GENERAL - well-appearing man in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, JVD flat, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored,
no accessory muscle use
HEART - RRR NL S1, loud S2, no m/r/g.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - Doplerable A. femoralis pulses in both extremities
right AKA amputation: skin dry over suture, no drainage, no
signs of infection
left BKA: amputation: skin over suture with some bloody serous
drainage,
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Lab results on discharge:
[**2110-8-13**]
BLOOD WBC-10.1
RBC-3.23*
Hgb-9.3*
Hct-30.1*
MCV-93
MCH-28.7
MCHC-30.9*
RDW-16.4*
Plt Ct-145*
Glucose-127*
UreaN-33*
Creat-2.3*
Na-143
K-4.4
Cl-101
HCO3-30
AnGap-16
Calcium-8.0*
Phos-2.2*
Mg-1.9
Cardiology Report ECG Study Date of [**2110-8-4**]:
Sinus rhythm. P-R interval prolongation. Probable left atrial
abnormality.
Rightward axis. Possible inferior wall myocardial infarction of
indeterminate age. Modest inferolateral ST-T wave changes which
are non-specific. Compared to the previous tracing of [**2110-8-1**]
there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 [**Telephone/Fax (3) 39880**]/428 73 102 -36
CAROTID STUDY, [**7-30**]:
FINDINGS: Scattered areas of calcific plaque involving the left
common,
internal and external carotid arteries and the right internal
and external
carotid arteries. The peak systolic velocities bilaterally,
however, are
normal as are the ICA/CCA ratios. There is normal antegrade flow
involving
both vertebral arteries.
IMPRESSION: Scattered plaque as described above; however, no
appreciable ICA stenosis bilaterally (graded as less than 40%
bilaterally).
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 39881**],[**Known firstname **] [**2055-7-5**] 55 Male [**-9/2760**] [**Numeric Identifier 39882**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/dif
Pathology ([**2110-8-5**])
DIAGNOSIS:
I. Above knee amputation, right:
- Gangrenous necrosis of skin and subcutaneous tissue.
- Acute osteomyelitis and osteonecrosis.
- Atherosclerosis.
- Soft tissue and bony resection margins appear viable.
II. Below knee amputation, left:
- Gangrenous necrosis of skin and subcutaneous tissue.
- Acute osteomyelitis and osteonecrosis.
- Atherosclerosis.
- Soft tissue and bony resection margins appear viable.
Brief Hospital Course:
This patient has a history of peripheral vascular disease with
multiple amputations
and chronic gangrene (both wet and dry) of his lower extremities
bilaterally. He originally presented on [**2110-7-23**] after he was
seen in HD and his lower extremities were noted to be getting
worse. The patient reports that for several weeks, he noted
increasing pain, drainage from his bilateral
wounds, and worsening smell of the wounds prior to his
presentation. He denies any fevers, chills, or sweats.
He was taken to the OR for a right above-the-knee amputation and
a left below-
the-knee amputation.
Given his overall condition with continues drainage and possible
infection from his wounds and a dropping blood pressure, the
patient required postoperatively multiple blood transfusions.
In addition the patient wasn't able to void and initial
placement of a Foley catheter wasn't successful. Thus, Urology
was consulted and placed a 22Fr coudet catheter. A voiding trial
is planned after the patient is discharged to rehab (please see
follow up instructions, if voiding trial is not successful). The
patient was on hemodialysis every third day.
He was also complaining of shortness of breath along with an
increased white blood cell count. Chest x-ray revealed a left
lower lobe collapse/consolidation and a pleural effusion.
His wound cultures did grow pseudomonas as well as group B
streptococcus. Several blood cultures were reported as negative.
The patient was put on a vancomycin/meropenem/gentamicin regimen
for initial coverage
of GNR. This regimen has been switched to cefepime according to
recommendations of Infectious diseases since [**2110-8-11**] and should
be continued for the next 6 weeks.The patient will require
weekly monitoring with CBC, LFT's, BUN, creatinine as well as
follow up.
Over the course of his hospital stay his condition improved.
Upon discharge the patient is afebrile and hemodynamically
stable. There is still some serosanguinous drainage present on
his left stump, no erythema, no pus noted. The patient is on
cefepime monotherapy.
Medications on Admission:
calcium acetate 667mg 2 capsule prior to meals, cozaar 25mg
QD, nephrocaps 1 capsule QD, lasix 20mg [**Hospital1 **], senna QD, colace
100mg [**Hospital1 **], omeprazole 20mg QD, simvastatin 40mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81mg QD,
carvedilol 6.25mg [**Hospital1 **], lantus 12U QHS, Humalog SSI
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Cefepime 1 gram Recon Soln Sig: 0.5 500mg Injection Q24H
(every 24 hours) for 6 weeks.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO PRN
(as needed) as needed for HD for cramping .
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
15. Insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-60 mg/dL 1 amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 0 Units
161-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 6 Units
281-320 mg/dL 10 Units 10 Units 10 Units 8 Units
> 320 mg/dL Notify M.D.
16. PICC CARE
Heparin Flush (5000 Units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line
flush
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for congestion.
18. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): taper s needed.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Bilateral foot gangrene requiring right above-the-knee
amputation and a left below-
the-knee amputation.
Discharge Condition:
good, hemodynamicaly stable,
Discharge Instructions:
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
Limit strenuous activity for 6 weeks.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2110-9-4**] 2:00
Urology placed 22Fr coudet, leave foley X at least 1 week, then
void trial at rehab. He should f/u with urology clinic if unable
to void [**Telephone/Fax (1) 5727**]
Follow up with Infectious Diseases [**2110-9-18**] 10:00am with Dr.
[**Last Name (LF) 1420**],[**First Name3 (LF) **] phone [**Telephone/Fax (1) 3395**]
Completed by:[**2110-8-13**]
|
[
"414.01",
"V45.11",
"041.7",
"790.7",
"707.15",
"458.29",
"571.5",
"433.10",
"730.06",
"305.1",
"440.24",
"511.9",
"041.02",
"428.0",
"E878.5",
"733.49",
"412",
"285.1",
"997.62",
"070.54",
"V58.67",
"250.70",
"585.6",
"433.30",
"787.91",
"286.7",
"788.20",
"428.22",
"403.91",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"39.95",
"99.04",
"84.3",
"84.15",
"99.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9427, 9506
|
4511, 6584
|
405, 476
|
9654, 9685
|
2454, 2466
|
14273, 14783
|
1376, 1515
|
6954, 9404
|
9527, 9633
|
6610, 6931
|
9709, 10739
|
1530, 1530
|
1552, 2435
|
2480, 4488
|
274, 367
|
10751, 13663
|
13686, 14250
|
504, 917
|
939, 1203
|
1219, 1360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,779
| 123,505
|
6354
|
Discharge summary
|
report
|
Admission Date: [**2128-8-6**] Discharge Date: [**2128-8-27**]
Date of Birth: [**2055-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / peanuts
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**8-13**]:
1. Redo sternotomy.
2. Coronary artery bypass graft x2, saphenous vein grafts
to left anterior descending artery and posterior
descending artery.
3. Mitral valve replacement with a size 27 [**Company 1543**] Mosaic
tissue valve.
4. Endoscopic harvesting of the long saphenous vein.
5. Insertion intra-aortic balloon pump through left femoral
artery.
6. open chest
[**8-16**]
1. Take back for Mediastinal washout and chest closure.
History of Present Illness:
History of Present Illness:73 year old male with CAD s/p CABG X
5
[**2110**] who was recently at [**Hospital6 3105**] after
experiencing "pressure" in his chest a few weeks ago. Per the
patient, he appeared to be in heart failure and was diuresed. At
this hospitalization, he was also found to be in A-fib. He was
discharged on [**8-5**] and the next morning felt pressure in his
chest again and went to [**Hospital1 18**]. A recent cardiac catheterization
reveals that his previous bypass grafts are stenotic. A recent
TEE shows 3+ MR.
Past Medical History:
CAD s/p CABG '[**10**]
HTN
s/p chole
hyperlipidemia
Social History:
significant for the absence of current tobacco use, quit smoking
30 years ago. There is no history of alcohol abuse.
Family History:
Brother died of heart attack at age 65.
Physical Exam:
Pulse:84 Resp:18 O2 sat:95/RA
B/P Right:151/84 Left:165/80
Height:5'6" Weight:180 lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Diminished breath sounds lung bases b/l. Well healed
sternotomy site.
Heart: RRR [] Irregular [X] Murmur [X] grade __2/6 diastolic
murmur____
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X] right leg well healed scar from previous
vein harvest site.
Neuro: Grossly intact [X]
Pulses:
Femoral Right: P Left: P
DP Right: P Left: P
PT [**Name (NI) 167**]: P Left: P
Radial Right: P Left: P
Pertinent Results:
[**2128-8-27**] 04:55AM BLOOD WBC-11.9* RBC-3.32* Hgb-9.9* Hct-31.1*
MCV-94 MCH-29.9 MCHC-31.9 RDW-14.3 Plt Ct-320
[**2128-8-27**] 04:55AM BLOOD PT-22.8* INR(PT)-2.2*
[**2128-8-26**] 09:43AM BLOOD Plt Ct-379
[**2128-8-26**] 09:43AM BLOOD PT-21.2* PTT-72.5* INR(PT)-2.0*
[**2128-8-25**] 05:38AM BLOOD PT-19.4* PTT-43.0* INR(PT)-1.8*
[**2128-8-24**] 03:17AM BLOOD PT-19.6* PTT-58.5* INR(PT)-1.9*
[**2128-8-27**] 04:55AM BLOOD Glucose-99 UreaN-23* Creat-0.8 Na-142
K-4.2 Cl-107 HCO3-29 AnGap-10
[**2128-8-26**] 09:43AM BLOOD ALT-73* AST-55* AlkPhos-79 Amylase-169*
TotBili-1.1
[**2128-8-26**] 09:43AM BLOOD Lipase-144*
[**2128-8-27**] 04:55AM BLOOD Vanco-20.5*
PA&lat [**8-25**]
TECHNIQUE: AP upright chest radiograph.
FINDINGS: Interval removal of the endotracheal tube. Right
central venous
catheter is unchanged. Moderate pleural effusion on the left
with surrounding
atelectasis appears worse compared to the prior study.
Atelectatic changes
seen within the right base are stable. Lungs are otherwise
clear with no
evidence of focal consolidation. No pneumothorax.
IMPRESSION:
Moderate left pleural effusion and surrounding atelectasis
appears slightly
worse compared to the prior study.
[**2128-8-24**]:
ARTERIAL STUDY
HISTORY: Cutdown for removal of an intra-aortic balloon pump on
the left.
FINDINGS: Duplex and color Doppler of the left inguinal area
was performed.
Waveforms at the left common femoral artery are monophasic which
indicate an
element of inflow disease, most likely at the iliac level.
Grayscale and
color Doppler also indicate areas of sequential stenosis
involving the
superficial femoral artery, velocities do not appear to be
elevated, but
likely due to poor inflow. All waveforms do remain monophasic
diffusely.
There is no evidence of a pseudoaneurysm or hematoma or AV
fistula.
IMPRESSION:
1. No sequela of recent cutdown for removal of a left femoral
access used for
an intra-aortic balloon pump.
2. Findings consistent with both inflow and outflow disease at
the femoral
level, i.e., superficial femoral arterial stenosis, probable
common femoral or
external iliac disease on the left.
[**2128-8-23**]
TECHNIQUE: Bilateral lower extremity grayscale and color and
pulsed-wave
Doppler.
COMPARISON: None.
FINDINGS: A clot is identified in the left greater saphenous
vein. A clot is
also identified in the right peroneal veins. There is a hematoma
around the
right proximal superficial femoral vein without evidence of
color flow to
suggest pseudoaneurysm or AV fistula. There is normal phasicity
of the common
femoral veins bilaterally. There is normal compression and
waveforms in the
common femoral, superficial femoral, popliteal, and posterior
tibial veins
bilaterally. There is normal compression of the peroneal vein on
the left. The
right peroneal vein is not compressible and no color flow could
be
demonstrated.
IMPRESSION:
1. Deep venous thrombosis in the right peroneal veins.
2. Superficical thrombophlebitis of the left greater saphenous
vein.
3. Hematoma around the proximal superficial vein without
evidence of color
flow to suggest pseudoaneurysm or AV fistula.
TTE [**8-16**]:
Conclusions
Chest Closure ECHO:
The left atrium is mildly dilated. No mass/thrombus is seen in
the left atrium or left atrial appendage. Overall left
ventricular systolic function is moderately depressed
(LVEF=35-40 %). The remaining left ventricular segments contract
normally and are unchanged from prior. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the ascending aorta. There are simple atheroma in the
descending thoracic aorta. No evidence of dissection. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. A
mechanical mitral valve prosthesis is present and well seated
without perivalvular leak. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room
[**2128-8-17**] EKG:
Atrial fibrillation with ventricular premature beats. Right
bundle-branch
block. Left anterior fascicular block. Compared to the previous
tracing
of [**2128-8-16**] the Q-T interval looks slightly shorter on the
current tracing.
The other findings are similar.
Brief Hospital Course:
The patient was admitted to the hospital preoperatively recently
diagnosed with atrial fibrillation who presented with chest pain
at rest.Past history of CABG. Admitted to hospital with CHF and
was diursed. He was taken emergently to the OR and emergently
placed on bypass please see intraoperative note for details. He
arrived from OR with open chest,paralyzed, sedated on multiple
pressors and inotropes, initally low index and mixed venous,
IABP 1:1. Of note this had been placed surgically in the OR.
IABP removed at bedside within 24hrs, purse string stitch in
place. Left leg cooler with weak pulse in the setting of
pressors and thromcytopenia. He was seen by the vascular service
but no intervention was warranted and left leg continued to
improve. Pressors and inotropes were weaned off slowly he
remained in atrial fibrillation. His chest was sucessfully
closed on POD#3. He awoke slowly over the course of three to
four days. He was aggressively diureses. He eventually extubated
and was very deconditioned, required aggressive pulmonary
toileting. He became alkalotic and lasix was adjusted. His renal
function remained stable. Chest tubes and pacing wires removed
without difficulty. Prior to transferring to floor he developed
left lower extremity erythemia and left calf pain. The concern
arose for DVT or compartment syndrome. He was again seen by the
vascular service. His studies were negative for significant DVT
please see reports for further details, negative for comparment
syndrome. The celulitis responed to antibiotic therapy. He was
started on IV vanco and was transitioned to cipro for one week.
Patient continued to progress but remained weak and
deconditioned, his left leg remains weaker then his right. He
otherwise remains neurologically intact. He was cleared by
speach and swallow to advacne to regular diet. He was started on
anticoagulation and his INR goal is [**3-5**] he was therapeutic at
discharge. This will need to be monitored closely while on cipro
he did become supratherapeutic while in the ICU and received
vitamin K. His diuretic therapy was initially dc'd due to
elevated creatinine but was restarted and increased at
discharged due to worsening bilateral effusions. He will need
his Bun/creat and CXR repeated and followed while at rehab. His
foley was discharged today and is DTV upon arrival to rehab. He
was seen by the wound nurse for left lower ext skin breakdown
the recs are as follows:
Pressure relief per pressure ulcer guidelines
Turn and reposition every 1-2 hours and prn
Heels off bed surface at all times
Multipodis Splints to LLE/ Please use lateral rotation bar to
prevent external rotation of his LLE
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion.
Elevate LE's while sitting.
Moisturize B/L LE's, periwound tissue and feet [**Hospital1 **] with Aloe
Vesta Moisture Barrier Ointment
Commercial wound cleanser or normal saline to cleanse
all open wounds.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each drg change.
Left lateral LE and left heel:
Apply a thin layer of DuoDerm Gel
Cover with Adaptic dressing
Dry gauze, ABD, Kling wrap (may use tubular netting to secure
the dressing on his calf)
No tape on his skin.
Change dressing daily.
Left lateral malleolus: Leave tissue intact
Apply Spiral Ace Wraps to LLE from just above toes to just
below knees before patient gets OOB or after elevating LE's for
30 minutes. Remove Ace Wraps at bedtime.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 14 the patient was hemodynamically stable, pain well
controlled and his wound was healing. The patient was discharged
to [**Hospital3 **] [**Location (un) 1456**] in good condition with appropriate
follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Aspirin 81 mg PO DAILY
2. Vitamin D [**2116**] UNIT PO DAILY
3. Furosemide 40 mg PO DAILY
hold for SBP < 90
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP < 90
5. Lisinopril 10 mg PO DAILY
hold for SBP < 90
6. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP < 90 or HR < 55
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q4H:PRN fever, pain
4. Albuterol-Ipratropium 2 PUFF IH Q6H
5. Bisacodyl 10 mg PR DAILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Tartrate 100 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
8. Milk of Magnesia 30 ml PO HS:PRN constipation
9. Vitamin D [**2116**] UNIT PO DAILY
10. Warfarin MD to order daily dose PO DAILY
[**3-5**]
11. Ciprofloxacin HCl 500 mg PO Q12H x 7days
12. Furosemide 40 mg PO DAILY Duration: 7 Days
hold for SBP < 90
13. Potassium Chloride 20 mEq PO BID Duration: 7 Days
Hold for K >
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Coronary artery disease
Severe Mitral regurg
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assist, left leg weakness
Resp: diminished bases
Sternal pain managed with oral analgesics
Edema: +1 general
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr.[**First Name (STitle) **] # [**Telephone/Fax (1) 170**] [**2128-9-28**] @ 1:pm
Cardiologist Dr. [**Last Name (STitle) 5686**] [**2128-9-15**] @ 1:15pm
Will need appt made with PCP to be seen in 4 weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2128-8-27**]
|
[
"414.01",
"707.25",
"280.0",
"272.4",
"414.05",
"682.6",
"428.32",
"427.31",
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"424.0",
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"707.07",
"518.51",
"401.9",
"287.5",
"998.00",
"998.59",
"440.20",
"459.81",
"412",
"427.32",
"790.29",
"E849.7",
"428.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"97.44",
"96.6",
"88.55",
"39.61",
"37.22",
"35.23",
"37.61",
"88.72",
"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
11769, 11869
|
6665, 10558
|
330, 791
|
11958, 12116
|
2383, 6642
|
12740, 13227
|
1584, 1625
|
11099, 11746
|
11890, 11937
|
10584, 11076
|
12140, 12717
|
1640, 2364
|
280, 292
|
846, 1358
|
1380, 1433
|
1449, 1568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,457
| 105,969
|
51456
|
Discharge summary
|
report
|
Admission Date: [**2131-1-14**] Discharge Date: [**2131-1-16**]
Date of Birth: [**2062-6-28**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Aspirin / Compazine / spironolactone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Hypertension, Fluid overload
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68F with CAD s/p CABG in [**2129**], diastolic CHF (EF >55%), h/o CVA
with left sided weakness, HTN, HLD, T2DM on insulin and CKD who
presents with chest pain and was found to be hypertensive and
volume overloaded in the ED. She reports that since Wednesday
[**1-10**] she has been having substernal chest pressure at rest.
She has been receiving SL nitro for the past few days at her [**Hospital1 1501**]
which has relieved the chest pressure. She has not walked since
leaving the hospital on [**1-2**], so she cannot express whether the
CP is worse with exertion. She also reports feeling worsening
SOB over the past 4-5 days. She has not previously has to wear
oxygen until the past 4-5 days. At home, she has 6 pillow
orthopnea and reports waking up feeling suddenly short of breath
on occasion. She states that she has been requesting to take
torsemide for the past few days because she feels more fluid in
her lungs and in her legs, and she was just restarted on
torsemide 20mg PO on Friday, 2 days PTA. She reports good
adherence to a low sodium diet at rehab.
.
On the day of admission, she was not able to keep down any of
her PO medications because of nausea and vomiting, which was
clear and non-bloody. She also reported that she felt
lightheaded today without vertigo.
.
In the ED, there was initially concern for aortic dissection
given decreased right radial pulse compared to the left. A
non-contrast CT chest was ordered which showed no evidence of
dissection but showed moderate pulmonary edema and cardiomegaly.
Cardiology was consulted and she was started on a nitro gtt for
hypertension and likely CHF exacerbation
.
She was recently admitted from [**2130-12-29**] to [**2131-1-2**] for right leg
pain and hyperkalemia. During this admission, her sironolactone
and torsemide were stopped because of elevated potassium and
creatinine, respectively. She was instructed to continue
holding these medications after discharge and has not taken them
since. At her last admission 2 weeks ago, both discharge and
admission systolic BPs were noted to be in the 150s. In the past
year she has had multiple recorded systolic BPs in the 160-180s
at various outpatient appointments. However, at her [**2130-12-27**]
visit in the heart failure clinic, her BP was noted to be
114/68.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, cough, hemoptysis, black stools or red
stools. S/he denies recent fevers or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing
sternal incision wound
- MI in [**2128**] and [**2129**]
- Diastolic heart failure (EF >55%)
- PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Cerebrovascular accident with L residual hemiparesis ([**10-29**])
-T2DM on insulin (last A1c=6.4%)
-Chronic kidney disease with microalbuminuria (stage III)
-Hyperlipidemia
-Hypertension
-Asthma - intubated "many years ago." Per patient last
exacerbation requiring hospitalization was 2-3 years ago.
-Morbid obesity
-UGIB [**7-30**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Social History:
She is currently in a [**Hospital1 1501**] after her last discharge because of
leg pain and being unable to ambulate. She is [**Name Initial (MD) **] former RN at
[**Hospital1 2025**]. Divorced, has 3 children. Born in Barbaros, in the US
since the [**2089**].
- Tobacco history: Never
- ETOH: Never
- Illicit drugs: Never
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Diabetes, unsure of cause of death, no reported CAD
- Father: Died in 30s from trauma after falling off a horse
Physical Exam:
Admission Exam:
VS: T=97.7 BP=162/123 HR=68 RR=8 O2 sat=99%/2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Speaking in
full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 4 cm above the clacivle at 45 degrees.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-26**] decrescendo systolic murmur at the
LLSB with radiation to the apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles in the lower
lung fields bilaterally.
ABDOMEN: +BS, soft/ND/mild TTP in RLQ. No HSM.
EXTREMITIES: [**2-23**]+ edema of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact with slight smile asymmetry and slight
tongue protrusion to the left. 4/5 strength in UEs bilat, RLE
[**4-25**], LLE [**3-25**] proximal and distal
PULSES:
Right: Carotid 2+ PT 2+
Left: Carotid 2+ PT 2+
Discharge Exam:
FS: 121, 163, 259 yesterday
VS: 98.5, 97.7, 141/53 (109-157/41-53), 53 (50s), 18, 100% NC
2L.
I/O: in 900/24hrs, out 2750/24hrs. Overnight: 250mg (foley)
Weight: 116.4kg
General: Obese Arfican-American woman, appears comfortable
HEENT: JVP is 4cm above clavicle
CV: RRR, nl S1/S2, 2/6 systolic murmur heard best at the LLSB
radiating to the apex
Lungs: minimal crackles at the lung bases bilat improved from
yesterday, otherwise CTAB
Abd: +BS, soft/NT/obese
Extr: 1+ edema of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
Neuro: 4/5 weakness in LUE, [**5-25**] RUE, [**3-25**] LLE, [**4-25**] RLE. Slight
tongue deviation to the left and asymmetric smile, unchanged
from admission
Pertinent Results:
Admission Labs:
[**2131-1-14**] 07:50PM BLOOD WBC-8.8 RBC-2.77* Hgb-8.4* Hct-26.8*
MCV-97 MCH-30.2 MCHC-31.3 RDW-13.7 Plt Ct-206
[**2131-1-14**] 07:50PM BLOOD Neuts-77.6* Lymphs-12.3* Monos-3.4
Eos-6.3* Baso-0.4
[**2131-1-14**] 08:15PM BLOOD PT-11.5 PTT-32.5 INR(PT)-1.1
[**2131-1-14**] 07:50PM BLOOD Glucose-90 UreaN-77* Creat-2.6* Na-142
K-5.3* Cl-111* HCO3-18* AnGap-18
[**2131-1-14**] 07:50PM BLOOD ALT-29 AST-23 LD(LDH)-237 AlkPhos-209*
TotBili-0.4
[**2131-1-14**] 07:50PM BLOOD Lipase-26
[**2131-1-14**] 07:50PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 16243**]*
[**2131-1-14**] 07:50PM BLOOD cTropnT-0.04*
[**2131-1-15**] 06:31AM BLOOD CK-MB-3 cTropnT-0.05*
[**2131-1-14**] 07:50PM BLOOD Calcium-9.8 Phos-3.3# Mg-2.0
[**2131-1-15**] 06:31AM BLOOD TSH-2.0
Discharge Labs:
[**2131-1-16**] 06:25AM BLOOD WBC-7.2 RBC-2.63* Hgb-7.8* Hct-25.3*
MCV-96 MCH-29.6 MCHC-30.9* RDW-13.9 Plt Ct-202
[**2131-1-16**] 06:25AM BLOOD Glucose-100 UreaN-75* Creat-2.7* Na-145
K-4.9 Cl-113* HCO3-24 AnGap-13
[**2131-1-16**] 06:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8
Urine:
[**2131-1-14**] 09:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2131-1-14**] 09:30PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2131-1-14**] 09:30PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2131-1-15**] 04:09AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2131-1-15**] 04:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2131-1-15**] 04:09AM URINE RBC-3* WBC-18* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
[**2131-1-15**] 04:09AM URINE CastHy-3* CastCel-1*
[**2131-1-15**] 04:09AM URINE Mucous-RARE
Microbiology:
[**2131-1-15**] 4:09 am URINE Source: Catheter.
**FINAL REPORT [**2131-1-16**]**
URINE CULTURE (Final [**2131-1-16**]): NO GROWTH.
Imaging:
[**2131-1-14**] CXR: The heart is moderately enlarged. The hilar and
cardiomediastinal contours are obscured by bilateral linear and
hazy
opacities which extend from the hilum to the periphery, with
multiple Kerley B lines, compatible with pulmonary interstitial
edema. No focal consolidation is seen. There is no pneumothorax
or large effusion. Multiple intact sternal wires are
redemonstrated. There are no osseous lesions identified.
IMPRESSION: Hazy and linear parenchymal opacities, new since
[**2130-12-30**], with increased central pulmonary congestion
and cardiomegaly, most compatible with cardiogenic pulmonary
edema.
[**2131-1-14**] Chest CT: 1. Moderate cardiomegaly with central
pulmonary vascular congestion and interstitial edema, most
compatible with cardiac decompensation. 2. No thoracic aneurysm
or aortic intramural hematoma. Evaluation for dissection limited
due to non-contrast technique.
[**2131-1-15**] ECHO: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The RV free wall is not well seen. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is at least moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mildly thickened aortic valve leaflets without aortic
stenosis or aortic regurgitation. Trace mitral regurgitation and
mild tricuspid regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2129-12-2**]
the findings are similar.
Brief Hospital Course:
68F with CAD s/p CABGx3, diastolic CHF (EF>55%), HTN, HLD, CKD,
T2DM on insulin, h/o CVA who presents with chest pain and was
noted to be hypertensive with volume overload.
.
# Acute on Chronic Diastolic CHF (EF >55%) - On admission,
patient appeared volume overloaded on exam (crackles, elevated
JVP, LE edema). Her home diuretics (torsemide and
spironolactone) were held after her previous admission 2 weeks
ago which likely contributed to her current CHF exacerbation.
She was given IV lasix with good urine output (2750cc in
foley/24hrs, with 900cc input) and she improved clinically, with
less overload on exam. Prior to discharge, she was tolerating PO
and her HTN had improved on her PO medications (she was
initially given nitroprusside ggt, which she was weaned off of
the day prior to discharge), now with normotensive blood
pressures (109-157/41-53). Dietary indiscretion does appear to
be a factor, which she was counselled on. Ischemia/ACS ruled
out with negative trop x2. Her dry weight not precisely known,
although prior weights in our records are approx 115kg, she was
123kg at admission to the CCU and was 116kg on discharge. Her
home dose of torsemide was restarted. It was not increased given
her euvolemic appearance (minimal LE edema, clear lungs) on
discharge and slight bump in creatinine to 2.7. Metoprolol was
changed to carvedilol 6.25mg [**Hospital1 **] for improved blood pressure
control. The patient is not on a ACEi/[**Last Name (un) **] due to her advanced
chronic kidney disease.
.
# HTN - BP at admission to the ED was 160/60 and she has a
history of HTN to the 160-180s systolic recently. Initially she
was not tolerating PO, and so was started on a nitroprusside
ggt. Her torsemide/spironolactone were recently discontinued,
both of which may have contributed to her HTN. She was weaned
off the nitro drip the day after admission and restarted on her
home medications (amlodipine, isosobride dinitrate,
hydarlazine); however, metoprolol was changed to carvedilol
6.25mg [**Hospital1 **] for improved blood pressure control.
.
# CAD s/p CABG: Patient presented with chest pain prior to
admission which resolved with nitro spray x3. Trop negative x2
and no concern for ACS at this time. Most likely etiology of
her CP is elevated afterload with SBP in the 200s in the ED.
Patient was continued on plavix, and started on carvedilol. No
further concerning symptoms with treatment of blood pressure.
.
# T2DM on insulin - Last A1c from [**10/2130**] was 6.4%, suggesting
good control at home. Patient was managed with home lantus
13units qam and HISS, which she is on as an outpatient.
.
# CKD - Her creatinine at admission is 2.6, which is within her
recent baseline of 1.8-2.6. Likely etiology is combination of
HTN and diabetes. There was concern about creatinine elevation
during prior admission, which is why her diuretics were held at
discharge. Patient was given lasix for fluid overload and
diuresed several liters. On the day of discharge, her creatinine
was 2.7. Lasix was stopped and home torsemide was restarted at
20mg daily. Torsemide was not increased further given slight
increase in creatinine.
.
#Hyperkalemia - Patient received Kayexalate 30gm for K of 5.7 on
the day after admission. Potassium remained within normal limits
for remainder of admission.
.
#Anemia - Baseline Hct is very variable in our records, but
appears to be in the mid-20s to low 30s. She is currently at 26
during this admission. No evidence of current bleeding. Likely
etiology is her CKD. Iron studies in records show nl serum
iron, nl TRF and high ferritin - suggests AoCD. Hct was
monitored and stable.
.
# H/o CVA - Neurologic exam is currently at baseline according
to previous records. She is not reporting any new neurologic
symptoms.
.
# HLD - Continued atorvastatin 80mg PO daily.
.
CODE: FULL (confirmed)
COMM: [**Name (NI) **], daughter is emergency contact ([**Telephone/Fax (1) 106688**])
.
Transitional Issues:
Patient will continued to be followed by physicians at her
extended care facility. She should have her creatinine and
electrolytes monitored regularly while on toresmide.
Medications on Admission:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. amlodipine 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
5. hydralazine 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO three times
a day.
6. isosorbide dinitrate 30 mg Tablet PO TID (3 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Thirteen (13) units
Subcutaneous QAM.
9. insulin lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1)
Subcutaneous once a day: humalog sliding scale.
10. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a
day.
11. atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20mg PO daily (stopped at last hospitalization
earlier this month, restarted [**2131-1-12**] according to records from
her facility)
13. oxycodone 5mg 1 tab q8h PRN pain
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. amlodipine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
5. hydralazine 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q8H (every 8
hours).
6. isosorbide dinitrate 20 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO Q 8H
(Every 8 Hours).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirteen (13)
units Subcutaneous once a day: in AM.
9. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) dose
Subcutaneous four times a day: Per home sliding scale. With
meals and at bedtime.
10. carvedilol 6.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
13. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital-[**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis: Hypertension and Acute on Chronic Diastolic
CHF
Secondary Diagnosis:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing
sternal incision wound
- MI in [**2128**] and [**2129**]
- Diastolic heart failure (EF >55%)
- PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Cerebrovascular accident with L residual hemiparesis ([**10-29**])
-T2DM on insulin (last A1c=6.4%)
-Chronic kidney disease with microalbuminuria (stage III)
-Hyperlipidemia
-Hypertension
-Asthma - intubated "many years ago." Per patient last
exacerbation requiring hospitalization was 2-3 years ago.
-Morbid obesity
-UGIB [**7-30**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
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 at [**Hospital1 827**]. You were admitted for high blood pressure and
fluid overload. You were given blood pressure medication and
water pills to take the excess fluid out of your lungs. Your
blood pressure was well controlled and your shortness of breath
and chest discomfort resolved with treatment. Please adhere to
your salt restrictive diet, as foods with salt will worsen your
symptoms.
The following changes have been made to your medications:
STOP lisinopril
STOP metoprolol
START carvedilol 6.25mg by mouth twice daily.
Please continue all other medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital1 **] MRI (MOBILE)
When: THURSDAY [**2131-1-18**] at 4:05 PM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2131-2-8**] at 12:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2131-4-30**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.21",
"412",
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"276.7",
"724.3",
"585.3",
"438.89",
"428.33",
"278.01",
"V45.81",
"250.40",
"403.90",
"428.0",
"493.90",
"728.87"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17066, 17160
|
10099, 14041
|
344, 351
|
18102, 18102
|
6265, 6265
|
19056, 19959
|
4277, 4516
|
15594, 17043
|
17181, 17181
|
14260, 15571
|
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|
4531, 5531
|
17355, 17610
|
5547, 6246
|
14062, 14234
|
276, 306
|
379, 3084
|
17269, 17335
|
6281, 7030
|
17200, 17248
|
18117, 18261
|
17641, 18081
|
3106, 3172
|
3934, 4261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,374
| 110,926
|
44892
|
Discharge summary
|
report
|
Admission Date: [**2104-8-25**] Discharge Date: [**2104-9-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
R hip hemiarthroplasty
History of Present Illness:
Patient is an 88 yo F with Alzheimer's dz, depression, GERD who
presents from [**Hospital 100**] Rehab following an unwitnessed fall. Per
report, the patient was found in a hallway after the staff heard
a "thump." The patient was lying on the ground complaining of R
hip pain. She was therefore brought into [**Hospital1 18**] for further
evaluation. Patient refuses to give additional history,
requesting to "please let me sleep."
.
In the ED, AVSS. The patient was complaining of pain everywhere
so CT head, neck, CXR, R knee, and hips were performed. Given
morphine 2mg IV. Imaging was significant for a R femoral head
fx. Given her significant dementia, she was admitted to medicine
with orho following
.
On arrival to the floor, patient insists on being allowed to
sleep. She does complain of pain to her right leg
.
ROS: Unable to assess given patient's mentation
Past Medical History:
1. Alzheimer's Disease.
2. Depression.
3. Gastroesophageal reflux disease.
4. Macular degeneration.
5. Hearing loss.
6. h/o pre-syncope and falls
7. Hemorrhoids
Social History:
Lives at [**Hospital 100**] Rehab facility currently. Per daughter, has been
suffering from dementia for several years, has not been able to
regularly recognize daughter in past 2 years. Reports patient
more unstable on feet in last few months with several falls.
Also has 2 sons but daughter [**Name (NI) **] is HCP.
Family History:
NC
Physical Exam:
VS: T 96.6, BP 128/76, HR 75, RR 16, 93%RA
Gen: lying in bed, awake and lucent, asking to go to sleep
HEENT: anicteric sclera, MMM, poor dentition
Neck: supple, no lad
Lung: CTAB anteriorly, patient would not allow posterior exam
Heart: RRR, 3/6 SEM heard best at base
Abd: soft, mild tenderness non-focal + BS, no rebound
Ext: warm, 1+ DP pulses, R hip internally rotated
Skin: friable, soft, no rash
Neuro: awake and alert/lucent, would not cooperate with rest of
exam
Pertinent Results:
MICRO:
C.diff [**8-28**]: positive
Urine [**8-31**] +E.coli >10^5
.
IMAGING:
EKG [**2104-8-25**]: NSR at 72 bpm, nl axis, early R wave progression, Q
in III, compared to EKG dated [**2099-12-28**], precordial TWI
resolved.
.
EKG [**2104-9-1**] 11:35 am: NSR at 78, NANI, I and aVL with new 1mm ST
depressions; II with new TWF, III and aVF with 0.[**Street Address(2) 1755**]
elevations and new TWF/TWI and deeper Q waves, V2 with [**Street Address(2) 4793**]
depressions, diffuse precordial T wave flattening.
.
EKG [**2104-9-1**] 3:49 pm: NSR with mult PACs, limb lead ST changes
resolved, still with inferior TWF/TWI, V2 with 2mm ST
depressions, diffuse precordial T wave flattening unchanged.
.
CT Head [**8-25**]: No ICH or fracture.
.
CT C Spine [**8-25**]: Study is limited by patient motion. No definite
fracture. Grade 1 anterolisthesis at the C3-4 level is likely
degenerative but clinical correlation is recommended.
.
CXR [**8-25**]: Mild prominence of pulm vasculature. Small Pericardial
Effusion.
.
CXR [**2104-9-1**]: In comparison with the study of [**8-31**], there are
even lower lung volumes with bilateral atelectatic changes,
especially at the left base. The area behind the heart is
difficult to evaluate and the possibility of pneumonia in this
region cannot be excluded in the absence of a lateral view.
.
XRay Hip [**8-25**]: displaced R femoral neck fracure.
.
cbc:
[**2104-8-25**] 04:20AM BLOOD WBC-11.9*# RBC-3.99* Hgb-12.2 Hct-36.3
MCV-91# MCH-30.7 MCHC-33.7 RDW-13.3 Plt Ct-250
[**2104-8-29**] 09:00AM BLOOD WBC-16.5* RBC-3.72* Hgb-11.4* Hct-34.3*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.5 Plt Ct-350
[**2104-9-2**] 05:57AM BLOOD WBC-17.0* RBC-3.40* Hgb-10.4* Hct-31.6*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.2 Plt Ct-429
.
coags:
[**2104-8-25**] 04:20AM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1
[**2104-9-2**] 05:57AM BLOOD PT-16.1* PTT-29.3 INR(PT)-1.4*
.
chem-10:
[**2104-8-25**] 04:20AM BLOOD Glucose-151* UreaN-23* Creat-0.8 Na-137
K-4.1 Cl-102 HCO3-24 AnGap-15
[**2104-8-28**] 04:50AM BLOOD Glucose-93 UreaN-28* Creat-0.7 Na-143
K-3.8 Cl-117* HCO3-20* AnGap-10
[**2104-9-2**] 05:57AM BLOOD Glucose-131* UreaN-27* Creat-1.0 Na-149*
K-4.0 Cl-119* HCO3-19* AnGap-15
.
LFTs
[**2104-8-25**] 04:20AM BLOOD CK(CPK)-39
[**2104-8-29**] 09:00AM BLOOD ALT-15 AST-42* AlkPhos-117 Amylase-184*
TotBili-0.5
[**2104-9-2**] 05:57AM BLOOD ALT-28 AST-57* LD(LDH)-371* CK(CPK)-142*
AlkPhos-152* TotBili-0.3
.
cardiac enzymes:
[**2104-9-1**] 04:45AM BLOOD proBNP-[**Numeric Identifier 96039**]*
[**2104-9-1**] 12:27PM BLOOD CK-MB-24* MB Indx-9.8* cTropnT-0.91*
proBNP-[**Numeric Identifier **]*
[**2104-9-1**] 05:31PM BLOOD CK-MB-21* MB Indx-10.0* cTropnT-1.01*
[**2104-9-2**] 05:57AM BLOOD CK-MB-16* MB Indx-11.3* cTropnT-0.92*
.
abg:
[**2104-9-1**] 12:45PM BLOOD Type-ART pO2-124* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
Brief Hospital Course:
A/P: 88 yo F with Alzheimer's dementia p/w a fall resulting in a
hip fx, s/p hemiathroplasty, complicated by C. diff infection.
She was transferred to MICU w/ hypoxic respiratory failure 2' to
evolving MI, CHF, and pulmonary edema. Poor prognosis and level
of consciousness. She was made CMO per family meeting on [**2104-9-2**],
and passed away on while on the medicine floor on [**2104-9-5**].
.
# R hip fracture: associated w/ fall at rehab. s/p R hip
arthroplasty. Unable to assess pain due to decreased mental
status. Morphine PO was given for pain and continued with code
status was made CMO.
.
# Acute myocardial infarction. Pt suffered an MI that was likely
the cause of her tachypnea. She ruled in with positive troponin
and MBI; she had ECG changes (ST elevation in III and aVF). She
had a peak Troponin of 1.01 She was managed medically w/
Lovenox, plavix, B-[**Last Name (LF) 7005**], [**First Name3 (LF) **]. All of her medications were
d/c-ed with her code status change to CMO.
.
# Tachypnea/Volume Overload/Pulmonary Edema. Likely related to
acute MI, leading to CHF and pulmonary edema. Pt was oxygenating
and ventilating well in the MICU, but had very poor mental
status. She did have a significant non-gap metabolic acidosis,
could be contributing as source of increased ventilation. She
was managed for her MI as above. Her acidosis was corrected by
lactated ringers and free water boluses 400cc q4h to reduce
hypercholemic acidosis. She was also treated w/ gentle diuresis.
With her changed to CMO status, her diuresis was stopped. The
patient was placed on morphine PO.
.
# C.diff colitis: Likely related to peri-operative antibiotics.
She was started PO vancomycin due to her worsening mental
status. With the change in her CMO status, the antibiotic was
stopped.
.
# Depressed mental status/decreased responsiveness: Pt had
dementia with subacute delerium. Over her hospital stay, she
became less responsive. She waxed and waned in her mental
status, which was likely delerium related to her MI and
infection. With her multiple medical problems and her
progressing non-responsive mental status, her prognosis was
deemed extremely poor. A family meeting was held, code status
was changed to CMO. She was given Morphine and Zydis PRN for
agitation.
.
# Leukocytosis. Likely related to significant C.diff, plus UTI,
plus possible MI. Worsened despite C.diff treatment. D/C-ed
antibiotics with change in code status.
.
# UTI. E.coli related. No antibiotics w/ change in code status
to CMO.
.
# Hypernatremia. Likely due to intravascular volume depletion
and diuresis. She received free water via NGT 400ml q4h, with a
calculated free water deficit to 1.5 L. With her CMO status,
her labs were d/c-ed and she stopped receiving water through her
NGT.
.
# Dementia. Advanced. Held antipsychotics given depressed mental
status and change in CMO status.
.
# Atrial fibrillation. Irregularly irregular on floor during
exam, reverted to sinus w/ PACs. Nursing reports brief episodes
of tachycardia to 160s. With her CMO status, her tele and vital
signs were d/c-ed.
.
# Depression: CMO as above, no meds.
.
# FEN: NPO given poor mental status and CMO.
# PPx: All d/c-ed as patient is CMO.
# Access: PIV d/c-ed w/ CMO status.
# Dispo: Expired while in hospital. Death Certificate filled
out.
.
# Code: CMO on [**2104-9-2**] after discussion with son [**Doctor Last Name **] and
daughter ([**Name (NI) **]) (power of attn) [**8-27**].
Medications on Admission:
[**Month/Year (2) **] 81mg daily
Pepto-Bismol q4-6hrs prn
Celexa 20mg daily
Colace 100mg [**Hospital1 **]
Namenda 5mg daily
Vitamin E 400units daily
Oxazepam 15mg prn
Milk of Mag
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
None
Discharge Condition:
None
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2104-9-5**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
8791, 8800
|
5078, 8532
|
266, 290
|
8849, 8856
|
2237, 4643
|
8909, 8944
|
1726, 1730
|
8762, 8768
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8821, 8828
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8558, 8739
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8880, 8886
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1745, 2218
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4660, 5055
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222, 228
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318, 1190
|
1212, 1375
|
1391, 1710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 102,024
|
14859
|
Discharge summary
|
report
|
Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD,
malignant HTN, history of SVC syndrome, and history of Posterior
Reversible Encephalopathy Syndrome (PRES) and intracerebral
hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**],
[**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for
hypertension, but most recently for diarrhea in addition to
hypertension.
.
In the ED, vitals were 98 90 102/65 20 98% RA. She was
complaining of abdominal pain X 3 hours, more severe than usual
[**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg
IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt
stable for floor; however, BP rose during ED course to SBP 270.
She then received hydral 50 PO X 1, home aliskeren, labetalol
1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine
2.5 mg IV X 1 and started on nicardipine gtt.
.
Upon arrival to the floor, she complains of severe abd pain
which started earlier today, it is sharp all over her abd and
constant. It feels different from her usual abd pain, although
she is not able to characterize it more. She has been having
some nausea and bilious emesis X 1 earlier today. She has been
having some mild diarrhea 2-3 episodes of loose, greenish stools
for the past few weeks. She denies any chest pain, headache,
vision changes. She was not able to take all of the medications
due to her GI distress.
.
While in the MICU she was weaned off a nicardipine drip and her
diarrhea resolved. Her BP remained WNL while on her home regimen
and she was transferred to the floor in stable condition. Last
HD was [**2142-5-21**].
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and
now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension and history of hypertensive crisis
with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to
frequent hospitalizations and inability to see in outpatient
setting - has appt scheduled with gyn on [**5-25**]
17. History of two intraparenchymal hemorrhages that were
thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] which has resolved
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother and brother. On disability for multiple medical
problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather.
Physical Exam:
100/63 81 18 100RA
GENERAL: Pleasant, thin young female sitting in the bed in NAD
watching TV.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP
clear. Neck Supple, No LAD.
CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB.
LUNGS: Breathing comfortably, CTAB, good air movement
biaterally.
ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No
rebound or guarding.
EXTREMITIES: No edema. Right femoral HD line nontender,
nonerythematous.
SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm
scattered along her lower extremities.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation to light touch throughout. 5/5 strength in her upper
and lower extremities
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2142-5-20**] 09:14PM LACTATE-0.9
[**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93
MCH-29.2 MCHC-31.6 RDW-18.8*
[**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2142-5-20**] 09:13PM PLT COUNT-145*
[**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137
POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*
[**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1
[**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93
MCH-30.2 MCHC-32.5 RDW-19.2*
[**2142-5-20**] 08:55PM PLT COUNT-126*
[**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2*
[**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT
BILI-0.4
[**2142-5-20**] 07:40AM LIPASE-58
Brief Hospital Course:
KUB: SBO
Head CT: (prelim read from radiology). unchanged from prior head
CT, no intracranial hemorrhage
EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3
(old), TW inversion V6 (new) compared to prior EKG [**5-15**].
CT CHEST/ABD: Preliminary Read
Normal aorta without dissection or acute abnormality. No PE.
Stable trace
ascites and small right pleural effusion. Unchanged small
pulmonary nodules
and lymphadenopathy in the chest. No acute abnormalities in the
abdomen to
explain epigastric pain.
EGD: Ulcer at GE junction.
# Hypertensive urgency: This is a chronic issue related to ESRD.
Head CT was negative for intracranial bleed. Weaned off
Nicardipine gtt and BP well controlled on home regimen.
Continued her home regimen of: Aliskiren 150 mg po bid,
Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID,
Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet
Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were
lower (see below) patient's BP meds were held occasionally, but
as she was transfused and the BPs started to trend back up the
meds were re-initiated. She then developed hypotension in the
setting of poor PO intake during her SBO. BP meds were held and
then re-initiated as the pressure came back up once she was able
to eat.
# Abdominal pain/UGIB: The patient has chronic abdominal pain
with previous negative workups. At first the pain resolved and
she was continued on her outpatient regimen of: 2-4 mg po
dilaudid q4 h as needed. GI was c/s re: abd pain and rec
CTA-abdomen to eval for mesenteric ischemia vs. partial SBO,
however with ESRD did not initially want to get CTA so KUB was
ordered. This showed no SBO. They recommended checking urine
porphyrobilinogen and serum lead levels which were negative and
LFTs were at baseline. The patient then developed a different
type of pain associated with her incision site. Pain service was
consulted and did a bupivicaine injection at the site which did
help. They will continue to follow her. She then developed a
third type of pain associated with a burning sensation in her
chest. EKG was unchanged from prior. A few hours later she had 3
episodes of coffee-ground emesis. She was placed on IV PPI and
transfused two units of blood. Afterward the pain resolved and
her hct remained stable. GI felt that the patient would need
general anesthesia in order to undergo an EGD which showed an
ulcer at the GE junction. She was started on empiric treatment
for H. Pylori and serologies were sent which came back negative
so the antibiotics were stopped. Her pain was controlled with
her outpatient regimen of PO dilaudid. She will follow up with
Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if
there has been resolution of the ulcer.
# SBO: Continued to be nauseous and vomited intermittently. she
was started on reglan and continued on zofran and compazine PRN
howeve she continued to have n/v. A KUB was done which showed an
SBO. Surgery was consulted, NGT was placed, she was made NPO and
serial abdominal exams were done. Eventually she was able to
transition to clear diet and then tolerated a regular diet
without pain or vomiting.
#. Fever: On hospital day #6 she spiked a fever to 101. Blood
and urine cultures were sent and a cxr were negative, however
she then had a seizure and in the post-ictal state aspirated
after vomiting. She had an episode of hypoxia with this and was
transferred to the ICU. In the ICU LP was attempted to rule out
meningitis as a possible cause of a seizure but this was
unsuccessful. Broad spectrum antibiotics were initiated (vanc
ctx) at meningeal dosing. She improved over the next few days
and antibiotics were discontinued because the suspicion for a
bacterial meningitis was low.
#. Seizure: This occured in the setting of fever, hypotension,
and initiation of reglan for vomiting. Neurology was consulted
and felt she should be continued on keppra indefinitely. EEG was
non-revealing. She should be continued on keppra 1gm with
dialysis three times weekly.
# ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent
dialysis on normal schedule.
# SLE: She was continued on prednisone 4mg daily. With multiple
abdominal symptoms it was thought she may have lupus flare in
the abdomen. C3, c4 were equivocal for active lupus flare, and
[**Doctor First Name **] was positive, as would be expected in lupus.
# Anemia: Has anemia of chronic renal disease and her Hct was
high on admission and epo was held per renal. However, her Hct
trended all the way down to 20 and she was borderline
hypotensive for her (ie SBP 120) and she developed coffee ground
emesis so she was transfused 2 units. Afterward her Hct was
stable at 25. She was also re-started on EPO per renal for her
chronic anemia. Hemolysis labs were negative.
# History of thrombotic events/SVC syndrome: She is
anticoagulated with warfarin as an outpatient. Previous
documentation in OMR states she does not need to be bridged
while subtherapeutic. Continued coumadin 4 mg po daily however
INR became supratherapeutic and the coumadin was then held. She
was started on heparin gtt while awaiting EGD. After EGD the
coumadin was re-started at 3mg daily however, in setting of poor
po intake her INR was supratherapeutic - likely [**2-12**] nutritional
deficiency of vitamin k. coumadin will be restarted when INR [**2-13**]
at dialysis.
# OSA: She is on CPAP at a setting of 7 as an outpatient.
Continued CPAP
#. CIN1: On last pap had CIN1. OB/GYN service was called re:
doing colposcopy in hospital as patient rarely makes o/p
appointments, hwoever they do not do this procedure in hospital
especially because it does not have to be done emergently - just
within one year. Will need outpatient colposcopy at some point
in next few months as they do not do this procedure in the
hospital.
# RLL nodule: A new 10 x 5 mm nodularity was found incidentally
within the right lower lobe of the lung on an abdominal CT.
This should be reassessed in 3 months.
# ACCESS: PIV, right groin HD line
# CODE: Full code
Medications on Admission:
1. Aliskiren 150 mg PO bid
2. Citalopram 20 mg PO DAILY
3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT
4. Hydromorphone 2 mg 1-2 Tablets PO Q4H
5. Fentanyl 25 mcg/hr Patch 72 hr
6. Gabapentin 300 mg PO TID
7. Hydralazine 100 mg PO Q8H
8. Hydralazine 100 mg PO BID PRn fro SBP> 180.
9. Prednisone 4 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Labetalol 1000 mg PO TID
12. Nifedipine 90 mg PO QAM
13. Nifedipine 60 mg PO QHS
14. Warfarin 3 mg PO Once Daily
15. Lidocaine 5 %(700 mg/patch) Topical once a day.
16. Nifedipine 90 mg PO once a day as needed for for SBP
persistently above 200.
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
UGIB- Ulcer at GE junction
Hypertensive Emergency
Anemia
ESRD on HD
SBO
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You had
an injection of lidocaine to help the pain around your surgery
sites. You then had some blood in your vomit. You were treated
for a bleed in your stomach with a blood transfusion and
medications. You stopped bleeding and felt better. You had a
scope of your abdomen that showed an ulcer. You were treated
with medications for this and need to have another scope of your
abdomen in 6 weeks. You also had high blood pressures while you
were here because you could not take your medicines with your
nausea and vomiting. Once you were on your home medicines your
blood pressure was better.
Medication Changes:
CHANGE: Pantoprazole to 40mg TWICE daily
Please call your PCP or come to the emergency room if you have
fevers, chills, worsening abdominal pain, nausea, vomiting,
blood in your vomit, blood in your stools, black/tarry stools or
any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**]
weeks for an EGD to re-look at your ulcer.
Please follow up with the OB/[**Hospital **] clinic for a colposcopy on
Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**].
Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in
the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm.
Completed by:[**2142-6-6**]
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68,543
| 182,762
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41500
|
Discharge summary
|
report
|
Admission Date: [**2174-2-7**] Discharge Date: [**2174-2-28**]
Date of Birth: [**2095-4-6**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / simvastatin / Niacin / Sulfa (Sulfonamide
Antibiotics) / Nifedipine / omeprazole / amlodipine
Attending:[**First Name3 (LF) 2553**]
Chief Complaint:
SOB, thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 72288**] is a 78yoF with h/o dCHF [**1-6**] cardiac amyloid,
hypertension, hyperlipidemia, atrial fibrillation s/p DCCV in
[**2173-3-5**], recently discharged from [**Hospital1 18**], who presents back
from rehab with right thigh pain, SOB, and hyponatremia.
.
She was admitted to this hospital from [**Date range (1) 90274**] from a CHF
exacerbation. During that admission, she had pulmonary edema
with BNP very elevated at 16,166. She was diuresed, but
hypotension was an issue. She was fluid restricted (1.0 L) for
persistant hyponatremia to 120's. Maintained on 40mg torsemide
daily and spironolactone 25mg twice daily. Her dry weight is
129lbs, and she was discharged at 127lbs.
.
In the ED, initial vitals were 98.6 72 111/67 18 100% 3L
Labs and imaging significant for labs with elevated BNP
(20,000), CXR with pulmonary edema, and XR femur without
pathologic fx.
Vitals on transfer were 97.2, 91, 104/70, 16, 94% RA
.
On arrival to the floor, patient is in NAD. She complains of
right anterior thigh discomfort, but says it is improved. Her
breathing feels good. She is sitting upright eating dinner.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Progressive dyspnea and LE edema throughout late [**2172**]
- [**2172-12-5**]: TTE concerning for restrictive physiology,
pulmonary hypertension
- [**2172-12-5**]: endomyocardial Bx positive for extracellular
amyloid
deposition and 30-40% plasma cells, skeletal survey positive for
multiple lytic lesions, SPEP with abnormal lambda band
- [**2174-1-5**]: C1 bortezomib/dexamethasone started with weekly
dosing
.
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Acute on chronic diastolic CHF
- Atrial fibrillation (d/c DCCV [**2173-3-5**], on coumadin)
3. OTHER PAST MEDICAL HISTORY:
ESOPHAGEAL REFLUX
ANEMIA - IRON DEFIC, UNSPEC
HYPOTHYROIDISM
ARTHRITIS
Social History:
Patient is a widow and lives alone in [**Location (un) 1411**] MA. She uses a
cane. She denies any falls. She has two adult
children. She is originally from [**Country 2784**] and emigrated in the
[**2111**]'s.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission physical exam:
VS: T=98.6 BP=133/76 HR=81 RR=18 O2 sat=97% on 2Lnc
GENERAL: cachectic, elderly caucasian female in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple with JVP of 12cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Bilateral
crackles in all lung fields, with some wheezes in the base.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Mildly tender to deep
palpation on right anterior thigh.
SKIN: resolving zoster infection on lumbar spine, healing well.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge physical exam:
Deceased
Pertinent Results:
Admission labs:
[**2174-2-7**] 01:05PM BLOOD WBC-6.5 RBC-4.59 Hgb-12.8 Hct-36.6
MCV-80* MCH-27.8 MCHC-34.9 RDW-17.3* Plt Ct-188#
[**2174-2-7**] 01:05PM BLOOD Neuts-87.0* Lymphs-9.6* Monos-2.6 Eos-0.1
Baso-0.6
[**2174-2-8**] 07:00AM BLOOD PT-19.2* PTT-29.3 INR(PT)-1.8*
[**2174-2-7**] 01:05PM BLOOD Glucose-84 UreaN-30* Creat-1.3* Na-125*
K-4.8 Cl-87* HCO3-26 AnGap-17
.
Imaging:
Chest X-ray (PA and Lateral): FINDINGS: PA and lateral views of
the chest were obtained. Cardiomegaly is again noted with mild
pulmonary edema. There are small bilateral pleural effusions
which appear similar to prior study. Bony structures are intact.
No free air below the right hemidiaphragm. IMPRESSION:
Cardiomegaly, mild pulmonary edema. Small bilateral pleural
effusions.
.
FEMUR (AP & LAT) RIGHT
FINDINGS: Four views of the right femur were provided. No
definite sign of
disease in the right femur. No fracture. Degenerative disease at
the right
knee is noted, tricompartmental with meniscal calcification
suggesting
chondrocalcinosis. No joint effusion. The views of the right
pelvis are
unremarkable.
IMPRESSION: No fracture or definite evidence of multiple myeloma
in the right femur.
.
UNILAT LOWER EXT VEINS RIGHT
FINDINGS: The right common femoral, superficial femoral, and
popliteal veins demonstrate normal compressibility, flow, and
augmentation. The right peroneal and posterior tibial veins
demonstrate color flow. Subcutaneous edema is noted.
IMPRESSION: No evidence for DVT. Subcutaneous edema.
.
PORTABLE CHEST RADIOGRAPH: Mild cardiomegaly is increased
compared to the
prior exam. Bilateral interstitial edema is improved. New focal
nodularity
particularly within the left lung are concerning for
disseminated infection. Prominence and some minimal
opacification at the right lung base may represent atelectasis
or worsening pulmonary edema, although infection cannot be
entirely excluded in the correct clinical setting.
IMPRESSION:
1. Interstitial edema is improved compared to the prior exam.
2. Mild cardiomegaly is increased compared to the prior exam.
3. Focal nodularity predominantly in left lung, new since the
prior exam, is concerning for disseminated infection. A
dedicated CT of the chest is
recommended for further evaluation.
.
CT Chest W/O Contrast:
FINDINGS:
The thyroid gland appears unremarkable.
The mediastinal, axillary and hilar lymph nodes do not meet size
criteria for pathology. The main pulmonary artery measures 3.1
cm, concerning for
pulmonary hypertension. Coronary artery calcifications are
noted.
Atherosclerotic calcifications are noted within the arch of the
aorta.
Centrilobular nodular branching opacities are noted in bilateral
lungs, left greater than right, consistent with bronchiolitis.
These are lower lobe predominant. Larger nodules and
consolidations are noted particularly within the right medial
lower lobe. Overall findings may represent airway secretions
with widespread aspiration complicated by bronchopneumonia or
diffuse airway infection due to viral or mycoplasma infection.
Moderate cardiomegaly is noted. Bilateral pleural effusions are
identified, right greater than left, with adjacent compressive
atelectasis. Ground-glass opacity and minimal septal thickening
is also noted in both lungs which may represent pulmonary edema.
Left superior segment bronchus appears obstructed which may be
secondary to secretions. Secretions are also noted layering
dependantly along the airways within the trachea and right
bronchus (series 4, image 79).
This study is not optimized for subdiaphragmatic evaluation.
Within this
limitation, the upper abdominal structures appear unremarkable.
Visualized osseous structures show no focal lytic or sclerotic
lesions
suspicious for malignancy.
IMPRESSION:
1. Diffuse bronchiolitis and early bronchopneumonia which may be
secondary to viral or mycoplasma infection. Alternatively,
considering intraluminal airway secretions and dependent
predominance, aspiration pneumonia is an additional
consideration.
2. Cardiomegaly and mild hydrostatic pulmonary edema.
3. Bilateral pleural effusions, right greater than left, with
adjacent atelectasis.
4. Main pulmonary artery measures 3.1 cm, raising the
possibility for pulmonary hypertension.
.
[**2174-2-18**] Chest X-ray:
Since many of the findings described in today's study can
overlap with
findings that of pulmonary amyloidosis, a three-month followup
CT is
recommended to determine resolution. In comparison with study of
[**2-8**], there is continued enlargement of the heart with evidence
of vascular congestion. However, the diffuse areas of pulmonary
opacification bilaterally have substantially reduced. There is,
however, some opacification in the retrocardiac area with
possible air bronchograms, raising the possibility of a lower
lung pneumonia. There is a pleural effusion most likely at the
left base, though there may be a small effusion on the right as
well.
.
Microbiology:
[**2174-2-8**] 3:16 am URINE Source: Catheter.
**FINAL REPORT [**2174-2-9**]**
URINE CULTURE (Final [**2174-2-9**]): NO GROWTH.
.
[**2174-2-8**] 6:45 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending) time 2
.
[**2174-2-8**] 3:16 am URINE HEM# 0112D [**2-8**].
**FINAL REPORT [**2174-2-9**]**
Legionella Urinary Antigen (Final [**2174-2-9**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
.
[**2174-2-8**] 4:25 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2174-2-8**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
# Cardiomyopathy secondary to amyloidosis: The patient was
initially admitted for tachycardia and fevers. Her condition
worsened, and based on discussion with the family, her goals of
care were transitioned to focus primarily on comfort measures
only. Immediate cause of death due to congestive heart failure.
She passed on [**2174-2-28**] with her family at the bedside.
Medications on Admission:
1. spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea, anxiety, insomnia.
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,FR,SA).
6. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO 2X/WEEK ([**Doctor First Name **],TH).
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular PRN as needed for allergy symptoms.
11. calcium carbonate 650 mg calcium (1,625 mg) Tablet Sig: One
(1) Tablet PO once a day.
12. midodrine 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
14. Outpatient Lab Work
Please check serum sodium, potassium, chloride, bicarbonate,
BUN, creatinine, and INR on [**2174-2-7**].
15. Tessalon Perle 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Amyloid cardiomyopathy
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2174-3-1**]
|
[
"348.30",
"V87.41",
"244.9",
"530.81",
"272.4",
"V58.67",
"203.00",
"053.19",
"323.81",
"480.9",
"V58.61",
"276.1",
"458.9",
"280.9",
"428.0",
"511.9",
"V49.86",
"780.09",
"345.3",
"715.90",
"425.7",
"053.14",
"483.0",
"277.39",
"058.29",
"428.33",
"427.31",
"250.00",
"516.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12095, 12104
|
10150, 10524
|
380, 387
|
12170, 12180
|
4045, 4045
|
12237, 12275
|
3048, 3163
|
12066, 12072
|
12125, 12149
|
10550, 12043
|
12204, 12214
|
3203, 3991
|
2543, 2637
|
10082, 10127
|
325, 342
|
415, 1978
|
4061, 10041
|
2668, 2741
|
2461, 2523
|
2757, 3032
|
4016, 4026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,134
| 198,911
|
10937
|
Discharge summary
|
report
|
Admission Date: [**2105-6-6**] Discharge Date: [**2105-6-12**]
Date of Birth: [**2047-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 y/o man with PMH significant for hypertension and type 2
diabetes mellitus presented with chest pressure and admitted
through the ED with concern for a type 2 abdominal aortic
dissection.
.
Patient was in his normal state of health until approximately
10:30 this morning when he developed [**2110-6-12**] chest tightness
radiating to his back as he was finishing moving his bowels.
This was associated with diaphoresis but no SOB, nausea, or
vomiting. He reports that he checked his blood sugar
approximately one hour after his sympoms started and it was 124.
After exepriencing the pain without relief for approximately two
hours, the pt came to the [**Hospital1 18**] ED for further evaulation.
.
In further ROS, he denies recent fevers or chills. No headaches.
No other episodes of chest pain or tightness. No SOB. Pt sleeps
flat at night with no difficulty. He reports that he likes to
walk and will often walk for up to five hours without difficulty
in warm weather. He denies any joint pain. He has been
experiencing increased leg "cramps" over the last week.
.
In the ED, the pt's VS were 97.6 88 190/70 14 100% on 2L NC. He
received a total of 15 mg IV lopressor but continued to be very
hypertensive with a SBP in the 170s to 180s. Given the pt's
sympoms there was a concern for aortic dissection so a CTA was
obtained which was concerning for a possible dissection near the
[**Female First Name (un) 899**]. Pt was placed on an esmolol drip with goal SBP of 110 and a
[**Female First Name (un) 1106**] surgery consult was obtained. As it is unclear if it is
a true abdominal aorta vs artifact, they wished to admit him to
the MICU for close monitoring and BP control until Monday at
which time an aortogram will be obtained.
.
In the MICU the patient was continued on esmolol gtt with goal
SBP <120. He was ruled out for MI by 3 sets negative cardiac
enzymes. [**Female First Name (un) **] surgery followed and recommended repeat CTA
abdomen in place of aorto-gram. Repeat CTA demonstrated stable
appearance of abdominal aortic intimal flap near [**Female First Name (un) 899**]. However,
indcidental finding of concurrent PE in the right main pulmonary
artery was found. Patient was started on heparin gtt and
coumadin. He was also started on labetolol for blood pressure
control, and the esmolol gtt was titrated off. Patient had been
on pneumoboots during his hospitalization. He has a previous
smoking history, but quit 18yrs ago. He has had no recent
travel. He notes recent exacerbations of "[**Last Name (un) **] horse"
muscular spasms in his legs, but these were bilateral. He has
had no further episodes of chest pain, pressure, shortness of
breath, abdominal pain, or nausea since his hospitalization.
.
He notes prior to this hospitalization, over the past year, he
has noted episodes of diarrhea and urgency that occur every
3-4days. Stools are nonbloody and not black. Also on ROS he
noted occasional episodes of blurry vision when his blood sugars
vary, and an enlarging mole on his right thigh. He denies
headaches, dizziness, changes in hearing, dysuria, arthralgias,
myalgias, rashes.
Past Medical History:
1. Type 2 diabetes mellitus- Pt was diagnosed in [**2099**]. He
started on insulin for improved blood sugar control
approximately 2.5 year ago.
2. [**Name (NI) **] Pt reports that he always had good blood
pressure with an average SBP of 120 until one year ago when it
became elevated. He was started on an antihypertensive
medication approximately six weeks ago.
3. Hypercholesterolemia
4. Nephrolithiasis
Social History:
Pt lives alone and is self employed in real estate. He quit
smoking approximately 18 years ago after smoking 1.5ppd for 22
years. He drinks three ETOH drinks per day. No history of DTs.
No drugs.
Family History:
[**Name (NI) 1094**] father died at age 85 from a MI
His mother is alive and well at age 82
[**Name (NI) 1094**] sister had cancer of fallopian tube in the past, in
remission x7yrs
Physical Exam:
PE on Admission:
74 178/96 16 100% 2L NC
Gen- Well appearing man resting comfortably on the strecher.
NAD. Able to speak in full sentences without difficulty.
HEENT- NC AT. PERRL. EOMI. Anicteric sclera. MMM. No lesions in
the oropharynx.
Cardaic- RRR. No m,r,g. No carotid bruits.
Abdomen- Soft. NT. ND. Positive bowel sounds. No bruits. No
appreciable organomegaly.
Pulm- CTAB. No wheezes, rales, or rhonchi.
Extremities- No c/c/e. 2+ DP pulses bilaterally.
.
PE on Transfer:
T 97.4 HR 77 (62-86) BP 133/60 (113-133/46-68) RR 20 97%RA
Gen: comfortably, well-appearing, NAD
HEENT: PERRL, anicteric, conjunctiva pink, OP clear with MMM
Neck: supple, no LAD, JVP nondistended
CV: RRR, no mrg, nml s1s2
Resp: B crackles [**3-12**]-up
Abd: +BS, soft, nt, nd, no hsm, no masses
Ext: symmetric, nontender, no edema, 2+ L DP pulse, 2 R DP
pulse
Skin: mole R thigh round smooth edges, grey with black border,
raised
Neuro: A&Ox3, CN II-XII intact, motor and sensation intact
grossly
Pertinent Results:
[**2105-6-6**] 10:01PM CK(CPK)-46
[**2105-6-6**] 10:01PM CK-MB-NotDone cTropnT-<0.01
[**2105-6-6**] 10:01PM HCT-31.1*
[**2105-6-6**] 01:10PM GLUCOSE-149* UREA N-31* CREAT-1.1 SODIUM-139
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2105-6-6**] 01:10PM CK(CPK)-71
[**2105-6-6**] 01:10PM CK-MB-NotDone cTropnT-<0.01
[**2105-6-6**] 01:10PM CALCIUM-9.8 PHOSPHATE-3.0 MAGNESIUM-1.5*
[**2105-6-6**] 01:10PM WBC-6.3 RBC-4.39* HGB-13.5* HCT-37.6* MCV-86
MCH-30.8 MCHC-36.0* RDW-12.3
[**2105-6-6**] 01:10PM NEUTS-70.9* LYMPHS-23.5 MONOS-3.4 EOS-2.0
BASOS-0.2
[**2105-6-6**] 01:10PM PLT COUNT-168
[**2105-6-6**] 01:10PM PT-11.7 PTT-22.7 INR(PT)-0.9
Radiology:
CTA Chest/Abd [**2105-6-6**]: Intimal flap of the descending aorta at
the level of the take off of the [**Female First Name (un) 899**], consistent with short,
focal type B aortic dissection. The intimal flap is only seen on
two axial images, however, is confirmed on thin cut coronal and
sagittal reformats. There is no proximal or distal extension
into the iliacs. The celiac, SMA, [**Female First Name (un) 899**] and renal arteries are
patent, and there is no evidence of abnormal perfusion to the
major abdominal and upper pelvic organs.
.
CTA Chest Abd [**2105-6-8**]:
1) Small nonocclusive, but central PE in the right main
pulmonary artery
extending into the lower lobe branch. This is new and was not
seen in the
prior CT 2 days ago.
2) Focal 9 mm dissection of the abdominal aorta at the level
of the [**Female First Name (un) 899**]
origin. There is no evidence of fluid around it and there is no
change in
comparison to the prior CT. The aorta otherwise is normal.
3) Markedly distended bladder. The lower portion of the pelvis
is not
included in the scan, according to the dissection protocol.
4) Contrast excretion through the gallbladder.
Brief Hospital Course:
58 y/o man with h/o hypertension and type 2 diabetes mellitus
presenting with chest pressure diagnosed with dissecting
abdominal aortic aneurysm and new onset pulmonary embolism.
During his hospitalization the following problems were
addressed:
1. Chest pain/ dissecting abdominal aortic aneurysm: CTA in
the ED confirmed diagnosis of dissecting AAA 1.7x1.6cm with 9mm
dissection at the region of the [**Female First Name (un) 899**] take-off from aorta. He was
started on an esmolol gtt for BP control with goal SBP <120, and
admitted to the MICU. Pain was initially controlled with iv
morphine in the ED. He had no further episodes of pain. He was
started on labetolol and the esmolol titrated off. [**Female First Name (un) **]
surgery followed the patient while in the MICU. They
recommended continued medical management, with plans for
reevaluation by CTA and [**Female First Name (un) 1106**] surgery follow-up 2-3 months
after the initial event. Repeat CTA of the chest and abdomen
[**2105-6-8**] showed stable appearance of the dissection. He was
transferred to the floor on labetolol 400mg tid. Blood pressure
was above the goal on this regimen and an ACE inhibitor was
added. Blood pressure stabilized with SBP <120 on Labetolol
400mg tid and Lisinopril 5mg qHS. [**Month/Day/Year **] surgery also
recommended aspirin. However, he was started on coumadin for PE
as described below..
2. Pulmonary embolism: Patient was diagnosed with PE on repeat
CTA performed [**2105-6-8**]. This was an incidental finding and not
seen on previous exam [**2105-6-6**]. He had been on pneumoboots for
ppx. He denied shortness of breath, chest pain, and was not
tachycardic or hypoxemic. He did report recent exacerbations of
bilateral LE muscle spasm pain, but it was unclear if this was
related. He had no recent travel, no previous clots, and had
quit tobacco 20yrs prior. No family history of clots.
Bilateral lower extremity ultrasounds revealed superficial clot
in the left tibial vein. Upper extremity doppler reveal a
superficial clot in the left radial vein. There were no deep
venous thromboses. [**Month/Day/Year **] surgery was again consulted about
risk of anticoagulation in the setting of dissection AAA. They
reported no contraindication, and he was started on a heparin
gtt and coumadin. INR was therapeutic at 2.2 on the day of
discharge. The heparin gtt was discontinued. The patient will
follow-up with Dr. [**Last Name (STitle) 2392**], his PCP, [**Name10 (NameIs) **] INR monitoring. He was
discharged to home on 5mg coumadin qHS. No hypercoagulable
work-up was done as an inpatient. It was also recommmended that
the patient had screening colonoscopy as work-up for possible
clot source, and his recurrent diarrheal episodes. He will
require at least 6months of anticoagulation.
3. Diarrhea: the patient reports a one year history of
recurrent episodes of urgent non-bloody loose stools. He had
one such episode in-house. It was recommended he continue with
a low-lactose diet, monitor what he eats prior to onset of
diarrhea, and have a colonoscopy.
4. Phlebitis: the patient developed a clot at the site of iv
in the left radial vein. There was swelling, pain and erythema
at this site. He was started on Keflex for concern of overlying
cellulitis or infected thrombophlebitis. Erythema resolved.
The patient will complete a 10day course of Keflex.
5. Type II diabetes mellitus: initially he was placed on a
regular insulin sliding scale. Once po intake stabilized, his
home regimen of metformin and NPH/Regular insulin was resumed.
He had a diabetic diet throughout the hospitalization.
6. Hypercholesterolemia: he was continued on his outpatient
dose of atorvastatin.
7. Hypertension: He was continued on labetolol as per HPI.
Lisinopril was added to maintain SBP <120.
8. Dispo: he was discharged to home. He will follow-up with
Dr. [**Last Name (STitle) 2392**] [**2105-6-15**] for review of his hospitalization and
continued INR monitoring. He will follow-up with Dr. [**Last Name (STitle) **] in
[**Last Name (STitle) **] surgery [**2105-7-15**]. He is a full code.
Medications on Admission:
Meds on Admission:
1. Glucophage 1000 mg [**Hospital1 **]
2. Humalin insulin 15 units [**Hospital1 **]
3. Lipitor 10 mg daily
4. An antihypertensive medication- Pt does not know the name.
.
Meds on Transfer:
1. Labetolol 400mg tid
2. Heparin gtt
3. Coumadin 5mg qHS
4. Ativan 1mg prn anxiety
5. Ambien 5mg qHS
6. Protonix 40mg daily
7. Colace prn
8. Tylenol prn
Discharge Medications:
1. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin Sodium 2.5 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
Disp:*60 Tablet(s)* Refills:*2*
6. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Fifteen
(15) units Subcutaneous twice a day.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
8. Outpatient Lab Work
INR on Monday [**6-15**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal aortic dissection
Pulmonary embolism (right main pulmonary artery)
Superficial thrombophlebitis of LUE and LLE.
.
Secondary:
Hypertension
Type II diabetes mellitus
Discharge Condition:
Good-- no chest pain or shortness breath. Tolerating POs.
Ambulating without difficulty.
Discharge Instructions:
If you develop chest pain, abdominal pain, shortness of breath,
dizziness, fever, or any other concerning symptom, please call
your primary care physician [**Name Initial (PRE) **]/or return to the emergency
department.
.
Please take all medication as prescribed. You will need to
follow-up regularly in Dr.[**Name (NI) 35528**] office for lab tests to
monitor your coumadin level. The dose of coumadin will be
adjusted according to your blood level. Please have this blood
test on Monday [**6-15**] at [**Hospital1 778**] (a prescription is included should
you need it).
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2392**], on Tuesday at 2pm.
.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2105-7-15**] 10:15 **Please note, you will need to
call Dr.[**Name (NI) 7257**] office prior to this appointment at ([**Telephone/Fax (1) 1804**] to update your medical information.
|
[
"285.9",
"441.02",
"451.82",
"401.9",
"999.2",
"250.00",
"415.19",
"453.42"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12526, 12532
|
7232, 11375
|
328, 335
|
12759, 12850
|
5361, 7209
|
13472, 13970
|
4153, 4335
|
11787, 12503
|
12553, 12738
|
11401, 11406
|
12874, 13449
|
4350, 4353
|
274, 290
|
363, 3494
|
11420, 11591
|
3516, 3923
|
3939, 4137
|
11609, 11764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,887
| 173,324
|
9620
|
Discharge summary
|
report
|
Admission Date: [**2146-10-8**] Discharge Date: [**2146-10-10**]
Date of Birth: [**2091-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation at OSH, extubation [**2146-10-8**]
Diagnostic paracentesis [**2146-10-8**]
History of Present Illness:
55yoM with EtOH induced cirrhosis on [**Month/Day/Year **] list (MELD 16 on
[**9-30**]), DM II, pancytopenia and multiple admissions for hepatic
encephalopathy who presents from an OSH with acute change in MS.
[**Name13 (STitle) **] [**Hospital3 **] records, the following history was provided
by his significant other. She states that over the past week the
patient has been more confused. He has continued on his
medication regimen and taken lactulose as directed. He has been
moving his bowels regularly. On the morning of [**2146-10-7**], she was
unable to wake him up in the morning. She called EMS. On
arrival, EMS found the pt obtunded. Blood sugar noted to 400. He
was taken to the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **].
.
At [**Hospital3 **], he had a head CT which was normal. He was
intubated for airway protection. UA neg. CXR showed an increased
density at the left base which could be air-space disease. Tox
screen neg. ASA and tylenol levels neg. Given 2 units pRBC's.
Ammonia level 344- Started on lactulose q1hr. CBC did show WBc
1.9 with 80% neutrophils and 25 bands. Glucose 329.
.
Pt recently admitted to [**Hospital3 3583**] for recent symptoms from
[**2146-9-4**] to [**2146-9-6**]. Then admitted to [**Hospital1 18**] from [**9-7**] until
[**9-9**] again with confusion.
.
Past Medical History:
# EtOH induced cirrhosis
- Portal hypertension
- Grade I esophageal varices
- Diuretic refractory ascites.
- On [**Month/Year (2) **] list after a recent 40lb weight loss, MELD score
19
- Multiple admissions to [**Hospital3 3583**] and [**Hospital1 18**] for hepatic
encephalopathy
- s/p TIPS [**2137**] with frequent revisions [**11/2145**] and then closure
in [**4-/2146**] secondary to hepatic encephalopathy
# Pancytopenia
-Chronic from underlying liver disease
-Baseline HCT in mid 20s
-Baseline platelets in 20-40
# CKD with baseline Cr 1.0
# DM2, insulin dependent
# s/p cholecystectomy for porcelain gallbladder in [**10/2145**]
# Carcinoid tumor in gastric fundus
# OSA (doesn't use his home BiPAP)
# Squamous cell skin ca on left shoulder
# Morbid Obesity
# Chronic Venous Stasis
Social History:
Lives with fiancee (refers to as "wife") [**Doctor Last Name **] in [**Location (un) 3320**]. 8py
h/o smoking, quit age 26. H/o alcohol abuse, quit ~[**2134**]. Remote
marijuana/cocaine use in the 60s-70s, no IVDU. Unemployed at
present. He previously worked as the director of food & beverage
services on a cruiseline in the Hawaiian islands.
Family History:
Mother died at age 56 of a CVA. Father died at age 84
Alzheimer's. Sister with type II diabetes, seizures. Brother
with heart disease. Another brother is healthy.
Physical Exam:
VS - Temp F98.6, BP 135/62 , HR 81, R18 , O2-sat 100% FI02 40%
GENERAL - ill appearing man in NAD, sedated and ventilated
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 - grossly distended, typanitic, dialted veins across abd
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - small puncture on lateral aspect of left knee with mild
erythema, no drainage or purulence, no warmth or swelling.
.
Pertinent Results:
Admission labs:
[**2146-10-8**] 01:55AM BLOOD WBC-2.1* RBC-3.13* Hgb-10.2* Hct-29.7*
MCV-95 MCH-32.6* MCHC-34.4 RDW-18.6* Plt Ct-26*
[**2146-10-8**] 01:55AM BLOOD Neuts-79.4* Lymphs-9.8* Monos-7.6 Eos-2.7
Baso-0.4
[**2146-10-8**] 01:55AM BLOOD PT-18.5* PTT-36.1* INR(PT)-1.7*
[**2146-10-8**] 01:55AM BLOOD Glucose-223* UreaN-36* Creat-1.0 Na-133
K-3.7 Cl-104 HCO3-24 AnGap-9
[**2146-10-8**] 01:55AM BLOOD Albumin-3.1* Calcium-8.8 Phos-2.8 Mg-1.8
[**2146-10-8**] 02:18AM BLOOD Ammonia-103*
.
[**2146-10-8**] Liver US: Limited [**Month/Day/Year 950**] with patent main portal
vein, main hepatic artery, and middle hepatic vein.
A moderate amount of ascites. Spot marked for paracentesis in
right lower
quadrant.
TIPS occlusion, an unchanged finding.
Brief Hospital Course:
55 yo male with EtOH cirrhosis on [**Month/Day/Year **] list, DM II,
pancytopenia and multiple admissions for hepatic encephalopathy
who presents with confusion and found to have hepatic
encephalopathy.
# Acute Change in Mental Status: The differential diagnosis
initially included hepatic encephalopathy, Infection (SBP, PNA,
UTI), EtOH. His EtOh level was negative and his Utox was
negative at [**Hospital1 46**]. He had a CT head which was negative. He had
a negative UA and a CXR with a question of a LLL density, and pt
had left shift with bands at OSH suggestive of infection and
possible PNA. Here the patient was afebrile with nl WBC without
a left shift or bands. CXR here showed a left sided effusion,
but no pneumonia. He also had an elevated ammonia initally at
344 which was suggestive of recurrent hepatic encephalopathy.
He had been intubated at [**Hospital3 3583**] for airway protection
and was transferred to our MICU where he was extubated and
transferred to the floor as his mental status improved while
being treated with lactulose and rifaxamin.
He had an abdominal U/S with dopplers which showed an unchanged
TIPS occulsion. He had a diagnostic paracentesis which was not
consistent with SBP, however one of the peritoneal cultures sent
grew out E.coli. This was thought to be a contaminent as he had
only 56 WBC and 3% poly on examination of his peritoneal fluid.
He was initially treated with ceftriaxone and was clinically
improving, however the E.coli which grew out was not sensitive
to ceftriaxone, supporting that the E.coli was a contaminant.
He was discharge on prophylactic ciprofloxacin. Prior to
discharge he was told that if he were to develop any warning
signs including fever, abdominal pain, or chills, he should go
to the emergency room immediately.
# ESLD: On the liver [**Hospital3 **] list for cirrhosis. Last MELD 16
on [**9-30**]. The patient was continued on nadolol, lasix, and
aldactone.
# DM II: The patient was monitored with qid finger sticks and
was continued on NPH and sliding scale insulin.
# Anemia: Baseline Hct 23-28. He received 2 units pRBC's at OSH.
Here his Hct remained within his baseline.
# Pancytopenia: His plt baseline runs from 22 to 40. He
developed no signs of active bleeding here and his plt remained
>20.
Medications on Admission:
Nadolol 20 mg PO DAILY
Acidophilus 3 Capsules PO once a day.
Miconazole Nitrate 2 % Powder Sig: One Topical [**Hospital1 **]
Pantoprazole 40 mg Tablet Delayed Release PO Q24H
Rifaximin 200 mg 3 Tablet PO BID
Lactulose 30ml PO 3-4 times daily: Titrated to [**6-21**] bowel
movements daily.
Furosemide 120 mg PO DAILY
Spironolactone 50 mg PO BID
Insulin lispro sliding scale and take your
Insulin NPH 75 units every morning and 70 units every evening.
Metoclopramide 10 mg Tablet 0.5 Tablet PO TID
Oxycodone 5 mg PO Q6H PRN pain.
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Lasix 80 mg Tablet Sig: 1.5 Tablets PO once a day.
10. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day.
11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous per sliding scale.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy
Five (75) units Subcutaneous qam.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy
(70) units Subcutaneous bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] [**Hospital3 269**]
Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
.
Secondary:
EtOH induced cirrhosis
- Portal hypertension
- Grade I esophageal varices
- Diuretic refractory ascites.
s/p TIPS [**2137**]
CKD with baseline Cr 1.6
DM2, insulin dependent
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted with confusion and possible SBP. Your ascitic
fluid was negative for SBP. One of the cultures did grow out E.
coli, however, given that you improved on just ciprofloxacin,
and you were essentially asymptomatic aside from confusion, we
think that this was a contaminant. That being said, you will go
home on ciprofloxacin as prophylaxis and this should be taken
everyday. Additionally, if you develop worsening confusion or
belly pain at home and/or you have fevers or chills, you should
return to the hospital as soon as possible.
Followup Instructions:
Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-10-14**] 1:00
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-10-21**] 9:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2146-10-11**]
|
[
"250.00",
"585.9",
"285.21",
"789.59",
"459.81",
"284.1",
"303.93",
"V04.81",
"278.01",
"572.3",
"571.2",
"456.21",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.07",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8611, 8678
|
4564, 4786
|
320, 407
|
8940, 8960
|
3791, 3791
|
9557, 9989
|
2955, 3119
|
7440, 8588
|
8699, 8919
|
6887, 7417
|
8984, 9534
|
3134, 3772
|
277, 282
|
435, 1763
|
3807, 4541
|
4801, 6861
|
1785, 2577
|
2593, 2939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,567
| 106,752
|
16707
|
Discharge summary
|
report
|
Admission Date: [**2169-1-30**] Discharge Date: [**2169-2-13**]
Date of Birth: [**2102-5-21**] Sex: F
Service: Vascular
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: The patient underwent an
abdominal computed tomography for anticipation for
intravascular abdominal aortic repair and determined she was
not a candidate. She is now admitted for open abdominal
aortic iliac aneurysm repair.
An outside cardiac workup included a cardiac catheterization
for a positive stress test. She underwent cardiac
catheterization and a angioplasty with stent placement of the
circumflex artery on [**2168-12-30**]. She now returns for
elective revascularization.
PAST MEDICAL HISTORY:
1. History of cerebrovascular accident in [**2167-11-5**];
which presented with left-sided weakness (from which she has
recovered).
2. Abdominal aortic aneurysm since [**2167-11-5**].
3. History of coronary artery disease; status post silent
myocardial infarction by electrocardiogram.
4. Atrophic left kidney.
5. Echocardiogram on [**2168-10-10**] demonstrated a left
ventricular hypertrophy with infrabasilar hypokinesis and an
ejection fraction of 45%, with moderate mitral regurgitation,
left atrial enlargement, and inferobasilar aneurysm.
6. Type III aortic dissection; treated medically.
7. Questionable renal artery stenosis.
8. Chronic obstructive pulmonary disease; on home oxygen as
needed.
9. Hypertension.
10. Diverticulosis.
11. Rectal polyps.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Sublingual nitroglycerin as needed.
3. Imdur 60 mg p.o. b.i.d.
4. Prilosec 20 mg p.o. q.d.
5. Lipitor 20 mg p.o. q.d.
6. Verapamil-SR 240 mg p.o. q.d.
7. Hydralazine 150 mg p.o. b.i.d.
8. Potassium chloride 20 mEq p.o. q.d.
9. Albuterol inhaler 2 puffs q.i.d.
10. Celexa 10 mg p.o. q.d.
SOCIAL HISTORY: The patient is a widow. She lives in [**Location 11269**]
with her three sons.
RADIOLOGY/IMAGING: A Duplex of the carotids showed moderate
plaque in both carotids bilaterally, but no hemodynamically
significant lesions.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2169-1-30**]. She underwent
aortobifemoral bypass surgery with [**Hospital1 **]-iliac artery ligation.
The patient tolerated the procedure well. She required 4
units of packed red blood cells intraoperatively with 200 cc
of cellsaver. An epidural catheter was placed
intraoperatively for postoperative analgesic control.
The patient was transferred to the Postanesthesia Care Unit
in stable condition. She was transferred to the Vascular
Intensive Care Unit for continued monitoring and care.
On postoperative day one, there were low oxygen saturations
with blood gas results of 7.31/43/56/23/-4. X-ray results
congestive failure. The patient's hematocrit was 30.6.
Blood urea nitrogen was 26. Creatinine was 1.7.
The Renal Service was consulted on postoperative day two
because of increasing creatinine. It was felt this patient's
oliguria was prerenal in origin secondary to hypertension
intraoperative and a singular functioning kidney. Their
recommendations were to check eosinophils, C3-C4 compliments.
A renal ultrasound with Doppler to rule out obstructive
disease. Keep systolic blood pressure between 120s and 130s.
Keep hematocrit greater than 30. No nonsteroidals, ACE
inhibitors, or angiotensin receptor blockers until resolution
of elevated creatinine and return of normal urine volume.
Medicines for creatinine clearance of 20 to 30. The
patient's oxygen saturation continued to remain in the 80s
and 90s with albuterol nebulizers and nonrebreather at 6
liters. Questionable congestive heart failure. The
peripheral arterial line was discontinued. An oxygen wean
was begun, and she was diuresed. She remained in the
Vascular Intensive Care Unit for continued pulmonary care and
monitoring. The epidural was discontinued, and oral
analgesics were begun.
By postoperative day four, the patient was passing flatus.
her diet was advanced to clear liquids. Her hematocrit
drifted to 27.8 (down from 29). Her creatinine showed
improvement from 2 to 1.9 with a blood urea nitrogen of 35.
There was improvement in her oxygenation. Intravenous Lasix
dosing was decreased from 100 mg intravenously q.6h. to 100
mg intravenously q.12h with a fluid restriction to one liter
per day. Her free water deficit equaled two liters allow the
patient to drink to thirst. Replace potassium and magnesium.
Physical Therapy saw the patient and felt that she would
require rehabilitation status post discharge.
By postoperative day four, her creatinine was back to
baseline of 1.6. Her hematocrit remained stable at 29.2.
She was tolerating oral intake. Her lines were discontinued
and was transferred to the regular nursing floor. The
[**Hospital 228**] transfer to the floor was delayed because of
respiratory status. Arterial blood gas results were
7.54/33/125/29 and 6. Aggressive diuresis continued and
aggressive pulmonary care was continued. Her Lasix dosing
was decreased to 80 mg intravenously, and this was converted
to 40 mg p.o. b.i.d. Recommendations from the Renal Service
were to keep her on -500,000 cc daily. The Renal Service
signed off. The patient continued to show excellent
diuresis. Her hematocrit was 32.6. Blood urea nitrogen was
26. Creatinine was 1.1.
The patient was transferred to the Trauma Surgical Intensive
Care Unit on [**2169-2-8**] for continued poor oxygenation.
Aggressive pulmonary care was continued. The patient was
nothing by mouth. She was continued on Levaquin and Flagyl.
An arterial line was placed.
Over the next 48 hours, the patient remained in the Surgical
Intensive Care Unit for continued pulmonary monitoring, and
she was transferred to the regular nursing floor on [**2169-2-9**]. Her creatinine was 1.7. Blood urea nitrogen was
37. Hematocrit was 29.6.
The patient's creatine phosphokinases and troponin levels
were flat. Electrocardiogram was without changes. She was
continued on Unasyn for questionable pneumonia.
The Renal Service was consulted again on [**2169-2-9**].
Their recommendations were to continue to hold her diuretics
for prerenal azotemia. The nephropathy secondary to contrast
had resolved, and treat her hyponatremia secondary to free
water loss and diuretics with D-5-W at 100 cc per hour times
24 hours.
The Pulmonary Service was consulted regarding the patient's
pulmonary status. Their recommendations were to begin
ambulation to chair with Physical Therapy and Occupational
Therapy. Consider studies for rule out pulmonary embolus.
Keep her oxygen saturations at no greater than 93%.
The patient was returned to the Vascular Intensive Care Unit
from the Surgical Intensive Care Unit on postoperative day 11
(which was [**2169-2-10**]) for pulmonary embolism. A
computed tomography of the chest was obtained which showed
thoracic aortic dissection and aneurysmal dilatation which
extended to the MH portion of the intra-abdominal aorta.
This was consistent with the patient's known of aortic
aneurysm. The left lobe was noted to be collapsed. This
could be related to mucous plug or other obstructive process
correlating with the patient's clinical examination. It
should be noted that patchy peripheral opacities were noted;
mostly in the left upper lobe which were secondary to an
acute inflammatory process.
The patient continued to show slow progressive improvement in
her pulmonary status. She was transferred to the regular
nursing floor on [**2169-2-12**].
The computed tomography, per the Pulmonary Service,
determined the etiology of her hypoxia were related to both
her underlying chronic obstructive pulmonary disease and her
lower lobe changes, and it was most imperative that the
patient do incentive spirometry and aggressive physical
therapy. If the left lower lobe does not open up with these
measures, then would have to consider a bronchoscopy.
DISCHARGE DISPOSITION: By postoperative day fourteen, the
patient continued to show improvement and stabilization of
her respiratory function. Her skin clips were removed, and
the patient was discharged to home. The patient was to
follow up with Dr. [**Last Name (STitle) 1391**] in his clinic in [**Location (un) **].
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Verapamil-SR 240 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d. (times one month).
3. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed
(for pain).
4. Metoprolol 50 mg p.o. t.i.d.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm with extension to iliac.
2. Status post aortobifemoral bilateral iliac ligation.
3. Respiratory failure secondary to atelectasis and
underlying chronic obstructive pulmonary disease; corrected.
4. Coronary artery disease; stable.
5. Chronic renal insufficiency compounded by secondarily
contrast-induced acute tubular necrosis; resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2169-2-13**] 09:52
T: [**2169-2-13**] 09:55
JOB#: [**Job Number 47275**]
|
[
"518.0",
"584.5",
"518.5",
"458.2",
"428.0",
"276.0",
"442.2",
"496",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"39.52",
"03.90",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8054, 8353
|
8619, 9267
|
8379, 8598
|
1570, 1907
|
2167, 8030
|
159, 187
|
216, 704
|
727, 1543
|
1924, 2148
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,092
| 103,191
|
14636
|
Discharge summary
|
report
|
Admission Date: [**2124-5-9**] Discharge Date: [**2124-5-24**]
Service: VASCULAR
HISTORY OF PRESENT ILLNESS: The patient was an 88-year-old
male with a history of cerebrovascular disease who presented
with signs and symptoms of peptic ulcer disease, but work-up
revealed the fact that the patient had postprandial abdominal
pain and was ultimately evaluated for mesenteric ischemia.
The patient's symptoms included intermittent abdominal pain,
as well as a description of an episode of diffuse abdominal
pain and "feeling lousy" after meals for the past several
months. The patient discouraged the patient from eating and
resulted in an [**7-1**] lb weight loss over the prior four months
before admission. Additionally, the patient noted a drastic
................., as well as an overall abdominal girth.
REVIEW OF SYSTEMS: He denied nausea or vomiting. He denied
diarrhea. No chills. Per the patient, he never had a [**Last Name 16423**]
problem "with his heart." He denied history of myocardial
infarction. No previous echocardiogram data. No prior
catheterization or rhythm disturbances. He did state that he
did have stress test long ago and could not remember exactly
what the nature or results of that were.
After being admitted for the work-up of mesenteric ischemia,
he did receive an arteriogram that showed significant
mesenteric vessel disease requiring likely operative
intervention. Prior to him going to the operating room, he
did get a cardiac consultation. Cardiology had seen the
patient, and given his multiple comorbidities, they
recommended work-up.
PAST MEDICAL HISTORY: Significant for diabetes times 30
years which is "labile." Prior history of stroke and
transient ischemic attacks. History of hypoglycemia from his
diabetes. Coronary artery disease with prior myocardial
infarction. History of hypertension. He denied tobacco. He
used alcohol occasionally.
SOCIAL HISTORY: He lived at home. He worked in a leather
factory. He repaired televisions and radios as his prior
occupations, but was retired on admission.
MEDICATIONS ON ADMISSION: Zestoretic q.d., Plavix 75 mg
q.d., Aspirin 325 mg q.d., Humulin N 15 q.a.m., Ambien 5 mg
q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.0??????, pulse
101, respirations 18, blood pressure 150/80, oxygen
saturation 95% on room air. General: The patient was in no
acute distress. He was a well-developed, well-nourished
white male. HEENT: Pupils equal, round and reactive to
light and accommodation. Extraocular movements intact.
Normocephalic, atraumatic. Conjunctivae normal. Oropharynx
negative. Neck: Supple. Trachea midline. No palpable
lymphadenopathy. Lungs: Clear to auscultation but decreased
throughout. Heart: Regular, rate and rhythm. Normal S1 and
S2. Abdomen: Scaphoid. Minimally distended. Tympanitic.
Nontender. Rectal: Heme negative. Normal tone. No masses.
Musculoskeletal: Grossly intact. Pulse exam was 2+ femoral,
2+ dorsalis pedis, 2+ posterior tibial bilaterally. No
evidence of tissue loss.
HOSPITAL COURSE: The patient was admitted on [**2124-5-9**],
for his mesenteric ischemia work-up. He did receive a
preoperative carotid ultrasound that revealed no significant
hemodynamic lesions, either on the right or left carotid
bifurcation. [**Last Name (un) **] consultation was obtained for blood
sugar management while he was in-house. Ultimately he was
given prehydration Mucomyst for his in-house angiogram which
showed significant three-vessel disease. Additionally his
work-up included not only cardiac work-up but also PFT
evaluation.
On [**2124-5-14**], he was received preoperative work-up, and
his labs were notable for a white count of 10.6, hematocrit
39.1, and a platelet count 243, BUN and creatinine of 31 and
1.6; coags were with a PT and INR of 13.9 and 1.3, with a PTT
of 29.4. He had cardiac clearance. Carotid ultrasound as
previously stated was negative. Chest x-ray showed mild
congestive heart failure. Recheck showed some worsening
failure. Urinalysis was negative. He was placed on
perioperative beta-blocker.
On [**2124-5-15**], the patient went to the Operating Room
where he underwent aorto-SMA bypass with an 8 x 40 mm PTFE
graft under the assistance of Drs. [**Last Name (STitle) 1391**], [**Name5 (PTitle) **], and
Shan. At the time of operation, the findings were a
calcified aorta and occluded left CIA. The patient's blood
loss was 100 cc. He received 2200 cc of Crystalloid. Urine
output was 420 cc for the case. There were no complications.
He went to the PACU with palpable popliteals bilaterally, and
his feet were warm. He received Heparin 500 U/hr, as well as
Neo-Synephrine, and Dobutamine. The patient remained
intubated.
Cardiac consultation was required ..................
postoperative due to the patient's Dobutamine requirement and
low cardiac index. Initial index was 1.1 intraoperative with
a PA pressure of 61/30, and CVP of 14. Dobutamine had been
started intraoperatively empirically for hemodynamic
findings. Electrocardiogram postoperatively was unchanged
with left bundle branch block. Cardiology recommended
following cardiac outputs, as well as PA saturations and
aortic saturations. Echocardiogram was rechecked with a goal
wedge stated to be approximately 18. His enzymes were
ordered to be cycled accordingly.
At the time of postoperative check at 6:30 p.m. on [**2124-5-15**], he was still on Dobutamine drip at 2.5, Heparin drip at
500 U/hr, and epidural for pain. He remained intubated and
sedated. His temperature was 38.1??????C, 80, with frequent APCs,
blood pressure 110/50, CVP 15, PA pressure 52/24, wedge 24.
Fick Cardiac output index numbers were 4.07 and 2.31, with an
SVR of 1179. Non-Fick output index were 3.89 and 2.21. He
was on ................... with an SIMV, pressure support of
60%, 700 x 10, 5 and 5. Arterial blood gases on that were
7.32, 35, 158, 22, and 98%. He had a mixed mean of 70. He
received a total 2700 cc of fluids. Immediately
postoperatively he received 1 U packed red blood cells. His
postoperative hematocrit was 29.2, with a creatinine of 1.8,
and PTT of 85 on Heparin drip as noted. His CK was 90,
troponin less than 0.3.
Postoperative chest x-ray showed mild congestive heart
failure. Swan-Ganz catheter was in good position. There was
no evidence of pneumothorax. Electrocardiogram showed no
acute ischemia. No changes. Echocardiogram postoperatively
demonstrated an ejection fraction of 25%, with decreased
right ventricular motion, which was a new finding. Overall
echocardiogram findings showed global hypokinesis which drove
the service to rule the patient out for myocardial
infarction. Adequate oxygenation had to be ensured.
The plan was to keep the patient intubated over night, rule
him out serially, and support him hemodynamically. The
patient was therefore admitted to the [**Hospital Unit Name 153**] for postoperative
management.
By postoperative day #1, he was doing well hemodynamically,
although he did have a temperature to 101.3??????. He was in
sinus rhythm at 93, with a blood pressure of 111/49. CVP was
9, PA pressure 48/20, output index of 6.1 and 3.49, with an
SVR of 630. He remained vented and supported. He was doing
otherwise satisfactory. He was noted to have a postoperative
creatinine at this time of 2.5 which was markedly elevated.
Again this was thought to be secondary to his recent contrast
load and intraoperative fluid shift and questionable
transient hypotension and low index output.
Over the next several days, the patient was weaned from the
vent on postoperative day #3. He was reintubated for
respiratory distress. He was noted to have a troponin leak
as well. At this time, his hematocrit was 29.9, and his BUN
and creatinine were up to 112 and 4.3, falling into acute
postoperative renal failure. He remained intubated and
sedated. He was noted to have some cool cyanotic toes. He
had a left posterior tibialis present by Doppler. He was
being supported with Dobutamine and being diuresed with
Natrecor for his pulmonary edema which had occurred
postoperatively from fluid shifts. He had a lactate of 1.8
at this time. He was continued on Heparin drip. He was on
broad-spectrum antibiotics of Vancomycin and Flagyl.
Renal was consulted shortly thereafter for his management of
acute renal failure. He continued to have fevers and
ultimately developed thrombocytopenia. A combination of
thrombocytopenia, fevers, respiratory failure, and acute
renal failure, metabolic acidosis was ominous at best. He
ultimately ruled in for myocardial infarction
postoperatively. His .................. was decreased
serially. He was supported. His Dobutamine was switched to
Milrinone and Natrecor, and he was started on Amiodarone for
ventricular ectopy/atrial fibrillation.
By [**2124-5-21**], the patient continued to be managed for his
congestive heart failure. Cardiology at this time had noted
that he was begun on Amiodarone for supraventricular
tachycardia. His blood pressure was 108/57, pulse ranging
90-120 for supraventricular tachycardia. He was continued on
Vancomycin, Levofloxacin, and Flagyl, with Lopressor 2.5
.................., Natrecor, Milrinone drip 0.5, Versed
drip, and Protonix. His hematocrit was 30. His platelet
count was down to 44, and his BUN and creatinine were
119/4.1.
His Natrecor was increased serially to assist with his heart
failure, and he continued to go into renal failure.
Ultimately he developed, on postoperative day #6, some new
wide complex tachycardia with stable blood pressure. He was
continued on Amiodarone drip, and he was changed to Milrinone
earlier. His Natrecor was increased serially. He was noted
to have a cold cyanotic right lower extremity with decreased
pulses. His index at this time remained to be 2.
The patient was being covered by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as Dr.
[**Last Name (STitle) 1391**] was out of time. Overall his cardiac parameters
improved. Although his right leg was worrisome, there was
nothing they could do in light of the situation except for
heparinization. There was nothing that could be done in
terms of revascularization. This was all thought to be due
to his overall hypoperfused state.
Over the ensuing days, the patient's clinical status
deteriorated; renal function was worse. The family at this
time had discussed on [**2124-5-23**], that the patient be made
DNR. He was given a 48-hour trial. The patient clearly had
a poor prognosis. Cardiology at this time recommended
instead of continuing with Milrinone, to try to introduce
Hydralazine for afterload reduction to stop his Natrecor
drip, as it had no affect on his pulmonary edema management.
His antibiotics were continued accordingly. By postoperative
day #9, the patient continued on Vancomycin, Levofloxacin,
and Flagyl. At this time, the day was [**2124-5-24**]. He was
on Lopressor, Protonix, Levaquin, Aspirin, Flagyl, Milrinone,
Amiodarone, and Vancomycin. His weight was up 16 kg, and he
was being supported with total parenteral nutrition. He
remained intubated on full ventilatory support. Overall his
outlook was grim.
A family discussion was held, and the patient was CMO.
Shortly after the removal of support, the patient expired at
approximately 3:30 p.m. on [**2124-5-24**]. The family was
accordingly notified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2124-8-28**] 15:26
T: [**2124-8-28**] 15:56
JOB#: [**Job Number 43132**]
|
[
"263.9",
"518.81",
"276.5",
"276.2",
"557.1",
"410.91",
"427.31",
"428.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.26",
"89.64",
"96.04",
"99.15",
"39.57"
] |
icd9pcs
|
[
[
[]
]
] |
2109, 2243
|
3119, 11746
|
2266, 3101
|
843, 1601
|
122, 823
|
1624, 1921
|
1938, 2082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,377
| 158,232
|
43554
|
Discharge summary
|
report
|
Admission Date: [**2149-8-20**] Discharge Date: [**2149-8-26**]
Date of Birth: [**2078-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Ativan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE, CP
Major Surgical or Invasive Procedure:
[**2149-8-20**] CABG x 5 (LIMA->LAD, SVG->PDA, SVG->LCx, SVG->OM,
SVG->DIAG)
History of Present Illness:
71 yo Male with known CAD s/p prior PCA and recent +ETT referred
for catheterization showing 3VD, referred for surgery.
Past Medical History:
CAD s/p PCI [**2146**]
insomnia
HTN
diverticulosis
asbestos exposure
hyperlipidemia
several MIs, NSTEMI [**3-7**]
hemorrhoids
Social History:
lives with wife
retired contractor
no current tob, [**3-8**] ppd x 50 years
12 beers/week
Family History:
mother and twin with ASD
Physical Exam:
NAD
Skin unremarkable
HEENT unremarkable
Neck supple
Chest lungs CTAB
Heart RRR No M/R/G
Abdomen benign
extrem warm, 2+pedal pulses, 1+ BLE edema
Pertinent Results:
[**2149-8-26**] 06:15AM BLOOD WBC-7.2 RBC-3.64*# Hgb-11.1* Hct-32.1*
MCV-88 MCH-30.6 MCHC-34.6 RDW-17.2* Plt Ct-419#
[**2149-8-26**] 06:15AM BLOOD Plt Ct-419#
[**2149-8-26**] 06:15AM BLOOD Glucose-105 UreaN-17 Creat-0.9 Na-142
K-4.6 Cl-102 HCO3-31 AnGap-14
Brief Hospital Course:
He was taken to the operating room on [**2149-8-20**] where he
underwent a CABG x 5. He was transferred to the SICU in critical
but stable condition on Neosynephrine and Propofol. He was
extubated that same day. His neo was weaned off on post op day
#2 and he was transferred to the floor. He received 2 units
PRBCs for a HCT of 20, and an additional 2 units 2 days later
for an HCT of 23. Post transfusion his HCT was 31. His repeat
HCT one day later was 32. He otherwise did well post
operatively, and He was ready for discharge on POD # 7.
Medications on Admission:
asa, imdur, lisinopril, zetia, toprol, hctz, lipitor,
gembibrozil
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-6**] Inhalation
Q6H:PRN as needed for shortness of breath or wheezing.
Disp:*QS 1 month* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p PCI [**2146**]
HTN
insomnia
hyperlipidemia
diverticulosis
asbestosis exposure
several MIs
excision of colon polyps
right hand tendon repaired
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 3302**] 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1843**], RN Phone:[**Telephone/Fax (1) 28471**] Date/Time:[**2149-11-21**] 12:30
LIPID NUTRITIONIST Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2149-11-21**] 1:00
[**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 5251**] Date/Time:[**2149-11-21**]
12:00
Completed by:[**2149-8-26**]
|
[
"790.01",
"412",
"413.9",
"501",
"278.00",
"414.01",
"401.9",
"458.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"88.72",
"36.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3393, 3451
|
1282, 1826
|
292, 371
|
3645, 3653
|
1001, 1259
|
3952, 4508
|
793, 819
|
1942, 3370
|
3472, 3624
|
1852, 1919
|
3677, 3929
|
834, 982
|
245, 254
|
399, 520
|
542, 670
|
686, 777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,876
| 128,912
|
42975
|
Discharge summary
|
report
|
Admission Date: [**2153-11-21**] Discharge Date: [**2153-11-28**]
Date of Birth: [**2070-7-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides) / Aspirin
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
black, watery stools
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 67434**] is an 83 yo woman with HTN and recent diagnosis
of metastatic colon cancer, s/p C1D1 FOLFOX [**11-12**] who was
referred to the ED today because of loose black stools. Since
starting chemotherapy, she reports having diarrhea approx 4-5x
daily, +nausea and anorexia, with poor po intake. Denies
diarrhea prior to starting chemotherapy. She reports LUQ
abdominal pain that radiates to the right, though points to L
ribcage area, which she has had for > 1 month. Denies vomiting.
She denies any acute onset of respiratory sx but states that she
notices some SOB when getting off the toilet, but otherwise
denies dyspnea on exertion, cough, or pleuritic chest pain. Of
note, she has continued her bowel regimen and iron supplements.
.
In the ED, her vital signs were T: 97.2, HR 137, BP 1148/73, RR
16, O2 98% on RA. She was found to have greenish stool that was
guiac negative in the ED. Also had 3 stool cards recently done
at her PCP's office that were guiac negative. HCT was 36 (above
baseline). Given the complaint of pleuritic chest pain and SOB,
CXR was done and unremarkable, and subsequent CTA showed a R
superior subsegmental PE. She was felt to be dehydrated with
initial HR sinus rhythm in the 140s, and received IVFs,
potassium repletion with improvement in rate to low 100s. She
received levo/flagyl for diarrhea. CT Head was performed prior
to starting a heparin drip and showed no obvious brain mets.
.
ROS: The patient denies any fevers, chills, + 20 lb weight loss,
+ nausea, - vomiting, + abdominal pain, + diarrhea, -
constipation, - hematochezia, - chest pain, + shortness of
breath, - orthopnea, - PND, - lower extremity oedema, - cough, -
urinary frequency, -lightheadedness, - focal weakness, - rash or
skin changes.
.
Past Medical History:
ONC history:
- Colon cancer: diagnosed with metastatic colon cancer [**10-1**]
during work-up for chronic left-sided abdominal pain and weight
loss of 10lbs /3 months. CT showed numerous hypo-enhancing
hepatic masses and a right adrenal mass as well as a cecal soft
tissue mass. Liver biopsy on [**2153-10-22**] was consistent
with colon cancer and CEA = 8331. Unable to complete colonoscopy
[**10-31**] b/c of fixed sigmoid
loops of bowel. CT colonoscopy showed known ileocecal valve
mass.
- Received one dose of chemotherapy [**2153-11-12**]:
Oxaliplatin 85 mg/m2 D1,D15
Leucovorin Calcium 400 mg/m2 IV D1,D15
Fluorouracil 400 mg/m2 IV D1,D15
Fluorouracil 2400 mg/m2 IV D1,D15.
.
Past Medical History:
1. Hypercholesterolemia.
2. Hypertension.
3. History of hysterectomy.
4. History of cholecystectomy.
5. Arthritis.
6. Basal cell cancer, removed.
7. GERD.
Social History:
She lives with her husband. In addition, she has two sons and a
daughter who all live in the area. She was a housewife in the
past. She has six grandchildren. She smoked three packs per
day for the age of 21 to age of 48. She does not drink alcohol.
Family History:
Her mother died of diabetes. Her father died at 74 of old age.
She had a brother who died at 42 of heart disease and a sister
died of diabetes.
Physical Exam:
Vitals: T: 97.6 BP: 146/54 HR: 115 RR: 19 O2Sat: 100% on 2L
GEN: Pt appears mildly uncomfortable, anxious
HEENT: Small surgical pupils, EOMI, sclera anicteric, no
epistaxis or rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, normal S1 S2, 2/6 SEM > LUSB, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, 2+ dp pulse b/l
NEURO: Alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission labs:
[**2153-11-21**] 10:30AM BLOOD WBC-5.8# RBC-5.13 Hgb-11.6* Hct-36.4
MCV-71* MCH-22.5* MCHC-31.8 RDW-15.8* Plt Ct-435
[**2153-11-21**] 10:30AM BLOOD PT-13.8* INR(PT)-1.2*
[**2153-11-21**] 10:30AM BLOOD Glucose-203* UreaN-17 Creat-0.7 Na-133
K-2.9* Cl-93* HCO3-22 AnGap-21*
[**2153-11-21**] 10:30AM BLOOD ALT-29 AST-44* CK(CPK)-52 AlkPhos-185*
TotBili-0.5
[**2153-11-21**] 10:30AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.5*
.
[**2153-11-21**] CT head w/o contrast: Generalized atrophy with no
evidence of mass effect or midline shift. Please note MRI is
more sensitive for assessment of subtle early metastases.
.
[**2153-11-21**] CT chest, abd, pelvis w/o contrast: 1. Thrombus in the
right subsegmental branch of the superior branch of the right
pulmonary artery. No other areas of pulmonary emboli noted.
2. Multiple hepatic metastases, unchanged from prior
examination.
3. Bilateral renal cystic structures are unchanged.
4. Metastatic collision tumor adjacent to the right adrenal
gland, unchanged.
5. Sigmoid diverticulosis without diverticulitis. Mucosal
thickening in the cecum adjacent to the ileocecal valve
consistent with patient's known
diagnosis of colonic mass.
.
[**2153-11-28**] 12:00AM BLOOD WBC-6.6 RBC-3.35* Hgb-8.0* Hct-23.9*
MCV-71* MCH-23.7* MCHC-33.4 RDW-19.9* Plt Ct-261
[**2153-11-28**] 12:00AM BLOOD Plt Ct-261
[**2153-11-28**] 12:00AM BLOOD PT-13.4 PTT-30.1 INR(PT)-1.1
[**2153-11-28**] 12:00AM BLOOD Glucose-117* UreaN-9 Creat-0.3* Na-137
K-3.8 Cl-99 HCO3-28 AnGap-14
[**2153-11-21**] 10:30AM BLOOD ALT-29 AST-44* CK(CPK)-52 AlkPhos-185*
TotBili-0.5
[**2153-11-28**] 12:00AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9
Brief Hospital Course:
83 yo F with recent dx of metastatic colon cancer s/p C1D1
FOLFOX chemotherapy [**11-12**] who presents with diarrhea, SOB, sinus
tachycardia and found to have R superior segmental PE.
.
# Pulmonary embolism: Subsegmental on CTA. Pt denies h/o DVT or
clotting hx, likely hypercoag. state secondary to malignancy. No
evidence of R heart strain on EKG. Sinus tach may be related to
PE or dehydration. Unclear from hx if this was an acute event or
incidental finding on presentation. No O2 requirement while in
ICU. Started heparin gtt, was transitioned to lovenox after
transfer out of the ICU. She was started on coumadin 2mg daily.
On discharge the INR was 1.1 and she was given a Rx for coumadin
2mg daily and lovenox for 5 days. She is to have your blood
drawn at home on [**11-30**] for an INR check to be faxed to her PCP
and Dr [**Last Name (STitle) **]. Further adjustments to the coumadin may be
necessary at that time.
.
# Dehydration: Pt with diarrhea and poor po intake for several
days. Sinus tachycardia and borderline low uop. Patient was
given IVF and lytes were replete. She became euvolemic with
hydration and resolution of the diarrhea.
.
# Diarrhea: Nonbloody, guiac positive after several hours of
diarrhea (likely due to irritation). HCT stable. Most likely
trigger is chemotherapy with FOLFOX. No fevers. C diff negative
x 3. Stool culture negative. Patient given loperamide and
lomotil, required rectal tube. Diarrhea gradually stopped and
her electrolytes stabilized. Further chemotherapy should be
carefully chosen in the setting of severe diarrhea caused by
FOLFOX. Patient should continue a lactose free diet. She should
also continue to avoid fresh fruits. Discharged on loperamide
prn.
.
# Colon cancer: Metastatic to liver, adrenal. Defer treatment to
primary oncology team. No chemotherapy while in the hospital
given her acute illness.
.
# Hypertension: SBP 140s-160s, stabilized on metoprolol and
nifedipine. Transtitioned back to atenolol and nifedipine on
discharge
.
# GERD: continued home PPI, increased dose to [**Hospital1 **] for worsening
symptoms.
.
#Hypercholesterolemia: Stain held as liver enzymes (AST, alk
phos) showed a slight increase during the ICU stay. The statin
was restarted upon discharge.
.
# Code: DNR/DNI - confirmed with pt.
.
# Comm: husband - [**Telephone/Fax (1) 92767**]
Medications on Admission:
ATENOLOL 25mg po daily
NIFEDIPINE SR 30mg po daily
OMEPRAZOLE 20mg po daily
OXYCODONE - 5 mg Tablet 1-2 tabs q4hr prn
PROCHLORPERAZINE 10 mg Tablet q6hr prn
SIMVASTATIN 40mg po qhs
ACETAMINOPHEN 1gm q6hr prn
DOCUSATE SODIUM 100mg po bid
FERROUS SULFATE - 325 mg po daily
MULTIVITAMIN daily
PYRIDOXINE 100 mg po daily
SENNA 8.6 mg po daily
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe (80mg)
Subcutaneous once a day for 5 days.
Disp:*5 syringes* Refills:*0*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Outpatient [**Name (NI) **] Work
PT, PTT, INR to be drawn [**2153-11-30**]
dx: pulmonary embolism on coumadin
Please fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD (Fax)([**Telephone/Fax (1) 10598**] [**Location (un) **],
[**Doctor First Name **] Z. MD, PHD (fax)[**Telephone/Fax (1) 12540**].
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO every
six (6) hours as needed for pain.
13. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for diarrhea for 7 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 100**] Rehab Home Care
Discharge Diagnosis:
Pulmonary embolism
chemotherapy induced gastroenteritis
Secondary dx:
Hypercholesterolemia.
Hypertension
GERD
Discharge Condition:
good, diarrhea subsided, ambulating with assistance.
Discharge Instructions:
You were admitted to the hospital for diarrhea. Upon admission
you had some chest pain and were found to have a blood clot in
your lung. You were in the ICU where you were started on blood
thinners and had aggressive repletion of your electrolytes. With
anti-diarrhea medicines your diarrhea eventually stopped. Tests
of your stool for infection were all negative. Your severe
diarrhea was most likely from your chemotherapy. You are being
discharged on coumadin as well as a short course of lovenox, a
blood thinner to control the blood clot in your lung.
.
The following changes were made to your medication regimen:
You were started on coumadin to thin your blood. You should take
2, 1mg pills a day. Your coumadin level in your blood will be
checked on Friday. Your doctors [**Name5 (PTitle) **] advice [**Name5 (PTitle) **] on further
medication changes at that time.
In addition you have started lovenox injections once daily for 5
day to help thin your blood.
Your omeprazole was increased from 1 pill daily to 1 pill twice
a day.
Your Colace and Senna are being held because of you diarrhea
Your were started on Loperamide as needed for diarrhea
Please continue to avoid lactose and fresh fruit in your diet.
Please follow up with your doctors as detailed below.
If you have shortness of breath, fever, severe diarrhea, chest
pain, palpatations, abdominal pain, or any other symptom
worrisome to you please call your doctor or go to the nearest
emergency room.
Followup Instructions:
Your PT,PTT,INR will be drawn at home on Friday and the results
sent to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD (Fax)([**Telephone/Fax (1) 10598**] [**Last Name (LF) **], [**First Name3 (LF) **] Z. MD,
PHD (fax)[**Telephone/Fax (1) 12540**]. Based on these results your coumadin
level will be adjusted
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2153-12-3**] 9:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2153-12-3**]
9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2153-12-10**] 9:00
Please call your primary doctor, [**Location (un) **],[**Doctor First Name **] Z. [**Telephone/Fax (1) 9347**] to
schedule a follow up appointment in [**1-24**] weeks.
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
Completed by:[**2153-11-29**]
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
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[
[]
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10189, 10254
|
5862, 8200
|
323, 329
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,194
| 131,145
|
49750
|
Discharge summary
|
report
|
Admission Date: [**2130-6-17**] Discharge Date: [**2130-7-2**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Codeine / Motrin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Hip and back pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2130-6-20**]
Aortic Valve Replacement (19mm CE Magna Pericardial Tissue
Valve) on [**2130-6-27**]
History of Present Illness:
83yo F with a hx of AS (valve area of 0.8 cm2) and hx of
hypoglycemia presented to emergency department with syncope x 2
and falls, initially c/o hip and back pain.
Past Medical History:
Aortic Stenosis, Hypertension, Breast Cancer s/p lumpectomy and
XRT, Gastroesophageal Reflux Disease, Hiatal Hernia,
Diverticulosis, Sciatica, Osteoarthritis, Carpal Tunnel
Syndrome, Rotator Cuff tendonitis, Hypoglycemia, s/p B knee
arthroscopy, s/p R TKR, s/p Cholecystectomy, s/p Rotator [**Last Name (un) **]
repair, s/p B Cataract surgery, s/p Tonsillectomy
Social History:
Lives alone. Is a retired psychologist. No kids, but many family
and friends in the area. No tob, occ EtOH.
Family History:
1. Father: Dementia, [**Last Name (un) 499**] CA
2. Mother: DM
3. Sister: Breast CA
4. Sister: [**Name (NI) **] CA with liver mets.
Physical Exam:
VS: T: 96.8, HR: 57, BP: 130/90, RR: 20, SaO2: 99% RA, 5'1",
64.4kg
GEN: Very pleasant elderly female in NAD
Skin: R Shoulder scar, RUQ abd scar, R knee scar (all well
healed)
HEENT: NC/AT, EOMI, anicteric, mmm
NECK: Supple, full ROM, -JVD
CV: RRR, S1, S2, +3/6 systolic crescendo/decrescendo murmur
appreciated most loudly in RUSB with ?radiation to carotids.
LUNGS: CTA bilaterally, tenderness to palpation over left flank
but no obvious bruising.
ABD: Soft, NT, ND, +BS, obese
EXT: BLE, mult. varicosities and spider veins
NEURO: A+Ox3, CN II-XII grossly intact, gait grossly normal
Pertinent Results:
[**6-19**] Carotid U/S: Mild plaque in the left internal carotid
artery, with an estimated percentage of stenosis less than 40%.
No evidence of stenosis in the extra-cranial right internal
carotid artery.
[**6-19**] Echo: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-30**]+)
mitral regurgitation is seen. Compared with the prior study
(images reviewed) of [**2128-10-12**], the severity of aortic stenosis
and mitral regurgitation have progressed.
[**6-20**] CARDIAC CATH: Selective coronary angiography showed a right
dominant system with no flow limiting stenoses. Limited
hemodynamics showed a normal pulmonary pressure (PA mean
18mmHg). The right and left sided filling pressures were normal
(RVEDP 9mmHg, LVEDP 13 mmHg). The cardiac output was preserved
(CO 4.1 l/min, CI 2.5 l/min/m2). The peak-to-peak gradient
across the aortic valve was 65 mmHg. The mean gradient was 49
mmHg. The calculated aortic valve area was 0.5 cm2 (assumed O2
consumption).
[**6-27**] Echo: There is mild symmetric left ventricular hypertrophy
with normal cavity size. Global mild to moderate LV systolic
dysfunction. 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
by continuity is 0.5, with a peak gradient of 45 mmHg. Ascending
aorta is not dilated. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Moderate to
severe (3+)mitral regurgitation is seen. Post-CPB: Well-seated
and functioning aortic valve prosthesis. No leak, no AI.
[**2130-6-17**] 12:00PM BLOOD WBC-8.2 RBC-3.98* Hgb-13.2 Hct-37.8
MCV-95 MCH-33.1* MCHC-34.9 RDW-13.0 Plt Ct-169
[**2130-6-25**] 06:40AM BLOOD WBC-4.7 RBC-3.77* Hgb-12.0 Hct-35.8*
MCV-95 MCH-32.0 MCHC-33.7 RDW-12.8 Plt Ct-186
[**2130-6-17**] 12:00PM BLOOD PT-12.7 PTT-22.1 INR(PT)-1.1
[**2130-6-27**] 06:20AM BLOOD PT-13.2* PTT-24.7 INR(PT)-1.2*
[**2130-6-17**] 12:00PM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-139
K-5.4* Cl-100 HCO3-28 AnGap-16
[**2130-6-25**] 06:40AM BLOOD Glucose-86 UreaN-18 Creat-0.6 Na-138
K-4.1 Cl-105 HCO3-23 AnGap-14
[**2130-6-20**] 02:30PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
[**2130-6-17**] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2130-6-17**] 12:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2130-6-17**] 12:00PM URINE RBC-0 WBC-[**4-2**] Bacteri-MANY Yeast-NONE
Epi-0-2
[**2130-6-17**]: Urine culture + for E. Coli
Brief Hospital Course:
Ms. [**Known lastname 104009**] was admitted for syncope most likely secondary to
her worsening aortic stenosis. Underwent x-rays to r/o any
fractures. She had an ECHO on [**6-19**] that proved that her AS was
worsening. CT surgery was consulted for evaluation of the
patient's candidacy for AVR. She underwent several studies prior
to sugery. Carotid duplex was negative for any evidence of
carotid stenosis. Cardiac catheterization revealed no CAD.
During her admission labwork, she was found to have a UTI.
Initially started on Ciprofloxacin and cultures came back
postive for E. Coli. She was switched to Nitrofurantoin. The
patient was scheduled for AVR after having completed 7 days of
antibiotics for a UTI. Urinalysis from [**6-20**] and [**6-22**] were both
negative and cultures each grew <10,000 organisms. Dental
clearance provided from her home dentist. She was finally
brought to the operating room on [**2130-6-27**] where she underwent a
aortic valve replacement. Please see operative report for
surgical details. She tolerated the procedure well and was
transferred to the CSRU for invasive monitoring in stable
condition. Later on op day she was weaned from sedation, awoke
neurologically intact and extubated. On post-operative day one
her chest tubes were removed and she was started on beta
blockers and diuretics. Throughout the rest of her post-op
course she was gently diuresed towards her pre-op weight. Later
on this day she was tranferred to the cardiac surgery step down
floor. She continued to do well, tolerate diet, pain controlled
on oral medications, and participated with physical therapy
until ready for discharge.
Medications on Admission:
At home: Diovan/HCTZ 25mg qd, Lipitor 10mg qd
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
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 BID (2
times a day).
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.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**1-30**]
Tablets PO Q4-6H (every 4 to 6 hours) as needed.
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hypertension, Breast Cancer s/p lumpectomy and XRT,
Gastroesophageal Reflux Disease, Hiatal Hernia, Diverticulosis,
Sciatica, Osteoarthritis, Carpal Tunnel Syndrome, Rotator Cuff
tendonitis, Hypoglycemia, s/p B knee arthroscopy, s/p R TKR, s/p
Cholecystectomy, s/p Rotator [**Last Name (un) **] repair, s/p B Cataract
surgery, s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incision and gently pat dry. Do not take
bath.
Do not apply lotions, creams, ointments or powders to incision.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
If you develop a fever, notice sternal drainage or redness
around incision, please contact office immediately.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 141**] in 2 weeks
|
[
"041.4",
"424.1",
"599.0",
"780.2",
"272.0",
"E888.9",
"553.3",
"251.2",
"715.90",
"401.9",
"530.81",
"562.10",
"V43.65",
"V10.3",
"922.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"35.21",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7653, 7738
|
4678, 6329
|
284, 410
|
8176, 8182
|
1884, 4655
|
1130, 1263
|
6425, 7630
|
7759, 8155
|
6355, 6402
|
8206, 8542
|
8593, 8682
|
1278, 1865
|
227, 246
|
438, 604
|
626, 989
|
1005, 1114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,596
| 189,041
|
28125
|
Discharge summary
|
report
|
Admission Date: [**2165-4-27**] Discharge Date: [**2165-5-12**]
Date of Birth: [**2138-11-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
2 days epigastric pain with nausea and comiting.
Major Surgical or Invasive Procedure:
[**5-9**] - Laparoscopic converted to open cholecystectomy
[**4-28**] - ERCP
History of Present Illness:
Ms. [**Known lastname 68378**] is a 26 year ofl female with 2 days of epigastric
pain ([**10-11**] in severity) with nausea and comiting. The [**Last Name (un) 2187**]
began the Friday prior to admission in the morning and awoke the
patient from sleep. It has been persistent in nature, and the
patient denies any similar symptoms previously
Past Medical History:
none
Social History:
Denies etoh or smoking. Has two small children at home.
Family History:
noncontributory
Physical Exam:
98.4 80 141/92 19 99%RA
gen: AAOx3, obese
CTA b/l
RRR
Obses abdomen, with tenderness to palpation in epigastrium.
No c/c/e
Pertinent Results:
[**4-27**] Abd US: Contracted gallbladder containing a large 2 cm
stone with associated gallbladder wall thickening, which may be
seen with chronic cholecystitis. No definited evidence of acute
cholecystitis.
[**4-28**] ERCP: FINDINGS: Fourteen spot fluoroscopic images were
obtained without a radiologist present. Images demonstrate
cannulization of the CBD, with injection of contrast. Multiple
filling defects are seen within the CBD. Per ERCP report, there
was successful extraction of two small stones. Contrast is seen
to opacify the cystic duct and a portion of the gallbladder,
without evidence of any filling defects.
IMPRESSION: Choledocholithiasis, with extraction of two small
stones
[**4-30**] CT: 1) No pulmonary embolism is detected. The evaluation
for segmental arteries was limited due to moderate atelectasis
at both lung bases and moderate bilateral pleural effusion.
2) Acute pancreatitis with no pancreatic necrosis. Free fluid is
noted in the retroperitoneal spaces and the pelvis.
3) Diffuse gallbladder wall thickening with no evidence of
cholecystitis.
4) IUD device is in place.
[**4-30**] CXR: FINDINGS: In comparison with study of [**4-29**], there are
substantially lower lung volumes. Little change in the
appearance of the left and possibly right pleural effusions.
Poor visualization of the heart border and medial aspect of the
hemidiaphragm could reflect a developing pneumonia, though this
could merely represent crowding of normal vessels.
[**5-7**] CT: 1. The pancreas remains enlarged consistent with
pancreatitis without evidence of necrosis. Marked improvement in
the free fluid in the abdomen. There is an area of phlegmon in
the right flank without focal abscess or pseudocyst.
2. Marked improvement in the bilateral effusions and bibasilar
atelectasis with some residual effusion on the left and
atelectasis on the right.
[**2165-4-27**] 02:05PM BLOOD WBC-8.6 RBC-4.38 Hgb-13.4 Hct-38.2 MCV-87
MCH-30.6 MCHC-35.0 RDW-14.5 Plt Ct-368
[**2165-4-28**] 05:10AM BLOOD WBC-18.0*# RBC-4.60 Hgb-14.3 Hct-40.1
MCV-87 MCH-31.2 MCHC-35.8* RDW-14.5 Plt Ct-355
[**2165-4-29**] 01:05PM BLOOD WBC-19.7* RBC-3.91* Hgb-11.8* Hct-35.1*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.8 Plt Ct-292
[**2165-5-1**] 03:29AM BLOOD WBC-21.9* RBC-3.57* Hgb-10.8* Hct-32.0*
MCV-90 MCH-30.3 MCHC-33.8 RDW-14.6 Plt Ct-316
[**2165-5-2**] 08:30AM BLOOD WBC-23.5* RBC-3.45* Hgb-10.4* Hct-31.4*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.3 Plt Ct-357
[**2165-5-3**] 08:38AM BLOOD WBC-25.4* RBC-3.56* Hgb-10.7* Hct-32.3*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.3 Plt Ct-418
[**2165-5-4**] 02:01AM BLOOD WBC-26.3* RBC-3.42* Hgb-10.2* Hct-30.7*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.1 Plt Ct-406
[**2165-5-6**] 03:16AM BLOOD WBC-24.6* RBC-3.06* Hgb-9.1* Hct-27.7*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.1 Plt Ct-465*
[**2165-5-8**] 06:37AM BLOOD WBC-17.8* RBC-3.19* Hgb-9.7* Hct-28.9*
MCV-91 MCH-30.3 MCHC-33.5 RDW-14.5 Plt Ct-606*
[**2165-5-11**] 04:20AM BLOOD WBC-10.6 RBC-2.43* Hgb-7.5* Hct-23.6*
MCV-97 MCH-30.7 MCHC-31.7 RDW-14.5 Plt Ct-503*
[**2165-4-27**] 02:05PM BLOOD ALT-778* AST-616* AlkPhos-124*
TotBili-3.5* DirBili-2.5* IndBili-1.0
[**2165-4-28**] 05:10AM BLOOD ALT-664* AST-397* AlkPhos-116
Amylase-1884* TotBili-3.5*
[**2165-5-6**] 03:16AM BLOOD ALT-39 AST-27 LD(LDH)-353* AlkPhos-80
Amylase-84 TotBili-0.4
[**2165-5-10**] 05:00AM BLOOD ALT-74* AST-89* AlkPhos-63 Amylase-63
TotBili-0.4
[**2165-5-11**] 04:20AM BLOOD ALT-96* AST-98* AlkPhos-58 Amylase-53
TotBili-0.3
[**2165-4-27**] 02:05PM BLOOD Lipase-6807*
[**2165-4-28**] 05:10AM BLOOD Lipase-3188*
[**2165-5-3**] 08:38AM BLOOD Lipase-81*
[**2165-5-4**] 02:01AM BLOOD Lipase-90*
[**2165-5-7**] 02:10AM BLOOD Lipase-101*
[**2165-5-11**] 04:20AM BLOOD Lipase-73*
[**2165-5-5**] 02:11AM BLOOD TSH-1.3
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment. On admission, she was started on IVF, made NPO,
and received Unasyn. The ERCP fellow was consulted for further
care.
Neuro: The patient received IV morphine with good effect and
adequate pain control initially. When tolerating oral intake,
the patient was transitioned to oral pain medications. She also
received Ativan for anxiety as needed. Post operatively, she
received a dilaudid PCA with good result. A psychiatry consult
was also obtained for her persistent anxiety, who recommended
Seroquel, with which she was discharged home.
CV: The patient was initially stable from a cardiovascular
standpoint; vital signs were routinely monitored. Following
her ERCP, however, the patient was persistently tachycardic to
the 120s and 130s; she was asymptomatic with occasional anxiety
throughout. In addition to the pleural effusions, the patient's
tachypnea and tachycardia were thought to be dur to a SIRS
response; the patient continued to spike temperatures following
the thoracentesis. The patient's tachycardia continued without
remission; on [**5-3**], the patient was started [**Female First Name (un) **] low dose of
lopressor, which was titrated appropriately throughout her stay.
She was discharged home on metoprolol as well.
Pulmonary: The patient was stable from a pulmonary standpoint
initially; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization.
Following her ERCP, however, the patient was anxious and
persistently tachypneic despite nebulized treatments; she was
also tachycardic. An ABG was obtained, revealing hypoxia with
an oxygen level of 63. A chest x-ray was obtained, revealing
"There are very low lung volumes with bibasilar atelectasis,
worse on the right side. There are small bilateral pleural
effusions." A trial of Lasix (20 mg IV x 1) was attempted as
she had been receiving large volumes of fluid, and it was
thought she was fluid overloaded given the pleural effusions and
worsening pulmonary status. Her symptoms did not improve,
however, though her urine output remained excellent. The
patient was transferred to the ICU on [**4-30**] for further
evaluation and treatment, and a CTA was performed to rule out a
pulmonary embolus. Thoracic surgery was consulted for
evaluation of her pleural effusions; she underwent a
thoracentesis (which was acellular on cultures) on [**5-1**].
Zopinex was also started with some relief of her symptoms in
addition. In addition to the pleural effusions, the patient's
tachypnea and tachycardia were thought to be dur to a SIRS
response; the patient continued to spike temperatures following
the thoracentesis. The patient gradually improved; i.e., her
tachycardia, tachypnea and temperature spikes gradually
resolved. On [**5-7**], a CT was performed--for details, please see
reports section.
GI/GU/FEN:
On admission, the patient was made NPO with IVF. She received
ZOfran and other antiemetics as needed. Her laboratory studies
were routinely evaluated for progression of her pancreatitis.
On [**4-28**], the patient underwent an ERCP with sphincterotomy; for
details, please see procedure note. The patient received sips
for comfort subsequently. As her pain, fevers, and
transaminitis did not immediately resolve, the Gold surgery team
was consulted for any additional treatments; they recommended
continuing conservative therapy. On [**5-3**], a post-pyloric feeding
tube was to be attempted, however the patient was refusing the
procedure.
The patient's diet was advanced when appropriate, which was
tolerated well. She received clears on [**5-5**]. Throughout her
admission, her LFTs were trended. On [**5-9**], the patient was taken
to the operating room for a cholecystectomy for gallstone
pancreatitis; for details, please see operative note. At the
time, the patient had been afebrile for >24 hours. She was made
NPO following the procedure, and on [**5-10**], she was advanced to
clears, and the DAT.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She was immediately
started on Unasyn, but spiked temperatures throughout her
hospitalization. In addition to the pleural effusions, the
patient's tachypnea and tachycardia were thought to be dur to a
SIRS response; the patient continued to spike temperatures
following the thoracentesis.
Cultures (blood and pleural fluid) were routinely monitored,
however they did not grow out any bacteria.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
Other: Social work was consulted during her stay for additional
support. Physical therapy and nutrition were also consulted.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
none
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day: Hold if dizzy or light-headed.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Followup Instructions:
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to arrange a follow
up appointment in [**1-2**] weeks at [**Telephone/Fax (1) 2723**].
|
[
"293.0",
"574.71",
"511.9",
"427.89",
"518.0",
"568.0",
"995.93",
"577.0",
"278.01",
"V64.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"51.85",
"51.22",
"38.93",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
11061, 11067
|
4881, 10394
|
362, 440
|
11133, 11139
|
1116, 4858
|
11646, 11831
|
930, 947
|
10449, 11038
|
11088, 11112
|
10420, 10426
|
11187, 11623
|
962, 1097
|
274, 324
|
468, 813
|
835, 841
|
857, 914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,755
| 174,926
|
954
|
Discharge summary
|
report
|
Admission Date: [**2123-1-27**] Discharge Date: [**2123-1-29**]
Date of Birth: [**2047-4-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 6348**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 75 year old right handed woman with a
history of atrial fibrillation on Coumadin, hypertension, and
Grave's Disease who presented with headache, vomiting, and
confusion, and was transferred from an OSH with left
temporoparietal IPH with midline shift and left uncal
herniation.
The history is obtained from the patient's husband and daughter.
The patient was in her usual state of health until 8:00-8:30 pm
on the evening prior to admission when she complained of a
headache and wanted to lay down. At approximately 10:00 pm she
called out her husband's name, and said help me. She walked from
the bedroom to the bathroom and vomited. Her husband found her
sitting on the edge of the tub confused, saying "give me a few
minutes". She had difficulty sitting upright and was leaning to
the left per her husband. She was more sleepy than usual. After
10 minutes, her husband called 911. [**Name2 (NI) **] husband denied any head
trauma. Per EMS notes, exam showed pupils pinpoint, EKG showed
sinus bradycardia at 50 bpm.
She initially presented to [**Hospital3 417**] Hospital, where SBP
174/79. Labs showed WBC 12.5, plt 185, INR 2.2, glucose 213, Cr
0.9. Head CT at the OSH showed 6.5 x 3.3 cm acute
intraparenchymal hematoma in the left temporoparietal lobe with
surrounding edema and 1.4 cm midline shift to the right, left
uncal herniation with impending transtentorial herniation. She
was given 2 U FFP and intubated. It is difficult to determine
what other medications she received, but they may include
Decadron 10 mg, Fosphenytoin 1 gm, Labetalol, Succs, Fentanyl,
and Valium. She was transferred to [**Hospital1 18**] for further care.
At the [**Hospital1 18**] ED, INR was 2.0 on admission. Here she was given
Vitamin K 10 mg IV, Profilnine, and Nicardipine gtt.
Past Medical History:
[**Doctor Last Name 933**] Disease
- status post radioactive iodine ablation
Atrial Fibrillation - not on coumadin, occured in setting of
hyperthyroid, resolved since treatment
Hypertension
Glaucoma
Social History:
Patient lives in [**Location 701**], MA with her husband, one daughter
who is ped radiologist at [**Name (NI) 1926**].
Tobacco: None
ETOH: [**12-25**] mixed drinks daily, last drink yesterday
Illicits: None
.
Family History:
Father - MI age 50, died 90s
Mother - Died 92 natural cuases
8 siblings
Physical Exam:
PHYSICAL EXAM:
VS: temp 97.7, bp 155/97, HR 76, RR 18, SaO2 100% (intubated)
Genl: Intubated, eyes open
HEENT: Sclerae anicteric, bilateral conjunctival injection
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Intubated, eyes open. Does not follow commands to
squeeze hands bilaterally. Does not arouse to name being called
or sternal rub.
Cranial Nerves: Pinpoint pupils nonreactive to light, 1.5 mm on
the left and 1 mm on the right. Minimal corneal reflex
bilaterally, slightly more brisk on the left. No gag reflex. No
obvious facial asymmetry. Eyes turn in the same direction as the
head with Doll's eye maneuver.
Motor/Sensation: No observed myoclonus, asterixis, or tremor.
The
patient withdraws her right>left upper extremity to noxious
stimulus. She occasionally spontaneously moves her right upper
extremiy. There is a flicker of contraction of her bilateral
lower extremities to noxious, but she does not withdraw them.
She
occasionally spontaneously rotates her left lower extremity.
Reflexes: 2+ and symmetric in biceps, brachioradialis, and
knees.
No ankle clonus. Toes equivocal bilaterally.
Pertinent Results:
IMAGING:
CT Head (prelim): large left temporal lobe intraparenchymal
hemorrhage with extensive surrounding edema resulting in 13mm
rightward shift of normally midline structures and entrapment of
the right lateral ventricle. There is associated mild left uncal
herniation
[**2123-1-27**] 01:15AM WBC-13.1*# RBC-4.07* HGB-12.0 HCT-34.1*
MCV-84 MCH-29.4 MCHC-35.1* RDW-13.1
[**2123-1-27**] 01:15AM NEUTS-87.9* LYMPHS-9.6* MONOS-2.1 EOS-0.3
BASOS-0.1
[**2123-1-27**] 01:15AM PLT COUNT-164
[**2123-1-27**] 01:15AM PT-21.2* PTT-27.0 INR(PT)-2.0*
Brief Hospital Course:
The patient is a 75 year old right handed woman with a history
of atrial fibrillation on Coumadin (INR 2.2),hypertension, and
Grave's Disease who presented with a left temporoparietal IPH
with midline shift and left uncal herniation.
Her exam evidences the absence of some brain stem reflexes (gag,
dolls eyes, corneal reflexes) though her exam was not completely
consistent with brain death. Given her poor exam and extensive
size of her hemorrhage she was not a surgical candidate. She was
admitted to the ICU her INR was reversed her SBP was kept less
than 140 and she was started on Dilantin and Mannitol. An MRI
showed Several areas of restricted diffusion within the left
occipital lobe, left thalamus, mid brain, and corpus callosum
most consistent with acute infarction. A few foci of increased
susceptibility within the left thalamus and to a lesser extent
midbrain suggestive of Duret hemorrhage.
On the first morning of her hospital day she had no eye opening
no blink to threat she made a weak attempt to localize on the
right and withdrew her lower extremeties and left arm. Stroke
neurology was consulted and felt that she should not have
surgery due to size of bleed and dominent hemisphere and
recommended medical management.
Extensive discussion were held with the family from
neurosurgery, neurology and critcal care team to discuss the
gravity of the situation.
On her second hospital day the patients exam did not not improve
the family had a meeting with pallative care they planned an
extubation with Morphine and Ativan for comfort. The patient
passed away on [**2123-1-29**].
Medications on Admission:
Medications prior to admission:
Coumadin 5 mg daily
HCTZ 12.5 mg daily
Lisinopril 10 mg qhs
Verapamil 120 mg Sust Release daily
Levothyroxine 88 mcg daily
Lumigan 0.03% drops OU daily
Pilocarpine 2% OU qid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cerebral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2123-4-7**]
|
[
"432.9",
"365.9",
"401.9",
"348.5",
"348.4",
"V58.61",
"242.00",
"427.31",
"780.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
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6468, 6477
|
4579, 6182
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346, 352
|
6540, 6549
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4005, 4556
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|
3085, 3216
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|
2200, 2401
|
2417, 2628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,087
| 129,686
|
53278
|
Discharge summary
|
report
|
Admission Date: [**2154-12-11**] Discharge Date: [**2154-12-18**]
Date of Birth: [**2078-4-5**] Sex: M
Service: SURGERY
Allergies:
diltiazem
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Lower gastrointestinal bleed
Major Surgical or Invasive Procedure:
[**2154-12-12**]: ex-lap and sigmoid colectomy
History of Present Illness:
Mr. [**Known lastname 109648**] is a 76M with history of atrial fibrillation on
warfarin, diverticulosis, hemorrhoids, and multiple episodes of
LGIB who presented with BRBPR. Patient was at home the morning
of admission, when he had a large bloody bowel movement. Per
report, was mostly bright red blood with minimmal amount of
stool. Patient then had 3 subsequent episodes of smaller, bloody
bowel movements. He called PCP, [**Name10 (NameIs) 1023**] referred him to the ED for
further evaluation.
On arrival to ED he was afebrile, HR 60, BP 140/11, and he was
satting 98% on 4L. On rectal exam, he was found to have frank
blood in the vault. Labs were notable for Hct 42 (stable), and
elevated Cr 1.5 (baseline 1-1.2). ECG did not show any changes
concerning for ischemia. He had another large, bloody bowel
movement in ED prior to transfer to the floor. On arrival to the
floor he remained hemodynamically stable, and had been weaned
off oxygen to room air. He denied any abdominal pain, nausea,
vomiting, or hematemesis, but continued to have multiple large
bowel movements that were bloody.
He was subsequently transferred to the MICU for active GIB based
on prelim CTA showing intraluminal hemorrhage in the proximal
sigmoid colon in the arterial phase with pooling in the delayed
phase images, consistent with active bleeding. He had received 3
units of pRBC and 3 units of FFP on the floor. He received an
additional 3 units of pRBC and 2 unit of FFP on the floor in
addition to a bag of platelets. He has in total received 6 units
of pRBC, 2 units of FFP, and one bag of platelets. He was also
given calcium gluconate 2 gm IV x 1. On admission to the ICU, he
had a large (250 cc) bloody bowel mvoement. He was taken to IR.
He was found to have active bleeding from the branch of the [**Female First Name (un) 899**]
bleeding into the sigmoid colon. However after 2 hours,
selective embolization was not able to be performed. Radiation
and contrast limits had been reached. The patient remained
hemodynamically stable but was continuing to have active
bleeding. Surgery consultation suggested that he go to the OR
for ex-lap and urgent sigmoid colectomy.
Of note, the patient was feeling in his otherwise normal state
of health. He denies any symptoms except malaise and "dizzy" at
time in addition to the BRBPR.
He was also recently hospitalized from [**2154-11-19**] to [**2154-11-22**] with
a diastolic congestive heart failure exacerbation attributed to
atrial fibrillation with RVR and dietary indiscretion. At that
time, he was cardioverted into NSR followed by chemical rhythm
control with amiodarone. He has remained in NSR. His weight on
discharge was 119 kg (262 lbs). His weight on current admission
was 252.60 lbs.
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:
1. Diverticulosis on [**8-28**] colonoscopy
3. Hemorrhoids
3. LGIB x3, last hospitalization on [**8-28**]
4. dCHF LVEF>55% and moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **] on [**11-29**] ECHO
5. Paroxysmal atrial fibrillation with RVR, CHADS2 score 3, now
on coumadin
6. Prostate CA s/p XRT
7. Hypertension
8. Hyperlipidemia
9. S/p hip and knee arthroplasties
10.S/p right hip replacement
11.S/p prior right DVT s/p hip replacment surgery
Social History:
Lives in [**Location 4628**] MA, with daughter, son-in-law, and
granddaughter. Smoked regularly from ages 21 until about a month
ago (55 pack-years). Denies significant alcohol history.
Family History:
Reports that no relative has had stroke, heart attack or other
heart problems, diabetes, or cancers.
Physical Exam:
Discharge Physical Exam
General: Patient appears very well, ambulating independently,
tolerating regular diet, passing flatus, stable urine output.
VS:98.6, 98.5, 64bpm, 134/74, 20, 96%RA
Neuro: A&OX3, appropriate behavior
Lungs: CTAB
Cardiac: RRR, SR on tele, no alarms
Abdomen: Non-distended, non-tender, midline incision closed with
staples and intact with9out drainage or signs of infection
Lower Extremities: No significant edema. Equal strength
bilaterally.
Pertinent Results:
[**2154-12-11**] 10:56AM BLOOD WBC-4.4 RBC-4.85 Hgb-13.9* Hct-42.6
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.9* Plt Ct-136*
[**2154-12-11**] 10:56AM BLOOD Neuts-71.2* Lymphs-20.9 Monos-6.2 Eos-1.4
Baso-0.4
[**2154-12-11**] 10:56AM BLOOD PT-30.4* PTT-33.4 INR(PT)-3.0*
[**2154-12-11**] 10:56AM BLOOD Glucose-91 UreaN-33* Creat-1.5* Na-141
K-4.5 Cl-106 HCO3-26 AnGap-14
[**2154-12-11**] 10:53AM BLOOD K-4.4
[**2154-12-11**] 10:53AM BLOOD Hgb-14.3 calcHCT-43
[**2154-12-17**] 04:45AM BLOOD WBC-4.3 RBC-3.23* Hgb-9.6* Hct-29.0*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.2 Plt Ct-121*
[**2154-12-16**] 06:00AM BLOOD WBC-6.2 RBC-3.35* Hgb-10.0* Hct-29.7*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.5 Plt Ct-104*
[**2154-12-15**] 05:35AM BLOOD WBC-7.2 RBC-3.68* Hgb-10.8* Hct-32.5*
MCV-89 MCH-29.4 MCHC-33.2 RDW-15.3 Plt Ct-104*
[**2154-12-14**] 11:00PM BLOOD WBC-9.2 RBC-3.72* Hgb-11.1* Hct-32.8*
MCV-88 MCH-29.9 MCHC-33.9 RDW-15.3 Plt Ct-107*
[**2154-12-14**] 05:35AM BLOOD WBC-10.6 RBC-4.04* Hgb-11.8* Hct-35.5*
MCV-88 MCH-29.1 MCHC-33.2 RDW-15.5 Plt Ct-102*
[**2154-12-13**] 05:34PM BLOOD WBC-14.9*# RBC-4.48* Hgb-13.2* Hct-39.5*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.6* Plt Ct-115*
[**2154-12-13**] 03:09AM BLOOD WBC-7.1 RBC-3.92* Hgb-11.4* Hct-33.7*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.9 Plt Ct-97*
[**2154-12-13**] 12:56AM BLOOD WBC-6.8# RBC-3.63* Hgb-10.9* Hct-31.6*
MCV-87 MCH-30.0 MCHC-34.3 RDW-15.2 Plt Ct-97*
[**2154-12-13**] 12:02AM BLOOD WBC-4.5 RBC-3.35* Hgb-9.9* Hct-28.8*
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.6* Plt Ct-89*
[**2154-12-12**] 03:16PM BLOOD WBC-3.4* RBC-3.44* Hgb-10.0* Hct-30.1*
MCV-88 MCH-29.1 MCHC-33.3 RDW-15.9* Plt Ct-114*
[**2154-12-12**] 06:20AM BLOOD WBC-3.0* RBC-3.68* Hgb-10.3* Hct-32.0*
MCV-87 MCH-28.0 MCHC-32.2 RDW-15.8* Plt Ct-121*
[**2154-12-12**] 06:20AM BLOOD WBC-3.0* RBC-3.68* Hgb-10.3* Hct-32.0*
MCV-87 MCH-28.0 MCHC-32.2 RDW-15.8* Plt Ct-121*
[**2154-12-12**] 01:48AM BLOOD WBC-3.9* RBC-3.65* Hgb-10.0* Hct-31.7*
MCV-87 MCH-27.5 MCHC-31.6 RDW-16.0* Plt Ct-124*
[**2154-12-11**] 07:15PM BLOOD WBC-4.0 RBC-4.11* Hgb-11.6* Hct-36.0*
MCV-88 MCH-28.2 MCHC-32.2 RDW-16.1* Plt Ct-115*
[**2154-12-11**] 10:56AM BLOOD WBC-4.4 RBC-4.85 Hgb-13.9* Hct-42.6
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.9* Plt Ct-136*
CTA ABD W&W/O C & RECONS Study Date of [**2154-12-11**] 10:32 PM
IMPRESSION:
1. Extensive sigmoid diverticulosis, though no clear site of
active
extravasation. No evidence of acute or chronic inflammation or
obstruction.
2. Normal appearance of the stomach and small bowel loops
without clear
active extravasation in the proximal GI tract.
3. Cholelithiasis.
4. Bony demineralization.
[**Last Name (LF) **],[**Known firstname **] [**2078-4-5**] 76 Male [**-1/4996**]
[**Numeric Identifier 109649**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. ALMASHAT/rate
SPECIMEN SUBMITTED: sigmoid colon, colonic donuts.
Procedure date Tissue received Report Date Diagnosed
by
[**2154-12-12**] [**2154-12-13**] [**2154-12-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/vf
Previous biopsies: [**-8/4484**] GI BIOPSIES. (3 JARS)
[**-8/2291**] GI BIOPSIES (3 JARS).
[**Numeric Identifier 109650**] NEEDLE PROSTATE BIOPSIES (20 JARS).
[**-7/4035**] RIGHT ACETABULAR HEAD.
(and more)
DIAGNOSIS:
I. Sigmoid colon, resection (A-F, H-J):
1. Colonic segment with diverticular disease and degenerating
intraluminal blood. No perforation is identified; resection
margins are viable.
2. The colonic mucosa demonstrates scattered, predominantly
superficial neutrophils and a rare non-necrotizing granuloma;
see note.
3. Regional lymph nodes with rare non-necrotizing granulomata.
II. Colonic donuts (G):
1. Unremarkable colonic segments.
2. One lymph node with no diagnostic abnormalities recognized.
Note: No diagnostic features of chronic colitis are identified.
The granulomata may represent a response to prior
diverticulitis or other injury (clinically s/p radiation
therapy), however, an infectious process, inflammatory bowel
disease (less likely) or other etiology cannot be entirely
excluded and further clinical correlation is required. Special
stains for acid fast bacilli and fungi will be reported in an
addendum
CHEST (PORTABLE AP) Study Date of [**2154-12-13**] 4:53 AM
FINDINGS: In comparison with the study of [**12-12**], there is a
right IJ catheter in place with its tip in the mid portion of
the SVC. Continued low lung volumes with some enlargement of the
cardiac silhouette and elevation of the left hemidiaphragmatic
contour. There is some increased opacification at the right base
medially. This could reflect some crowding of mildly engorged
pulmonary vessels suggesting elevated pulmonary venous pressure.
Other possibilities would be postoperative atelectasis. In the
appropriate clinical setting, supervening pneumonia would have
to be considered.
Cardiology Report ECG Study Date of [**2154-12-14**] 7:54:16 AM
Normal sinus rhythm with non-specific ST-T wave abnormalities.
Compared to the previous tracing of [**2154-12-12**] the Q-T interval is
now normal.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 124 106 388/444 7 39 43
FINDINGS: No previous images. There is substantial dilatation of
the
feces-filled right colon as well as moderate dilatation of the
left colon. The small bowel gas is essentially within normal
limits. Specifically, the stomach does not appear to be
substantially distended. If there is serious clinical concern
for gastric distention or intramural gas, CT would be the next
imaging procedure.
UNILAT UP EXT VEINS US LEFT Study Date of [**2154-12-15**] 10:36 AM
FINDINGS: The left internal jugular, axillary, and brachial
veins demonstrate normal compressibility and flow. The left
basilic vein demonstrates normal compressibility. The left
cephalic vein is not seen. The left subclavian vein demonstrates
normal symmetric flow. Subcutaneous edema is noted.
Brief Hospital Course:
76M history of diverticulosis, hemorrhoids, prior multiple LGIB
hospitalizations, heart failure with preserved ejection fraction
and paroxysmal atrial fibrillation on coumadin and amiodarone
presenting with a one day history of BRBPR. Hospital course was
complicated by persistent active GIB requiring transfer to MICU
s/p failed selective embolization of [**Female First Name (un) 899**] and resultant ex-lap
and sigmoid colectomy.
# GIB secondary [**Female First Name (un) 899**] bleed
Patient with active GIB from lower source based on angiography
in setting of supratherapeutic INR on coumadin (INR 3 on
admission). He remained hemodynamically stable despite
transfusion-dependent acute blood loss anemia from multiple
bloody bowel movements and correction of coagulopathy with FFP.
He was sent to IR for selective embolization of the bleeding [**Female First Name (un) 899**]
branch ([**2154-12-12**]), but this was unable to be performed after
multiple attempts. He subsequently went to the OR urgently on
[**2154-12-12**] for an open sigmoid colectomy.
Post-op course: OR->SICU, 7pRBC, 7FFP, 1plt. [**2154-12-13**] tx to
floor Hct stable, started sips. [**2154-12-15**] +flatus, BM x2, tol
sips, amb with nurse, mid 90s on RA, started clears. [**2154-12-16**]
clears-reg,home meds/PO pain meds,metoprolol incr 50''', started
lasix The patient's pain was appropriately managed with
intravenous pain medicaitons. His diet was advanced as
appropriate bowel function returned.
# Acute renal failure:
Cr elevated to 1.5 on admission likely pre-renal. His Cr trended
down to baseline of around 1.0-1.2 after colloid resuscitation
with blood products suggesting pre-renal etiology. His
creatinine normalized post operatively.
# Heart failure with preserved ejection fraction
Patient had recent admission for heart failure exacerbation
secondary to atrial fibrillation and dietary indiscretion. He
appeared hypovolemic with current admission weight (252.6 lbs)
below last discharge weight (262 lbs).
He was re-started on his cardiac medications after stabilization
including furosemide, lisinopril, spironolactone, and aspirin.
# Atrial fibrillation: He was recently admitted for atrial
fibrillation with RVR, s/p cardioversion and started on
amiodarone and coumadin. He was in NSR during admission. During
this admission post operatively he was noted to flip in to rapid
heart rates of 150-160 that were asymptomatic and would last
less than one minute. Cardiology was consulted and felt this was
atrial tachycardia and not AF. They advised patient be
discharged on Toprol XL 150 daily and amiodarone 200mg daily.
The toprol XL had been controlling the patient's heart rate
after it was being given as metoprolol 50TID. The patient was
instructed to follow up with both his PCP and cardiologist to
consider a Holter monitor. Despite the AF patient was advised to
not restart coumadin on discharge as the risk of recurrent
significant bleed from diverticulum is high.
# Hyperlipidemia
He was continued on lipitor.
.
# Thrombocytopenia:
Platelets ranged from 89 to 154 during admission. On prior
hospitalization, platelets ranged 150-170.
# Incidental finding
Small low-density lesion in the pancreatic tail for which MRCP
evaluation is recommended when clinically appropriate, since
differential considerations include an intraductal papillary
mucinous neoplasm.
This needs to be followed-up by his PCP.
Medications on Admission:
amiodarone 200 mg [**Hospital1 **]
lipitor 10 mg a day
furosemide 20 mg a day
lisinopril 40 mg a day
spironolactone 12.5 mg a day
warfarin 5 mg Tu,Sat; 3.75 mg other days
aspirin 81 mg a day
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 days: please take 200mg dose tonight [**2154-12-18**] and
decrease dosing to 200mg daily in the morning on [**2154-12-19**].
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
please take in the morning, start once daily dosing on [**2154-12-19**].
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): do not take more than 4000mg of tylenol daily.
do not drink alcohol while taking tylenol.
5. oxycodone 5 mg Capsule Sig: [**1-20**] Capsules PO every four (4)
hours as needed for pain for 5 days: please do not drive a car
or drink alcohol while taking this medication.
Disp:*40 Capsule(s)* Refills:*0*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*0*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diverticular bleed from sigmoid colon.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the colorectal surgery service after a Left
Sided Colectomy for surgical management of your diverticular
disease in your sigmoid colon which was bleeding and ycould not
be repaired without surgical intervention. Part of this bleeding
was also related to coumadin therapy which you were taking
related to a arrythmia. After surgery, you had a tachy arrythmia
of the atria causing us to have cardiology evaluate you and make
medication recommendatons for us to better manage you cardiac
issues. Coumadin has been stopped, you should not take this
medication until further discussion with cardiology and Dr.
[**Last Name (STitle) **]. You may restart your aspirin. You must see your primary
care provider at the time listed below as well as the
cardiologist next week as listed. At this appointment you may be
set up with a monitoring test and discuss your medications. You
Amiodarone dosing has been changed. You should take a dose of
Amiodarone 200mg tonight [**2154-12-18**] and then decrease the dosing
to 200mg daily only. You will be taking a new medication called
Toprol XL at 150mg daily. Visiting nursing services will be
coming to your home to monitor your blood pressure and heart
rate as well as to check on you after surgery. They may only
come for one visit, however, we would like to be sure you are
doing well at home and on your new medication regimen.
You have recovered from this procedure well and you are now
ready to return home. Samples from your colon were taken and
this tissue has been sent to the pathology department for
analysis. You will receive these pathology results at your
follow-up appointment. If there is an urgent need for the
surgeon to contact you [**Name2 (NI) 19605**] these results they will
contact you before this time. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 1-2 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
You will be given a small amount of the pain medication
oxycodone. Please take this as directed. Do not drinck alcohol
or drive a car while taking this medication. You may also take
tylenol for pain as written. Please do not take more than 4000mg
of tylenol daily. Do not drink alcohol while taking tylenol. You
should call the office if you develop new abdominal pain that is
increased in severity or not relieved with pain medications.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 1120**].
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call to make a follow-up appointment with the office
nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**] as well as Dr. [**Last Name (STitle) **]. Call
[**Telephone/Fax (1) 160**] to make this appointment.
Department: CARDIAC SERVICES
When: TUESDAY [**2155-5-6**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], 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
You have an appointment with your primary care provider at
[**Name9 (PRE) **] [**Name9 (PRE) 38299**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on [**2154-12-31**] at 130pm to discuss
your hospitalization and review your medications. Call
[**Telephone/Fax (1) 40715**] with any questions.
Department: CARDIAC SERVICES
When: TUESDAY [**2155-3-4**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**]
Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2154-12-18**]
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30,829
| 121,040
|
45211
|
Discharge summary
|
report
|
Admission Date: [**2123-4-15**] Discharge Date: [**2123-5-4**]
Date of Birth: [**2061-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Heparin Agents
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
[**2123-4-17**] Transthoracic ultrasound, Insertion of #24-French chest
tube in the right hemithorax.
[**2123-4-20**] Right decortication and creation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 72968**]
window (2 rib resection and open thoracoplasty).
[**2123-4-30**] Flexible bronchoscopy and percutaneous
tracheostomy tube with an 8.0 Portex Per-fit.
History of Present Illness:
61-year-old man with end-stage liver disease on [**Month/Day/Year **] list,
CAD, HTN, past heroin use on methadone, recurrent right pleural
effusion, presented with hypotension. He was supposed to go to
his follow-up appointment with Dr. [**Last Name (STitle) **] today, [**2123-4-15**],
in [**Hospital Ward Name 23**], when he mistakenly presented to the [**Hospital Ward Name 121**] lobby,
complained of lightheadedness, was found to have SBP in the 70s,
HR 80s, 98%RA. Patient was mentating well throughout this
episode. He was brought to th ED. Pt claims that SBP is normally
in the 80s.
.
Of note, patient has had recurrent right-sided pleural
effusions, s/p Pleurex catheter placement, multiple chest tubes.
Most recently he was admitted from [**2123-3-18**] to [**2123-4-2**] for
right-sided pleural effusion complicated by an empyema.
Initially he had a drainage cathether placed. Due to the
inability of his lungs to expand, on [**2123-3-18**] patient underwent a
right VATS decortication. Perioperatively patient required 4
units of FFP and 3 units of PRBC. Three chest tubes were
inserted and kept in for over a week. Patient was discharged
with levofloxacin for Stenotrophomonas from pleural fluid.
.
In the ED, T 97.4, BP 94/palp, HR 80, 94%RA. Labs revealed WBC
16.3 with a left shift, Hct 31.6 (at baseline), plts 119
(baseline). INR 1.9 (baseline). Cr 2.4 from baseline of 1.3 (1.6
on discharge on [**2123-4-2**]). His LFTs were unremarkable. CXR showed
reaccumulation of R pleural effusion. RUQ u/s showed no ascites.
Patient was given 2.5 L of NS with SBP consistently in the high
70s-80s. Got vancomycin and pip-tazo. Admitted to MICU.
Past Medical History:
1. Hepatitis C: diagnosed [**2113**], received 7 months IFN treatment,
but was not responsive.
2. Cirrhosis: secondary to Hepatitis C, patient also has history
of long time alcohol use. History of esophageal varices seen on
EGD ([**2115**]), though most recent EGD ([**2121-12-11**]) showed normal
mucosa but gastric varicies on US. Had esophageal varices s/p
TIPS in [**12-3**].
3. Coronary Artery Disease: s/p DES to 70% mid-LAD [**11-30**]
4. Hypertension: uncontrolled, not currently on any medications
5. Substance use: 20 year heroin use history, maintained on
methadone
6. Iron Deficiency Anemia
7. H/o R ankle fracture requiring ORIF
8. Sigmoid diverticulosis on colonscopy [**11/2121**]
Social History:
He lives by himself in [**Location (un) **]. He works as a gardener. He has
a long history of alcohol use, stopped 15 years ago. He has a 30
year smoking history, quit several months ago. He has 20 year
history of heroin use, has been maintained on methadone.
Family History:
Mother died from jaw cancer at very young age, father died from
lung cancer. He has five siblings: one sister died from sudden
cardiac death, the other sister and three brothers are well.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented elderly man, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: No breath sounds at R base, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 1+ pulses, 2+ bil edema to thighs
Pertinent Results:
[**2123-4-15**] 04:40PM BLOOD WBC-16.3*# RBC-3.59* Hgb-10.8* Hct-31.6*
MCV-88 MCH-30.1 MCHC-34.1 RDW-17.6* Plt Ct-119*
[**2123-4-16**] 04:22AM BLOOD WBC-10.1 RBC-3.26* Hgb-9.9* Hct-29.2*
MCV-90 MCH-30.5 MCHC-34.0 RDW-17.9* Plt Ct-89*
[**2123-4-17**] 06:20AM BLOOD WBC-12.0* RBC-3.39* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.7 MCHC-34.2 RDW-17.2* Plt Ct-91*
[**2123-4-18**] 06:50AM BLOOD WBC-7.5 RBC-3.42* Hgb-10.4* Hct-31.1*
MCV-91 MCH-30.4 MCHC-33.4 RDW-17.6* Plt Ct-73*
[**2123-4-19**] 05:00AM BLOOD WBC-8.1 RBC-3.26* Hgb-10.1* Hct-28.9*
MCV-89 MCH-30.9 MCHC-34.8 RDW-16.9* Plt Ct-60*
[**2123-4-20**] 05:05AM BLOOD WBC-10.2 RBC-3.48* Hgb-10.6* Hct-30.7*
MCV-88 MCH-30.5 MCHC-34.6 RDW-17.6* Plt Ct-74*
[**2123-4-20**] 05:05AM BLOOD PT-18.0* PTT-42.1* INR(PT)-1.6*
[**2123-4-18**] 06:50AM BLOOD PT-17.4* PTT-41.2* INR(PT)-1.6*
[**2123-4-17**] 01:00PM BLOOD PT-18.7* PTT-39.6* INR(PT)-1.7*
[**2123-4-17**] 06:20AM BLOOD PT-19.8* PTT-41.3* INR(PT)-1.8*
[**2123-4-16**] 04:22AM BLOOD PT-20.3* PTT-41.0* INR(PT)-1.9*
[**2123-4-15**] 04:40PM BLOOD PT-20.1* PTT-42.7* INR(PT)-1.9*
[**2123-4-15**] 04:40PM BLOOD Glucose-104 UreaN-63* Creat-2.4* Na-134
K-3.9 Cl-97 HCO3-22 AnGap-19
[**2123-4-16**] 04:22AM BLOOD Glucose-106* UreaN-48* Creat-1.8* Na-141
K-4.2 Cl-109* HCO3-23 AnGap-13
[**2123-4-17**] 06:20AM BLOOD Glucose-97 UreaN-30* Creat-1.2 Na-141
K-3.3 Cl-108 HCO3-22 AnGap-14
[**2123-4-18**] 06:50AM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-137
K-3.4 Cl-104 HCO3-22 AnGap-14
[**2123-4-19**] 05:00AM BLOOD Glucose-80 UreaN-11 Creat-0.8 Na-135
K-4.5 Cl-104 HCO3-23 AnGap-13
[**2123-4-20**] 05:05AM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-131*
K-4.6 Cl-102 HCO3-20* AnGap-14
[**2123-4-15**] 04:40PM BLOOD ALT-16 AST-38 AlkPhos-107 TotBili-2.1*
[**2123-4-17**] 06:20AM BLOOD ALT-22 AST-59* AlkPhos-113 TotBili-2.0*
[**2123-4-18**] 06:50AM BLOOD ALT-21 AST-56* AlkPhos-120* TotBili-2.2*
[**2123-4-19**] 05:00AM BLOOD ALT-25 AST-70* AlkPhos-148* TotBili-1.6*
[**2123-4-20**] 05:05AM BLOOD ALT-30 AST-67* AlkPhos-209* TotBili-1.7*
[**2123-4-20**] 05:05AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
[**2123-4-19**] 05:00AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.6
[**2123-4-18**] 06:50AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
[**2123-4-17**] 06:20AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.6
[**2123-4-16**] 04:22AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.8
[**2123-4-15**] 04:40PM BLOOD Ammonia-56*
[**2123-4-19**] 05:15PM BLOOD Vanco-23.1*
[**2123-4-15**] 08:45PM BLOOD Lactate-2.2*
.
Time Taken Not Noted Log-In Date/Time: [**2123-4-18**] 1:25 am
FLUID RECEIVED IN BLOOD CULTURE BOTTLES Site: PLEURAL
ONLY ANAEROBIC BOTTLE RECEIVED.
Fluid Culture in Bottles (Preliminary):
GRAM NEGATIVE ROD(S).
GRAM NEGATIVE ROD #2.
GRAM POSITIVE COCCUS(COCCI). IN PAIRS IN CHAINS.
.
[**4-15**] CXR
1. Reaccumulation of a large probably loculated right pleural
effusion with an air-fluid component noted posteriorly.
Diagnostic considerations with air-fluid component include
sterile and nonsterile etiologies such as a possibility of
recurrent or new empyema. Bronchopleural fistula may also be
considered.
2. Right middle libe collapse.
3. The reticular interstitial lines in the left lower lung have
been
documented on prior studies including [**2123-2-24**] CT.
.
[**4-15**] Abd U/s: No ascites.
.
CT chest:
1. Right chest tube now in place, with slightly increased air in
the right pleural space. Right pleural thickening has increased,
consistent with reactive change to known empyema.
2. Unchanged reticular interstitial opacities in the upper
lobes. Given
absence of change over several studies, interstitial lung
disease may be more likely than hydrostatic edema.
3. Unchanged small left pleural effusion.
4. Stable emphysema.
5. Cirrhosis.
[**4-21**] Echo: LVEF=30 %. Compared with prior, extensive regional
left ventricular systolic function is now seen and suggestive of
interim ischemia/infarction in the LAD and PDA territories
[**2123-4-30**] EEG: This is an abnormal portable EEG due to the slow and
disorganized background and the bursts of generalized slowing.
This
finding suggests widespread encephalopathy. Metabolic
disturbances,
medications, and infection are among the most common causes.
There were
no lateralized or epileptiform features seen.
[**2123-4-29**] MR of the Head: No MR evidence of ventriculitis, Trace
subarachnoid and intraventricular hemorrhage, and fluid in
bilateral mastoid air cells.
Brief Hospital Course:
Mr. [**Known lastname 96610**] is a 61-year-old man with end-stage liver disease
on [**Known lastname **] list, CAD, HTN, past heroin use on methadone,
recurrent right pleural effusion, presented with hypotension.
.
# Empyema: Has recurrent Empyema after prior empyema with VATS
decortication [**3-4**]. Had [**Female First Name (un) 576**](after receiving 4UFFP) which
showed frank pus. Had chest tube placed draining serosanguinous
fluid. Never had respiratory compromise. Was afebrile with
slight increase in WBC. Planned for [**Last Name (un) **] window by
thoracics. ID knows patient and followed in consultation and
recommended Vanc, Meropenum, and Bactrim(high dose). Pleural
fluid cultures were pending at time of transfer but gram +cocci
and gram neg rods seen on gram stain.
#Respiratory: Trach collar (Portex 8.0mm)35%02 96% sat
.
# Hypotension: Resolved to baseline SBP 90s-100s after 3.5L IVF.
Patient hypovolemic in setting of taking too much diuretic,
however sepsis was a possibility but unlikely as blood cultures
remained negative. Evenutally started furosemide and
spironolactone at low dose.
.
# Liver failure: no evidence of hepatic encephalopathy;
coagulopathy at baseline. INR elevated but unchanged. Continued
home lactulose and diuretics.
.
# ARF: Returned to baseline with 3L. Most likely prerenal
azotemia from dehydration vs ATN from hypoperfusion. Held
furosemide and spironolactone at first but restated them once Cr
returned to [**Location 213**].
.
# CAD: Currently asymptomatic, has previously been on ACEI, BB
probably being held bc of BP decreasing over past couple months.
#HEME: HIT screen- positive (no heparin) start fondaparinux.
platelets 88- goal keep plts >5
#Neuro: His examination is better that was seen earlier, and
his preliminary MRI results are reassuring that additional
neurologic complications are not present. At this time a
routine
EEG's will be helpful. The patients condition is likely to be
encephalopathy from his multiple medical problems, although
possible withdrawal from chronic narcotic use must also be
considered as possible complicating problem (has had methadone
stopped, restarted then reduced several times which may have
drawn out the withdrawal process.)
.
# General Care: FEN: followed and repleted elytes, regular low
Na diet, Prophylaxis: pneumoboots, home h2blocker, lactulose,
Access: PIV, Code: full, confirmed, Contact: HCP son [**Name (NI) **]
[**Telephone/Fax (1) 96617**], or dtr [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 96618**], discharged to
Rehab. Dressing changes normal saline moist (not to wet)
dressing loosley packed to chest wound [**Hospital1 **]. Hypernatremia trated
with free water.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Solution Sig: One (1) ML PO TID (3
times a day): hold for loose stools.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 weeks. [**Hospital1 **]:*21 Tablet(s)* Refills:*0*
6. Methadone 10 mg Tablet Sig: Six (6) Tablet PO once a day.
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Magnesium < 1.5.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Metoclopramide 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. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Methadone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) as needed for pain.
11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 0.5 mL Subcutaneous
DAILY (Daily).
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
15. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
16. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Right Empyema
Discharge Condition:
deconditioned, trached
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] with any concerns
regarding [**Last Name (un) 72968**] Window.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **]
Completed by:[**2123-5-4**]
|
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|
8503, 11205
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303, 677
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4061, 8480
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13,744
| 181,330
|
14185+14186+14187+14188
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2101-1-14**] Discharge Date: [**2101-2-8**]
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
white male with type 2 diabetes mellitus, mild mitral
regurgitation, hypercholesterolemia, congestive heart failure
and coronary artery disease, who underwent cardiac
catheterization, revealing severe three vessel disease with
an estimated left ventricular ejection fraction of 10% to
40%. He has been managed medically.
The patient was admitted to an outside hospital with a non-Q
wave myocardial infarction, where his left ventricular
ejection fraction was noted to be 29%. He was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac
catheterization, which showed severe three vessel disease and
aortic stenosis.
PAST MEDICAL HISTORY: As above.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Imdur 30 mg p.o.q.d., Lopresor 50
mg p.o.b.i.d., aspirin, Glucotrol, digoxin, Zyprexa, Lipitor,
Serzone, trazodone.
HOSPITAL COURSE: The patient was taken to the Operating Room
by Dr. [**Last Name (STitle) **] on [**2101-1-19**], where he underwent
coronary artery bypass grafting times three with left
internal mammary artery to the ramus, right saphenous vein
grafts to the obtuse marginal and left anterior descending
artery, as well as an aortic valve replacement with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
#23 valve.
The patient was transferred to the Surgical Intensive Care
Unit on Neo-Synephrine. Postoperatively, it was noted that
the patient had decreased movement on the right side of his
body. Dr. [**Last Name (STitle) **] had an extensive conversation with the
family; questions were asked and answered.
A neurologic consultation was obtained and it was felt that
the patient had a left middle cerebral artery territory
infarction.
The patient's hematocrit dropped, which required several
transfusions. He had large output from his chest tubes. A
chest x-ray revealed a large left hemothorax.
On postoperative day number three, the patient continued to
spike some fevers and his perioperative vancomycin was
continued. He was cultured. His white blood cell count was
normal at this time.
Because the patient had no gag reflex, percutaneous
endoscopic gastrostomy tube and tracheostomy consultations
were obtained. On postoperative day number four, the
vancomycin was switched to levofloxacin, as the sputum showed
gram negative rods and the patient was spiking to 102.6. The
Surgical Intensive Care Unit was consulted on the care of
this patient.
On [**2101-1-25**], percutaneous tracheostomy and
percutaneous intracutaneous gastrostomy tube were placed.
Over the ensuing days, the patient did well. He was started
on tube feeds. The patient, however, had severe right
hemiparesis and aphasia remained.
The patient did well and ventilatory support was weaned, and
his tube feeds were advanced to goal. He continued to spike
fevers, although his white blood cell count remained normal.
A left chest tube was placed, which evacuated a large amount
of serosanguinous fluid. A CT scan revealed a left
hemothorax which was organized.
On [**2101-2-3**], thoracic surgery was consulted for the
possibility of open decortication for the loculated
hemothorax.
On postoperative day 20, [**2101-2-7**], the patient's
maximum temperature was 100. He was in normal sinus rhythm
at 87 beats per minute. His blood pressure and oxygenation
were satisfactory on a tracheostomy collar. He was awake and
interactive with dense aphasia and a dense right hemiparesis.
Chest was clear to auscultation. He had a regular rate and
rhythm. His abdomen was soft, nontender, nondistended.
Extremities were warm and well perfused. His white blood
cell count was normal as were his electrolytes.
The patient was switched from Kefzol to ciprofloxacin for
sputum, which had gram negative rods. The patient was
discharged subsequently to a rehabilitation facility in
stable condition to follow up with thoracic surgery.
CONDITION AT DISCHARGE: Stable.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) **] in approximately one month.
DISCHARGE MEDICATIONS:
Zyprexa 15 mg per PEG-tube q.d.
Aspirin 325 mg per PEG-tube q.d.
Betoptic one drop affected eye b.i.d.
Metamucil one packet per PEG-tube q.d.
NPH insulin 28 units s.c.b.i.d.
Lopressor 25 mg per PEG-tube b.i.d.
Ciprofloxacin 400 mg i.v.b.i.d. or ciprofloxacin 500 mg per
PEG-tube b.i.d. for a ten day course, starting on [**2101-2-7**].
Nystatin swish and swallow 5 cc t.i.d.
Paxil 20 mg per PEG-tube q.d.
Motrin liquid 600 mg per PEG-tube q.6h.p.r.n.
Heparin 5,000 mg s.c.b.i.d.
The patient was tolerating tube feeds of Impact with fiber at
70 cc/hour.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 13197**]
MEDQUIST36
D: [**2101-2-7**] 13:33
T: [**2101-2-7**] 13:38
JOB#: [**Job Number 42207**]
Admission Date: [**2101-1-14**] Discharge Date: [**2101-2-8**]
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
white male with type 2 diabetes mellitus, mild mitral
regurgitation, hypercholesterolemia, congestive heart failure
and coronary artery disease, who underwent cardiac
catheterization, revealing severe three vessel disease with
an estimated left ventricular ejection fraction of 10% to
40%. He has been managed medically.
The patient was admitted to an outside hospital with a non-Q
wave myocardial infarction, where his left ventricular
ejection fraction was noted to be 29%. He was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac
catheterization, which showed severe three vessel disease and
aortic stenosis.
PAST MEDICAL HISTORY: As above.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Imdur 30 mg p.o.q.d., Lopresor 50
mg p.o.b.i.d., aspirin, Glucotrol, digoxin, Zyprexa, Lipitor,
Serzone, trazodone.
HOSPITAL COURSE: The patient was taken to the Operating Room
by Dr. [**Last Name (STitle) **] on [**2101-1-19**], where he underwent
coronary artery bypass grafting times three with left
internal mammary artery to the ramus, right saphenous vein
grafts to the obtuse marginal and left anterior descending
artery, as well as an aortic valve replacement with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
#23 valve.
The patient was transferred to the Surgical Intensive Care
Unit on Neo-Synephrine. Postoperatively, it was noted that
the patient had decreased movement on the right side of his
body. Dr. [**Last Name (STitle) **] had an extensive conversation with the
family; questions were asked and answered.
A neurologic consultation was obtained and it was felt that
the patient had a left middle cerebral artery territory
infarction.
The patient's hematocrit dropped, which required several
transfusions. He had large output from his chest tubes. A
chest x-ray revealed a large left hemothorax.
On postoperative day number three, the patient continued to
spike some fevers and his perioperative vancomycin was
continued. He was cultured. His white blood cell count was
normal at this time.
Because the patient had no gag reflex, percutaneous
endoscopic gastrostomy tube and tracheostomy consultations
were obtained. On postoperative day number four, the
vancomycin was switched to levofloxacin, as the sputum showed
gram negative rods and the patient was spiking to 102.6. The
Surgical Intensive Care Unit was consulted on the care of
this patient.
On [**2101-1-25**], percutaneous tracheostomy and
percutaneous intracutaneous gastrostomy tube were placed.
Over the ensuing days, the patient did well. He was started
on tube feeds. The patient, however, had severe right
hemiparesis and aphasia remained.
The patient did well and ventilatory support was weaned, and
his tube feeds were advanced to goal. He continued to have
low grade
fevers, although his white blood cell count remained normal.
A left chest tube was placed, which evacuated a large amount
of serosanguinous fluid. A CT scan revealed a left
hemothorax which was organized.
On [**2101-2-3**], thoracic surgery was consulted.
On postoperative day 20, [**2101-2-7**], the patient's
maximum temperature was 100. He was in normal sinus rhythm
at 87 beats per minute. His blood pressure and oxygenation
were satisfactory on a tracheostomy collar. He was awake and
interactive with dense aphasia and a dense right hemiparesis.
Chest was clear to auscultation. He had a regular rate and
rhythm. His abdomen was soft, nontender, nondistended.
Extremities were warm and well perfused. His white blood
cell count was normal as were his electrolytes.
The patient was switched from Kefzol to ciprofloxacin for
sputum, which had gram negative rods. The patient was
discharged subsequently to a rehabilitation facility in
stable condition to follow up with thoracic surgery.
CONDITION AT DISCHARGE: Stable.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) **] in approximately one month.
DISCHARGE MEDICATIONS:
Zyprexa 15 mg per PEG-tube q.d.
Aspirin 325 mg per PEG-tube q.d.
Betoptic one drop affected eye b.i.d.
Metamucil one packet per PEG-tube q.d.
NPH insulin 28 units s.c.b.i.d.
Lopressor 25 mg per PEG-tube b.i.d.
Ciprofloxacin 400 mg i.v.b.i.d. or ciprofloxacin 500 mg per
PEG-tube b.i.d. for a ten day course, starting on [**2101-2-7**].
Nystatin swish and swallow 5 cc t.i.d.
Paxil 20 mg per PEG-tube q.d.
Motrin liquid 600 mg per PEG-tube q.6h.p.r.n.
Heparin 5,000 mg s.c.b.i.d.
The patient was tolerating tube feeds of Impact with fiber at
70 cc/hour.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 13197**]
MEDQUIST36
D: [**2101-2-7**] 13:33
T: [**2101-2-7**] 13:38
JOB#: [**Job Number 42208**]
Admission Date: [**2101-1-14**] Discharge Date: [**2101-2-10**]
Service: Cardiothoracic Surgery
REASON FOR ADMISSION: The reason for admission is as
follows.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of coronary artery disease, diabetes, and aortic
stenosis who was [**Hospital 487**] Hospital on [**1-11**] complaining
of chest pain substernal in nature. He underwent a cardiac
catheterization which showed coronary artery disease with
blockages in the posterior descending artery, PDL, total
right coronary artery, LAV, first diagonal, second diagonal,
total [**Last Name (LF) 11641**], [**First Name3 (LF) **] ejection fraction of 40%. The patient had an
echocardiogram which showed aortic stenosis.
He was then transferred to [**Hospital1 188**] for further treatment of his cardiac disease. He was
admitted to the Cardiology Service at the [**Hospital1 346**].
PAST MEDICAL HISTORY: (His past medical history is)
1. Diabetes.
2. Aortic stenosis.
3. Hypercholesterolemia.
4. Chronic abdominal pain.
5. Supraventricular tachycardia.
6. Asbestosis.
7. Pleural plaques.
8. Right bundle-branch block.
9. Left atrial fibrillation.
10. Coronary artery disease.
11. Depression.
12. Anxiety; no clear [**Hospital1 **] diagnosis.
13. Hypotension.
MEDICATIONS ON ADMISSION: Medications were Lopressor,
nitroglycerin, Prinivil, Zyprexa, Lipitor, Serzone,
Glucotrol-XL 5 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed head, eyes, ears, nose, and throat with pupils were
equal and reactive to light. Extraocular movements were
intact. No jugular venous distention or bruits. Chest
revealed fine crackles. Cardiovascular examination revealed
systolic [**4-13**] cardiac murmur. The abdomen revealed positive
bowel sounds, transmitted murmur. Groin revealed there was
no hematoma or bruits. Neurologically, cranial nerves II
through XII were intact.
HOSPITAL COURSE: Hospital course was as follows. The
patient was taken to the cardiac catheterization laboratory
on [**2101-1-14**] and underwent a cardiac catheterization
which showed left main coronary artery was normal, left
anterior descending artery with 60% middle subtotal distal
and apex with diffuse first diagonal. Left circumflex,
occluded [**Year (4 digits) 11641**], total first obtuse marginal, 50% distal
circumflex, long severe, 90% third obtuse marginal, right
coronary artery with long 90% middle, 95% distal, 95%
proximal posterior descending artery and PLVBR. The patient
also had critical aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of
approximately 0.67 cm2.
The patient was then consulted by Dr. [**Last Name (STitle) **] from
Cardiothoracic Surgery. The patient was seen in consultation
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25067**]. The patient was then consented for
cardiac surgery.
On [**2101-1-18**], the patient was taken to the operating
room where a coronary artery bypass graft surgery times three
with left internal mammary artery to the [**Year (4 digits) 11641**], saphenous
vein graft to the obtuse marginal, left anterior descending
artery, and an aortic valve replacement using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] #23.
Please refer to cardiac surgical Operative Note for full
details of the procedure. The patient tolerated the
procedure well and was transferred to the Surgical Intensive
Care Unit in satisfactory and hemodynamically stable
condition.
In the Surgical Intensive Care Unit the patient continued to
do well; however, on [**2101-1-19**], the patient had some
right-sided weakness. He was seen by Neurology who felt the
patient, after looking at a CAT scan, had a large left
cerebrovascular accident of the middle cerebral artery
region. They felt it was okay to anticoagulate the patient.
The patient was anticoagulated.
Postoperatively, the patient was doing well. He still
remained intubated though. Hemodynamics were good. The
patient was seen by Physical Therapy because of his
cerebrovascular accident. He was receiving bedside physical
therapy to help him maintain his mobility. Neurologically
followed him postoperatively. He continued to do well.
Because of his inability to wean off the ventilator, the
patient underwent a bedside tracheostomy and percutaneous
endoscopic gastrostomy tube placement. This was done on
[**2101-1-25**]. On [**2101-1-25**], the patient also
had a bronchoscopy for his percutaneous endoscopic
gastrostomy tube placement which showed some mucous plugging.
From there, the patient continued to do well. He was
continued on his ventilatory. He was seen by the nutritional
support services.
At this point, placement to rehabilitation was considered as
the patient was going to be a long-term ventilator wean and
he would obviously need rehabilitation for his
cerebrovascular accident. The family was informed of all of
this. The family agreed that this would be the best plan.
The patient was then transferred to the Surgical Intensive
Care Unit Service because of his long-term care needs. He
had a right peripherally inserted central catheter line
placed for intravenous access; and, at this point, he was
then slowly starting to be weaned from his ventilator, and
his hemodynamic medications.
Neurology saw him and felt that (you know) the fact on
[**2101-2-6**] he had global aphasia and right hemiplegia,
and felt his deficit was going to be severe, and there was
some chance for any more recovery, but his deficits would
most likely be what they were; and they signed off.
At this point, the patient was then kept in the Surgical
Intensive Care Unit. He continued to do well. He was seen
by Speech and Swallow and Physical Therapy, and he was just
awaiting placement.
On [**2101-2-10**], the patient was then transferred to the
rehabilitation hospital (which was [**Hospital1 **]) via ambulance.
He had a tracheostomy, a percutaneous endoscopic gastrostomy
tube. He still had (you know) right hemiplegia and
right-sided deficits, but his cardiac status was good. His
valve was crisp and working well. He had no chest pain. His
electrocardiogram was stable.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: To [**Hospital **] [**Hospital **] Hospital.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft surgery with
aortic valve replacement.
2. Status post right cerebrovascular accident with right
hemiplegia, global aphasia deficits.
3. Status post percutaneous endoscopic gastrostomy.
4. Status post tracheostomy.
5. History of fail to wean.
6. History of diabetes.
7. History of coronary artery disease.
8. History of aortic stenosis.
9. History of hypercholesterolemia.
10. History of chronic abdominal pain.
11. History of supraventricular tachycardia.
12. History of asbestosis.
13. Pleural plaques.
14. History of depression.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 33202**]
MEDQUIST36
D: [**2101-5-17**] 13:01
T: [**2101-5-18**] 14:08
JOB#: [**Job Number 42209**]
Admission Date: [**2101-1-14**] Discharge Date: [**2101-2-10**]
Service: Cardiothoracic Surgery
REASON FOR ADMISSION: The reason for admission is as
follows.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of coronary artery disease, diabetes, and aortic
stenosis who was admitted to [**Hospital 487**] Hospital on [**1-11**]
complaining of chest pain substernal in nature.
He underwent a cardiac catheterization which showed coronary
artery disease with blockages in the posterior descending
artery, PDL, total right coronary artery, LAV, first
diagonal, second diagonal, total [**Last Name (LF) 11641**], [**First Name3 (LF) **] ejection fraction
of 40%. The patient had an echocardiogram which showed
aortic stenosis.
He was then transferred to the [**Hospital1 188**] for further treatment of his cardiac disease. He was
admitted to the Cardiology Service at the [**Hospital1 346**].
PAST MEDICAL HISTORY: (His past medical history is)
1. Diabetes.
2. Aortic stenosis.
3. Hypercholesterolemia.
4. Chronic abdominal pain.
5. Supraventricular tachycardia.
6. Asbestosis.
7. Pleural plaques.
8. Right bundle-branch block.
9. LAFB.
10. Coronary artery disease.
11. Depression.
12. Anxiety; no clear [**Hospital1 **] diagnosis.
13. Hypotension.
MEDICATIONS ON ADMISSION: Medications were Lopressor,
nitroglycerin, Prinivil, Zyprexa, Lipitor, Serzone,
Glucotrol-XL 5 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Head, eyes, ears,
nose, and throat revealed pupils were equal and reactive to
light. Extraocular movements were intact. No jugular venous
distention or bruits. Chest revealed fine crackles.
Cardiovascular examination revealed systolic [**4-13**] cardiac
murmur. The abdomen revealed positive bowel sounds,
transmitted murmur. Groin revealed there was no hematoma or
bruits. Neurologically, cranial nerves II through XII were
intact.
HOSPITAL COURSE: Hospital course was as follows. The
patient was taken to the cardiac catheterization laboratory
on [**2101-1-14**] and underwent a cardiac catheterization
which showed left main coronary artery was normal, left
anterior descending artery with 60% middle subtotal distal
and apex with diffuse first diagonal. Left circumflex,
occluded [**Year (4 digits) 11641**], total first obtuse marginal, 50% distal
circumflex, long severe, 90% third obtuse marginal, right
coronary artery with long 90% mid, 95% distal, 95% proximal
posterior descending artery and PLVBR. The patient also had
critical aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of approximately
0.67 cm2.
The patient was then consulted by Dr. [**Last Name (STitle) **] from
Cardiothoracic Surgery. The patient was seen in consultation
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25067**]. The patient was then consented for
cardiac surgery.
On [**2101-1-18**], the patient was taken to the operating
room where a coronary artery bypass graft surgery times three
with left internal mammary artery to the [**Year (4 digits) 11641**], saphenous
vein graft to the obtuse marginal, left anterior descending
artery, and an aortic valve replacement using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] #23.
Please refer to cardiac surgical Operative Note for full
details of the procedure. The patient tolerated the
procedure well and was transferred to the Surgical Intensive
Care Unit in satisfactory and hemodynamically stable
condition.
In the Surgical Intensive Care Unit the patient continued to
do well; however, on [**2101-1-19**], the patient had some
right-sided weakness. He was seen by Neurology who felt the
patient, after looking at a CAT scan, had a large left
cerebrovascular accident of the middle cerebral artery
region. They felt it was okay to anticoagulate the patient.
The patient was anticoagulated.
Postoperatively, the patient was doing well. He still
remained intubated though. Hemodynamics were good. The
patient was seen by Physical Therapy because of his
cerebrovascular accident. He was receiving bedside physical
therapy to help him maintain his mobility. Neurology
followed him postoperatively. He continued to do well.
Because of his inability to wean off the ventilator, the
patient underwent a bedside tracheostomy and percutaneous
endoscopic gastrostomy placement. This was done on
[**2101-1-25**]. On [**2101-1-25**], the patient also
had a bronchoscopy for his percutaneous endoscopic
gastrostomy placement which showed some mucous plugging. From
there, the patient continued to do well. He was continued on
the ventilator. He was seen by the nutritional support
services.
At this point, placement to rehabilitation was considered as
the patient was going to be a long-term ventilator wean, and
he would obviously need rehabilitation for his
cerebrovascular accident. The family was informed of all of
this. The family agreed that this would be the best plan.
The patient was then transferred to the Surgical Intensive
Care Unit Service because of his long-term care needs. He
had a right peripheral inserted central catheter line placed
for intravenous access; and, at this point, he was then
slowly starting to be weaned from his ventilator, and his
hemodynamic medications.
Neurology saw him and felt that (you know) the fact on
[**2101-2-6**] he had global aphasia, right hemiplegia,
and a right field cut and felt his deficit was going to be
severe, and there was some chance for more recovery, but his
deficits would most likely be what they were; and they signed
off.
At this point, the patient was then kept in the Surgical
Intensive Care Unit. He continued to do well. He was seen
by Speech and Swallow and Physical Therapy, and he was just
awaiting placement.
On [**2101-2-10**], the patient was then transferred to the
rehabilitation hospital (which was [**Hospital1 **]) via ambulance.
He had a tracheostomy, a percutaneous endoscopic gastrostomy
tube. He still had (you know) right hemiplegia and
right-sided deficits, but his cardiac status was good. His
valve was crisp and working well. He had no chest pain. His
electrocardiogram was stable.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: To [**Hospital **] [**Hospital **] Hospital.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft surgery with
aortic valve replacement.
2. Status post right cerebrovascular accident with right
hemiplegia, global aphasia deficits.
3. Status post percutaneous endoscopic gastrostomy.
4. Status post tracheostomy.
5. History of failure to wean.
6. History of diabetes.
7. History of coronary artery disease.
8. History of aortic stenosis.
9. History of hypercholesterolemia.
10. History of chronic abdominal pain.
11. History of supraventricular tachycardia.
12. History of asbestosis.
13. Pleural plaques.
14. History of depression.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 33202**]
MEDQUIST36
D: [**2101-5-17**] 13:01
T: [**2101-5-18**] 14:08
JOB#: [**Job Number 42209**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,211
| 155,493
|
30851
|
Discharge summary
|
report
|
Admission Date: [**2192-5-30**] Discharge Date: [**2192-6-6**]
Date of Birth: [**2131-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymtomatic
Major Surgical or Invasive Procedure:
cabg x4 [**2192-6-1**] (LIMA to LAD, SVG to OM1, SVG to OM2, SVG to
PDA)
History of Present Illness:
61 yo male with EKG abnormalities (ventricular couplets) and
first degree AV block suggestive of anterior septal infarct.
Referred for cath which revealed LAD 100%, CX 70%, RCA 90%,
LVEDP 41 with severe diastolic dysfunction. Referred for CABG.
Past Medical History:
MI
HTN
nephrolithiasis
benign colon polyps
obesity
PSH: tonsillectomy
Social History:
lives with daughter
works in insurance/tax/real estate sales
18 cigarettes per day for 40 years; quit 4 days prior to surgery
6oz. Scotch /night
Family History:
father deceased at 55 from MI
Physical Exam:
HR 70 RR 20 right 170/100 left 144/100
5'[**94**]" 245#
NAD
rash lower abdomen, right thigh sore ingrown hair with serous
drainage
EOMI,PERRLA
neck supple with full ROM, no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] bruits appreciated
CTAb
RRR no m/r/g
soft, NT, ND, + BS
warm, well-perfused with trace peripheral edema
no varicosities
neuro grossly intact
2+ bil. fem/DP/PTs
Pertinent Results:
[**2192-6-5**] 07:40AM BLOOD WBC-10.8 RBC-3.91* Hgb-13.1* Hct-36.3*
MCV-93 MCH-33.5* MCHC-36.0* RDW-13.1 Plt Ct-156
[**2192-6-5**] 07:40AM BLOOD Plt Ct-156
[**2192-6-5**] 07:40AM BLOOD Glucose-95 UreaN-23* Creat-1.3* Na-139
K-4.3 Cl-99 HCO3-31 AnGap-13
[**2192-5-30**] 09:00AM BLOOD ALT-19 AST-18 CK(CPK)-74 AlkPhos-125*
Amylase-64 TotBili-0.8 DirBili-0.2 IndBili-0.6
[**2192-5-30**] 09:00AM BLOOD VitB12-402 Folate-11.8 Ferritn-129
[**2192-5-30**] 09:00AM BLOOD %HbA1c-5.8
[**2192-5-30**] 09:00AM BLOOD Triglyc-91 HDL-38 CHOL/HD-3.4 LDLcalc-73
Cardiology Report ECG Study Date of [**2192-6-4**] 8:43:42 AM
Atrial fibrillation with rapid ventricular response. Q waves in
lead V1
through V4 with ST segment elevation suggest anterior myocardial
infarction of
indeterminate age. There are also Q waves inferiorly. Cannot
rule out old
inferior wall myocardial infarction. Compared to tracing of
[**2192-6-2**]
ventricular ectopy has improved. Other multiple abnormalities
described are
persistent. Clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**Known firstname **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
114 0 96 300/367.71 0 8 144
([**-6/3196**])
Cardiology Report ECHO Study Date of [**2192-6-1**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for CABG
Height: (in) 70
Weight (lb): 245
BSA (m2): 2.28 m2
BP (mm Hg): 145/84
HR (bpm): 63
Status: Inpatient
Date/Time: [**2192-6-1**] at 10:30
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW210-0:0
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.0 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.6 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.9 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderate-severe
regional left ventricular systolic dysfunction. Severely
depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid
inferoseptal - hypo; mid inferior - hypo; anterior apex - hypo;
septal apex -
dyskinetic; inferior apex - hypo; lateral apex - hypo; apex -
akinetic;
RIGHT VENTRICLE: Normal RV chamber size. Focal apical
hypokinesis of RV free
wall.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the
aortic arch. Normal descending aorta diameter. Complex (>4mm)
atheroma in the
descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
Filamentous
strands on the aortic leaflets c/with Lambl's excresences
(normal variant).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data The post-bypass study was performed while the patient was
receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions:
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
There is
moderate to severe regional left ventricular systolic
dysfunction with severe
lateral and anterior apical hypokinesis. There is an area of
dyskinesis in the
septal apex. Mid Septal, and inferior walls are hypokinetic .
Overall left
ventricular systolic function is severely depressed.
3. Right ventricular chamber size is normal. There is focal
hypokinesis of the
apical free wall of the right ventricle.
4. There are complex (>4mm) atheroma in the aortic arch. There
are complex
(>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. There are filamentous
strands on the
aortic leaflets consistent with Lambl's excresences (normal
variant).
6. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
7. Moderate [2+] tricuspid regurgitation is seen. Valve appears
structurally
normal and the annulus measures about 3.8cm in size
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive
infusions including Epinephrine
1. LV function appears markedly improved. Apex and septum are
only mildly
hypokinetic. RV function appears improved.
2. TR is improved to mild.
3. Aortic contours appear intact post decannulation.
4. Other findings are unchanged.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 73002**])
Brief Hospital Course:
Admitted for cath [**5-30**] and underwent cabg x4 on [**6-1**] with Dr.
[**First Name (STitle) **]. Transferred to the CSRU on propofol and epinephrine
drips. extubated that evening and transferred to the floor on
POD #1 to begin increasing his activity level. Beta blockade and
gentle diuresis titrated.Chest tubes and pacing wires removed on
POD #2. Went into A fib on POD #3 and started on amiodarone.
Beta blockade also increased for rate control. Urine culture
final growth negative from pre-op eval. Cleared for discharge to
home with VNA services on POD #5. Pt. is to make all follow-up
appts. as per discharge instructions.
Medications on Admission:
atenolol 50 mg daily
ASA 81 mg daily
MVI one tab daily
added here pre-op:
lipitor 20 mg daily
lisinopril 5 mg daily
thiamine 100 mg daily
folic acid 1 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 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:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 400 daily for one week and then decrease to 200 daily.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
s/p cabg x4
MI
HTN
nephrolithiasis
colon polyps
obesity
postop A fib
PSH: tonsillectomy
Discharge Condition:
stable
Discharge Instructions:
please shower daily and pat incisions dry
no lotions, creams or powders on any incision
call Dr.[**First Name (STitle) **] for fever greater than 100.5, redness or drainage
no driving for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 7842**] in [**12-20**] weeks
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-21**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2192-6-19**]
|
[
"278.00",
"V12.72",
"412",
"V13.01",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"39.61",
"37.22",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9508, 9571
|
7180, 7814
|
331, 410
|
9703, 9712
|
1417, 2739
|
10006, 10355
|
955, 986
|
8026, 9485
|
9592, 9682
|
7840, 8003
|
9736, 9983
|
2765, 7084
|
1001, 1398
|
280, 293
|
438, 684
|
7119, 7157
|
706, 777
|
793, 939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,946
| 165,056
|
26712
|
Discharge summary
|
report
|
Admission Date: [**2151-11-24**] Discharge Date: [**2151-12-2**]
Date of Birth: [**2067-6-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
percutaneous transhepatic catheter placement
History of Present Illness:
84yo female w/ HTN and recent SBO admitted with one week of
high-grade fevers. She went to see her PCP today with 6 days of
fevers to 102-103 despite taking Tylenol at home. She has not
had any cough, congestion, abdominal pain, change in bowel
movements or dysuria. She had had no change in appetite, but had
stopped her Synthroid and antihypertensives. She has not had any
procedures except for dental cleaning one month ago. She has no
sick contacts. The decision was made to check basic labs and
blood cultures and have her go home. After returning home, she
had worsening weakness, began having dry heaves, and seemed
confused to her son, so she came into the [**Name (NI) **].
.
In the ED, initial vs were: 102.9 110 119/63 46 95%. Labs were
notable for elevated LFTs, WBC 9.5 with 16% bands, Cr 1.3 from
baseline 0.8 to 1. Patient was given 4.2L IVF, vanc/zosyn. Her
pressures trended down to SBP 80, so a R IJ was placed and she
was started on Levophed. She had one episode of diarrhea. An
abdominal U/S showed a large liver mass, new from prior,
concerning for liver abscess vs malignancy. After all the
fluids, began having tachypnea and wheezing, but improved with
albuterol.Vitals prior to transfer were 110/50 73 97%2L 23 on
0.12mcg of levophed.
.
On the floor, patient is feeling tired but is alert and
oriented. She denies abdominal pain. All other ROS negative.
Past Medical History:
- hypertension
- hypothyroidism
- hyperlipidemia
- hyperparathyroidism
- severe osteoporosis with insuffiency pelvic fracturs and
vertebral
compression fractures
- spinal stenosis
- s/p proximal humeral fracature [**5-12**] which was managed
conservatively with nonoperative care
- admitted [**Date range (1) 65824**] for high grade small bowel obstruction;
She is s/p repair of incarcerated umbilical hernia causing
obstruction in [**2147**]
- slow-growing right adnexal cystic mass with concerning
appearance, with surgical excision previously recommended; she
declined.
- h/o impaired gastric emptying (had study)
- h/o hiatal hernia, mild gastritis
- right sided DVT [**7-8**] --> popliteal, peroneal, tibial veins -
tx'd with coumadin, lovenox bridge; resolution of dvt documented
[**10-8**] u/s.
Social History:
lives alone, independent with ADLs. walks with a walker. Denies
EtOH, tobacco.
Family History:
no family history of liver disease
Physical Exam:
Tmax: 36.8 ??????C (98.3 ??????F)
Tcurrent: 36.6 ??????C (97.8 ??????F)
HR: 67 (67 - 74) bpm
BP: 122/62(75) {122/62(75) - 135/69(84)} mmHg
RR: 16 (16 - 41) insp/min
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess, no LAD
Lungs: diffuse expiratory wheezes, slight basilar crackles
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Abdomen: obese, soft, mild tender with deep palpation of
bilateral lower quadrants, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Pertinent Results:
Admission labs:
[**2151-11-23**] 06:30PM UREA N-22* CREAT-1.2* SODIUM-137
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
[**2151-11-23**] 06:30PM GLUCOSE-116*
[**2151-11-23**] 06:30PM ALT(SGPT)-113* AST(SGOT)-89* ALK PHOS-182*
TOT BILI-0.7
[**2151-11-23**] 06:30PM CALCIUM-8.4
[**2151-11-23**] 06:30PM WBC-12.3*# RBC-4.07* HGB-11.4* HCT-33.9*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.0
[**2151-11-23**] 06:30PM NEUTS-78.8* LYMPHS-11.2* MONOS-9.6 EOS-0.2
BASOS-0.2
[**2151-11-23**] 06:30PM PLT COUNT-174
[**2151-11-23**] 06:30PM TSH-7.2*
AP CXR: low lung volumes with bibasilar opacities similar to
prior. Increased heart size.
.
RUQ U/S:
1. New 7.1 cm lesion in the right lobe of the liver,
predominantly hypoechoic with echogenic rim. Diff dx includes
necrotic tumor/met, infectious processs vs recent surgery;
correlate with symptoms. Additional imaging such as an MRI may
be obtained for further evaluation.
2. Gallbladder wall edema with wall thickness measuring 6mm and
with trace adjacent free fluid. Gall bladder is not distended,
however findings are concerning for acute cholecystitis in the
correct clinical setting.
.
EKG: sinus rhythm at 94bpm w/ prolonged PR. Normal axis, no ST
changes. Unchanged from 10/[**2149**].
.
CT abdomen [**11-24**]: IMPRESSION:
1. Arterial enhancing hepatic abscess in segment VII of the
liver. This
lesion is amenable to image-guided drainage.
2. Gallbladder wall thickening, which may be compatible with
cholangitis in the correct clinical context. No gallbladder or
bile duct stones.
3. Diffuse colonic diverticula without evidence of
diverticulitis. A CT scan of the pelvis should be obtained to
exclude diverticulitis which may have seated hepatic abscess.
CT Pelvis [**11-24**]: IMPRESSION:
1. Extensive diverticulosis with no evidence of diverticulitis.
2. Lobulated cystic right ovarian lesion, stable since [**Month (only) **]
[**2151**],
slightly increased since [**2148**]. Evaluation with ultrasound could
be performed if clinically indicated.
Echo: [**2151-11-30**]
The interatrial septum is aneurysmal. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No vegetation or abscess seen. Mild mitral
regurgitation. Trace aortic regurgitation
Discharge Labs:
[**2151-12-1**] 05:07AM BLOOD WBC-8.9 RBC-3.68* Hgb-10.2* Hct-30.6*
MCV-83 MCH-27.9 MCHC-33.5 RDW-15.8* Plt Ct-310
[**2151-11-30**] 05:25AM BLOOD Neuts-79.1* Lymphs-14.9* Monos-4.0
Eos-1.6 Baso-0.3
[**2151-12-1**] 05:07AM BLOOD Glucose-116* UreaN-20 Creat-1.1 Na-136
K-4.4 Cl-102 HCO3-29 AnGap-9
[**2151-12-1**] 05:07AM BLOOD ALT-91* AST-41* AlkPhos-87 TotBili-0.7
[**2151-11-30**] 05:25AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.1
Brief Hospital Course:
84yo female w/ HTN and recent SBO admitted with one week of
high-grade fevers and a new 7cm liver lesion.
1. Septic shock: Patient admitted with septic shock secondary to
polymicrobial bactermia with liver abscess. She underwent
initial early goal directed therapy with 4L IV fluid, right IJ
placement with initiation of levophed, and broad spectrum
antibiotics with Vanc/Zosyn. CT abdomen/pelvis was done, showing
an abscess amenable for U/S-guided drainage. IR placed
transcutaneous transhepatic catheter with drainage of purulent
fluid. The CT scan did not show any diverticulitis or other
potential source for bacteremia. Despite some mild gall bladder
thickening, the surgery team did not feel that there was
cholecystitis. CEA and alpha-fetoprotein were normal. TTE
showed no evidence of endocarditis as source of infection.
Following drain placement, septic physiology resolved and
patient was able to wean off pressors. Patient became afebrile,
leukocytosis resolved and LFTs slowly normalized. Purulent
fluid from liver abscess grew fusobacterium and blood cultures
returned with strep anginosus and fusobacterium. Vancomycin/
zosyn was tailored to zosyn and then to ertapenem on discharge.
Picc line was placed once patient was afebrile for > 24 hrs and
blood cultures were negative.
Patient will need 4 weeks of ertapenem ([**2151-12-1**] - [**2151-12-30**])
with weekly monitoring of CBC, BMP and LFTs. She will need a CT
scan in 3 weeks to ensure resolution of abscess prior to
discontinuation of antibiotics/ drain. She will need to have
transhepatic drain in place until follow up with surgery in
approximately 6 weeks. In addition, an ongoing investigation is
recommended for source of initial infection, in particular she
will need full dental evaluation.
2. Tachypnea: on admission, patient was noted to be tachypneic,
and had intermittent wheezing and respiratory distress through
ICU stay. On [**11-25**] she required non-invasive positive-pressure
ventilation in the setting of severe tachypnea. Respiratory
distress was felt to be multifactorial from reactive airways
disease (despire no hisotory of asthma/ COPD), atelectasis from
shallow breathing and b/l pleural effusions in the setting of
volume resuscitation and sepsis.
On [**11-26**], she was started on solumedrol for empiric treatment of
reactive airway disease which was changed to inhaled steriod on
[**11-28**] as there was no improvement in symptoms. On [**11-27**] she had
a lung CT which showed bilateral effusions and airspace disease
from likely atelectasis. She was diuresed gently given acute
kidney injury and respiratory status improved. By time of
discharge, patient was breathing comfortably on room air.
3. Rash: On [**11-30**] patient was noted to have an erythematous
puritic rash on her back. Dermatology was consulted and thought
that the rash represented miliaria in the setting of prolonged
bedrest although a localized allergic reaction could not be
excluded. Patient was treated conservatively with triamcinolone
cream and sarna lotion prn with significant improvement in
symptoms. Of note, during this time zosyn was also changed to
ertapenem. It is unlikely that the change in antibiotics
resulted in improvement in rash as there were no systemic signs
of an allergic reaction.
4. Acute kidney injury: In the setting of severe septic shock,
patient did have limited acute kidney injury with creatinine
rising from baseline of 0.9 - 1 to 1.3. Resolved with
supportive care and avoidence of nephrotoxins.
5. Hypothyroidism: continued synthroid
6. CAD: held antihypertensives, ASA and simvastatin in acute
setting but home medications were restarted near end of hospital
course
7. ovarian mass: detected incidentally on imaging and will need
outpatient f/u
Transitional Issues:
Polymicrobial liver abscess
- cont antibiotics x 4 weeks with ID f/u
- reimaging CT scan in 3 weeks: pt will need to be NPO 2 hrs
prior to scan
- keep drain in place until surgery f/u
- dental eval
ovarian mass
- dedicated evaluation/ imaging as outpatient
Medications on Admission:
- amlodipine 5mg daily
- celecoxib 100mg [**Hospital1 **]
- desonide 0.05% lotion to affected ear canal
- vitamin D2 50,000 units
- fluticasone nasal spray
- ketoconazole 2% shampoo
- levothyroxine 37.5 mcg daily
- lorazepam 0.25 to 0.5mg QHS PRN
- ranitidine 150 to 400mg [**Hospital1 **] PRN
- risedronate 35mg weekly
- simvastatin 20mg QHS
- Tylenol 650mg TID PRN
- Aspirin 81mg daily
- calcium/vit D3 600mg/200units daily
- Capzasin gel [**Hospital1 **]
- milk of magnesia
- senna
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
3. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
daily () for 4 weeks: end date: [**2151-12-2**]
.
4. triamcinolone acetonide 0.025 % Ointment Sig: One (1) Appl
Topical DAILY (Daily) as needed for itching: apply to
erythematous papules .
5. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
11. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
12. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for GERD.
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
15. Outpatient Lab Work
please check CBC, basic metabolic panel, LFTs every week for the
duration of antibiotic therapy. 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**] or to on [**Name8 (MD) 138**] MD
in when clinic is closed
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Septic Shock
Polymicrobial liver abscess
Strep anginosus and Fusobacterium bacteremia
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 65825**],
You were admitted to the hospital with a severe infection caused
by an abscess in your liver. A drain was placed in the abscess
by surgery, you were treated with antibiotics and your symptoms
improved. You developed a rash during your hospital stay which
was most likely caused by sweating. You will need to take
antibiotics for at least 4 weeks. The liver drain should be
left in place until you see the surgeons in follow up. You
should also be assessed by a dentist as the bacterial infection
in your liver may have come from your teeth.
Please make the following changes to your medication regimen:
START ertapenem 1gm daily for 4 weeks (end date: [**2151-12-30**]). **
You will need to have weekly labs monitored while on this
antibiotic
START triamcinolone lotion as needed for generalized itching
START lidocaine patch as needed for back pain
You were also started on a variety of medications to treat
constipation which can worsen during hospitalization
Please continue the rest of your medications as previously
prescribed
It was a pleasure taking care of you during this
hospitalization.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital3 249**] [**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
Department: TRANSPLANT CENTER
When: FRIDAY [**2151-12-24**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2151-12-15**] at 3:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2151-12-16**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"564.00",
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icd9cm
|
[
[
[]
]
] |
[
"87.51",
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icd9pcs
|
[
[
[]
]
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13119, 13189
|
6778, 10567
|
312, 359
|
13338, 13338
|
3558, 3558
|
14686, 16114
|
2703, 2739
|
11382, 13096
|
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|
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|
13229, 13317
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13353, 13497
|
1788, 2591
|
2607, 2687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,946
| 107,407
|
39147
|
Discharge summary
|
report
|
Admission Date: [**2199-1-2**] Discharge Date: [**2199-1-14**]
Date of Birth: [**2143-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Lethargy, severe ulceration of pannus on right side
Major Surgical or Invasive Procedure:
Skin [**First Name3 (LF) **] debridement by plastic surgery service
History of Present Illness:
[**Known firstname 803**] [**Known lastname 60400**] is a 55 year old morbidly obese woman who was
lost to medical care who was taken to [**Hospital3 **] ED when her
son called 911 due to concern over her recent decline in mental
status and mobility. Per son, she had been depressed the last
several months and then bedbound the last 3.5 weeks secondary to
fatigue. She had complained of chronic SOB but no other
localizing symptoms. Her son and sister tried to care for her
and encouraged her to go to ED but she refused secondary to
embarassment. Her son also [**Name2 (NI) 86727**] decreased PO intake the last
several days and confusion on day of admission. They gave her
two weeks to try ambulating on her own but when she remained
bedbound yesterday, called 911. After being removed from her
trailer, she was initially taken to [**Hospital3 **] and noted to
have necrotic pannus ulcers so was transferred to [**Hospital1 18**] for
plastic surgery evaluation for debridement and possible skin
grafts. Prior to transfer, a triple lumen power PICC was placed
and she was given flagyl and unasyn.
In our ED, initial vs were: T 97.1 HR 102 BP 96/40 RR18 SaO2%96.
She was noted to drop her oxygen saturations with movement and
transport so was placed on NRB but sats later 95%RA. She was
seen by plastics and had wounds debrided which were noted to be
foul-smelling but did not appear infected. She was given
morphine 4mg IV x 3 and vancomycin 1g IV. She had an isolated
drop in BP 55/32 with morphine which responded to IVF. ABG drawn
for labs and reportedly mixed venous and arterial and blood cx
drawn. She received 4L NS. VS prior to transfer: 124/62 101 18
100%2L
On the floor, reports fatigue and not feeling well but denies
fevers, chills, N/V/D, abdominal pain, SOB, chest pain.
Past Medical History:
Hypertension
Morbid obesity
Social History:
Lives alone in trailer. Has son [**Name (NI) **]. Denies ETOH use and
quit tobacco 1 year ago. Smoked x 30 years. Used to work in
retail ([**Company **]) but now on disability. Has dog. Her sister
[**Name (NI) **] [**Name (NI) 68224**] ([**Telephone/Fax (1) 86728**]-Home; [**Telephone/Fax (1) 86729**]-Work) is also
involved.
Family History:
None stated.
Physical Exam:
Vitals: T: 124/62 101 18 100%2L
General: Somnolent but arousable, slightly tachypneic and easily
agitated, no acute distress, morbidly obese
HEENT: Sclera anicteric, MM very dry, oropharynx with dried
exudate
Neck: supple, unable to assess JVP
Lungs: Distant breath sounds. Clear to auscultation anteriorly
CV: Regular rate and rhythm, normal S1, fixed split S2, no
murmurs, rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
GU: foley in place
Ext: warm, [**11-24**]+ edema B/L with chronic vensou stasis changes, 1+
pulses, no clubbing, cyanosis
Skin: Right pannus and groin/thigh ulcers with foul smelling,
purulent exudate and erythema; dsg with serosanguinous drainage.
No eschars noted.
Neuro: Somnolent but arousable. Initially not oriented (unsure
where she was and stated month was [**Month (only) **] but later oriented
to [**Location (un) 86**] and year [**2198**]). Perseverating on asking for water and
complaining of thirst. Unable to relate accurate history. MAE.
Normal muscle bulk and tone. CN grossly intact
Exam on transfer to floor:
VSS, afebrile, normotensive
alert, oriented to self, [**Hospital1 18**], month and year, not always day
of week. Not able to relay all the recent events but able to
converse with staff and family, frequently tearful with family
CV and lung exam unchanged
Skin: right pannus and groin thigh ulcers without any obvious
purulence, full thickness ulcers with exposed adipose tissue,
some areas necrotic alternating with pink tissue
Exam on discharge:
Tmax 98.9 BP 139/76 HR 80 RR 20 O2 93%-96% on Room Air
Alert, anxious about transfer to another facility
RRR
CTAB
Abdomen soft and nontender except for tender skin around ulcers
Pannus with large ulceration, no surrounding erythema, no
purulence
G/U: White chunky discharge from vagina (pt denies vaginal
itching)
Pertinent Results:
[**2199-1-2**]
BLOOD WBC-22.0* Hgb-12.8 Hct-41.0 MCV-97 RDW-13.9 Plt Ct-716*
Neuts-81.9* Bands-0 Lymphs-9.3* Monos-8.5 Eos-0.3 Baso-3.2*
Glu-163* UreaN-103* Creat-1.8* Na-130* K-4.7 Cl-94* HCO3-15*
AnGap-26*
ALT-33 AST-59* CK(CPK)-[**2217**]* AlkPhos-86 TotBili-0.6
ALBUMIN 2.3
%HbA1c-6.7* eAG-146*
TSH-0.68
[**2199-1-13**] PT: 26.5 PTT: 73.9 INR: 2.6
[**2199-1-14**] PT-45.4* INR(PT)-4.9*
CXR [**2199-1-3**]:
IMPRESSION: Enlarged left pulmonary artery, of indeterminant
chronicity. If this is a new finding it could reflect recent
pulmonary emboli.No evidence of pneumonia. Findings were
discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of approval.
ECHO [**2199-1-4**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is dilated with normal free wall
contractility. The aortic root is moderately dilated at the
sinus level. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is zt least
moderate pulmonary artery systolic hypertension.
IMPRESSION: Suboptimal image quality. Dilated right ventricle;
moderate (or more) pulmonary hypertension
RUE U/S
IMPRESSION: Extensive right upper extremity deep venous thrombus
extending
from the right subclavian vein to the right axillary and the
duplicated
brachial veins. Occlusive thrombus within the right basilic
vein.
Bilateral LE U/S
IMPRESSION: Nondiagnostic examination of lower extremity veins
due to
patient's body habitus and discomfort during the exam. Normal
color flow
within the right common femoral vein.
Brief Hospital Course:
55 year old female with morbid obesity and hypertension admitted
to [**Hospital Unit Name 153**] with transient hypotension, lethargy and pressure ulcers
now s/p debridement by plastics. Patient transiently hypotensive
in ED after morphine but remainder of SBPs in 110s-120s so
likely related to morphine as well as significant component of
dehydration by labs and exam. After IVF boluses pt remained free
of hypotension for the remainder of stay. Pt ruled out for MI.
PROBLEM LIST:
# Severe ulcerations: See detailed assessment and
recommendations below.
# RUE DVT in the presence of power PICC line, removed on [**1-10**].
Bridged with heparin gtt until INR>2. Coumadin 5mg given daily.
[**1-13**] INR 2.6, [**1-14**] INR 4.9. Coumadin held on [**2199-1-14**].
Recommend trending INR at LTAC and resuming Coumadin when
appropriate for a goal INR [**12-26**].
# Hypokalemia: KCl repleted orally, usually 40 mEq daily.
# Hypophosphatemia: Supplemental Neutrophos
# Vaginal candidiasis: Vaginal discharge noted on exam [**2199-1-14**]:
Patient without complaint for vaginal itching or discomfort.
Given one dose of fluconazole 200mg for candidiasis.
# Pulmonary HTN: seen on Echo, not previously known, pt may have
sleep apnea due to habitus but this has not yet been worked up.
Given that patient has a DVT as well, should consider PE if
condition worsens.
- Will need outpt follow-up sleep study
- Outpatient pulmonary hypertension workup.
# Depression, psychiatric, social situation: psychiatry
consulted for pt's anxiety and depression, started on celexa
which has now been titrated to 20 mg daily. SW for concern
about social situation, concern that she was immobile in home
for prolonged period at home and was not able to seek or obtain
proper care.
# SVT: Pt had an episode of SVT in ICU, reportedly brief run.
Now on metoprolol. Pt has had no further episodes of SVT
# HTN: currently normotensive, on metoprolol (for episode of
SVT)
# Recent acute renal failure: Cr elevated on admission, likely
prerenal +/- rhabo, urine lytes in ICU were consistent with
prerenal. Now resolved after hydration
#Glucose intolerance with mild elevated HgBa1c 6.7. Pt does not
know of a prior history of DM.
# Altered mental status: appeared altered and delirious on
presentation but this has resolved after treatment of infection.
TSH and B12 wnl
# PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**Location (un) **] - she has never seen this physician
but he took over the practice of her prior PCP who retired.
[**Name (NI) 1094**] sister said that Dr. [**First Name (STitle) **] would be willing to assume her
care when she is an outpt
# Communication: Patient, son [**Name (NI) **] [**Telephone/Fax (1) 86730**]. Also
has a sister [**Name (NI) **] [**Name (NI) 68224**] who is involved
([**Telephone/Fax (1) 86728**]-Home, [**Telephone/Fax (1) 86729**]-Work)
# Stage 4 Pressure Ulcers and panniculitis: Patient appears to
have developed severe pressure ulcers from large pannus and
immobility. Unasyn and vancomycin (started on [**2199-1-2**]) given
severe skin findings, leukocytosis and no other obvious source.
Vancomycin was discontinued on [**2199-1-8**] and Unasyn was continued
until further discussion with plastics, at which point it was
decided that she no longer appeared to have active infeciton.
Unasyn discontinued on [**2199-1-10**]. There was some initial concern
for possible deeper penetration of the ulcers, however pt would
be unable to fit in CT scanner and morevoer would not be an
operative candidate for deeper [**Date Range **] debridement in the
operating room. Plastic Surgery performed bedside debridement on
[**1-4**] and [**1-8**], [**1-11**], and [**1-14**].
- Continue foley and rectal tube to maintain clean [**Month/Year (2) **]
- Bowel regimen to maintain functioning rectal tube
- Vitamin C, Zinc
- Pain control with scheduled oxycodone and prn morphine before
dressing changes
- F/u with Plastics as outpatient (many on their team are
familiar with her care including Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
Here is the [**Last Name (NamePattern1) **] assessment by Surgery:
[**Last Name (NamePattern1) **] ASSESSMENT on [**2199-1-14**]:
Pannus: full-thickness ulcer: irregular, 30 x 26 cm, 10% black
necrotic tissue, 30 % yellow tissue, 60 % beefy red
granulation,large amount yellow exudate, no odor, edges
irregular
and attached, periwound skin intact, darker pigmentation changes
related to old injury, induration present, no fluctuance.
Right lateral thigh ulcer: full-thickness, irregular 10x14 cm,
80% yellow tissue, 20% beefy red granulation buds present, edges
attached, no odor, small yellow exudate, peri [**Date Range **] skin intact,
dry, no induration or fluctuance.
Proximal right thigh ulcer: 9x7cm, irregular, 90% beefy red
granulation, 10% yellow tissue, small yellow exudate, no odor,
edges attached, peri [**Date Range **] skin, no induration or fluctuance.
Lateral pannus ulcer: two small stage III, 3 x 1 cm, 1 x 0.5 cm,
90% pink, 10% yellow, edges attached, small yellow exudate, no
odor, peri [**Date Range **] intact, no fluctuance.
Perineum: Resolving perineal dermatitis from stooling, and
increase moisture. Much improved.
Patient premedicated with pain medication for sharp debridement
of pannus and right lateral thigh [**Date Range **]. Tolerate procedure
well.
Debridement every other day, much improved since admission to
[**Hospital1 18**].
Mid-pannus: large area of cellulitic skin, which has been marked
with marking pen, skin intact, no induration or fluctuance,
bears
watching.
Intergluteal ulcer: small linear stage II, related to
friction/shearing, stripping of epidermis, bed is pink, edges
macerated, no drainage.
Goals of [**Hospital1 **] care:Prevent Infection, Pressue Redistribution,
Decrease bacterial bio burden [**Hospital1 **] beds, sharp debridement,
healing by secondary intention.
[**Hospital1 **] CARE RECOMMENDATIONS on [**2199-1-14**]:
Pressure relief per pressure ulcer guidelines
Support surface Mighty Air
Lift system for positioning and OOB.
Turn and reposition every 1-2 hours off back
Heels off bed surface at all times Waffles
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion Bariatric cushion
Elevate LE's while sitting.
Moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta ointment.
Commercial [**Hospital1 **] cleanser all open wounds.
Pat the tissue dry with dry gauze.
D/C 1/4 strength Dakins.
Pannus Ulcer: pack loosely with wet to dry normal saline
Kerlix.
Protect peri [**Hospital1 **] skin with critic-aid antifungal ointment.
Cover with large Soft sorb dressings, and place [**Doctor First Name **] binder
to secure dressing. Dressing change [**Hospital1 **].
Right medial thigh ulcer: Apply no-sting barrier wipe peri
[**Hospital1 **]
skin. Pack loosely with wet to dry normal saline Kerlix
dressing. Cover with Soft sorb dressing, secure with Medipore
tape. Change [**Hospital1 **].
Right lateral thigh ulcer: apply Xeroform dressing to [**Hospital1 **]
bed,
apply no-sting barrier wipe Cavilon to peri [**Hospital1 **] skin, cover
[**Hospital1 **] with 4x4's, soft sorb, and secure with Medipore tape.
Change daily.
Right proximal thigh ulcers: Apply no-sting barrier wipe to
peri
[**Hospital1 **] skin. Apply small amount of DuoDerm [**Hospital1 **] gel to each
[**Hospital1 **] bed. Cover with 4x4 Mepilex dressing. Change every 3rd
day.
Perineum: Cleanse skin with Aloe Vesta foam cleanser. Pat dry.
Apply critic-aid antifungal to area. Re-apply after each 3rd
cleansing.
Intergluteal ulcer: apply critic-aid clear skin barrier
ointment daily, re-apply after each 3rd cleansing.
Separate pannus with large folded sheet, to prevent skin
against skin.
Nutritional consult - albumin 2.3
Support nutrition and hydration.
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous [**Hospital1 **] (2 times a day).
12. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Morphine 100 mg/4 mL Solution Sig: 4-6 mg Intravenous Q4H
(every 4 hours) as needed for pain >[**7-2**] or [**Month/Year (2) **] care/turning.
15. Outpatient Lab Work
Please check Chem 10, CBC, and INR daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 1456**]
Discharge Diagnosis:
Stage 4 pressure ulcers - abdominal wall, right groin, right hip
Panniculitis, cellulitis
Morbid obesity
Right upper extremity deep vein thrombosis
Hyperkalemia
Hyperphosphatemia
Hypertension
Vaginal candidiasis
Depression
Pulmonary hypertension
Supraventricular tachycardia
Discharge Condition:
Mental Status: Alert and oriented x 3
Ambulatory status: Bedridden given large body habitus
Tolerating regular diet
Discharge Instructions:
You will be going to a facility which will provide continued
care for your ulcer wounds. Please follow-up with plastics
surgery.
When you are well enough to leave the facility (or if this can
be arranged there), we recommend that you undergo a sleep study
to determine if you might have sleep apnea. We also found you
to have Pulmonary Hypertension and this should be re-evaluated
as well.
Followup Instructions:
Your facility will continue to provide appropriate [**Location (un) **] care
and debridement as needed. The facility should also assist you
in arranging a follow-up appointment in plastics surgery clinic
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9144**] or one of his associates
You have informed us that your prior PCP has retired but that
his colleague Dr. [**First Name (STitle) **] would be willing to be your new PCP.
[**Name10 (NameIs) 357**] schedule an appointment with him when you have left the
facility:
[**First Name11 (Name Pattern1) 4768**] [**Last Name (NamePattern1) 86731**], M.D.
[**Location (un) 86732**], [**Numeric Identifier 73722**]
([**Telephone/Fax (1) 86733**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,542
| 117,107
|
33748
|
Discharge summary
|
report
|
Admission Date: [**2196-11-17**] Discharge Date: [**2196-11-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old female with history of dementia, recent
hospitalization for fall/UTI/CHF, diagnosed at rehab the day
prior to admission with C difficile, presented with hypotension
(70s SBP), tachypnea, and tachycardia (140s). Labs showed
lactate 6.4, WBC 17.2 with 23% bands, elevated LFTs,
tense/distended abdomen. CT abdomen showed diffuse infectious vs
ischemic colitis. ED attending Dr. [**Last Name (STitle) 78073**] spoke with son/HCP
over phone and confirmed DNR/DNI status. Son wanted to continue
supportive care until he and his wife could reach the hospital,
with plan to focus on comfort care after that point. Central
line was placed with 4L IVF given and CVP 8-12. Phenylephrine
was then started for persistent hypotension. She received
vancomycin, piperacillin-tazobactam, and metronidazole. VS prior
to ICU transfer were: 82/48, 90-100s, 20-28 on 12 liters FM. In
the ICU, the patient was awake, but speech was infrequent and
incoherent.
Past Medical History:
Orthostatic hypotension (diagnosed [**12/2194**])
Chronic kidney disease, stage 3 -baseline Cr 1.5
Dementia
HTN
CHF
Chronic venous insufficiency
Gout
Iron deficiency anemia
Social History:
Lived in [**Hospital3 **]. No recent alcohol or tobacco use. Per
prior notes, son [**Name (NI) **] [**Name (NI) 78071**] [**Telephone/Fax (1) 78072**] is very involved and
helpful in her care. He is listed as next of [**Doctor First Name **] and was co-HCP
with his brother in [**Name (NI) 5256**].
Family History:
Unable to obtain due to dementia
Physical Exam:
GENERAL: Elderly woman on non-rebreather, does not respond
appropriately verbally but does moan in discomfort
CARDIAC: RRR no m/r/g
LUNGS: CTAB
ABDOMEN: NABS. Soft, diffusely TTP without rebound or guarding,
very distended and tympanitic.
EXTREMITIES: 2+ LE edema. Cool distal extremities. LLE with leg
brace.
Pertinent Results:
[**2196-11-17**] 07:56PM LACTATE-3.3*
[**2196-11-17**] 07:56PM TYPE-ART TEMP-36.6 O2 FLOW-12 PO2-281*
PCO2-55* PH-7.20* TOTAL CO2-22 BASE XS--6 INTUBATED-NOT INTUBA
COMMENTS-NON-REBREA
[**2196-11-17**] 01:45PM PT-13.3 PTT-32.7 INR(PT)-1.1
[**2196-11-17**] 01:45PM PLT SMR-NORMAL PLT COUNT-337
[**2196-11-17**] 01:45PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ SCHISTOCY-1+
[**2196-11-17**] 01:45PM NEUTS-52 BANDS-23* LYMPHS-14* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0 NUC RBCS-5*
[**2196-11-17**] 01:45PM WBC-17.2*# RBC-5.10 HGB-12.0 HCT-39.6
MCV-78*# MCH-23.6* MCHC-30.3*# RDW-18.2*
[**2196-11-17**] 01:45PM CORTISOL-113.6*
[**2196-11-17**] 01:45PM cTropnT-0.02*
[**2196-11-17**] 01:45PM ALT(SGPT)-65* AST(SGOT)-136* CK(CPK)-51 ALK
PHOS-73 AMYLASE-154* TOT BILI-0.2
[**2196-11-17**] 01:56PM LACTATE-6.4*
Brief Hospital Course:
The patient was maintained on phenylephrine, which was started
in the ED, until her son and daughter-in-law arrived for a
family meeting and to spend some time with her. The patient's
son, who is her health care proxy, expressed that the patient
would choose to have Comfort Measures Only if she could make the
decision for herself. She was started on an IV morphine drip,
titrated to comfort. The phenylephrine was stopped in the late
evening on [**11-17**]. Her blood pressure dropped quickly to the 40s
systolic and MAPs in the mid 40s, where she remained until about
6am. The patient was saturating 100% on a non-rebreather; her
respiratory rate slowly decreased. She passed at 7:05AM on
[**2196-11-18**] with no heart beating on the telemetry. The patient was
examined at that time with her daughter-in-law at the bedside.
The patient's son declined post-mortem autopsy.
Medications on Admission:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit 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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
superior part of shoulder.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
anterior part of knee.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Acetaminophen 500 mg/5 mL Liquid Sig: 1000 (1000) MG PO
every eight (8) hours: for arthritis pain.
16. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO Once Daily at 4 PM.
17. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO Q8H (every 8 hours) as needed for confusion,
insomnia.
18. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO HS (at bedtime).
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock secondary to Clostridium Difficile Colitis
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"276.2",
"428.0",
"459.81",
"274.9",
"995.92",
"038.9",
"294.8",
"785.52",
"403.90",
"008.45",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5817, 5826
|
3077, 3961
|
280, 286
|
5926, 5936
|
2175, 3052
|
5989, 5997
|
1796, 1830
|
5788, 5794
|
5847, 5905
|
3987, 5765
|
5960, 5966
|
1845, 2156
|
225, 242
|
314, 1266
|
1288, 1463
|
1479, 1780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,441
| 192,486
|
44525+44526
|
Discharge summary
|
report+report
|
Admission Date: [**2178-6-15**] Discharge Date: [**2178-6-20**]
Date of Birth: [**2120-7-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
L thigh tightness/pain
Major Surgical or Invasive Procedure:
7/24 L thigh fasciotomy
[**6-16**] Washout and partial closure of L thigh fasciotomy
[**6-16**] IVC filter placement
[**6-18**] Washout and complete closure of L thigh fasciotomy
History of Present Illness:
Mr. [**Known lastname 50388**] is a 57 year old man who was walking his dog and
fell, he was injected with Lidocaine by a neighbor, and then
went on to develop severe pain and edema in thigh. He then came
to [**Hospital1 18**] EW for further care.
Past Medical History:
Hepatitis B/C
former IV Drug user
Pneumonia
Social History:
n/a
Family History:
n/a
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp / Upper thigh swelling / wound c/d/i
Pertinent Results:
[**2178-6-20**] 06:55AM BLOOD
WBC-7.2 RBC-3.80* Hgb-11.2* Hct-32.1* MCV-85 MCH-29.5 MCHC-34.9
RDW-15.4 Plt Ct-186
[**2178-6-20**] 06:55AM BLOOD
Plt Ct-186
[**2178-6-19**] 06:25AM BLOOD
Glucose-112* UreaN-12 Creat-0.9 Na-136 K-4.1 Cl-96 HCO3-31
AnGap-13
[**2178-6-14**] 10:07 PM
CT LOW WXT W/C LEFT
FINDINGS: There is a large mixed density collection extending
from the upper posterior thigh within the hamstring muscle group
down to the mid thigh with associated fat stranding measuring
7.3 x 9.3 x 11.6 cm likely representing a hematoma. Fat
stranding is seen extending down posteriorly into the popliteal
fossa where there is a thrombus seen of the popliteal vein
beginning posterior to the knee and extending inferiorly out of
the plane of view. There is no evidence of fracture or
malalignment.
IMPRESSION:
1. Large intramuscular posterior thigh hematoma.
2. Left popliteal venous thrombus.
[**2178-6-14**] 8:22 PM
BILAT HIPS (AP,LAT & AP PELVIS; FEMUR (AP & LAT) LEFT
SEVEN VIEWS OF THE HIPS INCLUDING AP PELVIS:
There is no fracture or dislocation. The joint spaces of the
hips are preserved. The sacroiliac joints and pubic symphysis
are unremarkable. Surrounding osseous and soft tissue structures
are within normal limits.
IMPRESSION:
No evidence of fracture or dislocation.
Brief Hospital Course:
Pt admitted on [**6-15**]
57 y.o. who slipped and fell while walking his dog [**2178-6-13**]. Pt
felt some tightness around posterior aspect of thigh. Evaluated
for compartment syndrome of thigh
Medial 14, Anterior 18, Posterior 56, 51
[**6-15**]:
OR fasciotomy L thigh, f/u 2200 Hct 24.8 2 units PRBCs
-post-transfusion Hct 26.5 , q6 hr PTT Heparin goal of 60
[**6-16**]:
OR for partial closure and IVC filter
[**6-17**]:
Hct 22.7 2 units PRBCs/post transfusion Hct 28.5
[**6-17**]:
transfer to floor
[**6-18**]:
washout + closure of wound
[**6-19**]
stable
[**6-20**]
Anticoagulation / to be dc'd on lovenox
Medications on Admission:
[**Last Name (un) 1724**]: none
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): please take 70 mg / 0.7 ml [**Hospital1 **].
Disp:*60 Enoxaparin (Subcutaneous) 80 mg/0.8 mL Syringe*
Refills:*2*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
L leg compartment syndrome
L popliteal vein DVT
Post operative anemia requiring 4units PRBC's
Discharge Condition:
Stable
Discharge Instructions:
Keep incisions clean, dry, and intact.
If you have a fever greater than 101.5, notice any increased
swelling or redness, call your doctor or go to the emergency.
Resume all your pre hospital medications.
Physical Therapy:
Activity: Ambulate
Left lower extremity: Full weight bearing
Treatments Frequency:
Site: left leg
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Other
Dressing: Gauze - dry
please check wound site for bleeding and or oozing / If the
wound site is blleding (pt on lovenox) / please call Dr
[**Last Name (STitle) 20555**] office
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital1 18**] orthopedic
clinic. Call [**Telephone/Fax (1) **] to make that appointment.
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ENDOSCOPY SUITES Date/Time:[**2178-10-23**]
9:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2178-10-23**] 9:00
Call Dr [**Last Name (STitle) **] office and schedule an appoinment for2-3 months
to have your IVC filter removed. She can be reached at
[**Telephone/Fax (1) 2395**].
Completed by:[**2178-6-20**] Admission Date: [**2178-6-24**] Discharge Date: [**2178-6-26**]
Date of Birth: [**2120-7-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Left thigh swelling
Major Surgical or Invasive Procedure:
[**2178-6-24**]: Incision and drainage left thigh, compartment release
[**2178-6-26**]: Closure of fasciotomies
History of Present Illness:
This is a 57 year old male who had a recent admit on [**2178-6-13**] for
compartment syndrome secondary to a hematoma in his thigh. He
had a fasciotomy + IVC filter placement on [**2178-6-15**], was closed
on [**2178-6-18**], and discharged without incident on [**2178-6-20**].
Readmitted on [**2178-6-24**] for bleeding into L thigh.
Past Medical History:
Hepatitis B/C
former IV Drug user
Pneumonia
Social History:
n/a
Family History:
n/a
Physical Exam:
Upon admit:
AVSS
A+O
uncomfortable
CTA b/l
RRR
S/NT/ND/+BS
L thigh: tense around surgical incision
NVI distally
no pallor
2+ DP
Pertinent Results:
[**2178-6-24**] 09:21PM HCT-30.9*#
[**2178-6-24**] 09:00AM GLUCOSE-135* UREA N-25* CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2178-6-24**] 09:00AM ALT(SGPT)-66* AST(SGOT)-56* CK(CPK)-296* ALK
PHOS-46 TOT BILI-0.9
[**2178-6-24**] 09:00AM WBC-11.5* RBC-2.83* HGB-8.7* HCT-23.7* MCV-84
MCH-30.7 MCHC-36.7* RDW-15.4
[**2178-6-24**] 09:00AM PLT COUNT-254
[**2178-6-24**] 09:00AM PT-12.5 PTT-24.9 INR(PT)-1.1
[**2178-6-24**] 12:54AM TYPE-[**Last Name (un) **] O2 FLOW-33 PH-7.40
INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-PERIPHERAL
[**2178-6-24**] 12:54AM LACTATE-2.4*
[**2178-6-24**] 12:54AM HGB-9.1* calcHCT-27
[**2178-6-24**] 12:54AM freeCa-1.10*
[**2178-6-23**] 10:58PM GLUCOSE-161* UREA N-27* CREAT-1.0 SODIUM-134
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13
[**2178-6-23**] 10:58PM WBC-17.3*# RBC-3.61* HGB-11.0* HCT-29.6*
MCV-82 MCH-30.5 MCHC-37.1* RDW-15.2
[**2178-6-23**] 10:58PM NEUTS-88.0* LYMPHS-7.4* MONOS-4.1 EOS-0.4
BASOS-0.2
[**2178-6-23**] 10:58PM PLT COUNT-341#
Brief Hospital Course:
The patient was seen in the emergency room on [**2178-6-24**] (early am)
and taken to the operating room emergently for a washout and
compartment release. See operative note for details. He
tolerated the procedure well. He was extubated and brought to
the recovery room in stable condition. Once stable in the PACU
he was transferred to the floor. On [**2178-6-24**] he was transfused 2
units for a hematocrit of 23. This brought his Hct up to 30.9.
On [**2178-6-25**] he was taken to the operating room for closure of his
fasciotomies. See operative note for details. He tolerated the
procedure well. He was extubated and brought to the recovery
room in stable condition. Once stable in the PACU he was
transferred to the floor. On the floor he did well. He was
evaluated by physical therapy and progressed well. His pain was
well-controlled. His labs and vital signs remained stable. His
hospital course was otherwise without incident. He is
discharged today in stable condition.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take for constipation while on pain meds.
Disp:*60 Capsule(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4hours as
needed.
Disp:*90 Tablet(s)* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left thigh hematoma
Post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. Dry sterile dressing daily
as needed. If you notice any increased redness, swelling,
drainage, temperature >101.4, or shortness of breathe please
[**Name8 (MD) 138**] MD or report to the emergency room. Take all medications
as prescribed. You may resume any normal home medication.
Please follow up as below. Call with any questions.
Physical Therapy:
Full weight bearing, weight bearing as tolerated left leg
Treatments Frequency:
Dry dressings changes daily and as needed
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call
[**Telephone/Fax (1) **] to make that appointment.
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ENDOSCOPY SUITES Date/Time:[**2178-10-23**]
9:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2178-10-23**] 9:00
Completed by:[**2178-6-26**]
|
[
"998.12",
"070.54",
"958.8",
"285.1",
"453.8",
"E885.9",
"070.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"99.04",
"83.09",
"83.65",
"38.7",
"83.45"
] |
icd9pcs
|
[
[
[]
]
] |
8858, 8907
|
7429, 8428
|
5580, 5694
|
8993, 9002
|
6359, 7406
|
9565, 9952
|
6164, 6169
|
8451, 8835
|
8928, 8972
|
3422, 3455
|
9026, 9401
|
6184, 6340
|
9419, 9477
|
9499, 9542
|
5521, 5542
|
5722, 6059
|
6081, 6126
|
6142, 6148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,121
| 141,982
|
53078
|
Discharge summary
|
report
|
Admission Date: [**2201-3-31**] Discharge Date: [**2201-4-7**]
Date of Birth: [**2127-12-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for evacuation of L SDH
Major Surgical or Invasive Procedure:
[**2201-3-31**]: Left mini-crani for SDH evacuation
History of Present Illness:
73M initially admitted on [**2201-3-13**] for a L SDH, family felt he
was more confused. He was discharged home on [**2201-3-14**] and
returned to clinic on [**3-26**] where surgical evacuation was
discussed as SDH was becoming chronic.
Past Medical History:
HTN, hypercholesterolemia, dementia
Social History:
Lives with family
Family History:
nc
Physical Exam:
On admission:
Oriented to self, otherwise nonfocal neuro exam.
On Discharge:
A&o to self
expressive apasia
PERRL EOMs intact
R side neglect, but full strength throughout
No pronator drift
Incision c/d/i
Pertinent Results:
[**2201-3-30**] NCHCT
1. Stable extent and appearance of a left frontoparietal
subdural hematoma,
subacute-chronic.
2. Stable mild left frontoparietal sulcal effacement and 6 mm
rightward
shift.
3. No new hemorrhage or increased mass effect.
[**2201-3-31**] Head CT:
1. Status post evacuation of subdural, which has decreased in
size with small residual subdural identified as described above.
Decrease in mass effect is seen. No new hemorrhage seen.
NCHCT [**2201-4-1**]
1. Increase in left subdural fluid collection, with worsening
rightward subfalcine herniation and shift.
[**2201-4-2**] NCHCT
1. Stable left subdural fluid collection compared to [**4-1**],
[**2201**].
[**2201-4-3**] NCHCT
1. Stable appearance of left subdural fluid collection.
[**2201-4-6**] NCHCT
1. Stable size of left subdural fluid collection. No change in
Preliminary Reportmidline shift to the right of 6 mm.
Brief Hospital Course:
73M admitted for an elective left sided mini crani for SDH
evacuation. Post-operatively patient was admitted to the Neuro
ICU. He was awake and alert. A post-op head CT was stable and
the patient's diet was advanced. His neuro exam remained
unchanged during the afternoon. There was no issues overnight.
On [**4-1**], his exam remained stable, the subgaleal drain was
removed. His foley was d/c'd and some hematuria was noted. He
was transferred to the floor. A dilantin level was added on and
his level was 4.6 corrected, 300mg Dilantin x1 was given. A
repeat CBC was done [**4-1**] eve and was stable. The following
morning his exam was stable without concern. He was given a
bolus of dilantin po. In the early part of the afternoon he was
reported to have altered mental status. He was found to have a
new right drift as well as garbled speech. He had nausea with
dry heaves as well. Ct scan demonstrated no change in SDH. He
was transferred to the ICU for further care. An EEG was obtained
as it was thought he could be having seizure activity. The EEG
was ultimately negative. He did recieve a dilantin 500mg bolus
for a level of 7. A repeat CT head on [**4-3**] remained stable and
he had no more episodes of unresponsiveness and he was
transferred to the SDU.
He remained stable in the SDU and was transferred to floor [**4-5**].
He continued to improve neurologically. A repeat head CT was
obtained on [**4-6**] which showed stable to improve left frontal
SDH. Pt/OT evaluated the patient and they recommended acute
rehab. On [**4-7**], patient was discharged to rehab with a stable
exam.
Medications on Admission:
Dilantin, Atenolol 12.5mg daily, Rosuvastatin 5mg daily
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).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain, HA, Temp > 101.4.
4. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Left subdural hematoma
hematuria
altered mental status
confusion
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
You will need to have your sutures removed on [**4-10**] which can be
done at the rehab facility. If unable to do so, please call
[**Telephone/Fax (1) 1669**] to schedule an appointment for a wound check and
suture removal on [**4-10**].
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2201-4-7**]
|
[
"294.20",
"780.97",
"432.1",
"599.70",
"272.0",
"478.75",
"401.9",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
4761, 4831
|
1942, 3551
|
348, 402
|
4940, 4940
|
1022, 1281
|
6275, 6703
|
778, 782
|
3657, 4738
|
4852, 4919
|
3577, 3634
|
5122, 6252
|
797, 797
|
875, 1003
|
266, 310
|
430, 668
|
1290, 1919
|
811, 861
|
4955, 5098
|
690, 727
|
743, 762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,162
| 198,479
|
1408
|
Discharge summary
|
report
|
Admission Date: [**2111-11-21**] Discharge Date: [**2111-11-25**]
Date of Birth: [**2071-1-12**] Sex: F
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"Pre-syncope."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 y/o F with a history of MR/CP who presents with near syncope
and tachycardia.
.
Patient has long history of constipation. Today at her home,
she was in the bathroom for a long time with multiple stools
after an enema. Per her caretaker, she turned white and was
less responsive than baseline. She also reported mild abdominal
pain. EMS was called and reported initial heart rates in the
150s and felt her abdomen appeared distended on exam and
observed guarding prompting referral to the ED. She further
denies pain, normal mentation at this time per mother who is at
bedside. No recent illness, no fevers, chills, sweats. No n/v/d.
Constiptated recently, poor PO fluid intake and decreased her
bowel regimen per the recomendation of her home care provider.
.
Of note she was seen in the ED two weeks ago after turning pale
while choking. She received the Heinlich maneuver and her
symptoms resolved with supplemental oxygen by EMS. She was noted
by ED physicians to be tachycardic in the 110s and was advised
to follow-up with her primary care physician regarding this.
Also has had history of turning pale and decreased
responsiveness in the past, some in the setting of choking,
others in the setting of warm baths. These episodes are more
frequent recently. ? history of one seizure episode at 6
months.
.
In the ED inital vitals were, 98.7 135 118/93 24. Physical exam
was significant for guarding on exam with rigid abdomen however
non tender without rebound. CT torso with contrast was
obtained. The timing of the IV bolus limited the study however
no obvious PE demonstrated and stool noted in the sigmoid colon.
CXR unremarkable. An EKG demonstrated sinus tachycardia with no
ST changes or TWI. Initial lactate was 2.4. She received 2L of
NS and her repeat lactate was 1.2. Labs significant for a mild
hyperkalemia to 5.2 and mild leukocytosis to 12.2 left shift,
negative HCG. Her urinalysis was negative with a specific
gravity of 1.050. Despite improved lactate, given her
tachycardia and marked nursing concern she was transferred to
the ICU for overnight monitoring. Her baseline tachycardia per
report is in the low 100s.
.
On arrival to the ICU, initial vitals were 96.8 132 85/71,
105/85, 14 96-100% RA. She appeared comfortable, yawned
multiple times. Blood pressure recordings were difficult
secondary to flexed arms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Cerebral Palsy with mental retardation
2. UGIB several years ago in [**State 8449**]
3. Multiple UTIs
Social History:
Lives at home with mother. [**Name (NI) **] 24-hour caretaker
- [**Name (NI) 1139**]: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Father: Crohns disease
Mother: metastatic breast cancer
Paternal grandmother and aunt with ovarian cancer
Physical Exam:
Admission exam:
Vitals: 96.8 132 85/71, 105/85, 14 96-100% RA
General: Alert, oriented, no acute distress, patient non-verbal,
bilateral arms flexed
HEENT: Sclera anicteric, [**Name (NI) 5674**], oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, bilateral arms flexed and contracted
Discharge Exam:
VS: Tm: 99.2 Tc:97.3 BP:100/54 HR:77 RR:18 O2 Sats 96% on RA
.
pain: none
GEN: patient is non verbal, in bed and appears to be resting
comfortably
HEENT: CN 2-12 grossly intact but unable to follow commands to
fully assess-mild facial droop on the left is noted but is old
according to mother, [**Name (NI) 5674**]
NECK: no lad
CV: [**Name (NI) 8450**] no rmg
RESP: CTAB, no wrr
ABD: abdomen obese, active BS, some tenderness in the epigastrum
with mass c/w hernia-no signs of strangulation, active BS X4
EXTR: WWP, pulses 2+ and equal, sensation grossly intact, mild
edema in ble
DERM: no obvious rashes
NEURO: CN intact, strength grossly normal-able to move all
extremities, unable to assess sensation
PSYCH: mood and affect wnl, non verbal
Pertinent Results:
[**2111-11-21**] 05:22PM BLOOD WBC-12.2*# RBC-4.71 Hgb-13.0 Hct-39.2
MCV-83 MCH-27.7 MCHC-33.2 RDW-12.4 Plt Ct-283
[**2111-11-21**] 05:22PM BLOOD Neuts-93.6* Lymphs-4.1* Monos-1.7*
Eos-0.4 Baso-0.2
[**2111-11-21**] 05:22PM BLOOD PT-10.8 PTT-31.4 INR(PT)-1.0
[**2111-11-21**] 05:22PM BLOOD Glucose-126* UreaN-13 Creat-0.5
[**2111-11-21**] 05:22PM BLOOD Glucose-128* Lactate-2.4* Na-140 K-5.2*
Cl-105 calHCO3-25
Imaging:
CXR [**2111-11-21**]:
FINDINGS: The lung volumes are low. There is similar mild
relative elevation of the right hemidiaphragm. The heart is at
the upper limits of normal size. The lungs appear clear. There
are no pleural effusions or pneumothorax. There has been little
if any change.
CT chest/abd/pelvis w/ contrast [**2111-11-21**]: CHEST: Contrast
bolus timing is suboptimal for assessment at the segmental and
subsegmental pulmonary arteries. Given these limitations, there
are no main, right or left pulmonary emboli. No nodules,
consolidations, or effusions are seen in the visualized lung
parenchyma. The airways are patent to the segmental level. The
trachea deviates to the right at the level of the aortic arch.
There is no mediastinal mass. No mediastinal, hilar or axillary
adenopathy is present. The heart and great vessels are of normal
caliber. No coronary artery or aortic arch calcifications are
noted. A moderate hiatal hernia is present (3A:48).
ABDOMEN WITH CONTRAST: The liver enhances homogeneously. No
focal lesions
are identified. There is no intra- or extra-hepatic biliary
dilatation. The main portal and hepatic veins are patent. The
gallbladder is not distended. Pancreas enhances homogeneously.
The spleen is normal. Adrenal glands have normal attenuation and
contour. Kidneys enhance symmetrically and excrete contrast
promptly. Large parapelvic cysts are seen at the left renal
hilum. No mesenteric or retroperitoneal adenopathy is present.
The stomach, proximal small and large bowel have normal caliber
and appearance.
PELVIS: Moderate fecal loading is seen in the sigmoid and
rectum, otherwise the remainder of the bowel is of normal
caliber and appearance. The uterus and adnexa are normal. The
bladder is relatively decompressed. There is no free pelvic
fluid. There is no pelvic or inguinal adenopathy. Note is made
of significant atrophy to paraspinal and lower extremity
musculature.
BONE WINDOWS: There are no concerning lytic or sclerotic
lesions. Moderate cervical kyphosis is noted.
IMPRESSION:
1. No evidence of large pulmonary embolism; however, limited
evaluation for segmental and subsegmental PE owing to incomplete
opacification of the distal branches.
2. No evidence of acute abdominal process.
ECHO [**2111-11-23**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV
not well seen.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - body habitus. Suboptimal
image quality - patient unable to cooperate. Resting tachycardia
(HR>100bpm).
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus. No
cardiac cause of syncope seen. Left ventricular systolic
function is probably normal, a focal wall motion abnormality
cannot be excluded. The right ventricle is not well seen but is
probably normal. No significant valvular abnormality. Unable to
assess pulmonary artery systolic pressure
.
Head CT [**2111-11-25**]
IMPRESSION:
1. No evidence of acute intracranial process to account for
patient's syncope
or seizures.
2. Global cerebral atrophy, most prominently affecting the
bilateral frontal
lobes and the midbrain, most likely sequelae of cerebral palsy.
3. Acute-on-chronic inflammatory disease affecting the right
frontal and
ethmoidal air cells, with chronic inflammatory changes in the
maxillary
sinuses; correlate clinically.
.
EEG [**2111-11-24**]
IMPRESSION: This is a normal routine EEG in the waking state. No
focal
abnormalities or epileptiform discharges were present. Excess
diffuse
beta activity can be related to medication effect such as from
benzodiazepines or barbiturates. Note is made of a regular
tachycardia.
Brief Hospital Course:
40 y/o female with a history of MR/CP who presents with near
syncope and tachycardia.
.
# Narrow Complex TACHYCARDIA: Patient with baseline heart rate
in the 100s, presented with tachycardia in the 140s. EKG showed
sinus tachycardia. Did not present with infection, bolused 2L
IVF for potential hypovolemia, TSH and free T4 not suggestive of
hyperthyroidism, CT negative for PE, and no other evidence of
autonomic dysfunction. Per report of mother, primary caretaker,
patient has been very anxious recently regarding mother's new
diagnosis of breast cancer, and tachycardia is often related to
high levels of anxiety. Overnight, patient's heart rate goes
down to the 80's. TTE was also done and despite poor image
quality, no obvious cardiac abnormality was found. The patients
urine and blood cultures from [**2111-11-21**] were all negative. The
patient??????s case was discussed with his PCP and they will arrange
for a Holter monitor to be placed to evaluate for arrhythmias.
The patient??????s glycopyrrolate will also be discontinued, as this
may be contributing to her tachycardia. This was also discussed
with the patients PCP and she was initially placed on it for
secretion management but this didn??????t seem to be a problem while
the patient was in house.
# NEAR SYNCOPE: Patient has had several similar episodes in the
past, more frequent recently, including one episode attributed
to choking. Other episodes include while in the shower, going
into a pool, and during nausea/vomiting. Vasovagal likely given
this episode occurred while patient trying to defecate.
Orthostatic hypotension also possible, although history not
consistent with syncope on standing. Absence seizure possible,
especially given multiple episodes, history of cerebral palsy,
however, no report of post-ictal phase so less likely. Had TTE
to evaluate for structural abnormality contributing to
tachycardia/syncopal episodes, but was grossly normal. Patient
was also evaluated by the Neurology service while in house and
they recommended an EEG, which was normal. They also
recommended a head CT which showed no acute process to explain
syncope but did show chronic changes consistent with history of
cerebral palsy and some acute on chronic and chronic
inflammatory changes in the patients sinuses. The patient was
set up for ambulatory 24 hour EEG prior to discharge. The
patient will need to come back daily to the [**Hospital1 18**] [**Hospital Ward Name **] to
have her 24 hour recordings evaluated for several days. The
patient??????s mother preferred this over prolonged admission. The
patient had resources at home to safety be transported to [**Hospital1 18**]
daily.
.
#Abdominal pain/constipation:
The etiology of the abdominal pain may have been due to acute on
chronic constipation. The patient had a CT of her abdomen and
pelvis while in house and this did not show any obvious cause of
this. The patient initially had an elevated lactate, which
normalized with IV hydration. The patient was re-started on an
aggressive bowel regimen and she had a large bowel movement
prior to discharge. This bowel regimen should be continued as
an outpatient. The patient had some mild tenderness to
palpation in the epigastrum with a palpable mass. If this
continues an evaluation for a hernia could be considered,
although the CT did not mention this.
.
# MILD LEUKOCYTOSIS: No evidence of acute process on CXR or CTA
suggesting pulmonary process. Urinalysis was normal. Likely
reactive in presence of dehydration because the WBC returned to
[**Location 213**] after hydration. Urine and blood cultures are within
normal limits. On head CT, patient did show some chronic and
acute on chronic changes in her sinuses but her WBC was with in
normal limits and she did not show any obvious clinical symptoms
of sinusitis. As an outpatient, it should be considered
treating this patient conservatively with nasal saline if she
remains afebrile and asymptomatic. If she has recurrent fevers
and/or a leukocytosis, a course of antibiotics and an ENT should
be considered.
.
# History of UGIB
Hemoglobin was 13 on admission and 10.6 on discharge. Continue
omeprazole.
.
# CEREBRAL PALSY:
Patient coughs profusely with PO intake. While in house got a
speech and swallow evaluation and the recommendations are below:
1. PO diet: thin liquids, regular consistency solids, pt's
mother
is able to select appropriate foods and will order pt's meals.
2. Keep solid foods moist with sauce, gravy, condiments, etc.
3. Continue to cut solid food into bite-sized pieces.
4. Continue 1:1 supervision with meals, ensure only one bite at
a
time.
5. Pills crushed with applesauce (this is pt's baseline).
6. [**Name (NI) 1094**] mother will contact our department for outpt appointment
as needed ([**Telephone/Fax (1) 3731**]) or for further questions or concerns
after discharge.
.
# Renal Cyst in left hilum:
Please repeat a renal US or CT abdomen/pelvis in 6 months to
demonstrate stability of lesion.
.
# Normocytic anemia:
Patient presented with hemoglobin of 13 and was discharged with
hemoglobin at 10.6. No occult blood was found in her stool,
although with chronic constipation, sterocolic ulcers are a
possibility. More likely, this patient??????s anemia is likely
partially dilutional and partially iatrogenic. Her iron levels,
ferritin and TIBC were all within normal limits. A repeat CBC
should be draw as an outpatient.
.
#Transitional Issues:
-Follow up with PCP [**Last Name (NamePattern4) **] [**12-7**] weeks and they will arrange a holter
monitor and follow up on the final reads of the ambulatory EEG's
-Follow up with Neurology as outpatient
-Get repeat CBC and have PCP follow up
[**Name9 (PRE) 8451**] Imaging of renal cysts in 6 months
Medications on Admission:
1. Glycopyrrolate 1mg [**Hospital1 **]
2. Omeprazole 20mg daily
3. Colace 2tabs [**Hospital1 **]
4. Fleets enema Tues/Thurs/Sat
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QTUTHSA (TU,TH,SA).
Disp:*30 Suppository(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Sinus tachycardia secondary to dehydration
vasovagal syncope
Secondary: Normocytic anemia
Constipation
Cerebral palsy
Discharge Condition:
Mental Status: Confused - sometimes, non verbal.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 8452**],
You came to the hospital due to an elevated heart rate and an
episode of almost losing consciousness. You were found to be
dehydrated, and were given intravenous fluids which helped slow
your heart rate down. You had no evidence of an infection.
Your thyroid function was checked as well as an EKG and
Echocardiogram to look at the electrical activity of your heart,
which were both normal. You will be sent home with an
ambulatory EEG monitor which needs to be brought back daily.
You were taken off your glycopyrrolate, do not re-start this at
home.
It has been a pleasure taking care of you!
Followup Instructions:
Please follow up with your primary care doctor in [**12-7**] weeks for
an ambulatory cardiac monitor. Call [**Last Name (LF) 8453**],[**First Name3 (LF) **] B
[**Telephone/Fax (1) 8454**] as soon as possible for an appointment.
.
Please follow up with Neurology.
Department: NEUROLOGY
When: THURSDAY [**2111-12-3**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"707.22",
"276.7",
"V13.02",
"564.00",
"318.1",
"276.51",
"780.2",
"707.03",
"593.2",
"285.9",
"343.2",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17413, 17419
|
10951, 16389
|
284, 290
|
17590, 17590
|
4968, 10928
|
18439, 19026
|
3435, 3543
|
16893, 17390
|
17440, 17569
|
16740, 16870
|
17782, 18416
|
3558, 4188
|
4204, 4949
|
16410, 16714
|
2690, 3138
|
230, 246
|
318, 2671
|
17605, 17758
|
3160, 3267
|
3283, 3419
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,540
| 134,548
|
31661
|
Discharge summary
|
report
|
Admission Date: [**2160-2-3**] Discharge Date: [**2160-2-15**]
Date of Birth: [**2093-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
bronchoscopy x 3
History of Present Illness:
66 M with history of adenocarcinoma of unknown origin p/w
hemoptysis.
He was recently hospitalized on [**8-18**] with nausea/vomitting fever
found to have a pneumonia s/p treatment but also with lung/liver
masses, s/p lung biopsy and referred to oncology and offered
systemic chemotherapy in [**8-18**]. The patient traveled to the Dubai
for alternative herbal therapy for the past few months, and has
since returned to the states 1 week prior. He notes an
increasing productive cough for yellow sputum, initially blood
tinged progressive over the week. Last evening, noted increasing
hemoptysis, [**6-17**] teaspoons, with blood clots, and presented to
the ED.
He otherwise has some mild wheezes per report, denies cp,
although with R sided chest discomfort, nonpleuritic,
nonreproducible,no clear [**Month/Day (3) 74384**], episode of vomitting 2 days
ago, food particles no blood, no brbpr,diarrhea,constipation.
Affirms weight loss over the past few months, with some
anorexia.
.
.
In the ED, VS 99 95 157/93 20 96Ra, CTA performed demonstrated
no PE, but with large R sided lung mass
.
Onc Hx:
[**2147**]- Hematuria, with ? L RCC s/p L nephrectomy (in [**Country 9819**]),
arrived to US in [**2151**], with increasing mass in chest CT. PET
scan [**2158**] with multiple foci of abnormal uptake in soft tissue
densities seen in the right lung associated with subcarinal LAD
consistent with
metstatic disease, as well as uptake in a large mass involving
the dome of the right lobe of the liver. [**8-18**] presented to [**Hospital1 18**]
with n/v A CAT scan of the torso on admission revealed the right
lower lung mass now measuring 4.4 x 2.7 cm with extension to the
right lower lobe bronchus, multiple surrounding satellite
nodules and a right hilar lymphadenopathy. In addition, there
was a 7.6 cm low density lobulated liver lesion as well as a
tiny low density lesion in the body of the pancreas, (felt to be
insignificant on review with radiology). RLL Biopsy revealed
non-small-cell carcinoma consistent with adenocarcinoma.
Immunohistochemical stains for cytokeratin 7 and
CK 20 are positive, TTF-1 is negative. These findings support
the diagnosis of adenocarcinoma. The possibilities include a
tumor of pancreaticobiliary origin.
.
-MRI of the abdomen reveals a large predominantly cystic mass in
the right lobe of the liver measuring approximately 7.1 x 11 cm
x
8.3 cm. There are two smaller adjacent lesions, whose appearance
is most consistent with abscess. Renal cell metastasis seems
unlikely based on the MR appearance. Metastasis to T10 is
described as well as metastasis to the right lower lobe of the
lung. There is note made of hernia of the large bowel through
the anterior abdominal wall.
Past Medical History:
Presumed renal cell carcinoma status post left nephrectomy in
[**2147**] in [**Country 9819**].
Adenocarcinoma of Unknown origin to lung/liver ? bone
Possible Macroadenoma
ventral abdominal hernia
Social History:
Social History: The patient immigrated to the United States in
[**2151**] as a refugee from [**Country 16160**]. He denies tobacco, alcohol, and
drug use. He lives at home with his wife and children. He has
13 children. Import/Exporter from [**Country 651**]
Family History:
There are no known cancers in the family. The
patient does note that his father died of swelling in the throat
possibly related to either infection or cancer.
Physical Exam:
VS: 99 97 20 68 130/79 97RA
GEN: NAD, comfortable speaking in full sentences
HEENT: PERRL, EOMI, nonicteric sclera, no LAD, no JVD, Dry MM,
OP clear,
CV: RRR no mrg
CHEST: decreased BS R side, ? R side egophany, no wheezes,
rhonchi
Abd: Ventral abd hernia reducible, +BS NT/ND, no organomegaly,
EXT: No c/c/e
Neuro: AAOx3, no focal deficits, motor [**6-16**] throughout
Pertinent Results:
[**2-3**] CXR
IMPRESSION: Progression of right-sided pulmonary masses. No
evidence of superimposed acute cardiopulmonary abnormality
.
[**2-3**] CTA
No PE in the main or segmental arteries. Subsegmental arteries
eval. limited by resp. motion and contrast bolus.
Progression of disease with massive right sided lung masses,
including large 9 x 5 cm mass with endobronchial component
involving the RLL and RML bronchi, which may contribute to pt's
hemoptysis. RML is nearly completely collapsed/infiltrated with
tumor.
.
ECG Study Date of [**2160-2-4**] 8:30:20 AM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
.
CHEST (PA & LAT) [**2160-2-7**] 3:25 PM
The multiple pulmonary masses of the right lung including the
right upper lobe, right middle lobe, and right lower lobe appear
relatively unchanged. The right hemidiaphragm is elevated. No
new focal consolidative process is noted. The left lung is
clear. The cardiomediastinal silhouette and hilar contours are
unchanged. The osseous structures of the thorax appear normal.
IMPRESSION:
1. Unchanged multiple pulmonary masses of the right lung with no
new consolidative process.
.
CHEST (PORTABLE AP) [**2160-2-8**] 1:33 PM
FINDINGS: In comparison with earlier study of this date, the
patient has taken a much better inspiration, which has resulted
in some decrease in opacification of the right base. The large
masses persist.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2160-2-8**] 1:55 AM
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
CTA: There is no evidence of a pulmonary embolism in the main or
the segmental pulmonary arteries. The evaluation of subsegmental
branches is limited due to collapse-consolidation as well as
extensive tumor involvement of the right lower lobe.
There is minimal interval increase in the size of the multiple
bilateral pulmonary metastases. For example, there is a 41 x 32
mm pleural-based mass in the right upper lobe, previously 36 x
28 mm (image 33, series 9). There is a 56 x 51 mm lesion in the
right lower lobe, previously 52 x 48 mm (image 64, series 9).
There is interval increase in the collapse-consolidation in the
right lower lobe.
Right superior paratracheal loculations of air are unchanged
since [**2159-8-14**], probably tracheal diverticuli.
There also is minimal interval increase in the multi-station
mediastinal lymphadenopathy. For example, there is a 24 x 15 mm
pretracheal lymph node, previously 20 x 14 mm (image 151, series
9). The tumor in the right lower lobe surrounds the right
pulmonary artery, invading the adjacent bronchus intermedius and
may spread endobronchially. There are bronchial secretions
present in the right lower lobe bronchus--it is difficult to
distinguish endobroncheal secretions from tumor involvement.
There are multiple hepatic metastases which appear more cystic
and larger when compared to the prior examination, and this may
be related to treatment effect. There is a 73 x 56 mm metastasis
in the right hepatic dome, previously 62 x 60 mm (image 94,
series 9). There is a 94 x 49 mm metastasis in the right lobe of
the liver, previously 90 x 44 mm (image 119, series 9).
MUSCULOSKELETAL:
The lytic lesion in the inferior aspect of T10 vertebral body is
unchanged. There is no significant loss of height of the
vertebral body.
CONCLUSION:
1. No definite evidence of a central or segmental pulmonary
embolism; however, the possibility of subsegmental emboli cannot
be excluded, especially in the right lower lobe due to extensive
tumor involvement and atelectasis.
2. Minimal progression of metastatic disease with increase in
the size of pulmonary metastases and mediastinal lymphadenopathy
as described above.
3. There is interval increase in the collapse-consolidation in
the right lower lobe. There is progressive loss of volume in the
right lower lobe, likely a combination of endobronchial
extension and retention of bronchial secretions.
4. Interval increase in the size of hepatic metastases, which
appear more cystic and may be related to treatment effects.
5. There is stable appearance to the metastatic lesion in the
body of T10.
.
CHEST (PORTABLE AP) [**2160-2-8**] 12:09 AM
FINDINGS: In comparison with the study of [**2-7**], there is
increasing opacification at the right base with obscuration of
the hemidiaphragm. This could reflect interval development of
atelectasis, effusion, or pneumonia. The left lung remains
clear. Large masses are again seen in the right paratracheal
area and at the right base medially.
.
CHEST (PORTABLE AP) [**2160-2-11**] 8:31 AM
FINDINGS: In comparison with the study of [**2-8**], there is some
increasing opacification at the right base that could represent
atelectatic or change distal to one of the numerous metastatic
nodules. Some elevation of the right hemidiaphragm is seen with
a configuration, raising the possibility of subpulmonic
effusion. The left lung remains clear.
.
BONE SCAN [**2160-2-13**]
INTERPRETATION:
Whole body images of the skeleton were obtained in anterior and
posterior
projections demonstrate increased uptake within the T10
vertebral body, slightly more than on [**2159-8-14**] corresponding to
lytic metastasis on CT. There is increased uptake within both
knees (right greater than left) shoulders (right greater than
left), unchanged, and secondary to degenerative disease as
evidenced on radiographs.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION: 1. T10 metastasis, no other lesions identified. 2.
Degenerative
disease in the shoulders and knees.
.
[**2160-2-3**] 02:45PM HCT-33.0*
[**2160-2-3**] 07:30AM GLUCOSE-97 UREA N-14 CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-13
[**2160-2-3**] 07:30AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-105 TOT
BILI-0.3
[**2160-2-3**] 07:30AM ALBUMIN-3.0* CALCIUM-9.2 PHOSPHATE-3.3
MAGNESIUM-2.0
[**2160-2-3**] 07:30AM WBC-11.1* RBC-3.74* HGB-10.5* HCT-31.9*
MCV-85 MCH-28.0 MCHC-32.9 RDW-14.0
[**2160-2-3**] 07:30AM PLT COUNT-475*
[**2160-2-3**] 07:30AM PT-14.0* PTT-26.0 INR(PT)-1.2*
[**2160-2-2**] 11:25PM LACTATE-1.2
[**2160-2-2**] 11:15PM GLUCOSE-122* UREA N-17 CREAT-1.2 SODIUM-136
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-12
[**2160-2-2**] 11:15PM estGFR-Using this
[**2160-2-2**] 11:15PM WBC-10.8 RBC-3.75* HGB-10.6* HCT-32.0* MCV-85
MCH-28.3 MCHC-33.2 RDW-14.6
[**2160-2-2**] 11:15PM NEUTS-73.4* LYMPHS-17.4* MONOS-6.3 EOS-2.8
BASOS-0.2
[**2160-2-2**] 11:15PM PLT COUNT-399
[**2160-2-2**] 11:15PM PT-14.5* PTT-25.9 INR(PT)-1.3*
[**2160-2-15**] 06:10AM BLOOD WBC-12.7* RBC-3.78* Hgb-10.5* Hct-31.5*
MCV-84 MCH-27.7 MCHC-33.2 RDW-14.4 Plt Ct-542*
[**2160-2-15**] 06:10AM BLOOD Glucose-90 UreaN-20 Creat-0.9 Na-134
K-4.8 Cl-106 HCO3-18* AnGap-15
[**2160-2-10**] 12:02AM BLOOD ALT-13 AST-15 LD(LDH)-350* AlkPhos-97
TotBili-0.3
[**2160-2-10**] 12:02AM BLOOD cTropnT-0.06*
[**2160-2-15**] 06:10AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
[**2160-2-9**] 07:45AM BLOOD CK-MB-2 cTropnT-0.08*
[**2160-2-10**] 12:02AM BLOOD Hapto-454*
[**2160-2-10**] 12:02AM BLOOD TSH-4.1
[**2160-2-10**] 12:02AM BLOOD Cortsol-17.6
[**2160-2-8**] 03:38PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2160-2-9**] 11:36AM URINE Hours-RANDOM UreaN-363 Creat-69 Na-135
K-30 Cl-143
[**2160-2-9**] 11:36AM URINE Osmolal-497
.
BCx negative x 4
UCx negative
Sputum gs/culture negative
Brief Hospital Course:
66 M with adenocarcinoma of unknown origin p/w hemoptysis.
.
# Hemoptysis/Adenocarcinoma - Differential for adenocarcinoma of
unknown origin had been either lung vs GI and plans for
carboplatin and gemcitabine in the palliative setting. MR [**First Name (Titles) **] [**Last Name (Titles) 74385**] scan as above. He developed a RML collapse as well as a
post-obstructive PNA. He was treated with levo, but continued
to be febrile, so his antibiotics were broadened to
vanc/cefepime for 8 further days. He received a flexible
bronchoscopy on [**2-11**], showing increased tumor burden without
empyema. Tumor was debulked. He required 2 further
bronchoscopies. He received XRT x 2 with plans to receive 33
total sessions. His hemoptysis resolved and his HCT was stable
upond discharge. He was afebrile for > 48 hours upon discharge.
He was set up with oncology follow-up as well as XRT and chemo.
.
# Hyponatremia - Urine lytes consistent with SIADH. TSH and
cortisol wnl. He was fluid restricted with improvement in his
serum sodium.
.
# Anemia- Normocytic, appears to be [**3-15**] to ACD, in reviewing
recent iron profile. Stable. Hemolysis labs not suggestive of
hemolysis.
.
# Prophylaxis- Pneumoboots, no indication for PPI
.
# CODE: Full code
.
# Communication:
1) Zulaikha (Daughter, nurse [**First Name (Titles) **] [**Last Name (Titles) 121**] 9) [**Telephone/Fax (1) 74386**]
2) [**Name (NI) **] (Son) [**Telephone/Fax (1) 74387**]
Medications on Admission:
Iron
.
ALL: NKDA
Discharge Medications:
1. Outpatient Physical Therapy
Right knee OA
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
Disp:*60 ML(s)* Refills:*0*
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
6. Megestrol 40 mg/mL Suspension Sig: Eight Hundred (800) mg PO
QAM (once a day (in the morning)).
Disp:*[**Numeric Identifier 17514**] mg* Refills:*2*
7. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig: One
(1) dose Intravenous unknown: please give 30 minutes prior to
chemo and infuse over 15 minutes.
8. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
hemoptysis
adenocarcinoma of unknown origin to lung and liver
.
Secondary:
Presumed renal cell carcinoma status post left nephrectomy in
[**2147**] in [**Country 9819**].
Possible Macroadenoma
ventral abdominal hernia
Discharge Condition:
improved, afebrile
Discharge Instructions:
You were seen at [**Hospital1 18**] for bloody cough. You were given
bronchoscopies to remove tumor and control the bleeding. You
were also found to have a pneumonia, for which you were given a
full course of intravenous antibiotics. You also received
[**Hospital1 74384**] therapy 4 days a week as well as chemotherapy once per
week, which will continue per your oncologist. Your first
appointments for both of these are on Tuesday, [**2160-2-19**] as below.
.
You have follow up as below.
.
Please return to the emergency department or call your primary
care physician if you experience fevers/chills, worsening cough,
bloody cough, nausea/vomiting, or any other symptoms that
concern you.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-2-19**] 9:00
.
Provider: [**Name10 (NameIs) **] Oncology Phone:[**Telephone/Fax (1) 9710**]
Date/Time:Tuesday01/08/08 10:30AM
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2160-2-26**] 9:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-2-26**] 9:30
|
[
"162.4",
"785.6",
"786.3",
"285.22",
"276.1",
"486",
"276.3",
"198.7",
"198.5",
"162.5",
"197.7",
"V10.52",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"32.01",
"92.29",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
14122, 14128
|
11618, 13070
|
325, 344
|
14399, 14420
|
4174, 11595
|
15164, 15719
|
3606, 3768
|
13138, 14099
|
14149, 14378
|
13096, 13115
|
14444, 15141
|
3783, 4155
|
275, 287
|
372, 3091
|
3113, 3312
|
3344, 3590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,144
| 135,164
|
49698
|
Discharge summary
|
report
|
Admission Date: [**2202-11-24**] Discharge Date: [**2202-12-2**]
Date of Birth: [**2145-7-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
[**2202-11-25**] Esophagogastroduodenoscopy
History of Present Illness:
57 y/o female s/p redo-sternotomy, mitral valve replacement and
tricuspid valve repair, with prior admission for GI bleed and
hematocrit of 13 with elevated INR from [**11-4**] to [**11-16**] who
presented to ED with lightheadedness and a hematocrit of 12 and
INR 5.1.
.
Recent admission [**11-4**] for hct of 13 admitted with hct 12 on
[**11-28**]. Last admission she had guaiac + stool in the setting of
high INR and she underwent an EGD/[**Last Name (un) **] which was relatively
unrevealing for a source of GI bleeding. She was discharged home
in a stable condition after receiving PRBC and FFP with no signs
of continous bleed. Last admission, she underwent a TTE to
assess for integrity of the artificial valve site and revealed
trivial paravalvular mitral leak with a normally functioning
mitral valve and aortic bioprosthesis and tricuspid ring.
Past Medical History:
Mitral regurgitation and Tricuspid Regurgitation s/p
Redo-Sternotomy w/ Mitral Valve Replacement and Tricuspid Valve
Repair [**2202-10-11**], s/p Aortic Valve Replacement, Systemic Lupus
erythematosis, Hypertension, Pulmonary Hypertension, Raynaud's
disease, s/p cholecystectomy, Lupus nephritis, Rheumatic heart
disease, Portal hypertension, Anemia
Social History:
Patient is married with one son, denies tobacco, minimal EtOH.
Family History:
Grandmother died from a CVA at age 50. Father died at age 70
from complications of diabetes.
Physical Exam:
Gen: No acute distress, pale
Heart: Regular, rate and rhythm with + mechanical valve click
Lungs: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended
Ext: Warm, well-perfused -edema
Skin: Sternal wound clean/dry/intact and well-healed
Pertinent Results:
[**11-25**] Echo: No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is 10-15mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. Mild (1+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. The tricuspid valve leaflets are
mildly thickened. A tricuspid valve annuloplasty ring is
present. There is borderline pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion. Compared with the findings of the
prior study (images reviewed) of [**2202-11-4**], the findings
are similar.
[**11-24**] CXR: The patient is status post sternotomy and aortic and
mitral valve replacement. The heart is enlarged. The lungs are
clear.
============================
EGD: Normal esophagus, stomach, and duodenum
Brief Hospital Course:
As mentioned in the HPI Ms. [**Known lastname 9996**] presented to the ED with
lightheadedness with HCT of 12 and INR of 5.1. She was admitted
to the CVICU and transfused 4 units of PRBC's and 2 units of
FFP. She again had a GI work-up which included a EGD. EGD
revealed no sources of bleeding and she then underwent a capsule
study. Again on hospital day two she received an additional 2
units of blood. Hematocrit on the following day was 28.
===========================================
Pt was subsequently transferred to the medicine service for
further work-up of her anemia and atrial flutter:
1. Anemia: This is the pt's second admission for a markedly low
Hct. Haptoglobin added to admission labs was 20 suggesting
hemolysis, but LDH and bili should have been elevated if
hemolysis was cause of Hct drop to 13. Pt states that stools
are chronically dark as a consequence of iron supplementation,
but that her stool leading up to this hospitalization was
somewhat darker than usual. Given labs atypical for hemolysis,
GI bleed was felt to be more likely cause of her anemia. No
bleeding sources were found on two EGD's and a colonoscopy,
promptimg a capsule endoscopy which showed a non-bleeding ulcer.
Pt hematocrit stabilized and was at 26.7 at the time of
discharge.
2. Atrial flutter: Pt successfully cardioverted and in sinus
rhythm, flipped back into atrial flutter the day of discharge,
EP was made aware and did not wish for any additional
cardioversions. Pt. was given an extra dose of metoprolol and
discharged on metoprolol XL 75 QD, with her rate in the 80's.
3. S/p AVR/MVR: Pt's INR target is [**2-7**]. This needs to be very
closely followed as outpt given significant bleeds occuring when
slightly supratherapeutic and significant risk of thrombus
formation with mechanical mitral valve if subtherapeutic. Pt.
will follow up in [**Hospital **] [**Hospital 263**] clinic and have cardiology NP at
[**Hospital1 **] follow it up ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]). Pt. was discharged when INR
was 2.1 so there was no need for Lovenox as per CT surgery.
4. Lupus: Pt states that she developed joint pain last time she
discontinued hydroxychloroquine. It was continued during this
admission.
Medications on Admission:
1.Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Zantac 150mg [**Hospital1 **]
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses: please take 4mg (two 2mg tablets) daily until directed
otherwise by the office of Dr. [**First Name (STitle) 437**].
7. Multi-vitamin qd
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 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. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Anemia
2. Supratherapeutic INR
3. Atrial flutter status post cardioversion
Secondary:
1. Mitral regurgitation and Tricuspid Regurgitation status post
Redo-Sternotomy with Mitral Valve Replacement and Tricuspid
Valve Repair [**2202-10-11**]
2. Status post Aortic Valve Replacement
3. Systemic Lupus erythematosis
4. Hypertension
5. Pulmonary Hypertension
6. Raynaud's disease
7. Status post cholecystectomy
8. Lupus nephritis
9. Rheumatic heart disease
10. Portal hypertension
Discharge Condition:
Good, no [**Month/Day/Year **] blood in stools, no dizziness/lightheadedness,
medically stable for discharge.
Discharge Instructions:
You were admitted with anemia thought due to a gastrointestinal
bleed. The source of the bleeding remains unclear, however, you
had a capsule endoscopy during admission, the results of which
are pending. Your INR was supratherapeutic on admission, and
your goal INR was changed to 2.5-3.0. You should follow-up with
the anticoagulation nurses on Friday at the [**Hospital **] clinic in
the same way you had done previously.
During admission you developed an irregular heart rhythm called
atrial flutter. You were cardioverted with reversion of your
heart rhythm back to normal sinus rhythm. However, you reverted
back to atrial flutter/fibrillation, so we increased your dosage
of metoprolol to 75 mg Daily.
Please contact a physician or report to an emergency department
if you experience fevers, chills, chest pain, shortness of
breath, palpitations, dizziness, lightheadedness, black stools
or blood in your stools, or any other concerning symptoms.
Please take your medications as prescribed.
- Your dose of coumadin was changed to 5mg daily.
- No other changes were made to your medications.
Followup Instructions:
Please call the office of your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a
follow-up appointment within two weeks from discharge,
preferably within one week.
Follow-up with your rheumatologist: Provider: [**Name10 (NameIs) 177**] [**Name8 (MD) 103925**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2202-12-9**] 2:30
Follow-up with gastroenterology: Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**],
M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2202-12-9**] 4:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2202-12-20**]
10:00
Follow-up with cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2202-12-20**] 11:30a
Please follow up in coumadin clinic in [**Location (un) **] on Friday,
[**2202-12-3**], and on Monday, [**2202-12-6**].
Completed by:[**2202-12-2**]
|
[
"416.8",
"578.9",
"E934.2",
"427.32",
"398.90",
"710.0",
"790.92",
"401.9",
"V43.3",
"582.81",
"276.2",
"572.3",
"571.5",
"280.0",
"443.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"45.13",
"45.19",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6828, 6834
|
3283, 5537
|
331, 376
|
7367, 7479
|
2111, 3260
|
8632, 9614
|
1728, 1822
|
6170, 6805
|
6855, 7346
|
5563, 6147
|
7503, 8609
|
1837, 2092
|
276, 293
|
404, 1259
|
1281, 1632
|
1648, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,864
| 125,214
|
32496
|
Discharge summary
|
report
|
Admission Date: [**2116-9-12**] Discharge Date: [**2116-9-22**]
Date of Birth: [**2060-5-4**] Sex: F
Service: SURGERY
Allergies:
Lithium
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
cirrhosis. here for liver transplant
Major Surgical or Invasive Procedure:
[**2116-9-13**] Piggyback liver transplant
History of Present Illness:
55-y.o. female with hep C, cirrhosis, and HCC, with h/o
hepatic encephalopathy, who presents to receive liver
transplant.
Recently she sustained a fracture of the L little finger which
was non-operative. Otherwise she has been in her USOH. Denies
fever, chills, nausea, vomiting, and chest pain. No respiratory
symptoms. Reports baseline abdominal cramps.
Past Medical History:
1.Hepatocellular carcinoma
-s/p CT liver biopsy and RFA of segment VII liver [**4-9**]
-path c/w well to moderately differentiated HCC
-two new lesions on CT in [**5-9**]
2.Hepatitis C genotype 3 c/b cirrhosis and HCC
-diagnosed with hepatitis C in the [**2076**] after a trip to the
Caribbean
-on interferon in the past
-EGD [**5-9**] showed portal hypertensive gastropathy
3.Hepatic Encephalopathy
4.Shingles
5.ADHD
6.Disc disease
7.Fibromyalgia
8.PTSD
9.Depression
10.s/p C-section
11.s/p partial hysterectomy secondary to bleeding
12.s/p breast reduction
13.s/p appendectomy
14.s/p tonsillectomy
15. [**2116-9-13**] liver transplant
Social History:
Single, She has 1 daughter age 22. Currently on disability, used
to work as a real estate [**Doctor Last Name 360**]. She denies any significant
alcohol intake, has not had any alcohol in over a year. She
denies any smoking. She stopped tobacco about a year ago and
prior to that she smoked intermittently only. She denies any
history of IV drug use. She has other family that live out west.
Family History:
Denies any known history of liver disease or liver cancer. Her
mom did have coronary artery disease with a bypass graft as well
as carotid endarterectomy. Her maternal grandfather did have an
MI. Her dad is healthy. Her brothers and sisters are healthy. No
other known significant family history.
Physical Exam:
Vitals - T: 98.2 BP 121/52 HR 73 RR 18 94RA
General: awake, alert, NAD.
HEENT: anicteric.
Heart: RRR, NMRG, nl S1/S2.
Lungs: CTAB.
Abdomen: soft, NT/ND, no hepatomegaly, liver edge palpated at
costal margin.
Extremities: WWP, brisk cap refill, no CCE.
Pertinent Results:
[**2116-9-12**] 02:51AM BLOOD WBC-6.4 RBC-3.80* Hgb-13.7 Hct-41.0
MCV-108* MCH-36.0* MCHC-33.4 RDW-15.1 Plt Ct-59*
[**2116-9-22**] 04:58AM BLOOD WBC-10.6 RBC-3.10* Hgb-10.0* Hct-29.2*
MCV-94 MCH-32.2* MCHC-34.2 RDW-18.6* Plt Ct-124*
[**2116-9-21**] 05:43AM BLOOD PT-10.5 PTT-19.7* INR(PT)-0.9
[**2116-9-22**] 04:58AM BLOOD Glucose-163* UreaN-39* Creat-1.5* Na-138
K-3.8 Cl-100 HCO3-30 AnGap-12
[**2116-9-12**] 02:51AM BLOOD ALT-109* AST-141* AlkPhos-128*
TotBili-2.6*
[**2116-9-18**] 05:01AM BLOOD ALT-49* AST-25 AlkPhos-38* TotBili-0.1
[**2116-9-20**] 06:03AM BLOOD ALT-146* AST-66* AlkPhos-280* TotBili-0.5
[**2116-9-22**] 04:58AM BLOOD ALT-218* AST-95* AlkPhos-209* TotBili-0.7
[**2116-9-22**] 04:58AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.3*
[**2116-9-22**] 04:58AM BLOOD tacroFK-10.5
Brief Hospital Course:
55 yo female with hepatitis C, cirrhosis, and HCC, with h/o
hepatic encephalopathy. On [**2116-9-13**], she underwent a liver
transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. During mobilization of
the left lobe of the liver, a small hole was made in the
diaphragm that was repaired. Two drains were left in place.
Please refer to operative notes for complete details. Postop,
she was sent to the SICU for management where she was extubated.
A duplex of the liver on [**9-13**] demonstrated patent vasculature
and no ductal dilatation. LFTs Trended down. Drain outputs were
non-bilious. She was transferred out of the SICU on postop day
3.
Diet was advanced and an insulin drip was necessary initially
for hyperglycemia due to steroids. Steroids were tapered per
protocol. [**Last Name (un) **] was consulted and started NPH and sliding
scale. Insulin drip was stopped.
Cellcept was well tolerated, steroids were tapered to 20mg once
daily and prograf was begun on postop day 0. Dose was titrated
per trough levels. She was increased to 3mg [**Hospital1 **]. LFTs started to
trend up on postop day 6 with alk phos gradually increasing from
30-50 up to 200. AST and alt also increased from 20s and 50 to
90s and low 200s respectively. A repeat liver duplex was done on
[**9-22**] showing patent hepatic vasculature and no intrahepatic
biliary dilatation. Mild dilatation of the extrahepatic common
bile duct was noted. This was larger than was seen on [**2116-9-13**].
She felt well and was ambulatory. PT had worked with her and
declared her safe for discharge to home. She was taugh how to do
glucose checks and inject insulin. Extensive medication teaching
was done as well. VNA services from [**Hospital1 **] VNA [**Telephone/Fax (1) 75814**]
was arranged.
Of note, she had generalized postop edema that was treated with
lasix. She was sent home on lasix for a few days.
Pain was controlled with percocet. Vital signs were stable. The
incision was intact, without redness and dry.
Medications on Admission:
. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to [**4-6**] BM per day.
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet
PO bid ().
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Mycelex 10 mg Troche Sig: One (1) Mucous membrane five
times a day.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
once a day.
Discharge Medications:
1
1. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
2. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
Disp:*1 vial* Refills:*2*
3. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
4. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*2*
5. syringes
Insulin syringes U-100
Lo dose
25 or 26 gauge syringes
supply: 1 box
refill: 2
6. 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*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Two (2)
Tablet PO daily ().
16. Glucagon Emergency 1 mg Kit Sig: One (1) mg Injection prn:
low blood sugar.
Disp:*1 kit* Refills:*2*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*500 ML(s)* Refills:*0*
19. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
21. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
After four days of taking pills 2 times a day, reduce to 1 once
a day until you follow-up with Dr. [**Last Name (STitle) 816**].
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
HCV
hyperglycemia related to steroid
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
increased abdominal pain, jaundice, incision
redness/bleeding/drainage or any concerns
You will need to have lab draws every Monday and Thursday
[**Month (only) 116**] shower
No driving while taking pain medication
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-9-28**]
10:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2116-9-28**]
11:00
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2116-10-1**] 12:00
Completed by:[**2116-9-23**]
|
[
"314.01",
"311",
"E870.0",
"571.5",
"E849.7",
"584.5",
"998.2",
"782.3",
"572.3",
"537.89",
"250.00",
"155.0",
"309.81",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"34.82",
"38.93",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
8595, 8668
|
3219, 5258
|
303, 347
|
8749, 8756
|
2411, 3196
|
9160, 9644
|
1825, 2123
|
6336, 8572
|
8689, 8728
|
5284, 6313
|
8780, 9137
|
2138, 2392
|
227, 265
|
375, 737
|
759, 1398
|
1414, 1809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,586
| 197,982
|
50137
|
Discharge summary
|
report
|
Admission Date: [**2102-4-8**] Discharge Date: [**2102-4-12**]
Date of Birth: [**2051-12-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin / Methotrexate / Ticlid / Bactrim Ds /
Allopurinol / Tetracycline
Attending:[**First Name3 (LF) 2078**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2102-4-8**]
Percutaneous coronary angioplasty with LCx stenting [**2102-4-8**]
History of Present Illness:
50 year-old woman with CAD s/p AMI and Lcx stenting (bare metal
stent) in [**2096**] admitted earlier this week [**Date range (1) 32116**] for elective
catheterization for accelerating symptoms, s/p restenting of LCx
for instent restenosis and RCA stenting (stent X 2 to mid-RCA
and stent X 1 to proximal RCA), also with HTN, DM type 2 and
positive family history, now presenting with recurrent chest
pain 2 days post PTCA.
She reports that she developed upper chest pressure this AM
while watching TV, similar to her usual anginal symptoms. She
describes it as pressure, non-radiating, approximately [**7-21**] in
intensity, associated with some SOB and diaphoresis. No N/V. She
took NTG X 2 and ASA, without relief, and presented to the [**Hospital1 18**]
ED. No pleuritic component, discomfort non-positional.
In the ED, initial vitals were HR 88, BP 123/65, RR 20, Sat 97%
on room air. EKG with non-specific changes, LBBB. First set of
enzymes negative. CXR suspicious for pneumonia. She was given
NTG X1, Lopressor 5 mg IV X3, started on Nitro gtt and Heparin
gtt, as well as Integrillin given ongoing chest discomfort. A
bedside echo was remarkable for lateral wall hypokinesis. Given
ongoing chest discomfort, recent PTCA and lateral wall
hypokinesis suspicious for stent thrombosis, Ms. [**Known lastname 15505**] was
taken to the cath lab for further evaluation.
In the cath lab, she was found to have complete occlusion of
proximal Lcx stent treated with balloon angioplasty. There was
then concern for possible dissection, and a stent was deployed.
IVUS post stent negative for dissection. Final dilation of all
stents was performed.
On history, she reports low-grade fever on Thursday up to 101.
No cough, chronic rhinorrea, no chills. Still reports residual
chest discomfort post-procedure, much improved.
Past Medical History:
1. CAD, status post AMI in [**2096**], s/p LCx stenting in [**2096**] c/b
instent restenosis --> restented with 2 Cypher stents on
[**2102-4-5**]. Also s/p 2 cypher stents in mid RCA [**2102-4-5**] and
stenting of proximal RCA. LAD diffusely diseased up to 40%, no
intervention. EF 48% on ventriculography.
2. Mixed connective tissue disease manifested by myositis, +
[**Doctor First Name **], GERD, Raynaud's, sclerodactyly, malar rash, telangiectasia.
3. Diabetes mellitus type 2
4. Hypertension
5. Gout
6. Status post CVA without residual deficit
7. GERD with Barrett's esophagus
8. Peripheral neuropathy
9. ? H/O GIB in [**11-14**]. C-scope unrevealing
Social History:
She is married and lives with her husband. [**Name (NI) **] history of tobacco
or alcohol consumption.
Family History:
Notable for CAD including her mother who died at age 52 of an
MI. Father had CABG in his 50s and later died of an MI. Two
brothers with [**Name (NI) 5290**] in their 50's and one with a CVA.
Physical Exam:
Physical examination on admission to the CCU:
VITALS: T 97.3, BP 120/68, HR 71 regular, RR 14, Sat 97-100% on
room air
GEN: In NAD. Appears comfortable, lying flat.
HEENT: Poor dentition. MMM.
NECK: JVP not visible with patient flat.
RESP: Chest CTA bilaterally anteriorly. Few scattered basilar
crackles, no bronchial breathing over left chest.
CVS: Nl S1, S2. No S3, S4. No murmur or rub.
GI: Obese abdomen. BS normoactive. Abdomen soft and non-tender.
EXT: Left cath site without hematoma. No bruit. Arterial sheath
in place. Strong pedal pulses. No pedal edema.
NEURO: Alert and oriented. Moves all 4 extremities.
Pertinent Results:
Pertinent laboratory data on admission:
CBC:
WBC-7.8 RBC-3.07* HGB-9.5* HCT-28.0* MCV-91 MCH-30.8 MCHC-33.8
RDW-13.5
NEUTS-77.4* LYMPHS-15.2* MONOS-5.6 EOS-1.6 BASOS-0.2
PLT COUNT-149*
Coagulation profile:
PT-12.3 PTT-28.2 INR(PT)-1.0
Chemistry:
GLUCOSE-227* UREA N-22* CREAT-1.0 SODIUM-139 POTASSIUM-3.5
CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
PHOSPHATE-2.1*# MAGNESIUM-1.6
Cardiac enzymes:
CK(CPK)-89
cTropnT-0.10*
EKG: NSR, rate 88. LAD, LBBB. Anterior Qs. Non-specific ST-T
changes.
CXR [**2102-4-8**]: The cardiac silhouette is in the upper limits of
normal size. There is a slight prominence of the right
mediastinal contour, but this is stable when compared to the
previous studies and most likely represent tortuosity of
vessels. There is increased density in the left retrocardiac
area, which is _____ in the left hemidiaphragm and may represent
an early pneumonia. This is new when compared to the prior
study.
IMPRESSION: Probable left lower lobe pneumonia.
CXR [**3-/2902**]: AP VIEW OF THE CHEST dated [**2102-4-10**], is
compared to the prior AP chest x-ray dated [**2102-4-8**].
Since the prior exam, there has been interval development of a
small left pleural effusion. The lungs remain clear. The cardiac
silhouette has not changed in size, in the upper limits of
normal. There is stable medistinal widening consistent with
patient's known mediastinal lipomatosis. The soft tissue and
osseous structures are unremarkable.
**************
ECHO [**2102-4-8**]: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%); the
lateral wall appears hypokinetic in the apical window. The
mitral valve leaflets are mildly thickened. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior report (tape unavailable
for review) of [**2101-12-12**], the lateral wall may now be
hypokinetic.
ECHO: [**2102-4-11**]: The left atrium is elongated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with focal hypokinesis of the basal lateral
wall. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with mild [1+]
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is a small circumferential
pericardial effusion without evidence for hemodynamic
compromise. Compared with the prior study (tape reviewed) of
[**2102-4-8**], left ventricular function is similar. The pericardial
effusion may be minimally larger.
**************
Cath [**2102-4-5**]:
LMCA with mild plaquing. LAD diffusely diseased up to 40%. The
LCX revealed proximal ISRS 80-90% extending into OM1 with distal
edge 70% and subsequent 80% stenosis prior to distal major
bifurcation. The AV groove vessel was diminutive. The RCA showed
a proximal 70%, mild diffuse disease thereafter up to 80%. The
PDA had a modest 40% lesion at the origin and 50% lesions mid
vessel. A larger RPL1 had a origin 30% lesion.
2. Left ventriculography EF 48% with posterobasal hypokinesis.
3. s/p PTCA/stenting of the LCX/OM1 with overlapping Cypher DES.
s/p PTCA/stenting of the mid RCA with overlapping Cypher [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7930**] and of the proximal RCA.
6. The LCX and the RCA interventions were complicated by the
development
of ischemic mitral regurgitation (see PTCA comments).
Brief Hospital Course:
Ms. [**Known lastname 15505**] is a 50 year-old female with CAD s/p OM (for in
stent restenosis) and RCA stents on [**2102-4-5**], also with DM type
2, HTN, positive family history admitted with recurrent chest
pain 2 days post PTCA, found to have stent thrombosis of OM
stent, s/p balloon angioplasty and stent placement.
For her CAD, Ms. [**Known lastname 15505**] was started on Plavix 150 mg PO QD,
ASA, Toprol, Diovan and Nifedipine. She was weaned from NTG gtt.
She was also continued on Lipitor. She has a sensitivity to the
first line [**Doctor Last Name 360**] for in stent restenosis, ticlid, so instead,
she was placed on high dose plavix.
She was thought to have pneumonia since she has a low-grade
fever at home, and her CXR suspicious for left lower lobe
pneumonia. She continued to have low grade fevers in house, and
was pancultured. These grew nothing out and it was thought that
the fevers may have initially been secondary to the inflammation
from the myocardial infarction or to a pericardial effusion
although no rub was detected. Of note, she complained of
pleuritic type chest pain. She was covered with Levofloxacin. A
repeat PA and lateral were clear.
Ms. [**Known lastname 15505**] was found to be anemic and transfused 1 units of
PRBCs. She has chronic anemia. For her mixed connective tissue
disorder, the patient's Prednisone was continued at out-patient
dose. For her DM type 2: the Metformin was held. She was stared
on a regular insulin sliding scale QID. Once she was cleared by
PT, she was sent home. Her metformin was restarted at discharge.
Medications on Admission:
Prednisone 6 mg daily
Probenacid 500 mg PO BID
Cholchicine 0.6 mg QD
Nifedipine 30 mg PO daily
Diovan 320 mg PO daily
Toprol XL 300 mg PO daily
Omeprazole 20 mg PO BID
Celexa 20 mg PO daily
Metformin 500 mg PO daily
Dilaudid 4 mg PO BID
ASA 325 mg PO daily
MVI 1 tablet PO daily
Folic acid 1 mg PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
4. Probenecid 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. Probenecid 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Hydromorphone HCl 2 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
17. Outpatient Physical Therapy
Please evaluate for right lower extremity pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute MI with acute instent thrombosis of LCX stent
Coronary artery disease
hypertension
diabetes
depression
anemia
pneumonia
gout
peripheral neuropathy
Discharge Condition:
good
Discharge Instructions:
Take your atorvastatin, aspirin, plavix, nifedipine, valsartan,
toprol and nitro as needed. You can also continue your
glucophage. Take 3 more days of levofloxacin.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST OFFICE (SB) Where: LM [**Hospital Unit Name **] GASTROENTEROLOGY Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2102-4-26**]
12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2102-5-25**] 11:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2102-6-8**] 2:00
Follow up with physical therapy for evaluation of leg pain.
|
[
"996.72",
"530.81",
"423.9",
"414.01",
"357.2",
"250.60",
"401.9",
"274.9",
"285.9",
"410.51",
"530.85",
"424.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"37.22",
"36.01",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11265, 11271
|
7704, 9285
|
360, 467
|
11468, 11474
|
3981, 4007
|
11687, 12405
|
3135, 3327
|
9639, 11242
|
11292, 11447
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9311, 9616
|
11498, 11664
|
3342, 3962
|
4375, 7681
|
310, 322
|
495, 2319
|
4021, 4358
|
2341, 2999
|
3015, 3119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,659
| 116,163
|
31381
|
Discharge summary
|
report
|
Admission Date: [**2176-11-26**] Discharge Date: [**2176-12-3**]
Date of Birth: [**2126-1-28**] Sex: M
Service: SURGERY
Allergies:
Lactose
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
S/P MVC
abdominal pain
Major Surgical or Invasive Procedure:
[**2176-11-26**]
1. Diagnostic laparoscopy.
2. Exploratory laparotomy.
3. Control of liver hemorrhage.
4. Ileocecectomy with primary ileocolic anastomosis.
History of Present Illness:
Mr. [**Known lastname **] is a 50 year old male who was the restrained
passenger in
an MVC today. He has a history of Down's syndrome and was
agitated and grabbed the driver of a [**Doctor Last Name **] resulting in a
motor vehicle collision. He was brought to [**Location (un) 620**] where he
was noted to be hypotensive and complaining of abdominal
pain. FAST was negative. Non-contrast CT scans of the head,
C-spine, and torso revealed only a small amount of fluid in
the right paracolic gutter. He was transferred to [**Hospital 61**] for further evaluation. Currently he reports some
abdominal pain. I spoke with the manager of his group home
who reports that he has been feeling well lately and has had
no other complaints. Of note, he was given IV antibiotics at
[**Location (un) 620**] to cover for a possible infectious source as a cause
of his agitation and hypotension. He also received 3 L of IV
fluid there. Blood pressure was in the 60s to 70s for EMS.
Past Medical History:
Down's syndrome
hypercholesterolemia
hypothyroidism
pernicious anemia
intermittent explosive disorder
senile dementia
heart murmur requiring antibiotic ppx prior to dental procedures
Social History:
He lives in a group home ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). No etoh or tobacco.
Family History:
Unknown.
Physical Exam:
Temp:97.3 HR:52 BP:79/40 Resp:20 O(2)Sat:100
Constitutional: Awake and alert
HEENT: Has some facial bruising, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft. Left flank ecchymoses. Diffuse mild
tenderness to palpation without rebound or
Pelvic: Normal tone no gross blood. Pelvis is stable
Extr/Back: No TLS tenderness to palpation
Neuro: Awake and alert. Moves all extremities. No focal
deficit. Sensation intact. Follows commands
Pertinent Results:
[**2176-11-26**] 01:10PM WBC-7.0# RBC-3.06* HGB-10.8*# HCT-32.4*
MCV-106* MCH-35.2* MCHC-33.2 RDW-13.4
[**2176-11-26**] 01:10PM NEUTS-88.5* LYMPHS-8.4* MONOS-2.4 EOS-0.2
BASOS-0.4
[**2176-11-26**] 01:10PM PLT COUNT-231
[**2176-11-26**] 01:10PM PT-13.7* PTT-22.7 INR(PT)-1.2*
[**2176-11-26**] 01:10PM ALT(SGPT)-49* AST(SGOT)-63* CK(CPK)-186 ALK
PHOS-116 TOT BILI-0.3
[**2176-11-26**] 01:10PM LIPASE-29
[**2176-11-26**] 01:10PM GLUCOSE-95 UREA N-17 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2176-12-3**] 06:35 3.4* 3.54* 10.9* 32.2* 91 30.7 33.7 20.2*
151
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2176-11-26**] 13:10 88.5* 8.4* 2.4 0.2 0.4
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2176-12-3**] 06:35 151
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2176-11-27**] 00:49 184
Source: Line-aline
LAB USE ONLY
[**2176-12-3**] 06:35
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2176-12-3**] 06:35 113*1 12 0.7 137 3.0* 102 30 8
[**2176-11-26**] CT Abd : 1. Focal ileocolic stranding and focal cecal
wall thickening suggestive of mesenteric hematoma and focal
bowel wall contusion, respectively. Trace amount of
hemoperitoneum.
2. Acute fractures of the right posterior ribs 10 and 11.
3. Bilateral dependent consolidations and ground-glass
opacities, likely
atelectasis, although superimposed aspiration not excluded.
4. No other traumatic injury to the torso.
[**2176-11-26**] TTE :
Suboptimal image quality. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
No pericardial effusion. Mild-moderate tricuspid regurgitation
[**2176-11-27**] MRI C spine :
1. There is no evidence of ligamentous disruption identified or
prevertebral soft tissue abnormality seen. No evidence of
intraspinal hematoma, cord compression, or abnormal signal
within the spinal cord.
2. Degenerative changes at the atlanto-odontoid joint and the
remaining
cervical spine as described above.
Brief Hospital Course:
Mr. [**Known lastname **] was evaluated by the Trauma team in the Emergency
Room and taken to the Operating Room emergently for a diagnostic
laparotomy followed by exploratory laparotomy ( see formal Op
note for details). He tolerated the procedure relatively well
and returned to the Trauma ICU in stable condition with a stable
hematocrit following transfusion of 3 units of packed red blood
cells.
Post op in the ICU he had persistent problems with hypotension
despite adequate resuscitation and eventually was treated with
steroids for adrenal insufficiency which immediately normalized
his blood pressure and his pressors were weaned off. He was
weaned and extubated from the respirator on post op day 2 and
was able to deep breath and cough without difficulty thereafter.
Following transfer to the Surgical floor he continued to make
steady progress. His surgical wound was healing well without
evidence of erythema or drainage and he was gradually tolerating
a regular diet after his bowel function resumed. He did require
2 more blood transfusions as his hematocrit drifted down on
[**2176-12-1**] without evidence of active bleeding. Prior to discharge
his hematocrit was 32. His steroids were tapered off ending on
[**2176-12-3**] and his blood pressure ranged between 100-110/70.
[**Known firstname **] was also evaluated by the Physical Therapy service and they
recommended a short term rehab prior to his return home in order
to improve his gait and activity tolerance. After a relatively
uncomplicated stay he was discharged to rehab on [**2176-12-3**].
Medications on Admission:
Gemfibrozil 600 mg [**Hospital1 **]
Hydrocortisone 2.5% ointment topically as directed
Lactaid 4500 units daily
Levothyroxine 88 mcg daily
MVI 1 tab daily
Neurontin 400 mg TID
Peridex 0.12% as directed [**Hospital1 **]
Robitussin DN 2 tsp QID prn
TUMS 500 mg [**Hospital1 **]
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Avulsion of small bowel mesentery.
2. Injury to cecum.
3. Liver laceration.
4. Acute blood loss anemia
5. Adrenal insufficiency
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent at baseline
Discharge Instructions:
* You were admitted to the hopsital with internal injuries to
your abdomen following your car accident which required an
operation.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-10**] lbs until you follow-up with your
surgeon.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**3-6**] weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2176-12-13**] 1:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2176-12-3**]
|
[
"807.02",
"864.02",
"785.50",
"276.50",
"912.0",
"560.1",
"V64.41",
"758.0",
"281.0",
"285.1",
"255.41",
"863.89",
"244.9",
"E812.1",
"315.9",
"290.0",
"785.2",
"276.2",
"530.81",
"312.34",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
7076, 7173
|
4587, 6164
|
290, 448
|
7348, 7463
|
2420, 4564
|
9449, 9873
|
1801, 1811
|
6490, 7053
|
7194, 7327
|
6190, 6467
|
7535, 9051
|
9067, 9426
|
1826, 2401
|
228, 252
|
476, 1445
|
7478, 7511
|
1467, 1653
|
1669, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,312
| 165,574
|
29689
|
Discharge summary
|
report
|
Admission Date: [**2121-12-24**] Discharge Date: [**2121-12-31**]
Date of Birth: [**2041-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2121-12-23**] Cardiac Catherization
[**2121-12-26**] Coronary Artery Bypass Graft x5 (free LIMA->left anterior
descending artery, saphenous vein graft->posterior descending
artery, saphenous vein graft-> left circumflex, saphenous vein
graft-> diagonal, saphenous vein graft->ramus)
History of Present Illness:
80 year old female with 4 day history of worsening chest pain.
Chest pain preessure quality occuring in mid sternum and
radiating to left forearm and jaw not relieved with SL
nitroglycerin with associated shortness of breath. Presented to
OSH, troponin negative and transferred for further cardiac
evaluation.
Past Medical History:
Coronary Artery Disease s/p CABG
Myocardial Infarction
Angina
Hypertension
Hypothyroidism
Bronchitis
Social History:
Lives alone in [**Hospital3 4634**]
Tobacco denies
ETOH denies
Family History:
non contributory
Physical Exam:
Discharge
Vitals 97.8, SR 94, 132/64, 22 RA sat 92% wt 55.7kg
No acute distress
Neuro alert/oriented x3 strength 4/5
Heart RRR no murmur/rub/gallop
Pulm CTA anterior/posterior
Abd soft, NT, ND, +BS last BM [**12-30**]
Ext warm, CR <3sec pulses +1, edema +1 lower ext
Incision sternal healing, no drainage/no erythema/eccymotic
steris intact
Left EVH steris healing no drainage/erythema, thigh ecchymotic
Pertinent Results:
[**2121-12-30**] 06:50AM BLOOD WBC-8.4 RBC-3.33* Hgb-10.1* Hct-29.8*
MCV-90 MCH-30.3 MCHC-33.9 RDW-14.7 Plt Ct-172#
[**2121-12-24**] 01:45AM BLOOD WBC-12.6* RBC-3.40* Hgb-10.3* Hct-29.5*
MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-296
[**2121-12-24**] 01:45AM BLOOD Neuts-75.9* Lymphs-19.1 Monos-3.0 Eos-1.8
Baso-0.2
[**2121-12-30**] 06:50AM BLOOD Plt Ct-172#
[**2121-12-28**] 03:14AM BLOOD PT-13.5* PTT-37.6* INR(PT)-1.2*
[**2121-12-24**] 01:45AM BLOOD Plt Ct-296
[**2121-12-24**] 01:45AM BLOOD PT-13.2* PTT-88.4* INR(PT)-1.1
[**2121-12-26**] 01:12PM BLOOD Fibrino-128*
[**2121-12-30**] 06:50AM BLOOD Glucose-113* UreaN-21* Creat-0.9 Na-135
K-4.3 Cl-102 HCO3-25 AnGap-12
[**2121-12-24**] 01:45AM BLOOD Glucose-157* UreaN-15 Creat-1.7* Na-138
K-4.5 Cl-105 HCO3-23 AnGap-15
[**2121-12-24**] 01:45AM BLOOD ALT-11 AST-20 CK(CPK)-46 AlkPhos-92
Amylase-137* TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2121-12-25**] 12:02AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2121-12-29**] 03:04AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.8
[**2121-12-24**] 01:45AM BLOOD %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE
[**2121-12-25**] 03:52AM BLOOD Triglyc-170* HDL-35 CHOL/HD-4.5
LDLcalc-89
CXR [**12-30**]
CHEST, PA AND LATERAL
INDICATION: Evaluate for pleural effusion.
FINDINGS: There is status post sternotomy and the presence of
multiple surgical clips in the left-sided anterior mediastinum
is indicative of previous bypass surgery. Cardiac contours are
partially obscured by the presence of pleural and parenchymal
abnormalities but significant cardiac enlargement is most
likely. Also the thoracic aorta appears moderately widened and
elongated. There exist bilateral pleural effusions, more on the
left than on the right. In addition, crowded pulmonary
vasculature and linear densities in the left lower lung field
are indicative of atelectasis and infiltrates coinciding with
the pleural effusions that were already present on the
preoperative chest examination of [**12-24**] and persisted
during the perioperative episodes as seen on chest x-rays of
[**12-26**], 3, and 5.
In comparison with the next previous examination, no significant
interval change can be identified. The now obtained additional
lateral view identifies the pleural effusions to occupy the
posterior pleural sinusesand the basilar area of the interlobar
major fissures. Atelectases and infiltrates are located mostly
in the posterior segments.
IMPRESSION: Grossly stable findings. Postoperative pleural
effusions and atelectasis persist, further followup examination
is recommended.
ECHO [**12-26**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.7 cm (nl <= 5.2 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.7 cm (nl <= 3.4 cm)
Aorta - Arch: 2.1 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.2 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 0.5 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 1 mm Hg
Aortic Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Peak Velocity: 1.0 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 1.00
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Mild regional LV systolic dysfunction. Mildly
depressed LVEF.
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. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. There are complex
(>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
There are
complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. Trace
AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. See Conclusions for post-bypass data
Conclusions:
PRE-BYPASS: Note: Study interrupted and may appear in system as
2 separate
studies. The left atrium is mildly dilated. No atrial septal
defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be
fully excluded. There is mild to modreate regional left
ventricular systolic
dysfunction with mid to apical septal hypokinesis and mid to
apical inferior
hypokinesis. The apex appears hypokinetic.. Overall left
ventricular systolic
function is mildly to moderately depressed (LVEF 40-45%). Right
ventricular
chamber size and free wall motion are normal. There are complex
(>4mm)
atheroma in the aortic arc and the descending thoracic aorta.
Epiaortic scan
was preformed prior to aortic cannulation with no large plaques
visible at the
site of cannulation or cross clamp application. The aortic valve
leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened with
possible rheumatic deformity.. Mild (1+) mitral regurgitation is
seen. Mitral
annulular diameter measures on average 2.6 cm. Vena contracta
measures .1-.4
cm with provactive manuvers. Mitral regurgitation is central.
There is no
mitral stenosis.
POST-BYPASS:
Patient is atrially paced on .02 mcg/kg/min epinepherine and .5
mcg/kg/min
phenylepherine infusions.
Biventricular function and wall motion are unchanged. LVEF
40-50% with no
change in inferior and septal hypokinesis. Mitral regurgitation
is trace to
mild. Aortic contours are intact. Remaining exam is unchanged
from pre-bypass.
All findings were discussed with surgeons at the time of the
exam.
Brief Hospital Course:
Transferred in from outside hospital for further cardiac
evaluation. Underwent cardiac catherization which revealed
coronary artery disease. Post cardiac catherization she had
bleeding from groin site and was transfused and vascular surgery
consulted. Cardiac surgery was consulted and she underwent
preoperative workup. On [**12-26**] she was brought to the operating
room where she underwent a coronary artery bypass graft. Please
see operative report for surgical details. She tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke neurologically intact and was extubated. On
post-op day one she was transfused for decrease hematocrit and
remained in CSRU for hemodynamic monitoring. On post op day
three started on beta blockers and diuretics. She was gently
diuresed towards her pre-op weight. She was transferred to the
post op floor were she received the remainder of her care while
in the hospital. Physical followed patient during post-op course
for strength and mobility. She continued to make steady process
without any post-op complications and was discharged to rehab
post-op day five.
Medications on Admission:
ASA
Imdur
lasix
NTG
Prednisone
Atenolol
Levothyroxine
Lisinopril
Ambient
Combivir
Albuterol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 40mg twice a day for 7 days then decrease to 40mg once
daily.
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours):
twice daily for 7 days then decrease to once daily .
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab center
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Myocardial Infarction
Angina
Hypertension
Hypothyroidism
Bronchitis
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Followup Instructions:
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 63252**] after discharge from rehab - please call for
appointment
Dr [**Last Name (STitle) **] after discharge from rehab - please call for
appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-12-31**]
|
[
"790.29",
"440.0",
"599.0",
"433.30",
"414.01",
"998.12",
"440.1",
"244.9",
"435.2",
"401.9",
"410.11",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15",
"89.60",
"88.48",
"88.56",
"88.53",
"37.22",
"88.42",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10924, 10979
|
8189, 9397
|
333, 621
|
11124, 11131
|
1639, 8166
|
11597, 11996
|
1181, 1199
|
9539, 10901
|
11000, 11103
|
9423, 9516
|
11155, 11574
|
1214, 1620
|
283, 295
|
649, 961
|
983, 1085
|
1101, 1165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,273
| 121,415
|
6193
|
Discharge summary
|
report
|
Admission Date: [**2141-11-1**] Discharge Date: [**2141-11-7**]
Date of Birth: [**2070-8-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
left lung cancer
Major Surgical or Invasive Procedure:
[**2141-11-1**]: Left thoracoscopy, left thoracotomy and left
lower lobectomy with en bloc aortic wall resection and
reconstruction, mediastinal lymph node dissection, flexible
bronchoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 71-year-old gentleman who was referred to the
thoracic multidisciplinary clinic by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
evaluation of bilateral lung nodules. Mr. [**Known lastname **] has a history of
stage Ib melanoma, which was removed
from his face in [**2138**]. He developed a sharp chest pain while
lying flat on his back as well as a bit of a dry cough. He had
been treated with a Z-Pak for this
recently. He also had a sensation of chest congestion,
weakness, and fatigue. He notes a 7-pound weight loss since
[**2141-6-25**]. A chest x-ray was done to follow up on the flu-like
symptoms and cough and chest congestion. This revealed a mass
in the left lower lobe, which was followed by a CAT scan, which
confirmed the mass in the left lower lobe as well as a smaller
mass at the
right lower lobe. He denies any hemoptysis or purulent sputum
production. He denies any fevers, chills, or sweats. He denies
any new back or bony pain. He has been maintaining a reasonable
exercise regimen.
Past Medical History:
Prostate Cancer 8 years ago, s/p radical prostatectomy,
malignant melanoma diagnosed [**2139-6-26**], Rheumatic fever as a
child
Social History:
Pt is married with 3 children, works in publishing industry,
denies tobacco use, brief and distant history of cigar and pipe
smoking, drinks [**12-27**] glasses of wine with dinner
Family History:
Mother passed away with a h/o colon and lung cancer. Father died
of CAD. One sister with h/o malignant melanoma x2 still living.
Pt has 3 healthy children
Physical Exam:
98.0, HR 70, BP 115/52, RR18, 93-97% on RA. Pain [**2143-12-28**]
Gen: Well, NAD, A&Ox3, ambulatory
CV: RRR
Chest: CTAB, L thoracotomy incision C/D/I. Occlusive dressing
over chest tube insertion site C/D/I
Abd: benign
Pertinent Results:
Pathology pending at time of discharge.
On Discharge: [**2141-11-5**] 09:30AM BLOOD WBC-7.9 RBC-3.69* Hgb-11.4*
Hct-33.2* MCV-90 MCH-30.9 MCHC-34.3 RDW-14.7 Plt Ct-253 BLOOD
Glucose-92 UreaN-14 Creat-1.0 Na-141 K-4.0 Cl-108 HCO3-26
AnGap-11 BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
Cardiology Report ECG Study Date of [**2141-11-1**] 12:35:32 PM
Sinus rhythm. Non-specific QRS widening. Left axis deviation.
Possible
left anterior fascicular block. Diffuse non-diagnostic
repolarization
abnormalities. Compared to previous tracing of [**2141-10-10**] multiple
abnormalities persist without major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 168 118 394/394 59 -67 30
Brief Hospital Course:
Pt was admitted on [**2141-11-1**] and underwent a left thoracoscopy,
left thoracotomy and left lower lobectomy with en bloc aortic
wall resection and reconstruction, mediastinal lymph node
dissection, flexible bronchoscopy. Two chest tube were left in
place and placed to wall suction. The pt was extubated during
the evening of POD#0. Pain was well controlled with an epidural.
Peri-operative cefazolin was continued for 3 doses
post-operatively. Pt was begun on metoprolol peri-operatively.
Diet was begun as clears after extubation. Pt was transferred to
the surgical intensive care unit post-operatively. On POD#2 pt
was transfused with 2 units of PRBC's for a Hct of 27.1 which
increased to 29.8. On POD#2 chest tubes were placed to
water-seal and the pt was transferred out of the ICU. On POD#3
pt was tolerating a regular diet, chest tube continued to water
seal. Apical chest tube was removed on POD#3. On POD#4 epidural
catheter was removed, Foley catheter was removed, and IV fluids
were discontinued. On POD#5, [**2141-11-6**], remaining chest tube was
discontinued. Post-pull chest x-ray revealed a small L apical
pneumothorax which was stable from previous films. Pt was
discharged home in good condition.
Medications on Admission:
None
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): continue until you discuss with Dr. [**Last Name (STitle) 914**].
Disp:*60 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Non-small cell lung cancer, Stage IB melanoma s/p right temple
wide local excision w/SLN biopsy, prostate cancer s/p radical
prostatectomy ([**2132**]), h/o rheumatic fever as child
Discharge Condition:
Good
Discharge Instructions:
Please call Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever greater than 101.5, foul
smelling or colorful drainage from your incisions, redness or
swelling, severe pain, persistent nausea or vomiting, inability
to eat or drink, or any other symptoms which are concerning to
you.
No tub baths or swimming for 4 weeks. You may shower in 48h.
Remove your dressing in 48 hours and cover with a clean bandage
until healed. If there is clear drainage from your incisions,
cover with a dry dressing.
Activity: As tolerated
Medications: You should take a stool softener, Colace 100 mg
twice daily as needed for constipation. Pain medication may make
you drowsy. No driving while taking pain medicine.
Followup Instructions:
Follow-up appointment is scheduled for [**11-21**] at 10:30am
in the chest disease center [**Hospital1 **] [**Location (un) 448**]. Please come
at 9:45 am to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] to check
in and have a chest X-ray. Please call the office of
Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) 170**] to make any changes.
call Dr.[**Name (NI) 9379**] office [**Telephone/Fax (1) 170**] for a follow up
appointment to be seen in one month after discharge home.
|
[
"E878.6",
"285.9",
"V10.46",
"197.1",
"198.89",
"162.5",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.6",
"33.22",
"38.45",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5094, 5100
|
3111, 4332
|
338, 531
|
5326, 5333
|
2411, 2452
|
6143, 6656
|
2000, 2156
|
4387, 5071
|
5121, 5305
|
4358, 4364
|
5357, 6120
|
2171, 2392
|
2466, 3088
|
282, 300
|
559, 1634
|
1656, 1786
|
1802, 1984
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,330
| 118,295
|
17471
|
Discharge summary
|
report
|
Admission Date: [**2129-6-4**] Discharge Date: [**2129-6-8**]
Date of Birth: [**2049-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 80 yo man with DM2, CKD (baseline most recently
~2.0), HTN, BPH, depression and a recent admission (discharged
[**5-26**]) for volume overload who was found at home today by his son
unresponsive.
.
EMS could not measure his FSBS because it was critically high.
In the ED, his initial VSs were 101.6, 231/74, 74, 20, 97% on
RA. Initial finger stick was 667 here, serum blood sugarwas 636.
Pt received 4 x 10 units of insulin IV (not started on drip) and
4L NS. In addition, he received vancomycin, levofloxacin and
metronidazole for his fever after cultures were drawn.
.
The pt was not able to give any additional history.
.
The pt's son, who spoke to the pt on the day prior to
presentation, reported that he had no complaints one day PTA. He
did not c/o chest pain, shortness of breath, pain with
urination, nausea, vomiitng, cough, sputum production or
headache. The pt's son did report that the pt has been sloppy
with his insulin compliance of late due to the recent loss of
the pt's wife.
Past Medical History:
Type II DM
CKD, baseline Cr 1.6-2.0
HTN
BPH
Depression
Social History:
Denies tobacco, alcohol, recreational drugs.
Family History:
Noncontributory
Physical Exam:
On Admission:
Vitals: T: 101.6 BP: 191/70 P: 76 R: 27 SaO2: 97% on 2LNC
General: Unable to rouse, appears agitated. Does not respond to
voice commands.
HEENT: NCAT, PERRL but sluggish 4->3, no scleral icterus, MM
dry, no lesions noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, II/VI systolic murmur heard best at the
RUSB, no rubs or gallops appreciated
Abdomen: well-healed right lateral scar, soft, not apparently
tender, ND, normoactive bowel sounds, no masses or organomegaly
noted
Extremities: No edema, 2+ radial, trace DP pulses b/l
Lymphatics: No cervical, supraclavicular lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Difficult to rouse, not responsive to verbal
commands. Opens eyes spontaneously. PERRL but sluggish 4->3.
Unable to assess cranial nerves secondary to non-cooperative pt.
Moves all extremities, reeflexes 2+ at brachioradialis, biceps,
patella, diminished to absent at Achilles bilaterally. No
abnormal movements noted. Upgoing toes bilaterally.
Pertinent Results:
[**2129-6-4**] 09:13PM GLUCOSE-100 UREA N-37* CREAT-2.1* SODIUM-147*
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-30 ANION GAP-15
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) PROTEIN-57*
GLUCOSE-197
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-97 RBC-2*
POLYS-93 LYMPHS-2 MONOS-5
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-88 RBC-2*
POLYS-96 LYMPHS-2 MONOS-2
[**2129-6-4**] 05:05PM URINE HOURS-RANDOM
[**2129-6-4**] 05:05PM URINE UHOLD-HOLD
[**2129-6-4**] 04:33PM CALCIUM-8.4 PHOSPHATE-1.5*# MAGNESIUM-2.3
[**2129-6-4**] 01:12PM GLUCOSE-360* NA+-139 K+-3.5 CL--98* TCO2-33*
[**2129-6-4**] 01:00PM UREA N-41* CREAT-2.2*
[**2129-6-4**] 07:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2129-6-4**] 07:00AM URINE HOURS-RANDOM
[**2129-6-4**] 07:00AM URINE GR HOLD-HOLD
[**2129-6-4**] 07:00AM WBC-7.7 RBC-4.89 HGB-12.9* HCT-40.2 MCV-82
MCH-26.4* MCHC-32.2 RDW-14.8
[**2129-6-4**] 07:00AM NEUTS-78.9* LYMPHS-14.3* MONOS-4.5 EOS-1.2
BASOS-1.1
[**2129-6-4**] 07:00AM PT-13.0 PTT-26.5 INR(PT)-1.1
[**2129-6-4**] 07:00AM PLT COUNT-461*
[**2129-6-4**] 07:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2129-6-4**] 07:00AM URINE RBC-[**5-8**]* WBC-0 BACTERIA-0 YEAST-NONE
EPI-0
[**2129-6-7**] 05:41AM BLOOD WBC-9.3 RBC-4.43* Hgb-11.7* Hct-34.4*
MCV-78* MCH-26.4* MCHC-34.1 RDW-14.9 Plt Ct-346
[**2129-6-6**] 05:44AM BLOOD WBC-10.9 RBC-4.31* Hgb-11.3* Hct-34.0*
MCV-79* MCH-26.2* MCHC-33.3 RDW-15.0 Plt Ct-339
[**2129-6-7**] 05:41AM BLOOD Plt Ct-346
[**2129-6-6**] 05:44AM BLOOD Plt Ct-339
[**2129-6-4**] 07:00AM BLOOD Neuts-78.9* Lymphs-14.3* Monos-4.5
Eos-1.2 Baso-1.1
[**2129-6-7**] 05:41AM BLOOD Glucose-93 UreaN-22* Creat-1.7* Na-142
K-3.3 Cl-101 HCO3-35* AnGap-9
[**2129-6-7**] 05:41AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-97 RBC-2*
Polys-93 Lymphs-2 Monos-5
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-88 RBC-2*
Polys-96 Lymphs-2 Monos-2
[**2129-6-4**] 06:33PM CEREBROSPINAL FLUID (CSF) TotProt-57*
Glucose-197
[**2129-6-4**] 06:30PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
**FINAL REPORT [**2129-6-7**]**
GRAM STAIN (Final [**2129-6-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2129-6-7**]): NO GROWTH.
Brief Hospital Course:
#HONK/DM2: No known precipitant, although according to pt's
son, he likely has not been compliant with his insulin regimen
lately. There were no obvious infectious etiologies in spite of
his fever in the ED. His U/A was clean, his CXR and lung exam
were essentially normal. He had not been c/o headache, and he
had no WBC count. An LP done over 12hrs after abx started showed
a white count of 98, mostly PMNs, without any organism on gram
stain or culture. There was no evidence of an acute coronary
syndrome either by history or on EKG. The patient was
aggressively volume repleted, treated with insulin drip [**First Name8 (NamePattern2) **]
[**Last Name (un) **] protocol, and rapidly stabilized his blood sugars. Once
on the floor, the Pt. tolerated full diabetic diet, FSG
initially ranging from 196-238, but improving to 72-189 once his
home regimen of insulin (25am/10pm) was restarted. Plan on
continuing home regimen with close outpatient f/u.
.
## Fever: White count not elevated, no infiltrate on CXR, U/A
clean. As above, LP somewhat questionable considering earlier
dose of Abx. Pt. was started on meningitis dosing of
vancomycin, ceftriaxone and acyclovir for a 10 day course, which
will be completed on [**6-13**]. On the floor the pt. was afebrile, no
leukocytosis, no growth on cultures, clean chest film and clean
U/A. Also, the pt. was without any symptoms. A PICC line was
placed for further Abx therapy and good glycemic control was
continued. Consider dosing his Vanc by level, giving 1g for
trough less than 15. As before, course will be complete on
[**6-13**].
.
##Delirium: Likely related to HHNS and perhaps fever. Head CT
within normal limits. No evidence of other ingestions on tox
screens or history per son. Once on the floor the patient was
AAOx1-2, and at baseline, according to discussion with son and
PCP. [**Name10 (NameIs) **] improved versus admission. We continued to re-orient
as needed, and assist with feedings/ambulation as needed.
.
## HTN: Pt hypertensive to 220s/70s in the ED. Did not received
any antihypertensives. First, he was started with IV labetalol
with goal SBP in the 160s and chased with PO labetalol once NGT
was in place. On the floor, as his renal function improved we
restarted first his ACEI and then his [**Last Name (un) **].
.
## CKD: Cr 2.0 at last discharge, baseline per records from
1.6-2.0, raised to 2.4 on this admission but now back to 1.6.
At discharge he appears hydrated on exam. His I/Os were
near-neutral without his home dos aging of diuretics. He may
need to restart some dose of these diuretics in the near future.
.
##CHF: Pt. with stable weight near 235lbs. PLan to continue
daily weights, and restart diuretics when needed for fluid
retention. His home regimen was Metolazone 5 mg qam, 30 minutes
prior to furosemdie 80mg (daily). Perhaps one could first
restart his lasix and then add the metolazone if needed.
.
## Elevated troponin: Likely secondary to CKD and ARF. No EKG
changes suggestive of ischemia. Pt has no documented hx of CAD,
but given DM2, likely has underlying coronary disease. Recheck
ruled out MI.
.
## Depression: Con't celexa, SW will see pt. soon.
.
## FEN/Lytes: Diabetic/Heart healthy full diet.
.
## Prophylaxis: Heparin SC 5000 tid, no indication for PPI
.
## Code status: FULL CODE, discussed with son, [**Name (NI) 449**]
.
## Contact: [**Name (NI) 449**] [**Name (NI) **] (son) home [**0-0-**], cell
[**Telephone/Fax (1) 48800**], daughter-in-law [**Name (NI) **] [**Telephone/Fax (1) 48801**]
.
## Dispo: TO sub-acute/rehab
..
Medications on Admission:
Valsartan 80 mg daily
Aspirin 81 mg daily
Citalopram 20 mg daily
Metoprolol Tartrate 50 mg twice daily
Furosemide 80 mg qam
Ergocalciferol (Vitamin D2) 50,000 qweek
Insulin NPH-Regular (70-30) 25 units qam
Insulin NPH-Regular (70-30) 10 units q pm
Metolazone 5 mg qam, 30 minutes prior to furosemdie
Acetaminophen 500 mg [**11-30**] q6hrs prn pain
Lisinopril 40 mg daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
7. CeftriaXONE 2 gm IV Q12H
8. Ampicillin 2 gm IV Q6H
9. Acyclovir 1200 mg IV Q12H
10. Vancomycin 1000 mg IV Q48H
according to pharmacy calc of crcl of 18.
11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
12. HydrALAzine 20 mg IV Q6H:PRN SBP > 160
13. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN
For PASV picc before and after each use Inspect site daily
14. Insulin NPH 25units sq Qam/ 10units sq Qpm
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
non-ketotic hyperglycemic hyperosmotic crisis
Hypertensive urgency
delerium
Acute renal failure
Secondary:
1. Type II DM
2. CRI, baseline Cr 1.6-2.0
3. HTN
4. BPH
5. Depression
6. CHF
Discharge Condition:
good
Discharge Instructions:
Please continue your antibiotics as instructed for the full 10
day course(done on [**6-13**]). Continue to take your other
medications as prescribed. If you experience any symptoms that
worry you or your family please return to the hospital for
further treatment. Also, please weigh yourself daily to ensure
your fluid status is not worsening
Followup Instructions:
please followup with your PCP [**Name Initial (PRE) 176**] 3 days of discharge
Also, you have the following appointment for the future:
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2129-6-23**] 3:40
|
[
"424.0",
"250.22",
"428.22",
"047.9",
"428.0",
"584.9",
"585.9",
"600.00",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10179, 10234
|
5107, 8672
|
322, 328
|
10471, 10478
|
2702, 5084
|
10872, 11167
|
1543, 1560
|
9094, 10156
|
10255, 10450
|
8698, 9071
|
10502, 10849
|
1575, 1575
|
274, 284
|
356, 1385
|
1589, 2683
|
1407, 1464
|
1480, 1527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,620
| 122,484
|
3138
|
Discharge summary
|
report
|
Admission Date: [**2198-6-29**] Discharge Date: [**2198-7-3**]
Date of Birth: [**2139-4-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
[**Company 1543**] single chamber VVI via cephalic vein
History of Present Illness:
59 M PMH of HTN, atrial fibrillation, h/o lymphoma admitted with
bradycardia.
He presented to ED today with report of [**3-15**] weeks of
lightheadedness when standing that has been progressive over
that time period. Also has had increased fatigue. His beta
blocker was restarted in [**11/2197**] of Toprol 100mg qd. Prior to
that he had an admission in [**2196**] for dyspnea and found to be
bradycardic and in CHF. At that time, his BB was held given the
bradycardia and his CHF was treated with iv diuresis.
In the ED, VS: BP 129/66, HR 38 RR 11 96% on RA with an
unremarkable exam. Labs remarkable for ARF with Cr to 1.4 from
baseline of 1. EKG showed Af with slow venricular rate and a
new LBBB. CXR with fluid overload and he received lasix 40mg iv
once.
On evaluation on the floor, the patient reports that he feels
well laying down but would be dizzy if he tried to get up. He
denies any chest pain, shortness of breath, PND or orthopnea.
Denies increase lower extremity swelling.
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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Atrial Fibrillation, rate controlled, on coumadin
H/o lymphoplasmocytic lymphoma in remission - follwed by Dr.
[**Last Name (STitle) **]
H/o ITP in remission
DM - diet controlled
H/o LGIB in [**2196**]
H/o gastric ulcer
Social History:
Married, lives with wife. Retired state trooper. Has 3 adult
children.
Tobacco: None
EtOH: [**6-15**] drinks/day most days of the week
Drugs: None
Family History:
No h/o early MI, arrhythmia, cardiomyopathies, or sudden cardiac
death.
Sister- died of bile duct cancer
[**Name (NI) 14841**] type I diabetes
Father- died at age 55 from TPP
Brother- died of alcohol related accident
Mother- committed suicide in [**2150**]
Physical Exam:
ADMISSION:
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: Bradycardic, irregularly irregular
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : mid upper lung fields, Crackles : at bases, No(t)
Wheezes : , No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm, Rash: macular hyperpigmented lesion on upper
lateral thorax with scattered healing excoriations. Same rash
scattered on LE. , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, purpose,
Movement: Purposeful, Tone: Normal
Pertinent Results:
EKG: Bradycardic with AF at 30 with slow ventricular rate. New
LBBB.
2D-ECHOCARDIOGRAM:
[**3-/2197**]
The left atrium is dilated. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The ascending aorta is
moderately 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. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
The RV may be slightly dilated/hypokinetic. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Dilated ascending aorta.
Stress Echo [**11/2197**]:
57 yo man with Afib and recent episode of CHF was referred for
evaluation of shortness of breath. The patient performed 6
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol ~7 METs and stopped for fatigue.
This represents a fair exercise tolerance. No neck, back, arm or
chest discomfort was reported. Appropriate increase in shortness
of breath with the exercise. No significant ST segment changes
were noted. Rhythm
was Afib with one rare isolated VPDs and three V.couplets. Blood
pressure response to exercise was appropriate. Rapid increase in
ventricular rate at a low level of exercise.
IMPRESSION: Fair exercise tolerance. No anginal type symptoms or
ischemic EKG changes. Echo report sent separately.
.
Labs:
CBC trend:
[**2198-6-29**] 01:45PM BLOOD WBC-7.9 RBC-4.51* Hgb-14.0 Hct-39.3*
MCV-87 MCH-31.0 MCHC-35.6* RDW-14.4 Plt Ct-199
[**2198-6-30**] 05:49AM BLOOD WBC-5.3 RBC-4.25* Hgb-12.9* Hct-37.1*
MCV-87 MCH-30.4 MCHC-34.8 RDW-14.6 Plt Ct-166
[**2198-7-1**] 08:30AM BLOOD WBC-6.5 RBC-4.17* Hgb-13.1* Hct-36.6*
MCV-88 MCH-31.5 MCHC-35.9* RDW-14.4 Plt Ct-170
[**2198-7-2**] 04:05AM BLOOD WBC-8.1 RBC-4.09* Hgb-12.8* Hct-35.6*
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.4 Plt Ct-187
[**2198-7-3**] 07:00AM BLOOD WBC-6.6 RBC-3.97* Hgb-12.2* Hct-34.6*
MCV-87 MCH-30.7 MCHC-35.2* RDW-14.4 Plt Ct-155
.
Coags:
[**2198-6-29**] 01:45PM BLOOD PT-22.2* PTT-36.2* INR(PT)-2.1*
[**2198-6-30**] 05:49AM BLOOD PT-21.8* PTT-34.9 INR(PT)-2.0*
[**2198-7-1**] 08:30AM BLOOD PT-23.8* PTT-36.2* INR(PT)-2.2*
[**2198-7-2**] 04:05AM BLOOD PT-23.6* PTT-38.6* INR(PT)-2.2*
[**2198-7-3**] 07:00AM BLOOD PT-18.6* PTT-34.5 INR(PT)-1.7*
.
Chemistry:
[**2198-6-29**] 01:45PM BLOOD Glucose-193* UreaN-26* Creat-1.4* Na-139
K-4.1 Cl-100 HCO3-29 AnGap-14
[**2198-6-30**] 05:49AM BLOOD Glucose-128* UreaN-27* Creat-1.4* Na-138
K-4.4 Cl-101 HCO3-28 AnGap-13
[**2198-7-1**] 08:30AM BLOOD Glucose-117* UreaN-24* Creat-1.2 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
[**2198-7-2**] 04:05AM BLOOD Glucose-127* UreaN-22* Creat-1.2 Na-137
K-4.2 Cl-102 HCO3-25 AnGap-14
[**2198-7-3**] 07:00AM BLOOD Glucose-117* UreaN-18 Creat-1.1 Na-138
K-4.1 Cl-104 HCO3-26 AnGap-12
.
A1c:
[**2198-6-29**] 01:45PM BLOOD %HbA1c-6.5* eAG-140*
.
TSH
[**2198-7-1**] 08:30AM BLOOD TSH-2.7
.
Urine lytes
[**2198-6-29**] 01:54PM BLOOD Glucose-182* Na-140 K-4.1 Cl-97*
calHCO3-29
Brief Hospital Course:
59 yo M with history of atrial fibrillation presenting with
bradycardia likely from beta blocker use with heart rates in the
40's now s/p PPM.
.
# RHYTHM: Patient with history of atrial fibrillation.
Admission EKG with Atrial fibrillation with slow ventricular
response with heart rates in the 30-40's. Etiology thought
secondary to beta blcokade BB as patient with a similar
presentation in [**2196**] in setting of beta blocker use. On
admission beta blocker stopped and patinet monitored on
telemetry. HRs remained in 40s and though patient largely
asymptomatic decision made to placed pacemaker for rate control.
Regarding anticoagulation, patient on coumadin as an outpatient;
coumadin held in setting of procedure but restarted prior to
discharge.
OUTPATIENT ISSUES:
- Follow-up in device clinic
- INR monitoring
.
# CORONARIES: No h/o CAD. Stress echo in [**11/2197**] with no
evidence of ischemia. Biomarkers in house negative and EKG
without evidence of ischemia. Not on statin as outpatient. Last
lipid panel at goal. HgAc on this admission 6.5. Started on ASA
81mg QD for primary prevention prior to discharge.
OUTPATIENT ISSUES:
-- Repeat lipid panel.
.
# PUMP: [**2198-6-30**] TTE demonstrated normal left and right
ventricular wall thickness, cavity size, with global systolic
function with LVEF 65% however due to suboptimal technical
quality, a focal wall motion abnormality could not be fully
excluded. Patient without signs or symptoms of CHF on exam.
# HTN: Largely normotensive in house. On admission decision made
to hold beta blocker secondary bradycardia and [**Last Name (un) **] in setting of
[**Last Name (un) **]. [**Last Name (un) **], losartan 25mg QD, restarted prior to discharge;
beta-blocker discontinued. Patient normtensive prior to d/c on
monotherapy.
OUTPATIENT ISSUES:
- Monitor BP as an outpatient and consider uptitration of [**Last Name (un) **] v
as addition of 2nd agen.
.
# ARF: Baseline creatinine 1.0. On admission creatinine 1.4.
Elevation likely pre-renal in setting of bradycardia and poor
forward flow. Patient received intermittent IV hydration. [**Last Name (un) **]
initially held. Creatinine improved with hydration and [**Last Name (un) **]
restarted prior to discharge.
.
# Alcohol Abuse: Per report drinks 5-6 drinks/week with no h/o
of withdrawal symptoms or seizures. Counseled patient to
decrease intake given cardiac disease. consulted. Patient was
monitored closely for signs and symptoms of withdrawal. Social
work was consulted.
.
# Neuropathy: Stable throughout hospitalization. Continued on
pregabalin, tizanidine
# Hypertriglyceridemia: Continued on Fenofibrate.
# DM: Diet controlled per patient. Patient continued on a
diabetic diet in house and covered with insulin sliding scale.
Patient continued on [**Last Name (un) **] once [**Last Name (un) **] resolved and started on low
dose ASA for primary prevention.
OUTPATIENT ISSUES:
-- Consider starting oral regimen for diabetes, check urine
microalbumin, etc
# Lymphoplasmocytic Lymphoma: Followed by Dr. [**Last Name (STitle) **]. Most
recent imaging shows slow disease progression.
.
# CODE: Confirmed full; HCP is wife [**Name (NI) 5877**] [**Name (NI) **] [**Telephone/Fax (1) 14842**]
Medications on Admission:
DOXEPIN 50 mg qd
FENOFIBRATE 145 mg qd
LOSARTAN 25 mg qd
METOPROLOL SUCCINATE 100 mg qd
OMEPRAZOLE 40 mg [**Hospital1 **]
PREGABALIN 200 mg tid
TIZANIDINE 4 mg qhs
VIAGRA 100MG qd prn
WARFARIN 5 mg qd
Discharge Medications:
1. Outpatient Lab Work
Please check INR on Thursday [**7-5**] with results to Dr.
[**Name (NI) **] [**Known lastname **] at Phone: [**Telephone/Fax (1) 3393**]
Fax: [**Telephone/Fax (1) 14511**]
2. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
qd ().
3. doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime.
4. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. tizanidine 4 mg Capsule Sig: One (1) Capsule PO at bedtime.
9. Viagra 100 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
11. warfarin 5 mg Tablet Sig: 1.5 Tablets PO 3X/WEEK (MO,WE,FR).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with slow ventricular response
Chronic Diastolic Congestive Heart failure
Hypertension
Lymphoma
Diabetes, diet controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had a slow heart rate that we initially thought was due to
the metoprolol. AFter waiting 2 days for the metoprolol to wear
off, you still had a low heart rate so a pacemaker was placed.
You will need to watch the pacemaker site for any evidence of
bleeding, increasing swelling or pain or redness. You can take
the dressing off on Friday and take a shower, keeping the steri
strips in place. You will return in a week to have the pacer
site checked. No lifting your left arm over your head or lifting
more than 5 pounds with your left arm for 6 weeks. You can
shower, wash your hair and lift anything with your right arm.
Weigh yourself every morning, call Dr. [**Known lastname **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start taking Cephalexin three times a day for 2 days to
prevent an infection at the pacer site.
2. Check your INR on Thursday [**7-5**].
3. Continue your Metoprolol and Losartan
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2198-7-11**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2198-7-31**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2198-8-7**] at 9:30 AM
With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Known lastname 14839**], MD
Specialty: Internal Medicine
When: Friday [**7-13**] at 1pm
Location: [**Hospital1 **] HEALTHCARE - UPPER FALLS
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 3393**]
Department: CARDIAC SERVICES
When: WEDNESDAY [**2198-8-8**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2198-7-6**]
|
[
"427.89",
"428.0",
"E942.1",
"584.9",
"200.80",
"428.33",
"355.9",
"401.9",
"250.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.82",
"37.71"
] |
icd9pcs
|
[
[
[]
]
] |
12066, 12072
|
7280, 10508
|
321, 379
|
12258, 12258
|
3832, 7257
|
13478, 14928
|
2573, 2832
|
10759, 12043
|
12093, 12237
|
10534, 10736
|
12409, 13455
|
2847, 3813
|
2060, 2137
|
272, 283
|
407, 1934
|
12273, 12385
|
2168, 2390
|
1978, 2040
|
2406, 2557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,073
| 190,524
|
3639
|
Discharge summary
|
report
|
Admission Date: [**2101-2-21**] Discharge Date: [**2101-2-26**]
Date of Birth: [**2024-11-3**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Left IJ
Hemodialysis
History of Present Illness:
76-year-old woman w/CAD, SLE, CKD on HD (Tues Th S), known
rectovaginal fistula, p/w acute SOB at PCP's office where she
was hypoxic to 80% on 2L. She also appeared to have purple
extremities notes on the PCP's exam. She was sent to the ED for
further eval.
In the ED: She arrived in respiratory distress, cyanotic,
hypoxic to 70-80% on RA, 100% on NRB. Fingersticked twice in
40-50 and got d50 amps. UA noted to be positive, elevated
lactate to 2.4, CXR CT concerning for PNA. Got Vanco/levo/CTX
and 1L IVF. She was noted to blood in rectal vault on PR
tylenol dosing. Repeat hct showed 4 pt drop afte IVF. VS prior
to transfer: 100.4 133/64 23 100% on NRB.
On arrival to floor, unable to obtain ful history [**2-22**] language
barrier.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Diastolic CHF (ECHO [**2098**]: LVEF 60%)
SLE w/ chronic renal insufficiency [**2-22**] focal sclerosis (baseline
Cr 2.5-3.0)
CKD on HD (on Aranesp?)
Atrial fibrillation off coumadin
HTN
CAD s/p CABG ([**2093**]) on plavix
Hyperlipidemia
Gout
Mod-Sev MR
h/o diverticulitis
Rectovaginal Fistula
Osteoporosis
h/o esophagitis
h/o aspiration pneumonia
s/p cholecystectomy
Social History:
Cantonese speaking only.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
Pertinent Results:
pH7.42 pCO241 pO2290 HCO328 BaseXS2
.
8.8 > 11.7 < 33 <-- 3.2 > 12.8 < 44 ∆
39.9
N:94.7 L:2.9 M:1.6 E:0.6 Bas:0.3
.
Lactate:2.4
.
Trop-T: 0.08, CK: 52
.
Chem 10
138 97 57 314 AGap=23
5.1 23 8.1 ∆
.
PT: 12.0 PTT: 26.4 INR: 1.0
.
CT abd/pelvis w/ gastrograffin rectally (prelim read)
1. Sigmoid [**Last Name (un) **]-vaginal fistula confirmed by rectal contrast. No
extraluminal free air. No abscess.
2. Significant sigmoid diverticulitis.
3. Bilateral atrophic kidneys.
Brief Hospital Course:
76 yo F with lupus nephritis, CKD on HD, CAD s/p CABG, HTN,
rectro-vag fistula who presented from PCP with acute respiratory
distress.
# Hypoxia: This had resolved by the time she came to the floor.
DDx includes infection, hypervolemia, CHF exacterbation.
Unclear cause, not vol o/l on exam or on imaging, CT without
clear consolidation though patchy infiltrates with ground glass
opacities. Got CTX, levo and vanc in ED. UTI on UA, Bactermia on
BCX. SIRS physiology could precipitate acute respiratory
distress that quickly resolved with IVF and abx. Unlikely that
PNA would resolve so fast. CHF not likely as improved with
fluids. Gas 7.41/44/290 on NRB. Patient was initially on 4L
nasal cannula but weaned smooth to room air within 1.5-2 days.
Patient was initially treated with Vanc/cipro/flagyl and when
blood cultures grew our GNR/GPR likely clostridium vs. bacillus,
infectious disease recommended Vanc/Cipro/Meropenem. This was
narrowed to vanc/ceftaz/flagyl after speciation. Respiratory
status greatly improved after fluid removal at HD.
.
Bacteremia:
Clostridium Perfringens, E. Coli, proteus, and strep viridans
were isolated from her blood as well as providencia from her
urine. Her source was likely the RV fistula, especially in
setting of rectal bleeding in ED. She was initially on
vanc/cipro/[**Last Name (un) 2830**], however once cultures and sensitivities were
identified she was switched to vanc/ceftaz/flagyl for dosing at
HD. Her RV fistula was found to be nonsurgical on consult.
Surveilance cultures turned negative quickly.
.
Plan going forward:
-Continue to dose Vanc/Ceftaz at HD for a total of a 4 week
course
-Continue PO flagyl for 4 week course
.
# Hypotension: Septic shock was most likely etiolgy with UTI and
high grade bacteremia as precipitating event. Unclear what
baseline bp's are, but 90-100 on floor. Prior notes with bp
120-140's, and given CRF, likely runs higher. Got 1L in ED,
looked hemoconcentrated on hct. Consider hypovolemia with hct
drop, though less likely, no acute s/sx significant bleeding.
Patient was initially bolused gently given her
dialysis-dependent state, although she does make some urine.
Patient was kept on antibiotic course per above. Urine culture
also ultimately grew out GNR >100,000. Patient's
anti-hypertensives were initially held. She was restarted on low
dose metoprolol. She eventually became normotensive with IV abx.
.
# Thrombocytopenia: She has known thrombocytopenia (likely [**2-22**]
lupus) which has been slowly decreasing over years and was
around 90's in [**2100**]. On admission it was 44 and nadired at 35K
with stopping her heparin and treating her sepsis this increased
and stabilized in the 50's. Hematology/Oncology saw patient in
the MICU and recommended serologies to evaluate for heparin
induced thrombocytopenia which was negative. We continued to
hold her heparin in the setting of thrombocytopenia.
Differential includes sepsis induced marrow suppresion, MDS in
this older patient.
.
Plan going forward:
Dr. [**Last Name (STitle) 1968**] to arrange follow-up with Hem-onc
.
# CRF: Cr slightly up from baseline, likely slightly
hemoconcentrated initially. Responded well to gentle
rehydration. patient underwent hemodialysis on her home T/Th/Sat
schedule with no issues. Continue renagel, iron and renal diet.
.
# Rectal Bleeding/Anemia: Hct to 35 on repeat after blood found
during PR tylenol dosing. Known hemorrhoids. GI was made
aware, no acute need for scoping given this is a chronic issue
and patient's hematocrit remained stable. Given her coronary
artery disease, transfusion goal 30. She never required
transfusion and her hct was 38 on the day of discharge.
.
# Lupus: Continued plaquenil, prednisone
.
# Gout: Continued home allopurinol
.
# HTN: Restarted on metoprolol 6.25mg
.
# CAD: s/p CABG, continue home meds of statin, ASA, Plavix.
Holding BB as above.
.
Medications on Admission:
Clopidogrel 75 mg PO/NG DAILY Start: In am [**2-22**] @ 0037 View
Omeprazole 20 mg PO BID Start: In am [**2-22**] @ 0037 View
Metoprolol Succinate XL 50 mg PO DAILY Start: In am
Levothyroxine Sodium 50 mcg PO/NG DAILY Start: In am [**2-22**] @
0037
sevelamer HYDROCHLORIDE 800 mg PO TID W/MEALS [**2-22**] @ 0037 View
Torsemide 20 mg PO DAILY Start: In am [**2-22**] @ 0037 View
Allopurinol 100 mg PO/NG EVERY OTHER DAY [**2-22**] @ 0037 View
Ferrous Sulfate 325 mg PO/NG TID [**2-22**] @ 0037 View
PredniSONE 5 mg PO/NG EVERY OTHER DAY [**2-22**] @ 0037 View
Aspirin 325 mg PO/NG DAILY Start: In am [**2-22**] @ 0037 View
Hydroxychloroquine Sulfate 200 mg PO/NG DAILY Start: In am
[**2-22**] @
Atorvastatin 10 mg PO/NG DAILY Start: In am
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 weeks: last day [**2101-3-23**].
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 3 weeks: last
day [**2101-3-23**].
12. Ceftazidime 1 gram Recon Soln Sig: One (1) gram Intravenous
QHD (each hemodialysis) for 3 weeks: Last dose [**2101-3-23**].
13. Metoprolol Tartrate 25 mg Tablet Sig: .5 Tablet PO once a
day.
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Septic Shock
High grade bacteremia
UTI with sepsis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
fever. You were subsequently found to have bacteria in your
blood and you were started on antibiotics. These bacteria were
thought to be coming from the hole between your rectum and
vagina. The surgeons saw you for this and did not think they
needed to operate.
The following changes were made to your medications:
You were started on Vancomycin which should be given at dialysis
based on the blood levels they measure there until until [**2101-3-23**].
You were started on Ceftazadime which should be given at
dialysis per their schedule until [**2101-3-23**]
You were started on flagyl 500mg twice per day by mouth which
you should take everyday until [**2101-3-23**]
Your Toprol XL was reduced to 12mg per day because your blood
pressure was low here
Your Torsemide was stopped because your kidneys are failing
Followup Instructions:
PRN with Rehab MD
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2101-5-4**]
11:00
Completed by:[**2101-2-27**]
|
[
"995.92",
"038.9",
"272.4",
"428.30",
"414.00",
"424.0",
"V58.61",
"733.00",
"V45.81",
"619.1",
"710.0",
"569.3",
"V45.11",
"585.6",
"285.9",
"785.52",
"427.31",
"403.91",
"287.5",
"428.0",
"599.0",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9194, 9264
|
3214, 7105
|
298, 320
|
9359, 9359
|
2641, 3191
|
10441, 10615
|
2064, 2082
|
7904, 9171
|
9285, 9338
|
7131, 7881
|
9536, 10418
|
2097, 2097
|
2622, 2622
|
1117, 1565
|
251, 260
|
348, 1098
|
2111, 2607
|
9373, 9512
|
1587, 1956
|
1972, 2048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,561
| 117,086
|
37214
|
Discharge summary
|
report
|
Admission Date: [**2156-12-1**] Discharge Date: [**2156-12-4**]
Date of Birth: [**2107-8-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
tracheostomy failure
Major Surgical or Invasive Procedure:
Flexible bronchoscopy.
History of Present Illness:
The patinet is a 49 year old male with a history of sever
scoliosis complicated by secondary restrictive lung disease (FEV
27% predicted,) OSA who presented to an OSH on [**2156-11-19**] with
complaints of progressive dyspnea.
.
The patient has had worsening shortness of breath at rest over
the last year. OSH records also indicate the patient dozing off
throughotu the day, raising concerns of him falling alseep while
driving. On presentation to the ED, the he was found to be
hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 / 42,) with
episodes of bradycardia with 3-4 sec pauses, and was admitted to
the ICU. He was started on BIPAP at night, with intermitent use
during the day due to his severe hypercapnic respiratory
failure, but did not have good tolerance of non-invasive
ventilation. His respiratory status continud to worsen, and the
patient was found somnolent and difficult to arouse at night.
PCO2 was found during to be 130. Due to his severe scoliosis,
and failed nasal intubation, and ENT was consulted for a
semi-emergent tracheostomy. A #6 LTC cuffed Shiley trach was
placed, but started on Passy-Muir valve during the day time. On
[**2156-11-27**], the patient occluded the tracheostomy with severe
hypoxia, requiring CPR, but resolved with trach manipulation to
restablish the airway. A similar episode occured on [**11-20**], and a
#7 Bavona hyperlexible tracheostomy was placed. He has remained
on mechanic ventialation at night, AC, 400/14/5.
.
Per OSH records, there were concerns that the tracheostomy tube
tip appeard to be eroding at the posterior wall of the trachea
due to the patients baseline abnormal antatomy. The patient was
transfered to [**Hospital1 18**] for evaluation of a potential customized
tracheostomy vs other intervention.
Past Medical History:
Severe scoliosis
Prior pneumothoraces
Restrictive Lung Disease
Chronic respiroatyr failure
Cholecystectomy
Social History:
The patient is currently married, no alcohol, or tobacco
Physical Exam:
Trached, on trach mask, sitting in a chair
Severe scoliosis, slgith erosis on neck from trach
Abnormal resioatory movements
Distant heart sounds, tachycardic, no m/r/g
Abdominal ventral, soft, ntnd
1+ LE b/l
Pertinent Results:
[**2156-12-3**] 04:45AM BLOOD WBC-5.4 RBC-4.16* Hgb-12.1* Hct-38.2*
MCV-92 MCH-29.1 MCHC-31.7 RDW-13.1 Plt Ct-308
[**2156-12-2**] 12:26AM BLOOD WBC-5.4 RBC-4.06* Hgb-11.9* Hct-38.0*
MCV-93 MCH-29.3 MCHC-31.4 RDW-13.0 Plt Ct-277
[**2156-12-3**] 04:45AM BLOOD Glucose-103* UreaN-7 Creat-0.4* Na-141
K-4.1 Cl-94* HCO3-41* AnGap-10
[**2156-12-2**] 12:26AM BLOOD Glucose-119* UreaN-7 Creat-0.4* Na-141
K-3.7 Cl-91* HCO3-45* AnGap-9
[**2156-12-3**] 04:45AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
CXR [**2156-12-1**]: The interpretation of this radiograph is very
limited due to the severe scoliosis and deformity of the
thoracic cage. Tracheostomy tube tip is 5.5 cm above the carina.
Cardiomediastinal contours cannot be evaluated. There is no
evident pneumothorax. If any, there is a small right pleural
effUsion. The main central pulmonary arteries appear to be
enlarged. There are no prior studies available for comparison.
The asymmetric increased density in the right hemithorax could
be due to pleural effusion or lung opacities in the right lower
lobe, I suspect that also is due to the deformity of the
thoracic cage. If prior studies were available , comparison
could be performed to assess new abnormality.
Brief Hospital Course:
The patient is a 49 year old male with a history of severe
scoliosis, restrictive lung disease, OSA, who presented to an
OSH with worsening dyspnea, who developed hypercapnic
respiratory failure w/ semi-emergent tacheostomy placement, now
transfered for evaluation of posterior wall erosion.
# Hypercapnic respiratory failure: likely secondary to both
restrictive lung process due to severe scoliosis with additonal
OSA. Now status post tracheostomy placement with revision due to
hypoxemia with trach blockage. Patient has been using trach
valve during the day and CMV at night while at [**Location (un) 8641**]. He was
transferred here for evaluation of posterior trach erosion. IP
advanced the trach approximately 1 cm with overall improvement
of airway patency given the posterior erosion. He was noted to
have mild supraglottic edema as well. He still has a
significant amount of secretions. When lying flat to sleep, he
was placed on PS 10/5, but otherwise he is maintained on a trach
mask the remainder of the time. On the day of transfer, the
patients trach was switched from a flexible to a fixed bovina
7f, placed 1cm obove the [**Female First Name (un) 5309**] at 110cm. On bronchoscopy,
continued supraglottic edema was noted, and should have an ENT
evaluation when back at [**Location (un) 8641**]. The patient reports a 20lb
weight gain in the last 2 years, and dietary modifications and
weight loss techniques should be discussed with the patient on
discharge planning. Pulmonary Rehab is also recommended on
discharge. He will be transferred back to [**Hospital 8641**] hospital for
further care.
# Severe Scoliosis: He also was noted to have significant GERD
as well. His PPI was increased to 40 mg [**Hospital1 **]. He was maintained
on tylenol for pain; we avoided narcotics.
# RV failure: likely due to mod pHTN (45mmHg) in the setting of
OSA. Mild reduced RV function. He appeared volume overloaded,
and his furosemide was increased to 40 mg [**Hospital1 **] (was transferred
to us on 40 mg daily). His electrolytes will need to be
monitored on this dose of furosemide.
Medications on Admission:
Ambien 5mg HS PRN
Morphine 4-6mg q4h PRN pain
Percocet [**11-20**] tab q4H PRN pain
Claritin 10mg daily
Magnesium oxide 400mg [**Hospital1 **]
DuoNeb PRN
Protonix 40mg daily
Lorazepam 45mg q4 PRN
Colace 100mg [**Hospital1 **]
Humibid 1200mg [**Hospital1 **]
Lasix 40mg daily
Arixtra 2.5mg daily
ASA 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl Topical
PRN (as needed) as needed for trach site.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Respiratory failure status post recent tracheostomy tube
placement.
Secondary:
Severe scoliosis
Prior pneumothoraces
Restrictive lung disease
S/P cholecystectomy
Discharge Condition:
Mental Status:Clear and coherent
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Level of Consciousness:Alert and interactive
Discharge Instructions:
You were admitted because of shortness of breath and problems
with your tracheostomy. We performed a bronchoscopy and
extended your tracheostomy by 1 cm. We also started you on
pantoprazole for laryngeal inflammation caused by gastric
reflux.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Scheduled Appointments :
Provider [**Name9 (PRE) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2157-1-25**] 11:00
Provider CDC INTAKE,ONE CDC ROOMS/BAYS Date/Time:[**2157-1-25**] 12:00
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2157-1-25**]
12:30
|
[
"518.84",
"E878.8",
"416.8",
"530.81",
"519.09",
"737.30",
"327.23",
"518.89",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7198, 7213
|
3848, 5958
|
334, 359
|
7429, 7429
|
2614, 3825
|
8129, 8500
|
6318, 7175
|
7234, 7408
|
5984, 6295
|
7606, 8106
|
2385, 2595
|
274, 296
|
387, 2165
|
7443, 7582
|
2187, 2296
|
2312, 2370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,315
| 195,466
|
43165
|
Discharge summary
|
report
|
Admission Date: [**2151-4-15**] Discharge Date: [**2151-4-20**]
Date of Birth: [**2077-5-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Pneumovax 23 / Sulfa(Sulfonamide Antibiotics) /
Levofloxacin / Influenza Virus Vaccine
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
CVL insertion
Intubation
History of Present Illness:
73 year old female with history of cryptogenic cirrhosis
complicated by encephalopathy (and portal hypertension,
hypersplenism) with multiple recent admissions ([**Date range (1) **]/[**2151**])
who presented to [**Hospital6 5016**] with fatigue, shortness of
breath, wheezing, pruritis on [**2151-4-6**]. She denied any nausea
or vomiting, sick contacts.
.
At OSH, she was gently hydrated with normal saline and her
diuretics were discontinued. Her Rifaximin was initially
discontinued given concern it was causing her pruritis but then
resumed. Her lactulose was continued but her ammonia level
continued to rise and finally decreased to 21 on [**2151-4-11**] and 19
on [**2151-4-14**]. Her liver function tests rose gradually from 50s to
60s and TBili rose from 5.2 to 6.8. The patient was treated with
Vitamin K subcutaneously without much improvement in her INR
(1.9-2.5). The decision was to transfer her liver care and
work-up/second opinion to [**Hospital1 18**]. Regardless the outcome, family
is supportive and very involved and would not want [**Hospital1 1501**]
placement; they would rather take the patient home with them.
.
Renal was consulted for her acute on chronic renal failure,
which was felt due to hypervolemia from liver cirrhosis
extravascularly, hypovolemia from furosemide intravascularly.
She was fluid restricted to one liter and her sodium level
gradually corrected 137 by time of transfer. She was resumed on
her spironolactone by time of discharge without drops in her
serum sodium.
.
The patient was noted to have mild facial asymmetry on [**2151-4-11**]
and then swallowing dyskinesia [**2151-4-13**]. CT head showed advanced
periventricular subcortical white matter changes unchanged from
CT head [**2151-3-22**]. MRI was attempted for ?CVA but patient could
not cooperate with the exam; suboptimal MRI imaging suggested no
definite acute ischemic event. Neurology was consulted, who felt
the patient's oral lingual dyskinesia was most likely metabolic
+/- central pontine myelinolysis. EEG showed moderate-to-severe
generalized cortical dysfunction. Speech and swallow felt the
patient had moderate-to-severe pharyngeal dysphagia, with
impaired respiratory swallow coordination, premature spillage
into pharynx. Thus, the patient was made NPO except for
medications in applesauce and started on maintainance fluids.
NGT was not placed given concern for esophageal varices.
.
Of note, family recounts that her liver disease was first
noticed ~4 years ago. The patient had been sent to
Hematology/Oncology for lab abnormalities
(?anemia/thrombocytopenia). Eventually (~one year later),
ultrasound showed liver disease (?nodular liver w/ cirrhosis).
She was referred to Dr. [**Last Name (STitle) 89845**] at [**Hospital1 2025**], whom she saw ~twice a year
for management of her liver disease. The family, however, did
not feel anything had been done aside from diagnosis of
"cryptogenic cirrhosis." In particular, no EGD had ever been
performed. Colonoscopy was performed which showed a few polyps
(biopsied, cancer negative) and hemorrhoids. Approximately one
year ago, the patient started decompensating from her liver
disease, with encephalopathy. She has been hospitalized multiple
times since Spring [**2150**] for this and was noted since ~ [**2150-8-7**]
to have worsening renal function (baseline 1.3-1.5). In the last
2-3 weeks, the patient was found for the first time to have
hyponatremia (not a problem before).
.
Upon arrival to [**Hospital1 18**], the patient was resting comfortably in
bed. Moderately engagable, watching television.
.
ROS: Positive per HPI; patient unable to answer rest of ROS
Past Medical History:
* Hypertension
* Hyperlipidemia
* Hypothyroidism
* Anemia
* GERD
* Diastolic CHF
* Depression/anxiety
* Chronic kidney disease (baseline 1.5)
* Cryptogenic cirrhosis complicated by encephalopathy,
ascites/lower extremity edema and varices (diagnosed at [**Hospital1 2025**], no
biopsy done, reportedly negative hepatitis serologies), has been
on low protein/low sodium diet since [**2150**] and diuretics have
been standing since then).
Social History:
Originally from [**Male First Name (un) 1056**]. Spanish speaking only. Lives with
her son; daughter actively involved in her care. Denies smoking,
alcohol, illicit drugs. Pentacostal. Independent in her ADLs,
semi-independent in her IADLs.
Family History:
Father with alcohol abuse/cirrhosis and died at an early age.
Mother with COPD, hypertension and died in old age after
fracture
Physical Exam:
Admission:
VS: T98.3, BP147/46, HR73, RR18, 97% on RA
XXXXXXXX
GENERAL: comfortable, but uncooperative and non-interactive,
Jaundiced
HEENT: Sclera icteric. MMM. NGT in place, no JVD
CARDIAC: RRR with II/VI systolic ejection murmur
LUNGS: CTA b/l with no wheezing, rales, or rhonchi. decreased
breath sounds in bases
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEURO: Moves tongue wildly at almost all times. CNII-XII grossly
intact but not cooperative with exam. Moves all extremities
spontaneously. Mild facial droop on right. reflexes 2+
peripherally.
Pertinent Results:
Admission:
[**2151-4-15**] 07:40PM BLOOD WBC-9.9 RBC-3.55* Hgb-11.8* Hct-35.6*
MCV-100* MCH-33.2* MCHC-33.1 RDW-18.9* Plt Ct-62*
[**2151-4-15**] 07:40PM BLOOD PT-22.2* PTT-20.4* INR(PT)-2.1*
[**2151-4-15**] 07:40PM BLOOD Glucose-117* UreaN-76* Creat-2.6* Na-139
K-4.7 Cl-109* HCO3-19* AnGap-16
[**2151-4-15**] 07:40PM BLOOD ALT-40 AST-69* LD(LDH)-489* AlkPhos-208*
TotBili-4.9*
[**2151-4-15**] 07:40PM BLOOD Albumin-2.7* Calcium-9.7 Phos-4.2 Mg-3.0*
Brief Hospital Course:
Ms. [**Known lastname **] is a 73 year old woman with cryptogenic cirrhosis
complicated by encephalopathy likely ascites who presented as a
transfer from an OSH for evaluation and treatment of altered
mental status.
.
Floor course:
# Altered Mental Status: Originally the differential diagnosis
included hepatic encephalopathy, central pontine myelinolysis,
CVA, hyponatremia, steroid induced psychosis, and hospital
induced/ICU delirium. Hepatic encephalopathy was thought to be
likely contributing as worsening mental status decline mirrored
lactulose cessation at the OSH (due to poor PO intake)and family
reports that the facility initially gave the patient less
lactulose than worked at home (30mL TID vs 60mL TID).
Hyponatremia was also likely playing a role, but correction at
the outside facility did not seem to improve her mentation.
Neuro consult was obtained. Central pontine myelinolysis was
initially thought to be a possibility given her peculiar tongue
movements, but there was no clear evidence of rapid sodium rise
and no evidence on head CT. MRI was limited by motion and
neither ruled in or ruled out such a finding. Lactulose was
started at 30mL q2h with copious stool production (~10 BM/day)
which did nothing to clear her mental status over her first 3
days of admission.
.
# Cirrhosis: Diagnosis of cryptogenic cirrhosis is a diagnosis
of exclusion. Serologies were reportedly negative, but no biopsy
was performed. Has been on diuretics since ~1 year ago
(presumably for ascites). No EGD as of yet. Diagnostic Para
negative for SBP. Hepatitis serologies were repeated which were
negative. Autoimmune serologies were repeated and [**Doctor First Name **] was
positive at 1:160.
.
# Hypernatremia: Upon admission, Ms. [**Known lastname **] was eunatremic. Upon
the third day of her hospital stay, Ms. [**Known lastname **]' sodium was found
to be 152 likely secondary to copious stool production in the
setting of lactulose administration. D5W was started.
.
# [**Last Name (un) **] superimposed on CKD: Creatinine of 2.2 above baseline of
1.5. Likely secondary to decreased effective circulating volume
as above. Also question of hepatorenal syndrome.
.
# Asthma: Ms. [**Known lastname **]' initial reason for admission to the OSH was
shortness of breath which has been treated with steroids and
albuterol. She was methylpred 60mg daily upon transfer. She is
currently without respiratory distress on room air, and no focal
infiltrates on exam or CXR, until her fourth day of admission,
when she became hypoxic with SpO2 85% on RA. Due to concern for
fluid overload and wet appearance on CXR, lasix was started.
Unfortunately, Ms. [**Known lastname **] became progressively more hypoxemic and
was found to have a large diffuse infiltrates on CXR. Ms. [**Known lastname **]
was transferred to the ICU where she was intubated.
.
ICU course:
Patient was transferred to the ICU for acute respiratory failure
requiring urgent intubation and mechanical ventillation. She
became hypotensive and levophed was started. There was concern
that she developed septic shock initially thought to be due to a
pneumonia and she was started on broad spectrum antibiotics.
Urine output diminished and O2 saturation remained poor despite
maximal ventillation settings. Echocardiogram was repeated
without acute findings and abdominal ultasouhnd did not show
cholecystitis. Family meeting was held. Family expressed that
patient would not want to undergo prolonged intubation and that
continued invasive measures. Patient remained intubated and on
maximal support until all of her family could be at her bedside.
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Medications on Admission:
lactulose, atenolol, mvi, spironolactone, synthroid, rifampin,
prilosec, vitamin d, lasix, albuterol, zofran
Discharge Medications:
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Discharge Condition:
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Discharge Instructions:
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Followup Instructions:
Based on recurring family meetings and once all family members
were present, patient was made CMO and expired.
Completed by:[**2151-7-20**]
|
[
"571.5",
"272.4",
"403.90",
"785.52",
"038.9",
"333.82",
"518.81",
"428.32",
"V54.12",
"428.0",
"995.92",
"507.0",
"787.20",
"244.9",
"311",
"276.0",
"584.9",
"341.8",
"300.00",
"530.81",
"585.9",
"572.3",
"493.90",
"789.59",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.97",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10231, 10240
|
6201, 6443
|
379, 406
|
10394, 10506
|
5727, 6178
|
10665, 10806
|
4816, 4946
|
10096, 10208
|
10261, 10373
|
9963, 10073
|
10530, 10642
|
4961, 5708
|
318, 341
|
434, 4081
|
6458, 9937
|
4103, 4542
|
4558, 4800
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,964
| 175,807
|
11530
|
Discharge summary
|
report
|
Admission Date: [**2174-9-25**] Discharge Date: [**2174-9-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 88 year-old
woman who was hit in the head four weeks prior to admission
in the bathtub with no loss of consciousness, no headache and
no nausea or vomiting. After a week of headache on the left
side, no vomiting, but it did wax and wane and she did have
had a CT, which showed minuscule bleed. She did not get any
improvement with Tylenol. She was getting dinner and could
not pick up anything with her right hand and having
clumsiness for a week and now having shaking in the right
hand and unable to cut things and went to the Emergency
Department.
noninsulin dependent diabetes, congestive heart failure.
MEDICATIONS: Prevacid, atenolol 12.5 po q day, K-Ciel 10
milliequivalents po q day, Lasix 20 mg po b.i.d., ASA q.o.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Mental status, awake and alert,
oriented times three. She is able to speak fluently and
appropriately. Repetition intact. Attentive. Spelled world
forward and backward. Fund of knowledge intact. Cranial
nerves II through XII intact. Extraocular muscles are
intact. Positive nystagmus. Cataracts. Visual fields full.
Face symmetric. Palette rises symmetrically. Tongue
midline. Motor strength, trace pronator drift in the right
upper extremity, right grasp 4 - out of 5, interossea 5- out
of 5 otherwise all muscle groups are 5 out of 5. Sensory
decreased in the palm to temperature, question increase to
pin prick otherwise intact. Coordination finger to nose
slower on the right then on the left. Reflexes bilaterally
up going toes, otherwise intact. No clonus. Reflexes
symmetric.
LABORATORIES ON ADMISSION: White blood cell count 8.5,
hematocrit 31.6, platelet count 278, sodium 132, K 4.5,
chloride 94, CO2 26, BUN 21, creatinine 1.8, glucose 114.
Head CT shows subacute left subdural hematoma with no
increasing in the interval.
The patient was monitored in the Surgical Intensive Care Unit
for close observation. Her neurological status was awake,
alert and oriented times three with no drift. Moving all
extremities symmetrically. The patient was discharged to the
floor on [**2174-9-26**]. On the evening of [**2174-9-26**] the patient
became extremely confused and combative. The patient was
given Haldol and was provied with sitters. The patient's mental
status was clear by the morning of [**9-27**]. She was without
sitters. Her vital signs were stable and she was cognesent
of the events of the previous evening and apologetic. The
patient's mental status continued and remained clear after
that one episode of confusion. Her vital signs remained
stable and she was afebrile throughout her hospital stay.
MEDICATIONS ON DISCHARGE: Lopressor 12.5 mg po b.i.d.,
Tylenol 650 po q 4 hours prn, Dilantin 100 mg po t.i.d.,
Colace 100 mg po b.i.d.
CONDITION ON DISCHARGE: Stable.
The patient was seen by physical therapy and occupational
therapy and found to require a short rehab stay prior to
discharge home. The patient will follow up with Dr. [**First Name (STitle) **] in
two weeks time with follow up head CT.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2174-9-28**] 13:52
T: [**2174-9-28**] 14:06
JOB#: [**Job Number **]
|
[
"250.00",
"428.0",
"E888",
"401.9",
"293.0",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2802, 2913
|
924, 1739
|
112, 901
|
1754, 2775
|
2938, 3461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,570
| 170,555
|
43978
|
Discharge summary
|
report
|
Admission Date: [**2151-7-2**] Discharge Date: [**2151-7-9**]
Date of Birth: [**2086-7-9**] Sex: F
Service: MEDICINE
Allergies:
Novocain
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 64 y.o female with h.o breast cancer and recently dx
lung cancer who presented with generalized "weakness" and was
found to have cardiac tamponade based on echo. Pt reports
chronic SOB and cough, occasionally at rest, reports orthopnea
and a 3L 02 req at home with usual sats in the low 90's. Pt
reports that her breathing has been unchanged recently and upon
admission. Pt reports that she's had palpitations for the last
few weeks that have been unchanged, but denies CP or edema.
Otherwise denies headache, h.o stroke/TIA,changes in vision,
fevers, chills, CP, abd pain/n/v/d/c/melena/brbpr/dysuria, rash,
joint pain/swelling, paresthesias/weakness. No h.o DVT, PE,
bleeding, claudication.
Past Medical History:
- Stage IV metastatic lung cancer [**5-2**], tx with chemo
(taxol,[**Doctor Last Name **], avastin) and radiation.
- Breast cancer status post mastectomy in [**2133**], treated with CMF
chemotherapy initially and tamoxifen for 14-1/2 years and then
switched to Femara two years ago.
- Hypertension.
Social History:
She lives in [**Location 2498**] with her husband. She smoked from when she
was 18 years old until 17 years ago, one pack a day. She rarely
drinks a glass of wine, and works as a manager of an auto parts
store.
Family History:
She has a mother with ovarian cancer. She underwent the genetic
test when she was diagnosed with breast cancer, and was negative
for BRCA gene. Her father died when she was 4 years old, in a
plane crash.
Physical Exam:
VS: T 95.8 ; BP 123/76 ; HR112 ; RR22 ; O2sat 97% NRB 15L
Gen: NAD. appears to be tachypneic, able to speak in [**2-27**] word
sentences.
HEENT: NC/AT, PERRLA,EOMI, anicteric
CV: +s1s2 RRR no m/r/g tachycardic
Chest: b/l AE decreased airmovement lower R.lung field. Crackles
mid-lower lung field. +pericardial drain (yellow/straw liquid),
no erythema, C/D/I
Abd: +bs, soft, NT, ND
Ext: No C/C/E 2+pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2151-7-2**] 03:30PM BLOOD WBC-6.5 RBC-4.30 Hgb-12.4 Hct-37.4 MCV-87
MCH-28.9 MCHC-33.2 RDW-15.4 Plt Ct-383#
[**2151-7-2**] 03:30PM BLOOD Neuts-88.2* Lymphs-5.6* Monos-5.0 Eos-0.6
Baso-0.6
[**2151-7-3**] 03:06AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2151-7-2**] 03:30PM BLOOD PT-13.6* PTT-22.7 INR(PT)-1.2*
[**2151-7-2**] 03:30PM BLOOD Glucose-161* UreaN-15 Creat-0.4 Na-136
K-4.4 Cl-94* HCO3-34* AnGap-12
[**2151-7-2**] 03:30PM BLOOD CK(CPK)-46
[**2151-7-3**] 03:06AM BLOOD ALT-32 AST-25 LD(LDH)-221 AlkPhos-61
TotBili-0.2
[**2151-7-2**] 03:30PM BLOOD cTropnT-<0.01
[**2151-7-3**] 03:06AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.6 Mg-1.8
[**2151-7-2**] 05:10PM BLOOD Type-ART O2 Flow-15 pO2-235* pCO2-78*
pH-7.27* calTCO2-37* Base XS-6 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
PERTINENT LABS/STUDIES:
.
MEDICAL DECISION MAKING
EKG [**2151-7-2**] shows sinus tach. Compared to [**7-2**] later in day, TWI
I, AVL, AVR unchaged. Prominent T wave in V4-6 still present.
.
2D-ECHOCARDIOGRAM performed on [**2151-7-2**] at 13:47:40
demonstrated:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a moderate to large sized
circumferential pericardial effusion measuring 1cm
inferolateral, lateral and apical to the left ventricle
increasing to 2.3 cm anterior to the right ventricle and 1.8cm
around the right atrium. There is brief right atrial and left
atrial diastolic collapse c/w increased pericardial
pressure/tamponade physiology.
.
IMPRESSION: Technically suboptimal study. Moderate to large
circumferential pericardial effusion with evidence of increased
pericardial pressure/tamponade physiology.
.
.
Post-procedure ECHO performed on [**2151-7-2**] at 6:08:27
demonstrated:
In single view, there is only a small pericardial effusion.
Normal biventricular systolic function.
.
CARDIAC CATH performed on [**2151-7-2**] demonstrated: systolic arterial
HTN, mild pulsus paradoxus, hemodynamics c/w low pressure
tamponade, with some equalization of RA and pericardial
pressure. After removal of 625cc of fluid, clear separation of
filling pressures, pt with continued tachypnea/tachycardia.
Bedside echo showing minimal pericardial fluid.
.
HEMODYNAMICS: as above.
.
OTHER TESTING: CT chest [**2151-6-24**]
IMPRESSION:
1. Extensive right mediastinal and hilar lymphadenopathy with
partial right upper lobe atelectasis, contiguous with adjacent
central neoplasm. Treatment response cannot be evaluated as
there are no prior exams available for comparison. If the prior
PET/CT is made available, an addendum can be issued comparing
these two studies.
2. Diffuse smooth thickening of the interstitium raising
possibility of lymphangitic carcinomatosis, but differential
diagnosis includes hydrostatic edema, drug toxicity, and
atypical infection.
3. Diffuse ground-glass opacity with small focal areas of
consolidation in the left lung may represent infection and less
likely asymmetric pulmonary edema.
Nodular appearance of some foci of consolidation could also
reflect neoplasm.
4. Large pericardial effusion.
5. Compression fractures of the T7 and T11 vertebral bodies,
likely due to underlying metastases. Further evaluation for bony
metastases could be performed with a bone scan.
.
CXR [**2151-7-2**]:IMPRESSION:
1. Worsening bilateral opacities, left greater than the right,
with prominent interstitial markings. Findings may represent
worsening pulmonary edema or infection superimposed on a
background of lymphangitic carcinomatosis.
2. Right hilar mass compatible with patient's known
lymphadenopathy.
3. Cardiac size is difficult to estimate given the presence of
left lung opacification. Grossly, cardiac silhouette size is
unchanged.
4. Elevation of the right hemidiaphragm and low lung volumes.
Brief Hospital Course:
Pt is a 64 yo woman with h/o breast cancer, recently dx stage 4
lung cancer, with pericardial effusion/tamponade.
The patient presented with a pericardial effusion seen on Chest
CT [**6-24**]. Pt was feeling weak and dyspneic and an echocardiogram
on [**2151-7-2**] revealed low pressure tamponade physiology. Pt was
taken to the cath lab where fluid was drained and the patient
responded hemodynamically. Her dyspnea persisted after the
prccedure. Cultures from pericardial fluid were positive for
staph and enterococcus and vancomycin and levofloxacin were
started. The patient's dyspnea was thought to be secondary to
lymphangitic spread of her lung cancer. Her ABGs showed
respiratory acidosis with high CO2 retention. She had a 3L
oxygen by NC requirement at home but this was insufficient in
the hospital, where appropriate oxygen saturation was mantained
with NRB. Efforts to scale down produced visible respiratory
discomfort to the patient, including gasps for air. Also, the
patient's course was complicated by intermittent episodes of
atrial fibrilation that required metoprolol and diltiazem for
rate control. In the setting of worsening dyspnea, a discussion
with the family, in consideration of the goals of care, resulted
in the decision to proceed with comfort measures only. The
difficulty in breathing was appropriately managed with pain
medications including a hydromorphone drip. The patient's
secretions were managed with scopolamine. The patient remained
comfortable untill her death. Her family remained at the
bedside. The immediate cause of death was respiratory failure
and the antecedent cause was metastatic lung cancer.
Medications on Admission:
CURRENT MEDICATIONS:
albuterol
alendronate 70mg Qmonday
benzonatate 200mg TID
dexamethasone 20mg prior to chemo
zetia 10mg daily
femara 2.5mg daily
megace 10ml po daily
nystatin QID
valsartan 80mg daily
advair 50/500 [**Hospital1 **]
magic mouth wash
compazine 10mg Q4-6hprn nausea
Propoxyphene N-Acetaminophen 100/650mg 2 tab po q4-6hrprn
ambien 6.25 CR qhs, 5mg qhs
ca+vit D
psyllium
MVI
3L O2
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
stage 4 NSCLC
Pericardial tamponade
Respiratory failure
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2151-7-11**]
|
[
"733.00",
"518.84",
"199.0",
"423.8",
"276.2",
"427.31",
"276.6",
"423.3",
"V66.7",
"V10.3",
"401.9",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"93.90",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8777, 8786
|
6651, 8303
|
275, 282
|
8885, 8895
|
2355, 2355
|
8946, 8979
|
1583, 1790
|
8750, 8754
|
8807, 8864
|
8329, 8329
|
8919, 8923
|
1805, 2336
|
227, 237
|
8350, 8727
|
310, 1015
|
2372, 6628
|
1037, 1338
|
1354, 1567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,584
| 132,178
|
46540
|
Discharge summary
|
report
|
Admission Date: [**2115-2-17**] Discharge Date: [**2115-3-7**]
Date of Birth: [**2052-9-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2115-2-22**] Cardiac Catheterization
[**2115-2-26**] Mitral Valve Replacement (25/33mm Onyx Mechanical Valve)
History of Present Illness:
62yo woman with history of cardiomyopathy presented with several
days of worsening shortness of breath and cough. On initial
evaluation in ED, she was found to be in respiratory distress w/
pulse oximetry of 86% and was then intubated. She was found to
have multifocal PNA on chest film. Her blood pressure dropped to
80's/50's and she had a R IJ cordis placed and was given volume
resuscitation and levophed. Initial ABG was (pH 7.06/pCO2 92/pO2
103). Initial WBC of 16.7.
Past Medical History:
Diverticulitis, Colon Polyps w/ h/o GI bleed, h/o Pulmonary
Embolism, Depression, Hypertrophic Cardiomyopathy,
Gastroesophageal Reflux Disease, Anemia, Pulmonary Hypertension,
s/p Nasal cauterization d/t epistaxis, s/p Tubal ligation, s/p
Lumpectomy, s/p Tonsillectomy
Social History:
She is married, does not smoke cigarettes, and rarely drinks
alcohol.
Family History:
Father with MI at 62
Mother has HOCM and PPM
Physical Exam:
VITALS: T 100.0, BP 109/52, HR 105, RR 20, Sat 95%3LNC
GENERAL: Well-appearing, no acute distress, able to carry on
conversations in full sentences, no accessory muscle use
HEENT: EOMI, PERRL, MMM
NECK: Bandage over site of Right IJ (unable to appreciate JVD)
CV: RRR, 3/6 systolic murmur throughout precordium
RESP: Fine crackles [**12-26**] way up bilaterally
ABD: Soft, NT, ND, normoactive bowel sounds
EXT: WWP with no clubbing, cyanosis, or edema; 2+ DP pulses
bilaterally
NEURO: A&O x 3
Pertinent Results:
Echo [**2-18**]: IMPRESSION: Hypertrophic, obstructive cardiomyopathy
with at least moderate mitral regurgitation due to valvular [**Male First Name (un) **].
If clinically indicated, a TEE may better assess the degree of
intrinsic aortic valvular disease and to assess mitral valve
anatomy.
.
CTA CHEST [**2-17**]: IMPRESSION: 1. No pulmonary embolus. 2. Findings
consistent with diffuse multifocal pneumonia. There may be an
element of superimposed edema.
.
B/L LE Dopplers [**2-20**]: BILATERAL LOWER EXTREMITY ULTRASOUND: No
prior studies. Bilateral grayscale and Doppler son[**Name (NI) 867**] was
performed of the greater saphenous, common femoral, superficial
femoral, popliteal, and deep veins of the calf. Venous
structures compress normally and demonstrate normal flow,
waveforms, augmentation without intraluminal thrombus. No
abnormal adenopathy. IMPRESSION: No evidence of DVT.
.
TEE [**2115-2-21**]: The left atrial volume is markedly increased. No
spontaneous echo contrast is seen in the left atrial appendage.
No thrombus is seen in the left atrial appendage. The right
atrium is moderately dilated. There is severe symmetric left
ventricular hypertrophy. Left ventricular systolic function is
hyperdynamic (EF>75%). The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. No thoracic aortic dissection is seen.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened and calcified. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. There is partial
posterior mitral leaflet flail with moderate thickening of the
anterior leaflet. No mass or vegetation is seen on
the mitral valve. Torn mitral chordae are present. Severe (4+)
mitral
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2115-2-18**], the current
study shows severe mitral regurgitation not appreciated
previously likely because of the eccentricity of the regurgitant
jet.
.
Cardiac Cath [**2115-2-22**]: FINAL DIAGNOSIS: 1. No angiographically
apparent flow limiting cornary artery disease. 2. Elevated left
sided filling pressures. 3. Depressed cardiac index. 4. Normal
left ventricular ejection fraction. 5. 4+ mitral regurgitation.
6. HOCM with an inducible gradient of 120mmHg after PVC.
CHEST (PA & LAT) [**3-5**]
CONCLUSION: Marked improvement in the left basilar pleural
effusion as compared to four days ago, with only a tiny residual
effusion in the posterior left costophrenic angle visible today.
Also disappearance of the prior tiny right apical pneumothorax.
Continuing decrease in bilateral linear atelectasis was also
noted.
[**2115-3-5**] 07:55AM BLOOD Hct-27.5*
[**2115-3-4**] 07:20AM BLOOD WBC-7.0 RBC-3.26* Hgb-8.6* Hct-26.7*
MCV-82 MCH-26.4* MCHC-32.1 RDW-20.3* Plt Ct-424
[**2115-3-7**] 07:45AM BLOOD PT-29.6* PTT-94.2* INR(PT)-3.1*
[**2115-3-6**] 07:25AM BLOOD PT-23.6* PTT-79.6* INR(PT)-2.3*
[**2115-3-5**] 04:52PM BLOOD PT-20.2* PTT-59.5* INR(PT)-1.9*
[**2115-3-5**] 07:55AM BLOOD PT-18.6* PTT-90.1* INR(PT)-1.8*
[**2115-3-5**] 07:55AM BLOOD K-4.5
[**2115-3-4**] 07:20AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-134
K-4.5 Cl-97 HCO3-33* AnGap-9
Brief Hospital Course:
Ms. [**Known lastname 13551**] is a 62 year old woman with history of hypertrophic
cardiomyopathy presenting with respiratory failure and
hypotension attributed to pulmonary edema.
She was transferred from the ED to the MICU. In the MICU she was
monitored and started on broad-spectrum antibiotics (cefepime,
vancomycin, and levofloxacin) for presumed pneumonia. Her
respiratory status improved dramatically with mechanical
ventilation and positive pressure, and she was extubated on
[**2-19**]. Initial TTE on [**2-18**] revealed an EF of 65-70% with HOCM and
2+ MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**] a TEE on [**2-21**] which revealed 4+ MR and a
hyperdynamic left ventricle (EF>&75%). She then [**Month/Day (4) 1834**] a
cardiac cath on [**2-22**] which also revealed severe mitral
reguritation without significant coronary disease. Over the next
several days she received medical management until her stauts
improved for surgery. She was taken to the OR on [**2115-2-26**] and
[**Date Range 1834**] a mitral valve replacement. Please see operative
report for surgical details. Following surgery she was
transferred to the CSRU for invasive monitoring in stable
condition. Later on op day she required a bronchoscopy d/t an
airway obstruction and secretions were removed. Later on this
day she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one she was started on diuretics
and gently diuresed towards her pre-op weight. She was then
transferred to the SDU. On post-op day two she was started on
Coumadin with a Heparin bridge until her INR was therapeutic.
Chest tubes were removed on this day as well. Epicardial pacing
wires were removed on post-op day three. Physical therapy began
working with patient for strength and mobility. Over the
remainder of her hospital course she was without complications
and awaited her INR to increase to a therapeutic level prior to
discharge. Finally on post-op day 9 she was discharged home.
Medications on Admission:
Prozac
Tricor
Prilosec twice a day
Coumadin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
QD ().
Disp:*30 Tablet(s)* Refills:*1*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Verapamil 300 mg Cap, 24HR Sust Release Pellets Sig: One (1)
Cap, 24HR Sust Release Pellets PO Q24H (every 24 hours).
Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
11. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime for
1 days: INR to be checked [**3-8**] with results to Dr. [**Last Name (STitle) 98836**]
coumadin clinic.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement
Pneumonia
PMH: Diverticulitis, Colon Polyps w/ h/o GI bleed, h/o Pulmonary
Embolism, Depression, Hypertrophic Cardiomyopathy,
Gastroesophageal Reflux Disease, Anemia, Pulmonary Hypertension,
s/p Nasal cauterization d/t epistaxis, s/p Tubal ligation, s/p
Lumpectomy, s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-26**] weeks
Dr. [**Last Name (STitle) **] in [**12-25**] weeks
Completed by:[**2115-3-7**]
|
[
"280.9",
"424.0",
"276.2",
"V17.3",
"289.81",
"V12.51",
"455.2",
"518.0",
"429.5",
"428.20",
"518.81",
"455.5",
"425.1",
"995.92",
"486",
"416.8",
"038.9",
"077.99",
"372.39",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"00.17",
"33.22",
"88.53",
"39.61",
"96.71",
"88.56",
"37.23",
"96.04",
"35.24",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8837, 8895
|
5233, 7229
|
285, 399
|
9272, 9278
|
1871, 4044
|
1297, 1343
|
7324, 8814
|
8916, 9251
|
7255, 7301
|
4061, 5210
|
9302, 9573
|
9624, 9797
|
1358, 1852
|
238, 247
|
427, 902
|
924, 1194
|
1210, 1281
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,030
| 112,138
|
7108
|
Discharge summary
|
report
|
Admission Date: [**2158-5-4**] Discharge Date: [**2158-5-8**]
Date of Birth: [**2102-7-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nsaids / Sulfa (Sulfonamide Antibiotics) / Peanut
/ Shellfish / Bactrim
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hypoxia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
55 y/o F PMH fibromyalgia, osteoarthritis, HTN, DM who presents
with hypoxia. Patient presented to pre-op eval for right knee
replacement and found to have O2 sat 86% consequently referred
to ED. On arrival to ED VS T 96.7, BP 115/49, 117, 22, 67% RA.
100% NRB and 92-95% 4L. HR 95-112. Afebrile. Patient given 125mg
solumedrol IV, tylenol 1 gm po, Azithromycin 500 mg, Duonebs x
3, Oxycodone 30 mg po x 2, Lasix 20 mg IV, Vancomycin 1 gm IV.
Patient admitted to the ICU for close monitoring.
.
Patient reports progressive SOB for the last several months -
with minimal exertion and at rest. Reports orthopnea, PND
("gasping for air") for the past several months and lower
extremity edema for the last 1 month. Occasionally associated
chest pain. Patient recently treated for bronchitis and finished
levaquin 4 days ago - no fevers since completing ABx. No
worsened cough. Patient denies recent sick contacts. Denies
recent travel but is immobile at baseline. Extensive review of
systems revealed bloody nose for the past 1 month at night with
hemoptysis. Patient reports that oxygen level has been reported
to be low at prior doctor's appointment. She had a sleep study
in [**2127**] - does not sleep well and has daytime sleepiness.
Past Medical History:
- Fibromyalgia
- Lumbar disc degeneration
- Osteoarthritis
- Obesity
- Chronic Opiate Use and Chronic pain
- HTN
- Pre-diabetic
- Depression, Anxiety, PTSD
- GERD
Social History:
Lives with partner. Non-[**Name2 (NI) 1818**], non-drinker. No IV drug use.
Family History:
Mother passed away age 80 - breast cancer. Father age 80 - liver
and pancreatic cancer.
Physical Exam:
Upon admission:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 112 (107 - 119) bpm
BP: 130/92(99) {130/74(87) - 148/92(100)} mmHg
RR: 24 (12 - 24) insp/min
SpO2: 88%
Heart rhythm: ST (Sinus Tachycardia)
GEN: obese, slow speech but alert and oriented x 3.
HEENT: PERRL, EOMI, anicteric, MMM, unable to assess jvd
RESP: Decreased breath sounds throughout due to body habitus.
CV: RR, distant heart sounds due to body habitus.
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: + 3 pitting edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
.
At discharge:
Vitals: 98.8 97.9 108/61 109 20 95% on 2L
I/O: 0/[**Telephone/Fax (1) 26490**]/3100
FS: 125-166-119-140
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD at 8cm, no LAD, no thyromegaly
Lungs: Bibasilar crackles
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, 3+ bilateral LE edema to
thighs
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Labs upon admission:
[**2158-5-4**] 10:00AM BLOOD WBC-6.6 RBC-4.01* Hgb-13.1 Hct-39.3
MCV-98 MCH-32.5* MCHC-33.2 RDW-14.6 Plt Ct-211
[**2158-5-4**] 11:14AM BLOOD PT-12.2 INR(PT)-1.0
[**2158-5-4**] 10:00AM BLOOD UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-100
HCO3-34* AnGap-12
[**2158-5-4**] 10:00AM BLOOD ALT-51* AST-41* AlkPhos-111* TotBili-0.3
[**2158-5-4**] 10:00AM BLOOD proBNP-243*
[**2158-5-4**] 11:14AM BLOOD cTropnT-<0.01
[**2158-5-5**] 04:55AM BLOOD CK-MB-1 cTropnT-<0.01
[**2158-5-4**] 10:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
[**2158-5-4**] 11:35AM BLOOD Type-ART pO2-215* pCO2-60* pH-7.36
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
[**2158-5-4**] 03:04PM BLOOD Type-ART pO2-70* pCO2-65* pH-7.37
calTCO2-39* Base XS-8
Labs prior to discharge:
[**2158-5-8**] 08:25AM BLOOD WBC-6.9 RBC-4.44 Hgb-14.3 Hct-43.7 MCV-98
MCH-32.1* MCHC-32.7 RDW-14.3 Plt Ct-282
[**2158-5-8**] 08:25AM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-145
K-4.7 Cl-97 HCO3-38* AnGap-15
[**2158-5-5**] 04:55AM BLOOD CK(CPK)-50
[**2158-5-4**] 10:00AM BLOOD ALT-51* AST-41* AlkPhos-111* TotBili-0.3
[**2158-5-5**] 04:55AM BLOOD CK-MB-1 cTropnT-<0.01
[**2158-5-4**] 11:14AM BLOOD cTropnT-<0.01
[**2158-5-4**] 10:00AM BLOOD proBNP-243*
[**2158-5-5**] 04:55AM BLOOD TSH-0.77
[**2158-5-8**] 12:49PM BLOOD Type-ART Temp-36.7 pO2-59* pCO2-55*
pH-7.42 calTCO2-37* Base XS-8 Intubat-NOT INTUBA
Micro:
[**2158-5-4**] blood culture negative
[**2158-5-4**] MRSA screen negative
Imaging:
[**2158-5-4**] CXR: The lung volumes are low. Hazy perihilar opacities
are suggestive of mild pulmonary edema. Bibasilar opacities are
likely due to atelectasis. No definite pleural effusion is
idnetified. The visualized cardiomediastinal and hilar contours
are within normal limits.
IMPRESSION: 1. New mild pulmonary edema. 2. Bibasilar
opacities, probable atelectasis.
[**2158-5-4**] CTA: 1. No evidence of pulmonary embolism. 2.
Bilateral ground-glass opacities, possibly related to areas of
edema: bilateral subsegmental atelectasis as well as areas of
bilateral ground-glass opacity, possibly edema. 3. Hepatic
steatosis.
[**2158-5-4**] EKG: sinus tachycardia at 115
[**2158-5-5**] CXR: In comparison with the study of [**5-4**], there has
been some improvement in the degree of pulmonary edema,
especially since this is a AP rather than PA view. Continued
enlargement of the cardiac silhouette. Mild atelectatic changes
at the bases.
[**2158-5-5**] TTE: Suboptimal image quality. 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. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. with normal
free wall contractility. 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.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. No aortic
regurgitation is seen. Tricuspid regurgitation is present but
cannot be quantified. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
55 yo morbidly obese female with history of fibromyalgia,
osteoarthritis, HTN, and DM presented to the ED with hypoxemia,
likely a combination of underlying hypoventilation likely
secondary to obesity and narcotics with a component of diastolic
heart failure.
ICU Course: Admitted for hypoxia. ABG consistent with chronic
hypoventilation. CTA negative for PE, but with evidence of
pulmonary edema. Working diagnosis was pulmonary edema
(hypoxia, peripheral edema, orthopnea) in setting of chronic
hypoventilation of obesity. She was diuresed with IV Furosemide
and negative 4L in 24 hours. Oxygen saturation improved to
92-94% on 3-4L by NC. No antibiotics were given on arrival to
ICU as felt likely to not have pneumonia. Echo was done at
bedside that showed....... Additionally, she was noted to be on
multiple sedating medications for chronic pain/depression.
Doses were confirmed with pharmacy. Her large doses of sedating
meds at night likely contributing to chronic retention.
Medical floor course:
# Hypoxemia: Likely combination of decompensated heart failure,
and hypoventilation from narcotics and obesity. Diuresed well to
lasix, with improvement in SOB and hypoxemia. She will benefit
from an outpatient sleep study.
# Diastolic heart failure: Signs and symptoms of acute on
potentially undiagnosed chronic dHF with an mildly elevated BNP
which is often underestimated in the setting of obesity. She
was diuresed with lasix boluses. Her beta blocker was
continued, and an ACE inhibitor was initiated.
# Tachycardia: Stable for patient given prior office notes. CTA
negative for PE. Most likely a result of chronic pain. Improved
with diuresis.
# Fibromyalgia/Chronic pain: She was continued on her home dose
of Cymbalta, Oxycontin, and Oxycodone.
# Hypertension: Normotensive during admission. A clonidine
taper was initiated while in house and will be continued as an
outpatient. She was started on an ACE inhibitor which was
uptitrated as the clonidine was decreased.
# Diabetes: A1C 6.4 in 3/[**2158**]. Held Metformin while inpatient
and in setting of recent CTA. Sugars well controlled, did not
required insulin coverage.
# Depression: Mood stable and appropriate. Continued on home
duloxetine, trazodone, diazepam, and keppra.
Medications on Admission:
Medications according to pharmacy: ([**Location (un) 2274**] list not up to date)
- DIAZEPAM 5 MG TAB 3 tablets [**Hospital1 **] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 26491**])
- CLONIDINE 0.2 MG TAB 2 tablets by mouth at bedtime
- IRON, FERROUS SULFATE, ORAL
- MULTIVITAMIN ORAL
- Acetaminophen (TYLENOL) 325 mg Oral Tablet
- Trazodone 100 mg Oral Tablet
- Duloxetine (CYMBALTA) 150 mg daily ([**Last Name (NamePattern1) 26492**])
- Keppra 500 mg qhs
- Prochlorperazine Maleate 10 mg Oral Tablet 1 tablet two times
daily as needed for nausea - confirmed
- Metformin (GLUCOPHAGE XR) 500 mg Oral Tablet Extended Release
24 hr (2 tabs)
- Oxycodone 30 mg Oral Tablet [**1-15**] po Q4-6 hours for breakthrough
pain, no more than 6 per day
- Oxycodone (OXYCONTIN) 80 mg Oral Tablet Extended Release 12 hr
1 po Q 8 hours
- Lasix 10 mg daily (per patient not taking)
Discharge Medications:
1. diazepam 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
2. clonidine 0.1 mg Tablet Sig: see below Tablet PO HS (at
bedtime): Take 0.3mg tonight on [**5-8**], then 0.2mg for the next
three days ([**Date range (1) 11757**]), then 0.1 for the next three days
(4/29-4/31), then STOP.
3. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Five (5)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Per Dr. [**Last Name (STitle) 26492**].
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) as needed for nausea.
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
11. oxycodone 30 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not take take more than 6 hours per
day. Do not drive while on this medication.
12. oxycodone 80 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours: Do not
drive while taking this medication.
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Home oxygen
Home oxygen for sats >90%. Pt 85% on RA, 93% on 1L, and 96% on
2L. A handwritten script was given to the oxygen delivery
person.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypoxemia, Diastolic heart failure
Secondary Diagnosis: Obesity, Osteoarthritis, Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Weight at discharge: 290.6 lbs
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for low oxygen levels. This is most likely a
result of lower than normal respiratory rates, which are likely
a result of being overweight, taking large doses of narcotics,
and possibly sleep apnea, as we discussed. However, a sleep
study would be required to confirm this, and you should discuss
consultation with a pulmonary (lung) doctor with your primary
care doctor.
In addition, you have a component of diastolic heart failure
where your heart is stiff and does not pump as effectively.
This results in fluid accumulation. You were given diuretics to
help remove some of this fluid.
The following changes were made to your medication list:
START lasix 40mg daily
START lisinopril 10mg daily
DECREASE clonidine: Take 0.3mg tonight on [**5-8**], then 0.2mg for
the next three days ([**Date range (1) 11757**]), then 0.1 for the next three
days (4/29-4/31), then STOP
Followup Instructions:
The following appointment was made for you:
Name: [**Last Name (LF) 26493**],[**First Name3 (LF) 26494**]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Friday [**2158-5-12**] 10:10am
You need to establish care with a Pulmonologist (lung doctor)
and see them within 2 weeks. Please discuss this with your
primary care physician, [**Name10 (NameIs) **] she will refer you to a physician.
|
[
"300.00",
"715.90",
"278.03",
"327.23",
"428.33",
"729.1",
"416.8",
"338.29",
"V43.65",
"278.01",
"428.0",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11500, 11506
|
6601, 8871
|
353, 360
|
11662, 11662
|
3256, 3263
|
12875, 13380
|
1921, 2011
|
9807, 11477
|
11527, 11527
|
8897, 9784
|
11875, 12852
|
2026, 2028
|
11840, 11851
|
305, 315
|
388, 1625
|
11602, 11641
|
11546, 11581
|
3277, 6578
|
11677, 11826
|
1647, 1811
|
1827, 1905
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,532
| 122,585
|
45291
|
Discharge summary
|
report
|
Admission Date: [**2131-4-1**] Discharge Date: [**2131-4-6**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] YO F w CAD, dCHF, PAF (not on coumadin), and bovine [**Age over 90 1291**]
presenting from [**Hospital3 **] after ~2 weeks of progressive
fatigue and loss of appetite. For these symptoms, EMS was called
and brought the patient into the ED.
.
Upon arrival to the ED, the patient was initially triggered for
O2 sat 85%. Exam was notable for resp distress and wheezing,
rhonchi. Labs were notable for WBC 13.1 (87%N/0%B), BUN 29,
Creat 1.4, troponin and lactate both wnl. U/A with a few
bacteria but otherwise unremarkable. Blood and urine cultures
were sent. CXR with question of pneumonia. Patient was given
albuterol and ipratropium nebs and 500mg levofloxacin and
ceftriaxone. VS prior to transfer were: 93, 126/68, 36, 99% NIV.
.
Upon arrival to the MICU, she reports dry mouth despite drinking
"lots" of water. She also endorses mild cough.
.
Review of systems:
(+) Per HPI; believes she may have lost weight, does not believe
she had fevers but is unsure
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- CAD s/p 3V CABG [**2124**] with saphenous vein grafts to the LAD, OM
and posterior descending coronary arteries.
- s/p Aortic valve replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
bovine prosthesis. Normal function on echo of [**3-13**]
- CHF EF 65%, grade I diastolic dysfunction, mild MR
- Hypercholesterolemia
- h/o PAF
- Hypertension
- s/p TAH
- Left Total hip replacement
- Depression
- History of C.diff [**12/2129**]
Social History:
Walks with walker at baseline, lives at [**Hospital3 **], gets
help with ADLS, distant h/o tobacco (quit 50 yrs ago), no
illicit drugs or ETOH. Does not wear a lifeline, has one in
bldg. Reports occasional mechanical falls at home.
- Tobacco: Remote history
- Alcohol: None
- Illicits: None
Family History:
Mother died at 84 from stomach cancer, had hypertension. Father
died at [**Age over 90 **] y/o from "old age".
Physical Exam:
ADMISSION EXAM:
Vitals: 99.3 132/65 92 96% on 50% face mask
General: Alert, oriented, no acute distress although quite
tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~9cm, no LAD
Lungs: decreased air movement throughout, diffuse wheezing;
profound kyphosis
CV: Regular rate and rhythm, occasional irregular beats
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool feet b/l, scattered eccymoses and venous dermatitis
.
DISCHARGE EXAM:
Vitals: 98 123/68 86 95% (3L NC)
General: Alert, oriented, breathing comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~9cm, no LAD
Lungs: profound kyphosis, diffuse crackles/rales, no wheeze
CV: Regular rate and rhythm, occasional irregular beats
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: wwp, scattered eccymoses and venous dermatitis
Pertinent Results:
1. Labs on admission:
[**2131-4-1**] 10:09PM BLOOD WBC-13.1*# RBC-4.66 Hgb-13.6 Hct-40.3
MCV-87 MCH-29.2 MCHC-33.8 RDW-14.0 Plt Ct-215
[**2131-4-1**] 10:09PM BLOOD Neuts-87.3* Lymphs-8.3* Monos-3.5 Eos-0.7
Baso-0.2
[**2131-4-1**] 10:09PM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1
[**2131-4-1**] 10:09PM BLOOD Glucose-185* UreaN-29* Creat-1.4* Na-136
K-3.7 Cl-99 HCO3-26 AnGap-15
[**2131-4-1**] 10:09PM BLOOD CK(CPK)-90
[**2131-4-1**] 10:09PM BLOOD cTropnT-<0.01
[**2131-4-1**] 10:09PM BLOOD CK-MB-3 proBNP-1549*
[**2131-4-1**] 10:15PM BLOOD Lactate-1.1
.
2. Labs on discharge:
Na 142, K 4.6, Cl 100, HCO3 35, BUN 30, Cr 1.5
.
3. Imaging/diagnostics:
- Echocardiogram ([**2131-4-2**]):
The left atrium is elongated. 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. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
- CXR ([**2131-4-1**]):
No new focal airspace consolidation to suggest pneumonia.
No pulmonary edema. Unchanged moderate cardiomegaly, with
unchanged right rib deformities and right mid lung opacity.
.
- CXR ([**2131-4-3**]):
New mild pulmonary edema and new left small pleural effusion.
Stable moderate right lung base opacity. Stable mild
cardiomegaly and tortuous aorta. Stable deformity of the right
hemithorax secondary to old posterior rib fractures.
.
- CXR ([**2131-4-5**]):
As compared to the previous examination, there is a massive
improvement. The lung volumes have increased, likely reflecting
improved
ventilation. The size of the cardiac silhouette is decreased.
There is no
evidence of pulmonary edema. A focal parenchymal opacity on the
right is
unchanged. This opacity, however, is located near old rib
fractures and could reflect pleural thickening.
Status post sternotomy and valve replacement. No pleural
effusions.
Tortuosity of the thoracic aorta. An old right humeral fracture
could be
present.
.
4. Microbiology:
- Sputum culture ([**2131-4-2**]):
GRAM STAIN (Final [**2131-4-2**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2131-4-4**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
- Rapid Respiratory Viral Screen & Culture ([**2131-4-2**]):
Respiratory Viral Culture (Final [**2131-4-4**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2131-4-2**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
- Blood culture ([**2131-4-1**]): No growth to date
.
- Urine culture ([**2131-4-1**]): ** FINAL ** NO GROWTH.
Brief Hospital Course:
[**Age over 90 **] yo F with CAD, dCHF, PAF not on Coumadin, and bovine [**Age over 90 1291**] who
presented from [**Hospital3 **] facility after two weeks of
progressive fatigue and decreased po intake, found to have ARF,
leukocytosis, and pneumonia.
.
Patient admitted [**2131-4-1**] to the MICU with SOB, fevers, hypoxia
consistent with fever and CXR intially unclear. By [**2131-4-3**],
developed infiltrate consistent with PNA. Flu swab negative. No
diarrhea to suggest C. diff. TTE on [**2131-4-2**] showed no interval
change since [**2130-5-10**] with EF normal, normal [**Month/Day/Year 1291**]. Patient was not
on coumadin due to fall risk.
.
Patient initially treated with vanc/levoflox for pneumonia.
After resolution of fever and leukocytosis, she was transitioned
to po levofloxacin and will complete a 10-day course after
discharge. She was treated with IV furosemide boluses for
pulmonary edema. CXR showed dramatic resolution of pulmonary
edema and pneumonia. She developed slight acute kidney injury
(1.2 -> 1.5) which is comparable to baseline. Home furosemide
was held until resolution of renal function. Patient continued
to have a 3 liter oxygen requirement which will be weaned at
rehab. Aspirin dose was increased from 81 mg to 325 mg po qd.
Medications on Admission:
- Amiodarone 100mg daily
- Furosemide 20mg daily
- Simvastatin 20mg daily
- Venlafaxine 75mg daily
Discharge Medications:
1. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. venlafaxine 75 mg Tablet Extended Rel 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days: [**2131-4-1**] through [**2131-4-10**] for a 10-day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pneumonia
Diastolic congestive heart failure
.
SECONDARY DIAGNOSES:
Coronary artery disease
Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 96763**], you were admitted to the [**Hospital1 **] because you had weakness for 2 weeks and low
oxygen level. We found that you had pneumonia and treated you
with medications, which you will finish after discharge. We also
gave you medications to remove fluid from your lungs. You got
better. Your kidneys showed signs of minor injury and so we have
stopped your medication furosemide (lasix) for now. Please
discuss with the doctors at rehab and your primary care doctor
about restarting this.
.
Medications:
ADDED:
- levofloxacin 250 mg by mouth per day, [**2131-4-1**] through [**2131-4-10**]
for a 10-day course.
CHANGED:
- Aspirin 325 mg by mouth per day
REMOVED:
- Furosemide 20 mg by mouth daily
Followup Instructions:
Name: [**Last Name (LF) 3707**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP after discharge within 7 days. **
Please also discuss restarting furosemide (Lasix).
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2131-4-6**]
|
[
"414.01",
"584.9",
"V42.2",
"V43.64",
"518.82",
"428.33",
"V49.86",
"272.0",
"486",
"V45.81",
"428.0",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9285, 9351
|
7267, 8534
|
257, 263
|
9537, 9537
|
3539, 3547
|
10471, 11099
|
2395, 2508
|
8684, 9262
|
9372, 9372
|
8560, 8661
|
9720, 10448
|
2523, 3057
|
9459, 9516
|
3073, 3520
|
1176, 1593
|
209, 219
|
4109, 7244
|
291, 1157
|
9391, 9438
|
3561, 4090
|
9552, 9696
|
1615, 2070
|
2086, 2379
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,098
| 121,963
|
25677
|
Discharge summary
|
report
|
Admission Date: [**2180-11-6**] Discharge Date: [**2180-11-23**]
Date of Birth: [**2109-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Mid back and right shoulder pain, difficulty ambluating
Major Surgical or Invasive Procedure:
TEE
Left Knee Joint Aspiration
PICC placement
Central line placement
History of Present Illness:
71 year old male with h/o known C3-4 spinal stenosis with
cervical radiculopathy, HTN, DMII, AFIB on coumadin, s/p left
knee replacement who initially presented to the ED with about
[**2-17**] day history of mid back and right shoulder pain and
difficulty ambluating.
.
The patient is not a very good historian. His wife is a poor
historian as well. Per his wife, the patient had not been able
to ambulate over the last 2-3 days because of pain. His wife had
been giving him Oxycodone over the last few days for pain. His
wife also notes [**2-17**] week history of progressive LE edema and
increasing abdominal girth. The patient had a fever of 103 at
home. He reports b/l hand tingling. He denies dysuria,
frequency, bladder or bowel incontinence, cough, SOB, CP,
palpatations. He denies a h/o trauma. He walks with a cane or
walker at baseline. He reports [**2-17**] day history of constipation.
No vision changes. No photophobia.
.
Of note, he is scheduled for a cervical laminectomy with Dr.
[**Last Name (STitle) **] on [**2180-12-13**]. He receives his care at [**Hospital 882**] hospital.
.
ED course: Vitals T 100.3, BP 140/68, RR 16, Sat 95% on 2L. The
patient was evaluated by neurosurgery and felt not to have any
acute neurosurgical issues. He was given Levaquin and Vancomycin
for presumed PNA.
Past Medical History:
-known C3-4 spinal stenosis (surgery scheduled with Dr. [**Last Name (STitle) **]
on [**2180-12-13**])
-diabetes II
-high cholesterol
-hypertension
-GERD
-afib on anticoagulation
-sleep apnea
-Left total knee replacement [**6-18**]
-Bladder perforation after foley irritation leading to ARF
-status post removal of a neurofibroma in the lumbosacral spine
-s/p removal of 2 small [**Month (only) 499**] lesions
Social History:
He lives with his wife. [**Name (NI) **] denies current tob use, quit over 50
yrs ago. He drinks wine occassionally. He continues to work from
home as a salesman.
Family History:
Sisters and mother with [**Name2 (NI) 499**] ca, brother with diabetes.
Physical Exam:
Vitals on admission: T 101.2, BP 148/72, HR 177, RR 24, 93% on
4L
General: elderly gentlemen lying flat with cervical collar, NAD,
diaphoretic
HEENT: NC, AT dry MM, pupils small and sluggish
Neck: in hard collar, unable to assess JVD or carotids
Lungs: Anteriorly with coarse breath sounds and crackles at
bases. No wheezes
CV: irregulary irregular, tachy, no m/r/g
Abdomen: distended, tympanic, tender to palpation in LLQ (per
report this moved c/w prior exam), bowel sounds present, left
flank tenderness to palpation
Ext: warm, 3+ pitting edema to knees (Left >Right, chronic),
strong DP pulses b/l. Left knee with well healed scar
Neuro: A&Ox3. Pt unable to cooperate with neuro exam due to back
pain.
Pertinent Results:
ECHO Study Date of [**2180-11-22**]
1. The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler.
2.Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). [Intrinsic left ventricular systolic function may be
more depressed given the severity of valvular regurgitation.
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen.
6.The mitral valve leaflets are moderately thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen.
7.There is no pericardial effusion.
.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2180-11-18**]
Discitis and osteomyelitis at L1-2 level with epidural abscess
at L2 level, unchanged from the previous MRI study. Enhancement
of the epidural soft tissues in the lower thoracic and upper
lumbar region is unchanged. No new abnormalities are identified
.
MR [**Name13 (STitle) **] W &W/O CONTRAST [**2180-11-18**]
No evidence of epidural abscess, discitis or osteomyelitis in
the thoracic region. Multilevel degenerative changes. Evaluation
of paraspinal soft tissues and thoracic region is limited, as
the axial images were not obtained
.
MR [**Name13 (STitle) **] W& W/O CONTRAST [**2180-11-16**]
Probable progression of epidural abscess at L2. Increased
enhancement of the intervertebral disc and the adjacent
vertebral bodies at L1-2. Epidural enhancing tissue extending
superiorly from the L1-2 level to T9.
A repeat examination is recommended to evaluate paraspinal soft
tissue swelling in the lower thoracic spine. No evidence of
osteomyelitis, discitis, or epidural abscess in the cervical
spine. However, the evaluation of this level is quite limited.
.
BONE SCAN [**2180-11-15**]
Reason: PT WITH C3-4 SPINAL STENOSIS, ? OSTEOMYELITIS
1) Increased uptake at the left knee prosthesis on all three
phases,
suggestive of osteomyelitis or septic joint. 2) Intense uptake
in upper lumbar spine, correlating with site of suspected L1/2
discitis by prior MRI. 3)Increased bone uptake on the right at
approximately T11 may be degenerative. Consider anatomic imaging
if there is clinical suspicion of infection at this site. 4)
Increased uptake in the upper cervical spine and peripheral
joints, most likely degenerative.
.
PORTABLE ABDOMEN [**2180-11-11**]
IMPRESSION: No free air. No dilated bowel loops. Findings
suggestive of right lower lobe pneumonia
.
CT 100CC NON IONIC CONTRAST [**2180-11-11**]
1. Bilateral pleural effusions, right greater than left, with
right lower lobe consolidation/atelectasis.
2. Mild left lower lobe compressive atelectasis.
3. Cardiomegaly with a small pericardial effusion.
4. Tiny punctate focus of gas noted within the biliary system,
which may be related to prior sphincterotomy
.
XR L knee [**2180-11-9**]: Large left knee effusion and prepatellar
soft tissue swelling.
.
CT lumbar spine [**2180-11-8**]: 1. Evaluation for epidural abscess is
very limited on this examination and was much better assessed on
the MRI from the same day. No definite epidural abscess can be
seen on this CT examination. No areas of abnormal enhancement
are noted within the paraspinal tissues. 2. Narrowing of the
L1-2 intervertebral disc space with irregularly marginated,
sclerotic endplates of the L1 and L2 vertebral bodies consistent
with discitis, which was previously seen on the MR from the same
day. 3. Multilevel degenerative changes as described above with
mild grade I L4 on L5 retrolisthesis.
.
MRI lumbar spine [**2180-11-8**]: 1. Limited study secondary to patient
motion.
2. Findings are worrisome for L1/2 discitis, and probable
epidural abscess posterior to L2 vertebral body as described
above. There is mild spinal stenosis at this level. 3.
Arachnoiditis 4. Severe degenerative spinal stenosis at L3/4. 5.
Mild retrolisthesis of L4 upon L5 with moderate degenerative
spinal stenosis at this level.
.
LENI [**2180-11-8**]: no evidence of DVT
.
Echo [**2180-11-7**]: LVEF 50%, 1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed. Septal hypokinesis is
present. 3. The aortic valve leaflets are mildly thickened. 4.
The mitral valve leaflets are moderately thickened.
.
CT abd [**2180-11-7**]: Bilateral low attenuation non-enhancing
densities in the perirenal space, likely representing
hemorrhage. Inflammatory stranding from pyelonephritis or stone
passage seems less likely.
.
CXR [**2180-11-6**]: 1. Bilateral small pleural effusions. Left basal
atelectasis.
2. Left superior mediastinal widening due to enlargement of the
left lobe of the thyroid gland or left-sided SVC.
.
Abd XR [**2180-11-6**]: Dilated, air filled, loops of small and large
bowel with air and stool seen in the [**Month/Day/Year 499**] and rectum. The
findings represent ileus. Clinical correlation is requested.
.
head CT [**2180-11-6**]: No gross intracranial hemorrhage.
Brief Hospital Course:
# MRSA: Patient with MRSA bacteremia which cleared. Source
unknown likely epidural abscess, enterovesicular vistual, L knee
osteomyelitis. Serial Bl Cx were drawn and last Bl Cx positive
was on [**11-13**] (Staph coag negative); Continued on Vancomycin:
1000mg IV q12; monitoring trough. Pt was intially on Gentamycin
but was discontinued on [**11-13**] per Id as Bl Cx were negative
- Bone scan suggestive of L knee joint osteomyelitis, Veterbral
focus of osteomyelitis
- MRI spine showed Epidural abcess @ L1-L2 ; neurosurgery did
not think there was need for intervention for his epidural
abscess from initial evaluation, likely no role for biopsy of L2
disc with ? of discitis. He will be followed up for this as an
outpatient
- urine cx intially positive but were negative since [**11-10**]
(mixed bacterial [**Female First Name (un) **]); Pt has a h/o of bladder perforation
during catheter placement in the past and so we were concerned
about a ureterovesicular fistula. Urology did not perform a
cystoscopy as urine cultures were negative since [**11-10**].
- Arthrocentesis was performed 2/2 L knee swelling; analysis
revealed [**Numeric Identifier 64039**] WBC, RBC [**Numeric Identifier 44665**], no crystals, no bacteria; Pt
will be followed by Dr. [**Last Name (STitle) 64040**] from [**Hospital1 882**]/[**Hospital1 2025**] for
exploration of the knee joint after discharge from [**Hospital1 18**].
- TEE on [**11-22**] ruled out endocarditis
- we were following CK levels weekly as patient was on
Vancomycin
.
#. Afib with rapid ventricular response : most likely due to
underlying bacteremia; now rate/rhythm controlled on sotalol and
Metoprolol. Was intially on Diltiazem gtt which failed to
control his rate/rhythm. Patient was started on Loevnox
therapeutic dose of 1mg/kg [**Hospital1 **]. Not started on Coumadin as
patient was going to get knee surgery. Coumading can be started
after his knee surgery.
.
#. UTI with concern for pyelo given left flank pain on
admission. CT abdomen revealed bilateral low-attenuation
non-enhancing peri-renal densities consistent with RP
hemorrhage, but not pyelo
.
# Anemia: HCT was 33.8 on admission
- labs showed Retic-1.1 (low), Hapto-388 (high), TIBC-172 (low),
Iron-48 (N), Ferritin-1002 (high), TRF-132 (low)
- most likely ACD w/ marrow supression
- Transfusion threshold for HCT <21
.
#. Constipation: Continue aggressive bowel regimen as pt on
narcotics
- patient had abdominal tenderness earlier during this
admission, KUB demonstrated no free air or air-fluid levels
.
#. Back pain: Degenerative disk disease vs. ? epidural abcess
- pain well controlled on Oxycontin SR, morphine IV for
breakthrough
- cont Skelaxin (muscle relaxant)
- will f/u with Dr. [**Last Name (STitle) **] ([**Hospital1 18**]) from Neurosurgery for his
ervical stenosis and epidural abcess
.
#. Left Knee Effusion: knee tap repeated on [**11-12**]. tap was
hemorraghic with [**Numeric Identifier 64041**] WBC 85%polys. gram stain with 2+ PMN but
no microorganisms, cx unrevealing. No Crystals. Watch right knee
exam as appears erythematous.
- Dr. [**Last Name (STitle) 64040**] (@ [**Hospital1 882**]) is his primary orthopedician; pt will
see Dr. [**Last Name (STitle) 64040**] in 1 week after discharge and discuss further
follow up.
.
#. Delirium: likely secondary to bacteremia which was resolved
at the time of discharge
- CT head was negative to rule out IC lesion
- judiciously use pain meds, zyprexa for aggitation
.
#. DMII: held oral hypoglycemics. Checking FS QID, continue
NPH/Humolog/RISS.
.
#. HTN: cont metoprolol, Lisinopril
- continue to titrate as needed
.
#. Hypercholesterolemia: Continue lipitor
.
# FEN: diabetic, heart healthy diet
.
# Access: PICC, CVL removed [**11-18**] (site was bleeding on [**11-22**] but
stopped on [**11-23**]). will need to be monitored.
.
# PPX: PPI, bowel regimen, lovenox
.
# Code: Full as per wife.
.
# communication; Wife: [**Telephone/Fax (1) 64042**] Anobis
.
# C3-4 spinal stenosis: should have collar on when patient out
of bed
Medications on Admission:
-lipitor 20 daily
-glipizide 10 daily
-warfarin 4 daily
-lisinopril 20 daily
-metformin 500 [**Hospital1 **]
-diltiazem 360 daily
-baclofen 20 daily
-Colace 200 [**Hospital1 **]
-Sennakot 3 tabs [**Hospital1 **]
.
Allergies: PCN - rash
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metaxalone 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*3*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO Q4H
(every 4 hours) as needed for PRN constipation.
13. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
15. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
16. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
17. Insulin Regimen
Please continue to follow the insulin regimen based on the
attached sheet.
18. Vancomycin HCl 1000 mg IV Q 12H
19. Morphine Sulfate 2-6 mg IV Q4H:PRN breakthrough pain
hold for rr < 8 or oversedation; can administer this dose before
moving the patient
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Epidural Abcess
Left Knee Effussion
Atrial Fibrillation with Rapid Ventricular Rate
MRSA Bacteremia
Discharge Condition:
all vitals are stable
Discharge Instructions:
Please get the following levels checked every Monday and report
it to your physician.
1. Vancomycin (Trough in blood)
2. Creatinine
3. Liver Function Tests (AST, ALT, LDH, Total Bilirubin)
.
Please continue to use your Knee Immobilizer while in bed or at
rest.
.
Please continue to be on Lovenox. You will need to be started on
Coumadin after your Knee surgery.
.
You will need to be on IV Vamcomycin for few weeks until after
your knee surgery. Total duration will be evaluated by your
Orthopedician and ID specialist.
.
Please take all the prescribed medications. Please report to the
ED or to your Physician if you have any worsening of symptoms or
any other concerns.
Followup Instructions:
APPOINTMENTS
.
Orthopedics: Please call Dr. [**Last Name (STitle) 64040**] ([**Telephone/Fax (1) 64043**] to confirm
your appointment for early next week. We have left a message
with him about setting up an appointment for you early next
week.
.
Neurosurgery: Dr.[**Name (NI) 9034**] office will call you with the
appointment date and time.
.
Infectious Disease Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2180-12-22**] 10:00
.
Cardiology Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2181-1-24**] 11:00
.
Neurology Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2181-2-6**] 4:00
Completed by:[**2180-11-23**]
|
[
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"401.9",
"723.0",
"599.0",
"041.11",
"428.0",
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"293.0",
"427.31",
"V43.65",
"711.06",
"730.28",
"285.29",
"486",
"286.9",
"788.20",
"324.1",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"81.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14530, 14675
|
8511, 12538
|
372, 443
|
14819, 14843
|
3225, 8488
|
15563, 16381
|
2410, 2483
|
12825, 14507
|
14696, 14798
|
12564, 12802
|
14867, 15540
|
2498, 2505
|
276, 334
|
471, 1780
|
2519, 3206
|
1802, 2214
|
2230, 2394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,325
| 102,155
|
51416
|
Discharge summary
|
report
|
Admission Date: [**2201-5-26**] Discharge Date: [**2201-6-1**]
Date of Birth: [**2142-8-30**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 58F Spanish speaking with cirrhosis
and renal failure, gets usual care at [**Hospital1 112**], presented to [**Hospital1 18**] ER
after taking some drugs off the street and lethargy. T 100.9,
BP88/50 HR 69 O2 99%2L, she was initially given Narcan 0.4mg
with some improvement in mental status and dose was repeated X
2. She had a low grade fever T 100.9 and LP was done. Prior to
LP, she was given ceftriaxone 2 grams. She continued to be
lethargic so received 2mg IV narcan X 2 and planned for narcan
gtt, however, she was arousable to voice so this was not
started. Last dose of Narcan was 10 AM [**5-26**]. CT head and CXR in
the ER were unremarkable. She also had a several BS in the 64-75
range and received Dextrose. Per ER notes additional history was
obtained from family (2 daughters) who stated that patient
abuses oxycodone, vicodin, T3 (no tyelnol in tox). Family denied
that patient was on sulfonylureas for diabetes.
.
At time of transfer to the ICU, she was easily arousable. She
complained of lower back pain, which she's had for years.
Otherwise denies any chest pain, shortness of breath. Denies any
abdominal pain, fevers or chills at home. Daugther thinks she
took altogether 34 pills (vicodin and tylenol #3) over past [**2-15**]
days. She does not think her mom is depressed.
Past Medical History:
Chronic lung disease - BOOP
Depression
Hypercholesterolemia
Multiple overdose (states has been admitted ~6 times, last time
6 months ago)
Cirrhosis
Diabetes
Arthritis
Kidney Failure
Social History:
Lives with her son, no smoking (prev 5ppd), denies etoH. No IVDA
per daughter
Family History:
non contributory
Physical Exam:
VS: Tmax: Temp: BP: / HR: RR: O2sat
.
General Appearance: pleasant, comfortable, NAD, non toxic
Eyes: : PERLLA, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, op without exudate or lesions, no
supraclavicular or cervical lymphadenopathy, JVP to cm, no
carotid bruits, no thyromegaly or thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
Gastrointestinal: nd, +b/s, soft, nt, no masses or
hepatosplenomegaly
Musculoskeletal/extremities: no cyanosis, clubbing or edema
Skin/nails: warm, no rashes/no jaundice/no splinters
Neurological: AAOx3. Cn II-XII intact. 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps.
No asterixis, no pronator drift, fluent speech.
Psychiatric:pleasant, appropriate affect
Heme/Lymph: no cervical or supraclavicular lymphadenopathy
GU: no catheter in place
Rectal: guiaic negative
Pertinent Results:
Admit labs:
[**2201-5-26**] 01:32AM WBC-11.1* RBC-3.38* HGB-10.3* HCT-32.7*
MCV-97 MCH-30.4 MCHC-31.5 RDW-15.7*
[**2201-5-26**] 01:32AM NEUTS-76.2* LYMPHS-19.6 MONOS-3.7 EOS-0.4
BASOS-0.3
[**2201-5-26**] 01:32AM PLT COUNT-182
[**2201-5-26**] 01:32AM GLUCOSE-92 UREA N-32* CREAT-3.1* SODIUM-136
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2201-5-26**] 01:32AM ALT(SGPT)-25 AST(SGOT)-50* ALK PHOS-380* TOT
BILI-0.4
[**2201-5-26**] 01:32AM LIPASE-13
===================================================
[**2201-5-26**] 10:38PM TSH-0.35
[**2201-5-26**] 10:38PM calTIBC-351 VIT B12-950* FOLATE-8.6
FERRITIN-31 TRF-270
[**2201-5-26**] 10:38PM ALBUMIN-3.1* CALCIUM-8.2* PHOSPHATE-3.9
MAGNESIUM-1.8 IRON-78
[**2201-5-26**] 10:31AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-560*
POLYS-44 LYMPHS-50 MONOS-0 MACROPHAG-6
[**2201-5-26**] 10:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-52*
GLUCOSE-51
[**2201-5-26**] 10:30AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-[**Numeric Identifier **]*
POLYS-68 LYMPHS-25 MONOS-0 EOS-1 ATYPS-3 MACROPHAG-3
==================================================
Micro:
CSF, Blood cultures no growth, finalized.
RPR non reactive.
Stool cultures including c. diff x1 negative.
=======================================
ECG: Normal ECG.
================================================
CT HEAD W/O CONTRAST [**2201-5-26**] 6:03 AM
CT HEAD W/O CONTRAST
Reason: r/o ICH
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with lethargy, AMS
REASON FOR THIS EXAMINATION:
r/o ICH
CONTRAINDICATIONS for IV CONTRAST: kidney disease, not needed
INDICATION: 58-year-old female with lethargy and altered mental
status. Rule out intracranial hemorrhage.
No comparison studies.
TECHNIQUE: Non-contrast CT of the head.
FINDINGS: There is linear hyperdensity within the nondependent
portions of the choroid plexus likely calcified choroid.
Posterior to the mid brain and anterior to the cerebellum, there
is linear hyperdensity which is not in a characteristic location
for hemorrhage, likely a benign structure, correlation with MRI
of the head is recommended if clinically warranted. There is no
mass effect, shift of normally midline structures, or acute
major vascular territorial infarction. The ventricles are normal
in size and symmetric.
The visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION: No definite intracranial hemorrhage.
=================================================
CHEST (PORTABLE AP) [**2201-5-26**] 5:43 AM
CHEST (PORTABLE AP)
Reason: r/o acute process
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with somnolence
REASON FOR THIS EXAMINATION:
r/o acute process
INDICATION: 58-year-old female with somnolence. Rule out acute
process.
No comparison study.
PORTABLE UPRIGHT CHEST RADIOGRAPH: Lung volumes are low. The
cardiomediastinal silhouette is within normal limits. There is
increased interstitial opacity diffusely with prominent hila
bilaterally. There are no appreciable effusions.
IMPRESSION: Low lung volumes. Likely mild pulmonary edema. If
there is further concern, repeat evaluation with better
inspiration is suggested.
=====================================================
ABDOMEN U.S. (COMPLETE STUDY) [**2201-5-27**] 2:14 PM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: CIRRHOSIS. EVAL FOR ASCITES. FEVER
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with h/o DM, cirrhosis a/w fever, lethargy.
Please evaluate for cirrhosis, ascites.
REASON FOR THIS EXAMINATION:
Please evalute for ascites, cirrhosis.
INDICATION: Assess for ascites and cirrhosis.
COMPARISON: None available.
ABDOMINAL ULTRASOUND: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**]
images were obtained and demonstrate the liver to be of
coarsened echotexture without ascites. No focal hepatic lesions
are demonstrated in this study limited by patient factors. The
gallbladder is nondistended. There is no pericholecystic fluid,
no evidence for cholelithiasis and the common bile duct is
nondistended measuring 5 mm. Portal venous flow is normal in
terms of direction. The left kidney measures 10.4 cm
pole-to-pole and the right kidney 10.1 and there is no evidence
for hydronephrosis, nephrolithiasis, or renal mass. The spleen
is homogenous in terms of echotexture and measures 4.3 cm.
IMPRESSION:
1. Coarsened echotexture of liver consistent with fatty liver.
2. No ascites.
The study and the report were reviewed by the staff radiologist.
=
=
=
================================================================
Discharge labs:
[**2201-5-31**] 07:05AM BLOOD WBC-9.9 RBC-3.26* Hgb-9.8* Hct-30.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.6* Plt Ct-178
[**2201-5-26**] 09:05AM BLOOD Neuts-70.7* Lymphs-23.6 Monos-5.3 Eos-0.3
Baso-0.2
[**2201-5-31**] 07:05AM BLOOD Plt Ct-178
[**2201-5-31**] 07:05AM BLOOD PT-15.1* PTT-37.1* INR(PT)-1.3*
[**2201-5-31**] 07:05AM BLOOD Glucose-110* UreaN-20 Creat-0.8 Na-140
K-3.6 Cl-106 HCO3-25 AnGap-13
Brief Hospital Course:
58 yof with history of CKD, Cirrhosis and history of multiple
drug overdoses with opiates presented to ER with altered mental
status.
.
Please note, discharge summary not updated by [**Hospital Ward Name 332**] ICU team,
thus discharge summary limited. Patient transferred to floor on
HD#3
1. Altered Mental Status/ Lethargy/Opiate overdose - Secondary
to opiate overdose.
- CXR, UA negative for infection, urine and blood cultures, LP
negative for infectious etiology. Given narcan x 1 with
improvement in mental status.
- Given empiric lactulose by ICU team with concern for hepatic
encephalopathy
- By HD#3 mental status at baseline, lactulose discontinued
without return of confusion
- Evaluated by psychiatry who did not feel patient was suicidal
- No further opiods prescribed.
.
2. Acute renal failure - Improved with IVF in ER. Combination
of dehydration. Lasix and lisinopril outpatient medications
were held and then re-started once creatinine at baseline.
.
3 DM - held glargine insulin and aspart on admit. ISS. Patient
was taking 80 units of lantus at night and 28 units of aspart
before each meal. Only able to safely titrate insulin to 20
units glargine at night and 20 units aspart before meals as
patient was having morning lows around 100. will need ongoing
titration.
.
4. NASH/ Cirrhosis - LFTs unremarkable but carries a diagnosis
per history. Abdominal ultrasound consistent with NASH.
.
5. Chronic low back pain - Neurontin and lidocaine patch
continued
.
6. Chronic diastolic heart failure/Coronary Artery Disease/HTN:
With altered mental status, acute renal failure, lasix and
lisinopril held. By discharge, back on lasix, lisinopril,
aspirin, statin, beta blocker.
.
7 Chronic lund disease/BOOP - continued prednisone at 5mg
.
8)Depression: evaluated by psychiatry, maintained on celexa.
Not suicidal. Offered follow up
.
Patient with history of severe non compliance with appointments
and medications as per [**Hospital1 756**] Records. Extensive teaching by
nursing, physicians and social work. Support and resources
offered. VNA and PT arranged. Repeatedly emphasized importance
of primary care. Daughter involved and trying to facilitate
ongoing healthcare. Medication usage extensively reviewd.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Sennosides 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Insulin Aspart 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous three times a day: 10 minutes before each meal. do
not take if you are not going to eat.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
14. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation three times a day as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Opiate abuse/overdose
2. Altered Mental Status
3. Depression
4. Type II DM, uncontrolled
5. Chronic diastolic heart failure
6. BOOP
7. NASH
8. Hypokalemia
9. Thrush
10. coagulopathy
11. Anemia
12. Hypertension
13. Acute renal failure
14. hyperlipidemia
Discharge Condition:
stable, mental status at baseline, afebrile
Discharge Instructions:
You must follow up with your primary care doctor and with
psychiatry.
If you develop fevers, chills, confusion or any other new
concerning symptoms contact your doctor.
Do not take any narcotics such as codeine, tylenol #3, percocet,
oxycodone, oxycontin, morphine, dilaudid and do not use and
illegal drugs.
Do not take any medications that are not on the list of your
discharge medications. If you are starting any medications,
you must let your primary care doctor know.
Followup Instructions:
Follow up with your primary care doctor, Dr. [**Last Name (STitle) 106620**] at [**Hospital1 **]. Call [**Telephone/Fax (1) 9251**] to make an appointment for later
this week or early next week.
If you would like to have a new primary care doctor here, call
[**Telephone/Fax (1) 1247**] to set up an appointment. Once you see the new
primary care doctor, they will help you set up a psychiatry and
social work appointment.
|
[
"965.00",
"428.32",
"272.0",
"276.51",
"112.0",
"276.8",
"571.5",
"348.30",
"516.8",
"250.02",
"428.0",
"584.9",
"E850.2",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11873, 11931
|
8025, 10276
|
290, 296
|
12230, 12275
|
3059, 4466
|
12802, 13230
|
1968, 1986
|
10299, 11850
|
6414, 6516
|
11952, 12209
|
12299, 12779
|
7604, 8002
|
2001, 3040
|
229, 252
|
6545, 7587
|
352, 1651
|
1673, 1857
|
1873, 1952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,079
| 149,676
|
38330
|
Discharge summary
|
report
|
Admission Date: [**2200-10-7**] Discharge Date: [**2200-10-11**]
Date of Birth: [**2136-6-12**] Sex: M
Service: MEDICINE
Allergies:
Iodine / adhesive tape
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
Packed RBC transfusion - 1 Unit
History of Present Illness:
HPI: 64 yo M with CAD s/p multiple coronary artery stents on
ASA, Plavix who presented to ED with 5-6 bloody bowel movements
since yesterday evening. He was recently admitted to [**Hospital **]
hospital and treated for diverticulitis. He is still on a 1-week
course of Cipro and Flagyl. He has had 3 episodes of
diverticulitis since [**1-24**]. He denies ever having BRBPR in the
past, despite being on ASA and Plavix for many years. He had a
recent colonoscopy which showed diverticulosis. Denies
light-headedness, syncope, weight loss, night sweats, fevers, or
chills. Also denies chest pain, SOB, or palpitations.
Transferred to [**Hospital1 18**] ED for further management.
Past Medical History:
CAD s/p CABG ([**2191**]) and multiple stents
HTN
HL
Obesity
GERD
prostate CA s/p prostatectomy
s/p appendectomy
s/p CCY
Social History:
- Tobacco: smoked cigars for 20 years and quit in [**2174**]
- Alcohol: 6 drinks per week
- works as CEO for local manufacturing company
Family History:
Mother died of MI in his 60's. Father with MI in his 60's and
is alive today at age 87. Brother with [**Name2 (NI) **].
Physical Exam:
VSS
Gen: A&Ox3, NAD
HEENT: OP clear, MMM
CV: RRR, S1/S2 nl, no MRG
Lungs: CTAB, no w/r/r
Abd: soft, NT, protuberant, NABS
Ext: no c/c/e, WWP
Neuro: non-focal
Skin: no rashes, intact
Psych: calm, appropriate
Pertinent Results:
[**2200-10-7**] 02:59AM WBC-8.2 RBC-3.81* HGB-11.9* HCT-34.1* MCV-90
MCH-31.3 MCHC-35.0 RDW-14.3
[**2200-10-7**] 02:59AM NEUTS-71.9* LYMPHS-23.0 MONOS-4.2 EOS-0.6
BASOS-0.3
[**2200-10-7**] 02:59AM PLT COUNT-263
[**2200-10-7**] 02:59AM PT-14.4* PTT-23.4 INR(PT)-1.2*
[**2200-10-7**] 04:01AM WBC-6.6 RBC-3.59* HGB-11.3* HCT-31.8* MCV-89
MCH-31.4 MCHC-35.5* RDW-14.4
[**2200-10-7**] 04:01AM NEUTS-71.8* LYMPHS-23.4 MONOS-3.8 EOS-0.9
BASOS-0.2
[**2200-10-7**] 04:01AM PLT COUNT-244
[**2200-10-7**] 02:59AM GLUCOSE-150* UREA N-11 CREAT-1.1 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12
Brief Hospital Course:
## GI bleed: Mr. [**Known lastname **] was admitted to the ICU from the ED
for closer monitoring. It was presumed that his bleeding was [**12-18**]
known sigmoid diverticulosis in the setting of ASA and Plavix
use. Hct and BP were stable during his stay in the ICU. GI and
Surgery were consulted, who recommended conservative management.
He did not undergo repeat endoscopy during this admission. After
transfer to the floor on [**10-8**], he began having dark brown to
black stools. On [**10-9**], he became asymptomatically hypotensive
to 84/52 with associated 4-point drop in Hct. He received 1 unit
PRBC transfusion at that time with an appropriate response. Only
his Plavix was initially held upon transfer out of ICU, but
after his drop in Hct and hypotension, his ASA too was held.
Both ASA and Plavix will be held at the time of discharge.
.
## Coronary artery disease: ASA and Plavix will be held upon
discharge. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4154**] over the
phone, who was covering for patient's outpt Cardiologist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**] at [**Location (un) **]. The patient was told to call Dr.
[**First Name (STitle) 4640**] after the holiday weekend to discuss this issue further.
Patient states that he is not on a beta-blocker b/c it makes him
confused, tired, and unable to function at his job-> only takes
BB peri-operatively per his report.
.
## Diverticulitis: He had 3 episodes of acute diverticulitis
within the past 8 months, the most recent being 1 week prior to
this admission to [**Hospital1 18**]. He was sent home on a 1-week course of
Ciprofloxacin and Flagyl, which he completed during this
admission. He was evaluated by Surgery as outpt, who apparently
decided not to pursue surgical management at that time given
that a lot of the colonic inflammation had resolved. However, it
would be helpful to entertain this discussion once again in
light of his lower GI bleed. This was broached with the patient,
who stated that he would like to follow-up with the Surgery
group at [**Hospital1 18**]. He was given the phone number for the [**Hospital 2536**] clinic
so that he can call to make an appointment.
.
## HTN/hypotension: Given the patient's hypotension and likely
slow, yet active, bleed, his Imdur was held upon discharge. His
Lasix and Lisinopril were continued at the outpatient doses.
.
## Hyperlipidemia: Continued on his home Ezetimibe and
Simvastatin (on Vytorin combination pill as outpt).
.
## GERD: Continued on his home PPI.
.
## Gout: Continued on his home Allopurinol.
Medications on Admission:
Plavix 75 mg Tab 1 Tablet(s) by mouth once a day
Vytorin (ezetimibe/simvastatin) [**9-4**] 10 mg-20 mg Tab 1
Tablet(s) by mouth once a day/PM
Aspirin 81 mg Tab, Delayed Release 1 Tablet(s) by mouth at noon
daily
Allopurinol 100 mg Tab 1 Tablet(s) by mouth once a day
Furosemide 40 mg Tab 1 Tablet(s) by mouth once a day
Lisinopril 20 mg Tab 1 Tablet(s) by mouth once a day
Isosorbide Mononitrate SR 60 mg 24 hr Tab 1.5 Tablet(s) by mouth
once a day
Multivitamin Tab 1 Tablet(s) by mouth once a day
omeprazole 40 mg Cap, Delayed Release Oral 1 Capsule, Delayed
Release(E.C.)(s) Twice Daily
-Glucosamine/chondrotin/MSN complex 1500/1350 mg. PO BID
-Ciprofloxacin 500 mg. PO BID since [**10-4**]
-Flagyl 500 mg. PO TID since [**10-4**]
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticular bleed
Acute blood-loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had bleeding in your lower GI
tract. You did not require any blood transfusions, and your
bleeding stopped on its own. Because of the GI bleeding, your
Aspirin and Plavix were held after discussing this with the
doctor covering for your Cardiologist this holiday weekend.
Please call your doctor or return to the ER if you notice blood
in your stool again. Your 1-week course of antibiotics
(Ciprofloxacin and Metronidazole) was completed during this
admission, so you do not need to continue taking those. Because
your blood pressure was running low, your Imdur was also held.
Followup Instructions:
1) Please call Dr. [**Last Name (STitle) 911**] to schedule a follow-up appointment
next week.
2) Please call Dr. [**First Name (STitle) 4640**] on Monday, [**10-13**] to discuss the
long-term plan for your Plavix.
3) Please call the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to
schedule an appointment to discuss whether you need an operation
on your colon.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2200-10-11**]
|
[
"412",
"414.00",
"278.00",
"401.9",
"V45.81",
"272.4",
"274.02",
"530.81",
"276.52",
"285.1",
"V45.82",
"562.13",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6300, 6306
|
2359, 4977
|
299, 332
|
6393, 6393
|
1719, 2336
|
7176, 7674
|
1355, 1477
|
5762, 6277
|
6327, 6372
|
5003, 5739
|
6544, 7153
|
1492, 1700
|
245, 261
|
360, 1039
|
6408, 6520
|
1061, 1183
|
1199, 1339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,226
| 128,963
|
33988
|
Discharge summary
|
report
|
Admission Date: [**2149-3-31**] Discharge Date: [**2149-5-27**]
Service: MEDICINE
Allergies:
Bactrim / Ceftriaxone / Vancomycin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Respiratory failure, s/p bradycardic arrest. development of
paravertebral hematoma and injury to c5-c6 from fall.
Major Surgical or Invasive Procedure:
Paravertebral Hematoma Drainage
Intubation
Chest Tube Placement
History of Present Illness:
Ms. [**Known lastname 62523**] is a 83 yo woman with fall (head and right knee
hematoma), 2nd day in a row (per notes denied loc). Went to [**Hospital 8125**]
Hospital, neg head ct, uti->cipro (nitrate +, 3+ LE, [**5-6**] WBC,
[**1-29**] RBC, mod epi, mod bacteria). She then c/o difficulty
swallowing/choking on secretions, became acutely short of
breath, resp arrest (agonal) with bradycardia (s/p epi),
intubated, s/p chest compressions x 15 minutes, with versed on
med flight and ativan 2mg iv x2, metoprolol 2.5mg iv x2 at
[**Hospital1 **]. Arrived intubated on transfer, T 100.8 Hr 84 BP 130/87
sating 94% on vent. Noted to have ecchymosis on head, hard
collar for cervical stabilization. No sedation in ED here, GCS
8. Family: son on [**Hospital3 635**], called from [**Name (NI) **] but no repsonse. Vent
500/10/0.6/5. Neuro consulted, rec MRI/MRA head/MRI c-spine. She
received 2L IVF prior to icu arrival.
Past Medical History:
CVA
hypothyroid
left humerus fracture s/p ORIF
open ccy
hypertension
D/C summary from [**Hospital1 **] [**Date range (1) 40693**] for inability to walk/move legs,
TSH then 1.1.
per son: has dementia [**12-28**] brain damage after having scarlet
fever at age 13 - with episodes of hallucinations (auditory and
visual) no alzheimers, is a paranoid, won't let anyone in to her
life, 'they are secret'
Social History:
Lives alone with son next door, per recent [**Name (NI) **] D/C summary
long h/o tobacco but quit 15 years ago, denied etoh. Only
relative is son, husband died 7 years ago, no other children.
Family History:
Son age 50, s/p MI x2.
Physical Exam:
VS: T 98.7 HR 68 BP 151/90 RR 18 Sat 100% on AC 500/10/.[**5-1**]
GEN: NAD
HEENT: PERRLA, no conjuctival injection, anicteric, OP clear, MM
dry, B periorbital ecchymosis, frontal hematoma, nasal hematoma
Neck: in hard cervical collar
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS, no HSM
EXT: cold, dry, +1 distal pulses BL; right knee ecchymosis,
swelling
NEURO: follows commands, moves all 4 extremities, nods yes/no to
questions, CN II-XII grossly intact. 1+ DTR's B biceps, triceps,
beracioradialis, withdraws to babinski
Pertinent Results:
Admission labs:
[**Age over 90 **]|106|21 AG 12
---------<224
4.6| 22|1.0
.
10.9
11.6><155
31.8
N:90.2 Band:0 L:5.3 M:3.9 E:0.6 Bas:0.1
CK: 253 MB: 10 MBI: 4.0 Trop-T: 0.02
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Fibrinogen: 254
PT: 15.1 PTT: 36.1 INR: 1.3
ABG: 7.39/44/241
Urine Culture [**4-2**]: GRAM POSITIVE BACTERIA. 10,000-100,000
ORGANISMS/ML
Imaging:
1)CT head ([**3-31**]): No acute intracranial process. Small scalp
contusion anteriorly.
2)Cxray ([**3-31**]): 1. ET tube in satisfactory position; however, the
findings suggest overinflation of its cuff. 2. Coarse reticular
opacities at the right lung apex, raising the possibility of
aspiration pneumonitis.
3)MRI ([**4-13**]
Brief Hospital Course:
A/P: 84F PMH hypothyroidism, multiple falls, p/w respiratory
failure and bradycardic arrest, s/p paravertebral hematoma
drainage, no active issues.
1) Respiratory failure/VAP/Pneumothorax: Patient was initialy
intubated at the OSH in setting of bradycardic respiratory
arrest which per the record may have been the result of an
aspiration event. She initially looked quite good on the vent,
following commands, with good mechanics and so she was extubated
on [**4-1**]. Within 2-3 hours, she had what is presumned to be be
another respiratory event. She became hypoxic to the 20's, with
marked cyanosis, requiring an oral airway for adequate
oxygenation by ambu-mask. She was emergently intubated by
anesthesia, fiberoptically as she was still in the hard cervical
collar. After she was re-intubated, she had a CT of the neck
which showed disruption of the anterior longitudinal ligament at
the C5/6 level with large prevertebral hematoma. neurosurgery
was consulted and the patient was taken to the OR on [**4-8**] to
have the hematoma drained. She began to have infiltrates on her
CXR and copious secretions beginning on [**4-4**] suggestive of VAP.
Sputum and mini-BAL cultures were sent and eventually grew out
MRSA and S. pneumonia. Further complicating her respiratory
status she had an iatrogenic pneumothorax on [**4-5**] as the result
of a sub-clavian central line placement. Thoracic surgery was
consulted and a chest tube was placed with good resolution of
the pneumothorax. Patient has received intermittent diuresis
with lasix to improve her resp status. Patient was successfully
extubated on [**4-15**] with no complications. She had no respiratory
complications thereafter.
2) Mental status: Patient arrived to unit intubated. She
appeared to follow commands and there were no notable focal
deficits. Her mental status appeared good enough that she was
extubated on [**4-1**] and immediately after extubation she was able
to answer simple questions appropriately. After becoming
re-intubated her mental status was unclear and she was often
agitated, though sometimes following commands. A CT scan on [**4-9**]
showed a small amount of layering intraventricular hemorrhage
within the right lateral ventricle. Neurosurgery was informed
and they felt that it was not likely to be a result of her
hematoma drainage. Neurology was consulted but found it quite
difficult to assess the patient secondary to sedation. There
was some concern about decreased strength and movement on her
left side, which appears to be a new finding compared to her
exam prior to her first extubation. This finding did not seem to
persist after she moved to the floor. An MRI/MRA of the head was
performed [**4-13**] and was unremarkable for acute stroke, or mass
lesion. For much of the admission, we assumed that her dementia
was significant, and indeed on [**4-24**], psychiatry was consulted in
the setting of seeking guardianship, and formally judged the
patient to not have capacity.
.
For unclear reasons, perhaps related to resolution of pain and
discomfort, and with no clear relationship to the periodic
evidence of bacterial colonization of her urethra and Foley, her
mental status cleared to a quite lucid and well-oriented state
starting on [**5-6**], confirmed by a follow-up assessment by the
same psychiatry attending who had seen her on [**4-24**] and again on
[**4-30**]. She was mostly well-oriented, though sometimes eccentric,
after that time. She was able to consent to neurosurgery.
Additionally she made her son her healthcare proxy. We stopped
the process of pursuing guardianship.
3) Other issues of infection: Her initial leukocytosis and fever
in the MICU resolved as she was on the floor. Her diagnosis of
VAP as described above was consistent with her continued copious
secretions. Sinusitis - acute vs chronic on CT head.
Coagulase-negative S. aureus were seen from A-line cultures, but
peripheral cultures negative and all other blood cultures NGTD.
She started vancomycin, zosyn, and ciprofloxacin on [**4-4**]. Zosyn
and cipro were stopped on [**4-6**] and replaced with ceftriaxone,
continuing vanco. (see below re: rash). Ceftriaxone was then
changed because of rash the next day to levofloxacin, and she
was then on vancomycin and levofloxacin through until [**4-13**]. She
was briefly put on ciprofloxacin again for a UTI from [**5-10**] to
[**5-13**] but when quinolone resistant Citrobacter grew out we
discontinued this and changed her Foley; a subsequent urine
culture showed a small number (<5000) GNRs, likely a small
remaining colonization.
.
4)Rash: Started after patient received one dose of Ceftriaxone
on [**4-7**]. Ceftriaxone was stopped and the rash gradually
resolved. Ceftriaxone was added to her record as a drug allergy
and her antibiotics were changed to vancomycin/levofloxacin, as
above.
5) C5/6 prevertebral hematoma/disruption of the anterior
longitudinal ligament: While the patient was initially believed
to have sustained these injuries as the result of a mechnical
fall, there was some concern on the part of neurosurgery that
the injuries were out of proportion to the mechanism of injury
and there were some initial concerns re: home safety prior to
admission. This was reviewed extensively by the social work,
and legal services. After collecting additional information from
other patient's friends and family. For a time, the team was
pursuing guardianship. However, as above, the patient's mental
status eventually cleared.
.
While delirious, the patient had not wanted surgery, which went
against the advice of the medical team and therefore prompted
the question of guardianship. However, when lucid, the patient
sought surgery and in fact was quite frustrated that she could
not have it earlier than the proposed date of [**2149-5-23**].
.
Neurosurgery saw the patient as a pre-op evaluation on the [**5-22**]
and after reviewing the c-spine films, deemed that the surgery
was no longer necessary and that the patient could follow up in
clinic in 4 weeks.
.
6)Anemia: Baseline hematocrit in mid-20s. Improved with
transfusion in anticipation to OR ([**4-8**]). No signs or symptoms
of bleeding. Hemodynamically stable. Stools were guaiac negative
as well. Resolved later in admission.
.
7)Bradycardic arrest: Likely bradycardia in the setting of
aspiration/respiratory failure. Less likely acute ischemic
cardiac event; no EKG changes, cardiac enzymes elevated in the
setting of rescucitation. Low probability for PE per Well's
criteria. She was monitored on telemetry during her stay in the
MICU, and taken off telemetry on the floor. There were no
further events on the floor.
.
8)History of CVA: No residual deficits per son. Expressed as L
sided weakness. Aspirin was held. She did have an MRI which did
not suggest an acute stroke. Eventually heparin SC was restarted
on [**5-7**].
.
9)Recent falls: Unclear etiology. Unknown if mechanical,
syncopal due to neurocardiogenic/ arrythmia/ structural cardiac,
neurologic. As above, there was also the question of elder
abuse. There were no acute abnormalities on MRI/MRA brain. She
had a normal echocardiogram at [**Hospital3 **] on [**2149-3-25**]. This
may need further workup in the [**Hospital **] rehabilitation
setting.
.
10)Hyperglycemia: This was a feature of the patient's earlier
portion of her admission, and patient was placed on insulin
sliding scale and blood sugars were followed closely. Eventually
she required no sliding scale insulin for days at a time and we
d/c'ed the insulin and fingersticks. Earlier it was thought she
had underlying diabetes; our observations of her on the floor
were not consistent with this, and likely the hyperglycemia was
due to the acute stress and infections of the earlier portion of
her stay.
.
11)Fusiform aneursym of the R ICA: Neurosurgery aware; no
intervention necessary.
.
12)Hypothyroidism: Patient was continued on Levoxyl.
.
13)Nutrition: The patient was fed by NG tube with tube feeds for
the first portion of the admission. The NG tube was eventually
removed and a trial of PO was done. Speech and swallow were
consulted and did a video swallowing study on [**5-5**], and judged
her to be dysphagic and to be at significant risk were she to
take POs. With the consent and understanding of the patient, a
G-tube was placed by IR. She had some difficulty with nausea
when tube feeds were at higher rates (>40 cc/hr) but tolerated
tube feeds well. Speech and swallow was reconsulted and to have
prethickened nectars by mouth and the feeds via g-tube. They
were reconsulted again on [**5-26**] and a repeat video swallow study
allowed for her po diet to be advanced to ground solids,
prethickened nectars, and pills crushed in puree.
.
14)Fungal vaginal infection developed while in the hospital,
being treated with nystatin cream.
Medications on Admission:
aspirin 81mg daily
levothyroxine 100 mcg daily
citalopram 10mg dialy
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor
Discharge Diagnosis:
Primary Diagnosis: Respiratory Failure
Cardiac Arrest
Ventilator Associated Pneumonia
Pneumothorax
c5-6 spine instability req soft collar
Discharge Condition:
stable
Completed by:[**2149-6-12**]
|
[
"V09.0",
"839.05",
"294.8",
"599.0",
"E888.9",
"E930.5",
"482.41",
"293.0",
"244.9",
"V12.59",
"518.81",
"693.0",
"E879.8",
"482.30",
"V15.88",
"303.90",
"512.1",
"349.82",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"31.42",
"33.24",
"96.6",
"28.0",
"38.93",
"96.72",
"44.32"
] |
icd9pcs
|
[
[
[]
]
] |
12342, 12399
|
3395, 5099
|
355, 421
|
12581, 12619
|
2662, 2662
|
2013, 2037
|
12420, 12420
|
12248, 12319
|
2052, 2643
|
202, 317
|
449, 1366
|
2678, 3372
|
12439, 12560
|
5114, 12222
|
1388, 1788
|
1804, 1997
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,080
| 146,529
|
12764
|
Discharge summary
|
report
|
Admission Date: [**2168-9-13**] Discharge Date: [**2168-9-21**]
Date of Birth: [**2084-7-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Lethargy, disorientation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84M initially presented to [**Hospital1 **] ED with behavorial
changes. Pt's daughter makes daily AM visits to help pt with
bathing, feeding, etc; this morning, she noted that he was
sleepy, which is normal for him, as he is on a fentanyl patch.
Around 1 pm, a neighbor reported to her that he had been
incoherent. She
returned around 5:30 pm and found him naked, incontinent of
urine, disoriented, and lethargic. She reports increased L leg
dragging (he has some weakness at baseline) and new inability to
ambulate. Pt's BP on arrival to OSH was 164/121. CT head
demonstrated a R thalamic bleed with 3rd ventricular extension.
Past Medical History:
HTN, Afib, CAD, MI s/p ?[**5-13**] stents, renal ca s/p R
nephrectomy, aortic aneurysm s/p EVAR, bladder ca, ?C7 tumor s/p
surgery c/b Staph infections x 5 with residual LUE & LLE
weakness
Social History:
Lives alone. Ambulates with walker. Daughter has been helping
with ADLs.
Family History:
Non-contributory
Physical Exam:
On Admission:
T: 98.7 BP: 121/76 (164/121 on presentation to OSH) HR: 65 R: 20
O2Sats: 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA, EOMI, R ptosis
Neck: Supple. Large contracted scar in posterior neck.
Lungs: CTA bilaterally.
Cardiac: irregularly irregular
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, somewhat lethargic
Orientation: Oriented to person, place, and date.
Recall: [**3-8**] objects at 5 minutes.
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. 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 in L finger flexors & extensors [**3-10**], R ankle
DF
& TF [**2-11**]; otherwise [**5-10**] throughout. No pronator drift.
Sensation: Decreased proprioception, pinprick b/l LE.
Reflexes: B T Br Pa Ac
Right 2+2+2+ 1+ 1+
Left 2+2+2+ 1+ 1+
Toes upgoing on L, equivocal on R.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin, intention tremor b/l UE
Pertinent Results:
Labs on Admission:
[**2168-9-13**] 01:00AM BLOOD WBC-10.6 RBC-5.14 Hgb-14.7 Hct-45.2
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.9 Plt Ct-214
[**2168-9-13**] 01:00AM BLOOD Neuts-82.4* Lymphs-12.4* Monos-3.9
Eos-1.2 Baso-0.2
[**2168-9-13**] 01:00AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2168-9-13**] 01:00AM BLOOD Glucose-116* UreaN-27* Creat-1.8* Na-144
K-4.0 Cl-107 HCO3-24 AnGap-17
[**2168-9-13**] 01:00AM BLOOD CK(CPK)-71
[**2168-9-13**] 01:00AM BLOOD cTropnT-0.04*
[**2168-9-13**] 01:00AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.4
Labs on Discharge:
[**2168-9-21**] 05:15AM BLOOD WBC-8.9 RBC-4.07* Hgb-11.8* Hct-36.1*
MCV-89 MCH-28.9 MCHC-32.6 RDW-14.5 Plt Ct-188
[**2168-9-13**] 01:00AM BLOOD Neuts-82.4* Lymphs-12.4* Monos-3.9
Eos-1.2 Baso-0.2
[**2168-9-13**] 01:00AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2168-9-21**] 05:15AM BLOOD Glucose-89 UreaN-33* Creat-1.7* Na-143
K-4.2 Cl-113* HCO3-21* AnGap-13
[**2168-9-21**] 05:15AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.4
[**2168-9-19**] 05:45AM BLOOD Triglyc-124 HDL-29 CHOL/HD-4.7 LDLcalc-83
[**2168-9-19**] 05:45AM BLOOD %HbA1c-5.6
-----------------
IMAGING:
-----------------
Head CT [**9-13**]:
FINDINGS:
A right thalamic bleed now measures 2.1 x 2.4 cm and is slightly
decreased in size from the study approximately three hours prior
when it measured 2.2 x 2.9 cm. There is extension into the left
lateral ventricle and left side of the midline. There is again a
layering of blood products into the occipital horns bilaterally
(series 2, image 16) with a right corona radiata hypodensity
that may reflect prominent Virchow-[**Doctor First Name **] space. The right
mastoid air cells appear clear. There is some opacification on
the left, unchanged from prior. Visualized paranasal sinuses
unremarkable. There is mild perilesional edema as before. There
is no significant shift of midline structures. Ventricles,
sulci, cisterns are of normal configuration and size for age.
Basal cisterns are preserved. Periventricular white matter
changes likely reflect chronic
microvascular disease.
IMPRESSION: Overall unchanged appearance of right thalamic
intraparenchymal
hemorrhage with intraventricular extension. While this can
relate to
hypertensive hemorrhage, other etiologies like mass/vascular
cannot be
completely excluded. F/u MR [**Name13 (STitle) 430**] without and with contrast can
be considered, preferably after resolution of the hemorrhage,
based on the clinical condition.
Brief Hospital Course:
MR. [**Known lastname 39376**] is a 84 yo right handed man with a history of
hypertension and atrial fibrillation who presented with the
onset of altered mental status and found to have a right
thalamic bleed with extension into the 3rd ventricle.
# NEURO: Patient was admitted to NSURG ICU after being
transferred from OSH with newly identified right thalamic
hemorrhage with intraventricular extension. Repeat head CT was
performed and was without evidence of extension of the
hemorrhage. Given the lack of required surgical intervation, he
was transitioned to the neurology stroke service. He had repeat
head CTs, which showed stable hemorrhage. Blood pressures were
maintained with a goal SBP of <140. Neuro exam on discharge was
notable for left sided pronator drift, and slight left sided
weakness in an upper motor neuron pattern.
# Cardiovascular/Atrial fibrillation: The patient initially had
an episode of atrial fibrillation with RVR. He was started on
metoprolol for rate control. Given the location of his
hemorrhage, he is at significant risk for potentially fatal
hemorrhage, so should not be restarted on Coumadin. He can,
however, start taking a full dose aspirin for prophylaxis.
# Apnea: Mr. [**Known lastname 39376**] was noted to have periods of apnea extending
up to 30 seconds. His daughters denied any prior history of
apnea including sleep apnea. These events occurred while the
patient was sleeping and he did maintain oxygen saturation >89%
when they occurred. It was felt to be partially medication
related and all medications with possible respiratory
suppression were discontinued (except fentanyl patch, which he
had been taking at baseline). There was also concern for
central thalamic pain syndrome, for which he was started on a
low dose of gabapentin. However, this caused significant
somnolence, and was discontinued. The patient appears to be
very sensitive to any psychoactive medications, so care should
be taken to minimize their use.
Medications on Admission:
lisinopril, Lipitor, Lasix, Diovan, Duragesic 50 mcg', ASA
(2x/wk), allopurinol
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for hand pain.
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) as needed for constipation.
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Right sided thalamic hemorrhage with intraventricular extension
Discharge Condition:
Left pronator drift, and left sided weakness in an upper motor
neuron pattern. Alert, oriented to hospital but not date.
Discharge Instructions:
CALL IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Neurology follow-up:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2168-10-25**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"412",
"427.31",
"V45.82",
"401.1",
"729.89",
"V45.73",
"431",
"333.2",
"V10.52",
"414.01",
"786.03"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7986, 8131
|
5374, 7367
|
341, 347
|
8239, 8363
|
2932, 2937
|
8820, 9442
|
1329, 1347
|
7498, 7963
|
8152, 8218
|
7393, 7475
|
8387, 8797
|
1362, 1362
|
277, 303
|
3468, 5351
|
375, 1009
|
2000, 2913
|
2951, 3449
|
1704, 1984
|
1031, 1222
|
1238, 1313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,846
| 150,438
|
17909
|
Discharge summary
|
report
|
Admission Date: [**2165-6-16**] Discharge Date: [**2165-6-18**]
Date of Birth: [**2117-5-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
[**2165-6-17**] colonoscopy with epinephrine injection and clipping x 2
History of Present Illness:
48 M with PMH of B12 deficiency who presents with BRBPR s/p
colonoscopy/polypectomy 3 days ago, presents with BRBPR x3,
filling the toilet bowel otherwise asymptomatic. The patient
received a colonscopy three days prior to admission. The patient
states he had stools between the colonoscopy and his
presentation to the ED that were brown, without melena or BRBPR.
The patient was in the ED going to floor but became hypotensive
while 2nd IV was being placed to 80/40, diaphoretic, received
1.5L NS and normalized to 110/70s.
.
On arrival to the floor, the patient now complains of abdominal
cramping. Denies nausea, vomiting. No further BRBPR. Denies
melena. Denies fevers, chills, chest pain, SOB, dysuria,
hematura.
Past Medical History:
High triglycerides
High blood pressure NOS
B12 deficiency
Anemia, baseline hematocrit 36-39, likely B12 deficiency
Social History:
He is a lifetime nonsmoker. He denies alcohol or illicit drug
use. He works as a corrections officer. He lives with his wife
and three kids, three dogs, and two cats.
Family History:
Mother is 81 and has hyperlipidemia, high cholesterol, and
arthritis.
Father died at 74 from complications of Parkinson's disease,
stroke
4 siblings (three brothers and a sister, some of whom he thinks
have high blood pressure and high cholesterol).
He has three daughters who are healthy.
There is no known family history of early coronary disease,
diabetes, or
malignancies.
Physical Exam:
VS: 97.1 61 124/74 15 99%RA
GEN: NAD
HEENT: PERRL, nonicteric sclera, EOMI, OP Clear
CV: RRR no mrg
CHEST CTA b/l no mrg
ABD: +BS soft tender to palp, diffuse, focal to LLQ, no RT, no
invol guarding, no organomegaly, nondistended, rectal per ED brb
in rectal vaulat
EXT: no c/c/e
NEURO aaox3, no focal deficits
SKIN, wwp, no rashes
Pertinent Results:
[**2165-6-16**] 02:00PM PT-12.2 PTT-29.5 INR(PT)-1.0
[**2165-6-16**] 02:00PM NEUTS-55.5 LYMPHS-35.0 MONOS-4.5 EOS-4.5*
BASOS-0.6
[**2165-6-16**] 02:00PM LIPASE-41
[**2165-6-16**] 02:00PM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-62
AMYLASE-40 TOT BILI-0.4
[**2165-6-16**] 02:00PM estGFR-Using this
[**2165-6-16**] 07:55PM HCT-26.5*
.
[**2165-6-17**] COLONOSCOPY: Lower GI bleeding - A visible vessel with
an attached clot and active bleeding was found at 50 to 55 cm in
the left colon. The bleeding site was successfully treated with
epinephrine injection and endoclipping. There were multiple
large clots and liquid blood in the sigmoid colon.
.
Brief Hospital Course:
48 year old man who recently underwent routine colonscopy and
polypectomy. He returned with a 4 unit lower GI bleed which was
succesfully treated with repeat colonoscopy, epinephrine
injections, and endoclips applied to the culprit vessel.
Patient also has vitamin B12 deficiency of unclear etiology. He
was started on oral replacement therapy. It was recommended that
he have outpatient anti-intrinsic factor antibodies sent for
possible atrophic gastritis.
Medications on Admission:
Gemfibrozil 600mg [**Hospital1 **]
Vit B12 250mcg QD
.
ALLERGIES: No known drug allergies.
Discharge Medications:
1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Cyanocobalamin 1,000 mcg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Lower GI bleed
2. Anemia from acute blood loss and B12 deficiency
Secondary:
1. Hypertension
2. Hypertriglyceridemia
Discharge Condition:
Hemodynamically stable with stable hematocrit.
Discharge Instructions:
You were admitted with a bleed in your GI tract. Your
hematocrit is now stable and the source of bleeding was
stabilized.
It will be important for you to continue taking all your
medications as prescribed. You were started on vitamin B12,
which you should take each day. Please be sure to follow-up
with Dr. [**Last Name (STitle) **].
Followup Instructions:
You have the following appointment scheduled:
1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2165-6-20**] 2:30
2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Date/Time:[**2165-7-10**] 9:15
3. [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2165-7-17**]
10:50
Completed by:[**2165-6-19**]
|
[
"285.1",
"E849.0",
"V12.72",
"724.2",
"E879.8",
"401.9",
"458.9",
"272.4",
"266.2",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
3704, 3710
|
2901, 3363
|
319, 392
|
3884, 3933
|
2224, 2878
|
4320, 4760
|
1478, 1857
|
3504, 3681
|
3731, 3863
|
3389, 3481
|
3957, 4297
|
1872, 2205
|
274, 281
|
420, 1139
|
1161, 1277
|
1293, 1462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,029
| 184,132
|
52701
|
Discharge summary
|
report
|
Admission Date: [**2106-1-14**] Discharge Date: [**2106-1-18**]
Date of Birth: [**2039-2-13**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid (PF)
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 year old female with 1v CAD s/p RCA BMS in [**2102**], dilated
cardiomyopathy with improvement in EF to 55% over the last few
years with a recent exacerbation in [**12-18**], DM, Crohns,
pancreatic insufficiency who presents from cardiology clinic
today for abnormal labs. Patient was recently admitted to
medicine service with SOB and diagnosed with diastolic CHF
exacerbation although at the time BNP was in the 200 range. Over
the last month since that admission she has had total body
volume overload due to her chronic diastolic heart failure with
over 20 lb weight gain over several months. She endorses malaise
but no worsening SOB or CP. She sys the swelling is mostly in
her upper extermities, neck and head. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr.
[**First Name (STitle) 437**] have been slowly increasing her diuretic regimen to try to
combat this weight gain and recently she was switched from lasix
to torsemide 60mg with metolazone twice weekly to try to help
the symptoms.
Today she came to the cardiology clinic for IV Lasix and was
given 80mg x1 along with 40meq of potassium po. However, after
this stat labs drawn before the lasix showed hyponatremia to 118
and hypochloremia to 72. She was given salty snacks and 2 salt
packets. However, repeat stat labs showed Na 113 and Cl 69. BUN
48, Cr 2.6, K 3.2, bicarb 25. She was then referred into the
ED.
In our ED, VS: T 97.6, P 75, BP 116/88, RR 16, O2sat 96%.
Complained of malaise, flank pain with urination, and edema but
denied chest pain, seizures, mental status changes, SOB. On exam
more swelling in neck, face, shoulders than in legs and the
lungs were clear. She had no MS changes in ED and remained
hemodynamically stable. Labs in ED unchanged from clinic (Na
114 and K3.3). She received 40meq of KCl and 2 more salt tabs.
She was also fluid restricted in ED. CXR showed basilar
atelectasis. She was given percocet for flank pain in ED and
urine cultures and UA sent.
T:97.6, HR:73, BP:120/75, 16 98% on RA prior to transfer to ICU.
on arrival to the floor the patient had no acute complaints.
ROS revealed a cough for the last 1.5 weeks, productive of green
sputum, no hemoptysis. She also has had malaise and myalgias for
the same amount of time. No rhinorrhea or post nasal drip. No
other sick contacts in the home although her son had a stroke
recently and just came home from [**Hospital3 **] yesterday. no
recent travel. No chest pain, palps, sob, dysuria. Mild upper
abdominal and back pain new in the last week without change in
her bowel habits (she has occ loose stools and streaks of blood
in her stools from her chrons disease that has not changed since
being on asacol). No frothy urine, foul smelling urine, or
frequency of urination. No rashes.
Past Medical History:
1. Coronary artery disease s/p RCA w/bare metal stent on [**2102-2-2**]
(single vessel disease)
2. Diastolic CHF (Recent ECHO [**2105-10-15**], EF~55%)
3. Crohn's Disease: h/o pancolitis w/o small bowel involvement;
colonoscopy [**10-14**] showed no active disease, was on 5-[**Month/Year (2) **]
4. Chronic Renal Failure (Cr~1.4 at baseline)
5. DM Type II on insulin
6. Hypertension
7. h/o idiopathic dilated CMP, now resolved
8. Peptic ulcer disease
9. Alcoholic cirrhosis
10. GERD
11. Rheumatoid arthritis
12. Pulmonary embolus in [**2098**]
13. Total right knee replacement with subsequent chronic pain
14. [**Doctor Last Name **] mal seizure in childhood
15. Cervical disc disease
16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-
Ray with EMG consistent with mild radiculopathy
17. History of GI bleed of unclear etiology ([**2-/2103**]),
questionable hemorrhoids
18. h/o MRSA right knee wound infection s/p knee replacement
19. Anemia
20. H/o CDiff colitis ([**5-/2102**])
21. Osteopenia
22. Chronic pancreatitis
23. Cervical spndylysis
24. Candidal esophagitis X3
Social History:
Patient lives with a disabled son in [**Name (NI) 669**]. One other son
currently incarcerated. Last son recently back from rehab. She
was married but divorced a long time ago. 4 pack year smoking
history, quit 15 years ago. Drank ~1 pint alcohol/day x 10
years, quit 15 years ago. Denies illicit drug use. Ambulates
with a walker at baseline.
Family History:
Mom died of [**Name (NI) 499**] cancer. Father with DM requiring bilateral
below the knee amputation. One sister has had cervical
cancer(cured) and rheumatoid arthritis. Son with stroke 2 years
ago. Extensive family history of hypertenison.
Physical Exam:
PHYSICAL EXAM
Vitals: T:97.6, HR:73, BP:120/75, 16 98% RA weight 222lbs (dry
weight 190 per Dr.[**Doctor Last Name **] note in [**2105-12-9**])
General - pleasant african american female in NAD.
HEENT - anicteric sclera conjunctiva pink and moist. OP clear
with dry MM
Neck - obese neck, no JVD
Pulm - CTAB
Cardiac - RRR, nl S1/S2, no murmurs appreciated
Abdomen - non distended, NABS, mild TTP in the RUQ and LUQ as
well as along flanks
Ext - 2+ pitting edema BL. L knee scar [**2-10**] surgery. No pitting
edema in arms.
neuro: A+OX3
Pertinent Results:
Admission labs:
Na:118
K:3.3
Cl:69
.
Na:114 Cl:71 BUN:48 Gluc:305 AGap=16
K3.3 CO2:27 Cr:2.3
(Na 118 in clinic, 113 after salt tabs, 114 on arrival to ED,
and 118 after salt tabs in ED, 135 on [**2105-12-29**])
.
Other Urine Chemistry:
Na:52
K:26
Cl:65
Osmolal:230
WBC: 8.9 Hgb:13.7 PLT:280 HCT:38.9
N:80.1 L:14.8 M:3.9 E:0.8 Bas:0.4
PT: 13.0 PTT: 27.1 INR: 1.1
.
proBNP: 416
Imaging:
CXR:
Basilar atelectasis due to low lung volumes. No focal
consolidation or superimposed edema noted.
ECHO [**10-18**] - The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2104-1-15**],
there is no significant change
Brief Hospital Course:
# Hyponatremia: Patient presented to cardiology clinic with a Na
of 118, then received diuretics and dropped to 114 pointing
towards hypovolemic hyponatremia. BNP in the ED was 400 and has
h/o BNPs in 1000 range with exacerbation in the past, making
hypervolemic hyponatremia less likely etiology. Was bolused
with 500 cc doses of normal saline, with gradual increase in her
Na content. She was transferred from the ICU to the general
medical floors, and continued to improve with small 500 cc NS
boluses. For the last 2 days prior to discharge, no boluese
were given. She was restarted on her torsemide prior to
discharge with communciation with her outpatient cardiologist
Dr. [**First Name (STitle) 1255**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Recommendations were made to discontinue metalozone, as this
most likely exacerbated her hyponatremia. Sodium at discharge
was 131. Should have CMP followed up as outpatient.
Additionally, assess for signs of heart failure given cessation
of metolazone.
# Influenza like illness: complained of cough, headache, and
general malaise. Had rapid influenza test which was negative.
Was having sputum production with slight yellow tinge. CXR
showed likely atelectasis and not pneumonia. Cultured sputum
which was initially positive for gram positive cocci in pairs
and clusters as well as rare GNR's. Empirically started on CAP
treatment with ceftraixone and azithromycin, but speciations
came back as MRSA. Given lack of severity in clinical
presentation, felt this represented colinization rather than a
MRSA pneumonia, and antiboitic therapy was discontinued. White
count remained WNL and patient remained afebrile while on the
general medical floors.
Provided with cepachol for sore throat and
guanifesin-dextromethorphan for cough. Blood cultures were
still pending at time of discharge. Should evaluate for
resolution of respiratory symptoms at followup.
# Acute on Chronic renal failure - baseline 1.4-2.0. Had
elevations in creatinine to 2.7. Prerenal in etiology, improved
with hydration. Discharged at baseline creatinine of 1.5.
Should consider checking renal function within three months to
assess for interval change.
# Flank Pain: Complaining of constant chronic flank/back pain.
On exam was isolated to lower back region in the lumbosacral
area. Does have history of L/S disc disease, and may be related
to obesity in the presence of disc pathology. Did not seem
renal in nature given lack of CVT and unrevealing urine studies.
Was provided with Percocet for pain control with control of
symptoms. No imaging studies were persued in house. Had CT
abdomonial imaging in [**8-/2105**] that showing diverticulosis without
significant abdominal pathology, but was without IV contrast and
could not appropriately assess for abscess or pyelonephritis at
that time. If continues to have flank pain, may consider repeat
imaging.
# Chronic Diastolic Heart Failure - ECHOs from past showed
compromised EF, but has resolved with EF of >55% in 10/[**2105**].
Held further diuresis while in the hospital, but was continued
on carvedilol. Placed back on torsemide 60 mg qday prior to
discharge. Assess for signs of heart failure at follow up, as
metalozone was discontinued.
# Crohn's disease - stable disease state continued home regimen
of asacol
# CAD/HTN - continued on [**Year (4 digits) **], statin, carvedilol and fish oil.
Felodipine was discontinued while hospitalized as had episode
sof lower extremity swelling that was felt to be more secondary
to felodipine use rather than heart failure exacerbation.
Reassess blood pressure at follow up.
# DM - insulin-dependant. Continued insulin glargine 40 U qhs as
well as SSI for blood glucose control.
# Chronic pain (left flank/back/right knee)- continuded
lidocaine patch, neurontin
renally dosed, and percocet Prn with oxycontin 20 mg, as well as
home diazepam. Should reassess pain assessment needs and affirm
patient has narcotics contract if necessitating prolonged
narcotic use.
# History of GERD- discontinued omeprazole as past therepeutic
interval for PPI dosing. Should reassess GERD symptoms and
resume if returns.
# History of pancreatic insufficiency: continued pancreatic
enzyme supplementation without issues.
PENDING LABS AT DISCHARGE: Blood Cultures
TRANSITIONAL ISSUES:
# Code - full confirmed
# Communication with sister [**Name (NI) **] [**Telephone/Fax (1) 108729**]
Medications on Admission:
MEDS AT HOME:
Coreg 25mg [**Hospital1 **]
Dextromethorphan-guaifensin 100mg-10mg/5mL [**1-10**] tsp Q6H PRN
Diazepam 5mg [**Hospital1 **] PRN for pain/spasm
Felodipine 5mg daily
Folate 1mg daily
Gabapentin 600mg [**Hospital1 **]
Lantus 40units Sc QHS
Lidocaine patch
Zenpep 20K-68K-109K unit capsules (4 capsule TID with meals, 2
capsules with snacks)
Asacol 1600mg TID
metolazone 5mg Sundays and thursdays
Nitro SL PRN
Omeprazole 20mg daily
Percocet 5-325mg Q6H PRN pain
simvastatin 20mg daily
torsemide 60mg daily
Tylenol Q6H PRN
[**Hospital1 **] 325mg daily
Colace 100mg [**Hospital1 **]
Vit D2 800units daily
Iron 325mg TID
Glucosamine-chondroitin 250-200 TID
OMega 3 fish oil 1000mg [**Hospital1 **]
Senna [**Hospital1 **] PRN
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain or spasm: Do not take while driving or
operating heavy machinery; do not drinka lcohol while taking
this medication.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day.
6. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on/ 12 hours off applied to knee.
8. lipase-protease-amylase 20,000-68,000 -109,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO once a day: 4 capsules by mouth three times a
day with meals/ 2 capsules with snacks.
9. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN: 1 tablet sublingulally every 5-10 minutes up to
3x as needed for chest pain.
11. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO q6h PRN as needed for pain.
13. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
21. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Outpatient Lab Work
Please check BMP
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY: hyponatremia
.
SECONDARY:
Chronic c heart failure
Coronary artery disease
Crohn's Disease
Renal Failure (Cr ~1.4 to 2.0 at baseline).
Diabetes Mellitus Type II
Hypertension
Idiopathic dilated CM - improved to normal EF~55% ([**12-18**])
Hx of Peptic ulcer disease.
Alcoholic cirrhosis.
Gastroesophageal Reflux Disease
Rheumatoid arthritis.
Total right knee replacement with subsequent chronic pain.
Cervical/Lumbosacral disc disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 108723**],
You were admitted to the hospital with very low sodium levels.
You were initially admitted to the intensive care unit for
close monitoring of your sodium levels. Your levels corrected
with intravenous fluid rehydration. You were transferred to the
general medical floors, and your sodium levels conitnued to
improve without much more fluids. It was determined your low
sodium was from over-diuresis.
.
In addition to the low sodium, you had general malaise and a
cough for several days. We initially started you on
antibiotics, but after further analysis of your lab tests, felt
your symptoms were not from a pneumonia but most likely from a
virus. If your symptoms worsen or do not improve within the
next week, you should follow up with your primary care doctor.
.
We have been in touch with your cardiologists, and some of your
home medications have been changed:
.
METOLAZONE 2.5 mg Thurs/Sundays----> STOP TAKING THIS
MEDICATION
OMEPRAZOLE 20 mg -----> STOP TAKING THIS MEDICATION
FELODIPINE 5 MG-----> STOP TAKING THIS MEDICATION (possibly
causing worsening swelling)
.
Please continue to take the rest of your home medications as
directed.
*Carvedilol 12.5 mg Tab 2 Tablets orally 2x a day (cardiac
medication to slow down your heart rate)
*Torsemide 20 mg 3 Tablets by mouth daily (diuretic/aka "water
pill")
*Asprin 325 mg by mouth once a day (cardiac medication)
*Mesalamine 400 mg Tablet Four (4) Tablets, orally 3 times a
day (for Crohn's Disease)
*Lipase-protease-amylase 20,000-68,000 -109,000 unit Capsule,
Delayed Release(E.C.) 4 capsules by mouth three times a day
with
meals/ 2 capsules with snacks. (for pancreatic insufficiency)
*Simvastatin 10 mg Tablet 2 tablets at night (for cholesterol)
*Omega-3 fatty acid 1 Capsule orally 2 times a day (for
cholesterol)
*Insulin Glargine 40 U at night
*Dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup 5 ML
orally every 6 hours as needed for cough.
*Diazepam 5 mg Tablet 1 Tablet by mouth 2 times a day as needed
for
pain or spasm: Do not take while driving or operating heavy
machinery; do not drink alcohol while taking this
medication.
*Folic acid 1 mg Tablet 1 Daily
*Gabapentin 600 mg Tablet 1 Tablet orally twice a day.
*Lidocaine 5 %(700 mg/patch) Topical DAILY 12 hours on/ 12
hours off
applied to knee as needed for pain.
*Nitroglycerin 0.4 mg Tablet, Sublingually as needed every [**5-18**]
minutes up to 3x as needed for chest pain.
*Oxycodone 20 mg Tablet Sustained Release 12 hr orally every 12
hours
Do not operate heavy machinery while taking this medication.
Do not
drink alcohol while on this medication.
*Oxycodone-acetaminophen 5-325 mg Tablet 1 orally every 6hrs
as
needed for pain. Do not operate heavy machinery while taking
this
medication. Do not drink alcohol while on this medication.
*Ferrous sulfate 325 mg 1 Tablet orally 1 time a day
*Cholecalciferol (vitamin D3) 400 unit Tablet 2 orally daily
*Bisacodyl 5 mg Tablet 2 Tablets daily as needed for
constipation.
*Senna 8.6 mg Tablet 1-2 Tabs by mouth at night as needed for
constipation
*Docusate sodium 100 mg Capsule by mouth 2 times a day (stool
softener)
.
.
Regarding your heart failure, weigh yourself every morning, and
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
.
It has been a pleasure taking care of you Ms. [**Known lastname 108723**]!
Followup Instructions:
Please keep the following appointments below.
.
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2106-1-26**] at 10:20 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5808**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2106-1-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], 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: PAIN MANAGEMENT CENTER
When: MONDAY [**2106-2-1**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: RHEUMATOLOGY
When: MONDAY [**2106-5-10**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"487.1",
"403.90",
"571.2",
"585.2",
"584.9",
"518.0",
"V43.65",
"577.8",
"276.8",
"428.32",
"714.0",
"555.1",
"250.00",
"425.4",
"428.0",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14171, 14228
|
6578, 10886
|
298, 305
|
14714, 14714
|
5425, 5425
|
18279, 19658
|
4609, 4853
|
11825, 14148
|
14249, 14693
|
11069, 11802
|
14865, 18256
|
4868, 5406
|
10941, 11043
|
246, 260
|
10905, 10920
|
333, 3115
|
5441, 6555
|
14729, 14841
|
3137, 4225
|
4241, 4593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,639
| 179,535
|
27469
|
Discharge summary
|
report
|
Admission Date: [**2191-7-18**] Discharge Date: [**2191-7-23**]
Date of Birth: [**2119-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2191-7-18**] Mitral Valve Repair (28mm annuloplasty band and
quadrangular resection)
History of Present Illness:
71 y/o male with known coronary artery disease with increased
symptoms (dyspnea on exertion and chest tightness) who was
referred for cardiac cath. During cath he was found to have
severe mitral regurgitation and was then referred for surgical
intervention.
Past Medical History:
Coronary Artery Disease s/p LAD stent x 2 [**2184**], Hyperlipidemia,
B cell lymphoma s/p chemi/XRT and mediastinoscopy
Social History:
Auditor. Quit smoking 30 yrs ago (30ppy hx), [**4-9**] glasses
wine/wk.
Family History:
non-contributory
Physical Exam:
VS: 55 17 137/53 6'1" 113.4kg
HEENT: EOMI, PERRL, NCAT, OP benign
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR +murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+pulses
throughout
Neuro: MAE, A&O x 3, non-focal
Pertinent Results:
Echo [**7-18**]: PRE-BYPASS: The left atrium is mildly dilated.
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the
descending thoracic aorta. There is no aortic valve stenosis.
Mild to moderate ([**2-7**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
are myxomatous. There is moderate/severe mitral valve prolapse.
Moderate to severe (3+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. POST CPB: Preserved
biventricular systolic function. Posterior leaflet has been
resedted, and there is an annuloplasty ring in mitral position.
Trace MR and no evidence of dynamic LVOT obstruction. No other
change in valve structrue or function.
CXR [**7-22**]: Prior right internal jugular catheter has been
removed. No pneumothorax. There has been general overall
improvement with residual bilateral pleural effusions, greater
on the left side and associated atelectasis. I doubt the
presence of consolidation. A small amount of residual
postoperative gas is demonstrated along the anterior chest wall.
[**2191-7-18**] 03:30PM BLOOD WBC-10.7 RBC-3.04* Hgb-9.9* Hct-28.1*
MCV-92 MCH-32.6* MCHC-35.4* RDW-13.2 Plt Ct-146*
[**2191-7-20**] 01:41AM BLOOD WBC-11.5* RBC-2.48* Hgb-8.0* Hct-22.8*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.3 Plt Ct-144*
[**2191-7-22**] 07:35AM BLOOD WBC-9.6 RBC-2.46* Hgb-7.8* Hct-22.5*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.8 Plt Ct-213
[**2191-7-23**] 04:45AM BLOOD Hct-29.3*#
[**2191-7-18**] 05:08PM BLOOD PT-14.8* PTT-36.4* INR(PT)-1.3*
[**2191-7-20**] 01:41AM BLOOD PT-13.6* PTT-31.2 INR(PT)-1.2*
[**2191-7-18**] 05:08PM BLOOD UreaN-13 Creat-0.8 Cl-112* HCO3-24
[**2191-7-22**] 07:35AM BLOOD Glucose-108* UreaN-19 Creat-0.7 Na-136
K-4.3 Cl-98 HCO3-32 AnGap-10
[**2191-7-21**] 06:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.2
[**2191-7-20**] 08:30AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2191-7-20**] 08:30AM URINE RBC-[**4-10**]* WBC-0-2 Bacteri-MANY Yeast-FEW
Epi-0-2
Brief Hospital Course:
Mr. [**Known lastname 62132**] had his pre-operative work-up done as an outpatient
and was a same day admit for surgery. On 6.12 he was brought to
the operating room where he underwent a Mitral Valve repair
utilizing a Annuloplasty band and quadrangular resection. Please
see operative report for surgical details. He tolerated the
procedure well and was transferred to the CSRU in stable
condition for invasive monitoring. Later on op day he was weaned
from sedation, awoke neurologically intact and was extubated. On
post-op day one his chest tubes and Swann-Ganz catheter was
removed. He was weaned off of Inotropes on post-op day two and
was started on beta blockers and diuretics. He was gently
diuresed towards his pre-op weight during his hospital course.
Later on this day he was transferred to the cardiac surgery
telemetry floor. On post-op day three his epicardial pacing
wires were removed. He continued to make steadily clinical
improvements without complications post-operatively. Although he
did require several blood transfusions secondary to anemia with
a low HCT. Physical therapy followed patient during entire
post-op course and he was discharged home with VNA services and
the appropriate follow-up appointments on post-op day 5.
Medications on Admission:
Atenolol 25mg qd, Lisinopril 5mg qd, Lipitor 10mg qd, Aspirin
325mg qd, Plavix 75mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair
PMH: Coronary Artery Disease s/p LAD stent x 2 [**2184**],
Hyperlipidemia, B cell lymphoma s/p chemi/XRT and
mediastinoscopy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 8506**] Follow-up appointment should
be in 2 weeks
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**] Follow-up appointment should be
in 1 month
Completed by:[**2191-8-11**]
|
[
"401.9",
"V10.79",
"V45.81",
"424.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6048, 6097
|
3449, 4701
|
293, 382
|
6310, 6316
|
1220, 1874
|
6615, 6890
|
917, 935
|
4838, 6025
|
6118, 6289
|
4727, 4815
|
6340, 6592
|
950, 1201
|
234, 255
|
410, 669
|
691, 812
|
828, 901
|
1884, 3426
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,949
| 183,721
|
44232
|
Discharge summary
|
report
|
Admission Date: [**2162-8-27**] Discharge Date: [**2162-8-31**]
Date of Birth: [**2092-11-9**] Sex: M
Service: CARDIOLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
male with a history of SVT diagnosed six years ago basically
presenting now with chest pain and an elective
catheterization with a history of reversible defects in his
inferior territory on a stress test in [**Month (only) **] of this year
and an EF of 55%. His catheterization showed a 50% proximal
RCA stenosis, 99% mid RCA stenosis. Two stents were placed
upon admission on the day of admission on [**2162-8-27**].
In the post catheterization area, the patient developed
systolic blood pressures down into the 70s. His crit dropped
from 41 to 38. A CT scan done immediately following the crit
drop revealed a moderate to large hematoma. An ultrasound of
the groin revealed no AV fistula or pseudoaneurysm. In the
CCU, the patient was hemodynamically stabilized. His crit
ultimately dropped to a nadir of 31. He was transfused 1
unit of packed red blood cells and his crit stabilized to
around 33 to 34.
The patient remained asymptomatic with no chest pain, no
dizziness, and no shortness of breath.
PHYSICAL EXAMINATION ON TRANSFER FROM THE CCU TO THE FLOOR:
Vital signs: Temperature 98.4, blood pressure 101/71, heart
rate 95, respirations 18, saturating 93% on room air.
General: He was lying in bed in no acute distress, breathing
comfortably. HEENT: He had moist mucous membranes, no JVD.
The neck was supple. Chest: Fine crackles at the base.
Cardiac: Regular rhythm with a II/VI systolic murmur at the
left sternal border. Abdomen: Nontender, nondistended,
bowel sounds active. Extremities: He had no cyanosis, 1+
deep dorsalis pedis pulses bilaterally. He had 1+ edema
bilaterally in the lower extremities. Neurologic: No gross
deficits.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Parkinson's disease.
ADMISSION MEDICATIONS:
1. Toprol XL 25 once a day.
2. Trihexyphenidyl 4 mg in the morning, 2 mg in the
afternoon, 2 mg before bed.
3. Mirapex 1.5 mg three times a day.
4. Sinemet 5/200 twice a day.
ALLERGIES: The patient has no known drug allergies.
LABORATORY/RADIOLOGIC DATA ON TRANSFER: White count 13,
stable, crit 33.4 which was stable. Coagulations were within
normal limits. The Chem-7 was within normal limits. His
troponin was 0.34, down from previous value in the CCU of
0.45. His CK was 136 which was down a bit from previous
value in the CCU of 172.
HOSPITAL COURSE: The patient is a 69-year-old patient with a
history of CAD, status post two stents placed on the day of
admission in his proximal and RCA basically now presenting
with a complication post catheterization, retroperitoneal
hematoma initially treated in the CCU with 1 unit of packed
red blood cells now being transferred out to the floor. His
crit is stable in the low 30s. The plan was to continue him
on his current medications including aspirin, Lipitor,
Plavix, Toprol, continue to monitor his hematocrit for a
couple more days to make sure that it was going to stabilize
in the low 30s and continue his regular Parkinson's
medications.
The patient received a PT evaluation on the second day of
transfer from the CCU. He was essentially cleared by PT who
felt that he was safe to ambulate. By hospital day number
five, the patient remained with a stable hematocrit and
stable vital signs and was discharged home in good condition.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Retroperitoneal hematoma.
3. Parkinson's disease.
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg twice a day.
2. Plavix 75 mg once a day.
3. Aspirin 325 mg once a day.
4. Atorvostatin 20 mg once a day.
5. Nitroglycerin 0.3 mg as needed.
6. Pramipexole 0.75 mg three times a day.
7. Sinemet 50/200 mg twice a day.
8. Trihexyphenidyl 4 mg twice a day.
9. Famotidine 20 mg twice a day.
FOLLOW-UP PLANS: The patient is going to follow-up with Dr.
[**First Name (STitle) **] [**First Name (STitle) **] within one week.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 3809**]
MEDQUIST36
D: [**2162-10-15**] 01:50
T: [**2162-10-16**] 17:52
JOB#: [**Job Number 94884**]
|
[
"285.1",
"998.12",
"411.1",
"414.01",
"272.4",
"458.2",
"332.0",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"36.07",
"37.23",
"88.56",
"96.49",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
3638, 3956
|
3530, 3615
|
2542, 3509
|
1972, 2524
|
3974, 4332
|
1897, 1949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,099
| 173,756
|
4344
|
Discharge summary
|
report
|
Admission Date: [**2200-5-28**] Discharge Date:
Service: CARDIAC SURGERY
Date of discharge is pending; awaiting rehabilitation bed.
CHIEF COMPLAINT: New onset exertional angina and positive
stress test.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
male who started to experience progressive exertional angina
a couple months ago. He had been having midsternal chest
pain after routine activities or after walking one block.
Symptoms resolved with rest. He had a stress test on
[**2200-5-24**], which is positive. He was admitted to the Cardiac
Medicine service to undergo cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Remote history of stomach ulcer fifty years ago.
3. Prostate cancer, status post radiation therapy five years
ago.
4. Diabetes mellitus.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg q.d.
2. Amaryl 2 mg q.d.
3. Lopressor 25 mg b.i.d.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**2200-5-28**], which showed severe three vessel
disease. Cardiac surgery consultation was obtained at this
point and decision for surgery was made. The patient
underwent a coronary artery bypass graft times two on
[**2200-5-30**], with left internal mammary artery to left anterior
descending, and saphenous vein graft to OM. He was
transferred to the CSRU postoperatively. He was extubated on
postoperative day one. He was hemodynamically stable and
doing well.
Later on [**2200-6-2**], he was transferred to the regular floor.
About three hours after coming out of the Intensive Care
Unit, the patient developed atrial fibrillation with a rapid
rate in the 130s and blood pressure in the 80s. He was given
intravenous fluids and transferred back to the Intensive Care
Unit for further hemodynamic management. He was started on
Neo-Synephrine to maintain his blood pressure and given
Lopressor to control his heart rate.
Over the next few days, he slowing improved. Postoperative
day six, he was deemed stable to transfer to the floor. He
was complaining of some sternal misalignments. A chest x-ray
was obtained which showed the wires in good position and some
well aligned. He is otherwise doing very well. His pacing
wires were discontinued on postoperative day seven. He is
ambulatory with support. He is now ready for discharge to a
rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Tylenol 650 mg p.o. q4hours p.r.n.
4. Amiodarone 400 mg q.d.
5. Amaryl 2 mg q.d.
6. Regular insulin sliding scale.
CONDITION ON DISCHARGE: Good.
FOLLOW-UP: Primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], in two
weeks and with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2200-6-7**] 09:35
T: [**2200-6-7**] 10:55
JOB#: [**Job Number 18791**]
|
[
"250.00",
"427.31",
"997.1",
"414.01",
"285.9",
"458.2",
"401.9",
"780.09",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"37.22",
"88.53",
"39.61",
"36.15",
"88.56",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
2387, 2569
|
839, 911
|
929, 2361
|
162, 217
|
246, 629
|
651, 813
|
2594, 3084
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,115
| 152,540
|
53017
|
Discharge summary
|
report
|
Admission Date: [**2105-12-22**] Discharge Date: [**2105-12-28**]
Date of Birth: [**2034-4-20**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Iodine; Iodine Containing / Shellfish
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
71M with CAD s/p CABG [**10/2105**], CHF (EF 30%), frequent admits for
CHF exacerbation who was transferred from the [**Hospital1 1516**] service with
hypertensive emergency. He initially presented to the ED after
acute SOB on [**12-22**] while at rest. He states he was lying on his
couch with his feet up when he became acutely SOB. He denies
associated chest pain. He sat up and felt slightly better. He
denies recent dietary indiscretion, med change, or med
noncompliance. He reports 2lb weight gain, occasional mid-chest
tightness with exertion at baseline. After 30 minutes, his
symptoms had not improved so he called EMS. EMS reports BP
240/110, HR 72, and O2sat 100% on NRB, with labored breathing.
He received 40mg IV Lasix en route to the ED. In the ED, his BP
was 209/103, O2sat 93% on RA, c/o headache, no respiratory
distress. EKG with no evidence of ischemia. He was started on
NTG drip and given IV enalapril 1.25mg IV. His BP improved to
175/101. He also received ASA 325mg and percocet x 2. He was
admitted to [**Hospital1 1516**]. On the floor his BP was 130s/60s. He was taken
for L and R heart cath to evaluate his grafts. In the cath lab,
his grafts, including LIMA-LAD, SVG-RCA, and SVG-OM1, were
patent. His L subclavian artery and stent were patent. Her R
renal artery had 60% stenosis with no significant stenosis.
During the case, his BP was 190s-220s/110s-120s. He received NTG
300mcg bolus + drip, fentanyl 25mcg, versed 0.5mg, Lasix 20mg
IV, and heparin 1000U IV. R heart cath showed PCWP of 31. He was
transferred to the CCU for management of hypertensive emergency
and CHF exacerbation.
.
Currently, he continues to complain of headache. He denies chest
pain, shortness of breath, confusion, back pain, abdominal pain.
His femoral arterial sheath was pulled at 4pm.
Past Medical History:
Coronary artery disease s/p CABG [**10/2105**] (LIMA->LAD; SVG to OM2;
SVG to PDA)
Type II diabetes mellitus
Hypertension
Cardiomyopathy (EF 30-35%)
Post-CABG atrial fibrillation with recent Holter that showed no
atrial fibrillation
Hypercholesterolemia
Pseudogout
Peripheral [**Year (4 digits) 1106**] disease s/p lower extremity artherectomy
Tobacco use
prior TIA [**2091**]
s/p R CEA [**12/2102**]
s/p stenting of R brachiocephalic to subclavian
Social History:
Has not smoked since CABG, although has a significant smoking
history (at least 100 PYs). There is no history of alcohol abuse
and he denies illicit substance use. He is retired and
previously worked selling men's clothing. He is divorced and
lives alone.
Family History:
His brother had CABG 2 years ago and also smoked. Mother and
sister with breast cancer. He has 3 children, no history of
breast cancer in them. His son had gynecomastia with onset at
age 12, which required surgical excision
Physical Exam:
T 95.0, BP 196/104, HR 69, RR 11, O2sat 92% 2LNC, I/O [**Telephone/Fax (1) 109284**]
General: NAD, appears comfortable, lying in bed HOB 30deg,
speaking in full sentences
HEENT: PERRL, EOMI, dry MM
Neck: JVP ~9cm, no bruits
CV: PMI nondisplaced, RRR, 2/6 systolic murmur at RUSB
RESP: breath sounds decreased at both bases, rales 1/3 up b/l
Abd: +BS, soft, NT, ND, no masses
Ext: trace BLE edema, 2+ DPs on right, 1+ DP on left
Neuro: A&Ox3, CNs III-XII intact to challenge, strength 5/5
UEs/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l, sensation intact to LT throughout
Pertinent Results:
Admission Labs:
GLUCOSE-176* UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
.
CK(CPK)-70 CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier **]*
.
WBC-10.2 RBC-3.69* HGB-11.4* HCT-33.2* MCV-90 MCH-30.8 MCHC-34.3
RDW-15.8*
NEUTS-70.7* LYMPHS-20.9 MONOS-5.3 EOS-2.8 BASOS-0.3 PLT
COUNT-282
.
PT-12.0 PTT-24.6 INR(PT)-1.0
.
Cardiac Cath [**2106-12-23**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated LMCA and 3 vessel native coronary artery disease.
The LMCA
had severe diffuse disease with heavy calcification. the LAD had
proximal 90% stenosis with heavy clacification. The distal
vessel had
competitive flow from [**Female First Name (un) 899**]. The LCX was a non-dominant vessel
that was
occluded proximally. The RCA was a dominant vessel and was
occluded
proximally. The SVG-OM1 was patent without lesions. The SVG-RCA
was
patent without lesions. The LIMA-LAD was patent.
2. The LSCA had no demonstrable gradient across the proximal
stent which
was difficult to engage. Non-selective [**Female First Name (un) 899**] angiography
demonstrated no
critical lesions in the LSC or the origin fo the [**Female First Name (un) 899**].
3. Right renal artery angiography demonstrated 60% lesion that
did not
have significant gradient with vasodilator therapy.
4. Resting hemodynamics were performed. The right sided filling
pressures were mildly elevated (mean RA pressure was 9mmHg and
RVEDP was
14mmHg). The pulmonary artery pressures were elevated measuring
54/16mmHg. The left sided filling pressures were elevated (mean
PCW
pressure was 31mmHg and LVEDP was 36mmHg). The systemic arterial
pressures were significant elevated measuring 198/86mmHg. The
cardiac
index was reduced measuring 2.1 l/min/m2. There was no
significant
gradient across the aortic valve upon pull back of the catheter
from the
left ventricle to the ascending aorta.
FINAL DIAGNOSIS:
1. LMCA and native 3 vessel coronary artery disease.
2. Patent LIMA-LAD, SVG-OM2 and SVG-PDA.
3. Elevated left and right sided filling pressures.
4. Depressed cardiac index.
5. Non-hemodynamically significant right renal artery stenosis.
.
Head CT [**2105-12-24**]:
FINDINGS: There is no hemorrhage, mass effect, or shift of
normally midline structures. There is no evidence of infarction.
Low attenuation in the periventricular white matter is
consistent with chronic microvascular infarction and was seen on
[**2107-1-4**]. However, a right caudate lacunar infarction is
also old. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is a new linear calcification in the region of the right
middle cerebral artery within the sylvian fissure. The
visualized paranasal sinuses are clear. The bones are
unremarkable.
IMPRESSION:
1. No evidence of hemorrhage or mass effect. No evidence of
infarction. Note that MRI with diffusion-weighted imaging is
more sensitive.
2. New linear area of calcification along the right middle
cerebral artery in the region of the right sylvian fissure.
While this may represent atherosclerosis, an underlying aneurysm
should be suspected. Correlation with CT angiography is
recommended for further evaluation.
.
[**2105-12-26**] MRI/A:
FINDINGS, BRAIN MRI:
There are several areas of slow diffusion identified in the
brain. These areas are small and noted in the right posterior
frontal, left frontal subcortical, right occipital subcortical,
and left medial occipital cortical regions indicative of small
acute infarcts. Location in both cerebral hemispheres suggests
embolic event. There is mild-to-moderate brain atrophy and small
vessel disease seen in the periventricular and subcortical white
matter. A chronic small right cerebellar infarct is identified.
There is no mass effect or midline shift seen.
IMPRESSION: Several small cortical and subcortical areas of slow
diffusion indicative of acute infarcts.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. No evidence of [**Month/Day/Year 1106**]
occlusion or high-grade stenosis seen. There is no evidence of
aneurysm visualized at the site of calcifications seen on CT.
However, on susceptibility-weighted images, a subtle low-signal
intensity seen in this region indicating presence of the CT-
demonstrated calcification. This calcification could be due to
calcification in the vessel wall or a calcified plaque or a
calcified embolus.
IMPRESSION: No evidence of [**Month/Day/Year 1106**] occlusion or stenosis seen
on MRA of the head.
Brief Hospital Course:
A/P: 71M with hx of CAD s/p CABG, CHF (30%) transferred to the
CCU with hypertensive emergency and CHF exacerbation.
.
# Hypoglycemia: Had 1 episode of symptomatic hypoglycemia
(confusion, headache, jaw and arm numbness) to 32 after getting
his home morning doses of insulin. Symptoms resolved with
improvement in glucose. Insulin dosage was moderately decreased
and he had no further episodes of hypoglycemia. He was sent
home on [**12-29**] prior outpatient dose, with close follow up with PCP
and suggested possible co-managment with [**Last Name (un) 387**].
.
# Hypertensive emergency: Unclear etiology as patient denies med
noncompliance and dietary indiscretion, and renal artery
stenosis does not appear to be significant enough. Was initially
treated with nitro drip, but now on all oral medications (added
clonidine 0.2 [**Hospital1 **], imdur 30mgQD, norvasc 10mg QD) and controlled
to 100-130 systolic. He had headaches associated with high blood
pressures (above 160 systolic), with nausea and vomiting that
resolved with control of BP. Head CT was negative for acute
process, but showed linear opacification thought to be MCA
atherosclerosis, confirmed by MRA.
We simplified BP management with Enalopril 40mg QD, Imdur 30 QD,
Toprolol XL 75mg QHS, lasix 40mg QD, Amlodipine 10mg QHS.
.
# CHF: H/o both systolic and diastolic dysfunction with EF
30-35%, likely ischemic cardiomyopathy. History c/w acute
pulmonary edema, likely [**1-29**] hypertension. No h/o dietary
indiscretions, no medication noncompliance. He ruled out for MI
with no EKG changes to suggest new ischemic event, 3 sets
cardiac enzymes with flat CKs and troponin very mildly elevated.
Appears euvolemic at discharge. Continue ACE-i, lasix 40 QD.
.
# CAD: h/o CAD s/p 3v CABG [**09**]/[**2104**]. pMIBI two weeks ago revealed
only fixed defects. EKG with no evidence of acute ischemia. CE
x3 with flat CKs and very mildly elevated troponin. Cath
revealed patent grafts. Continued ASA, betablocker, statin.
.
# Rhythm: H/o perioperative Afib, subsequent Holter monitor with
no recurrence. Currently in NSR. Did have several small runs of
NSVT and in combination with low EF he should have outpatient
follow-up with repeat echo in 6 weeks for risk stratification
for ICD placement. He has follow up with [**Doctor Last Name **] on [**2105-1-6**].
.
# Type II DM: (see hypoglycemia) Had episode of low BS. Cut
home regimen of NPH/regular insulin by half. Continued [**Doctor First Name **] diet.
.
# ARF: Cr was up and down during admission. Had slight bump in
bun/cr likely secondary to diruesis (to early for contrast
nephropathy). He received mucomyst before and after cath, but no
hydration secondary to CHF exacerbation. On day of discharge
slightly dry. Will follow up with PCP in the next week.
.
# Small Embolic strokes: Found small ?embolic subacute embolic
strokes on MRI. Not likely cause of above neuro symptoms.
Thought to be embolic showers likely secondary to cardiac cath
on the [**12-23**].
.
# Confusion: Likely sundowning as it seems to usually occur in
the evenings. Appears to correlate with rise in BP, likely as
preceding event rather than effect from BP. Was treated with
seroquel QHS while in the hospital.
Medications on Admission:
metoprolol 37.5mg [**Hospital1 **]
ASA 81mg qd
hexavitamin qd
Regular 12units QAM, 4units QPM
NPH 30units QAM, 14units QPM
Ranitidine 150mg [**Hospital1 **]
Enalapril 40mg qd
lipitor 10mg qd
lasix 40mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. insulin
Your insulin dosage has been changed.
please take:
NPH: 15u at breakfast and 7u at dinner
Regular insulin: 6u at breakfast and 2u at dinner
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CHF
CAD s/p CABG
Hypertensive emergency
Diabetes
Hypoglycemia
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, call your doctor:
chest pain, shortness of breath, weakness, nausea, vomiting,
weight gain.
.
You need to see a cardiologist for follow up. Please call Dr.
[**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7236**] to make a follow up appointment
within the next 2 weeks.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 1300**] on tuesday morning [**2105-12-29**] and make a follow up
appointment to see her sometime next week. She should refer you
to an appointment at [**Last Name (un) **] Diabetes Center for diabetes
control, as you has problems with your blood sugars during your
hospital course.
.
Please call Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7236**] to make a follow
up appointment within the next 2 weeks.
.
You have the following appointments:
1) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2106-1-6**] 1:00
.
2) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2106-1-18**] 10:00
.
3) Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2106-3-9**] 3:00
|
[
"712.30",
"428.0",
"250.80",
"272.0",
"V12.59",
"414.01",
"285.9",
"440.1",
"440.20",
"427.89",
"V45.81",
"425.4",
"275.49",
"402.91",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
13250, 13308
|
8388, 11609
|
343, 358
|
13414, 13421
|
3795, 3795
|
13810, 14889
|
2947, 3172
|
11865, 13227
|
13329, 13393
|
11635, 11842
|
5736, 7709
|
13445, 13787
|
3187, 3776
|
284, 305
|
386, 2185
|
7726, 8365
|
3811, 5719
|
2207, 2658
|
2674, 2931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,432
| 166,813
|
2326
|
Discharge summary
|
report
|
Admission Date: [**2148-1-23**] Discharge Date: [**2148-1-26**]
Service: MEDICINE
Allergies:
Pravachol
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 year-old male with a history of ESRD on HD (M/W/F), DM, CAD
who presents with hyperkalemia. The patient last HD session was
yesterday ([**2148-1-22**]). He was called by his outpatient dialysis
unit after being found to be hyperkalemic. He reports aches in
his "bones" everywhere, but denied chest pain, palpitations,
SOB, nausea, vomiting or other complaints.
.
In the ED, 98.2 72 185/86 17 99%. His potassium on admission was
7.4. He was given 1g calcium gluconate, 1 amp D50, 10U Regular
insulin 50mEQ Bicarb and kayexalate 30g. The patient's ECG
showed mildly peaked t-waves. Repeat potassium was 7.3 then 6.5.
The patient was evaluated by Nephrology in the ED. He did not
have a BM in the ED.
.
On arrival to the ICU the patient was initiated on HD. He had
complaints of "body pains," but denied fevers, chills, SOB, URI
symptoms, feeling sick or other complaints. The Spanish
interpreter was called, but the patient was unable to hear the
interpreter over the phone. The patient's history was based on
patient interview and prior history obtained via interpreter in
the ED.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, headache,
rash or skin changes.
Past Medical History:
#DM type II- insulin dependent; HbA1c 6.2 in [**2145**]
#ESRD (m,w,f dialysis dependent @ [**Location (un) **]): A1C 6.8
#HTN
#Hyperlipidemia
#CAD s/p MI
#h/x osteo L heel/foot
#PVD- s/p angioplasty of the left anterior tibial
peroneal,tibioperoneal trunk and posterior tibial arteries on
[**2145-9-14**]
Surgical History:
#avf [**9-18**]
#arteriogram gram [**9-18**]
#s/p r bka [**2143**]
#L AKA [**2145**]
Social History:
Originally from [**Male First Name (un) 1056**]. Lives with his wife. Retired
[**Name2 (NI) **]. Tob: smoked for 15 years approx 3-4packs per day; quit
50yrs ago. EtOH: h/o abuse, no longer drinks. Illicits: denies
use. Pt lives with wife and daughter. [**Name (NI) **] three daughters and
four sons. Is from [**Male First Name (un) 1056**], moved to US 45 or 46 years ago.
.
Family History:
Strong family history of diabetes. Father died from
complications of diabetes. Denies hx of heart disease or cancer.
Physical Exam:
GEN: no acute distress
HEENT: PERRL, dry MM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/ b/l BKA
GENITAL: uncircumsized, retracted foreskin showed 1cmx0.5cm
ulcer with yellowish/clear discharge. Painful to touch. left
inguinal hard nodules, immobile
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities. non-focal
Pertinent Results:
[**2148-1-23**] 06:10PM BLOOD WBC-11.2*# RBC-3.89* Hgb-11.9* Hct-39.3*
MCV-101* MCH-30.6 MCHC-30.3* RDW-15.6* Plt Ct-175
[**2148-1-26**] 06:35AM BLOOD WBC-8.4 RBC-3.44* Hgb-10.2* Hct-33.3*
MCV-97 MCH-29.7 MCHC-30.6* RDW-15.8* Plt Ct-186
[**2148-1-23**] 06:10PM BLOOD Neuts-79.3* Lymphs-12.3* Monos-3.9
Eos-4.1* Baso-0.4
[**2148-1-23**] 06:10PM BLOOD PT-11.9 PTT-25.1 INR(PT)-1.0
[**2148-1-23**] 06:10PM BLOOD Glucose-168* UreaN-49* Creat-7.1*# Na-143
K-7.4* Cl-100 HCO3-30 AnGap-20
[**2148-1-24**] 03:41AM BLOOD Glucose-100 UreaN-24* Creat-4.7*# Na-145
K-4.8 Cl-101 HCO3-34* AnGap-15
[**2148-1-26**] 06:35AM BLOOD Glucose-92 UreaN-49* Creat-7.1*# Na-143
K-4.6 Cl-97 HCO3-33* AnGap-18
[**2148-1-23**] 06:10PM BLOOD CK(CPK)-82
[**2148-1-23**] 06:10PM BLOOD CK-MB-NotDone
[**2148-1-23**] 06:10PM BLOOD cTropnT-0.25*
[**2148-1-24**] 03:41AM BLOOD Calcium-9.1 Phos-4.0# Mg-1.9
[**2148-1-26**] 06:35AM BLOOD Calcium-8.0* Phos-5.8* Mg-1.9
[**2148-1-23**] 6:35 pm SEROLOGY/BLOOD ADDED AT ACC #68751M -
[**2148-1-23**].
RAPID PLASMA REAGIN TEST (Final [**2148-1-25**]):
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Preliminary): SENT TO STATE.
TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE.
[**2148-1-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-1-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
Time Taken Not Noted Log-In Date/Time: [**2148-1-24**] 11:59 am
SWAB SOURCE:URETHRAL.
**FINAL REPORT [**2148-1-25**]**
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
[**2148-1-25**]): Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final [**2148-1-25**]): Negative for Neisseria Gonorrhoeae by
PCR.
Time Taken Not Noted Log-In Date/Time: [**2148-1-24**] 11:59 am
SWAB SOURCE:URETHRAL.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Virus isolated so far.
[**2148-1-24**] 2:11 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab INFLUENZA A/B BY DFA INCLUDED
IN RAPID
RESPIRATORY VIRAL SCREEN AND CULTURE..
**FINAL REPORT [**2148-1-27**]**
Respiratory Viral Culture (Final [**2148-1-27**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2148-1-25**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2148-1-25**] 5:15 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
Source: glans penis.
**FINAL REPORT [**2148-1-26**]**
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
[**2148-1-26**]):
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
No specimen received for viral culture.
Radiology Report CHEST (PA & LAT) Study Date of [**2148-1-23**]
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac,
mediastinal and hilar
contours are within normal limits. The lungs are clear. The
pulmonary
vascularity is normal. No pleural effusion or pneumothorax is
seen.
Multilevel degenerative changes are redemonstrated in the
thoracic spine.
IMPRESSION: No acute cardiopulmonary abnormality.
Cardiology Report ECG Study Date of [**2148-1-23**] 6:01:52 PM
Sinus rhythm. Left axis deviation with left anterior fascicular
block.
Compared to the previous tracing of [**2147-8-2**] there is diffuse
peaked T waves
suggestive of hyperkalemia. Clinical correlation is suggested.
Cardiology Report ECG Study Date of [**2148-1-24**] 4:09:16 AM
Sinus rhythm. Compared to tracing #1 diffusely peaked T waves
have somewhat
improved.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2148-1-26**]
IMPRESSION: Aspiration with thin barium. Mild-to-moderate
residual in the
valleculae and piriform. Delay in oral phase of swallow with
premature spill
seen into the valleculae and piriform sinuses.
Brief Hospital Course:
#. Hyperkalemia: The patient was found to have an elevated
potassium of 7.4. He received calcium, insulin/glucose, bicarb
and kayexalate in the ED. ECG showed peaked t-waves. Pt
otherwise asx except for muscle aches. Patient underwent
emergent dialysis in the MICU but it remained unclear as to why
he is hyperkalemic. He denied dietary changes. On HD 2 his
hyperkalemia resolved and he was restarted on his M,W,F dialysis
schedule.
.
#. Penile Ulcer: Patient found to have a single painful ulcer on
exam with associated inguinal adenopathy. An RPR was reactive
but treponemal specific antibodies are pending result as these
were sent to the state lab. HSV and GC/Chlamydia were negative.
Urology was consulted and they concluded that the lesion could
be consistent with carcinoma but that this should be evaluated
as an outpatient. Dermatology was also consulted and they will
see the patient as an outpatient and biopsy the lesion. Given
the patient's (+) RPR he was treated for primary syphilis
empirically with IM penicillin G.
.
#. Leukocytosis: Patient with WBC of 11.2 and low grade fever on
admission. CXR showed no acute process. Influenza swab and
cultures were negative. Leukocytosis resolved.
.
#. Aspiration: Patient was seen by S&S and underwent video
swallow study to evaluate for aspiration and this revealed that
he was aspirating thin liquids. His wife, who is his primary
care taker, was informed of this result and explained how to
prevent this by thickening thin liquids.
.
#. HTN: Patient's home metoprolol was continued and lisinopril
was initially held given hyperkalemia. After hyperkalemia
resolved lisinopril was re-started. BP was well controlled.
Medications on Admission:
ASPIRIN 81mg daily
Lantus 13U daily
LISINOPRIL 10mg daily
METOPROLOL SUCCINATE - 50 mg daily
EPOETIN ALFA [EPOGEN] 13200U three times a week
SEVELAMER HCL 800mg TID
NEPHROCAPS daily
OXYCODONE-ACETAMINOPHEN 2 tabs TID:prn
BISACODYL - 5 mg qweek prn
DOCUSATE SODIUM [**Hospital1 **]
FERROUS SULFATE - 325 mg (daily
SENNA - 8.6 mg [**Hospital1 **]
ALPRAZOLAM - 0.25 mg qhs:prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 7923**] ([**Numeric Identifier 7923**]) units
Injection three times a week.
5. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO three times a day as needed for pain.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a week as needed for
Constipation.
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 for Constipation.
11. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Insulin Glargine 100 unit/mL Solution Sig: Thirteen (13)
units Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hyperkalemia
Penile Ulcer
ESRD
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted because you had high potassium in your blood
after hemodialysis. We treated you with medications and emergent
hemodialysis in the intensive care unit and this resolved. On
physical exam you were found to have and ulcer on you penis. We
sent some test that suggested you have syphilis but confirmatory
tests are still pending. We treated you for syphilis regardless.
You will need to have a biopsy of the lession to evaluate the
possibility of cancer.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2148-1-30**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2148-2-2**]
11:00
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20,575
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18542
|
Discharge summary
|
report
|
Admission Date: [**2146-12-2**] Discharge Date: [**2146-12-13**]
Date of Birth: [**2089-11-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male
with history of pulmonary artery disease and known lung
cancer with brain metastasis, who presented to the Medical
Center on [**11-24**] with complaints of intermittent
episodes of bilateral arm pain with exertion and at rest over
the past month. Pain is relieved by sublingual
nitroglycerin. He underwent cardiac catheterization on
[**11-24**], which showed an ejection fraction of 45%, 30%
left main lesion, 90% LAD lesion, 100% circumflex lesion, and
90% RCA lesion, and it was totally occluded in the mid
portion.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] of Cardiology referred the patient to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] of Cardiothoracic Surgery in the setting of
brain metastasis and the question of the risk of bleeding
during Heparinization and go on cardiac bypass of surgery.
Dr. [**Last Name (STitle) **] of Neurology also has to evaluate this situation.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Lung cancer with brain metastasis.
3. Seizure approximately one month ago.
4. Hypercholesterolemia.
5. Status post surgical hernia repair.
SOCIAL HISTORY: Patient was a one pack a day smoker for 40
years and had minimal use of alcohol.
ALLERGIES: He had no known drug allergies.
MEDICATIONS AT TIME OF EXAMINATION:
1. Imdur 90 mg p.o. q.d.
2. Diltiazem CD 240 mg p.o. q.d.
3. Hydrochlorothiazide 12.5 mg p.o. q.d.
4. Toprol XL 75 mg p.o. q.d.
5. Dexamethasone 4 mg t.i.d.
6. Dilantin 300 mg q.h.s.
7. Aspirin 81 mg p.o. q.d.
8. Nystatin swish and swallow as needed.
9. Doxycycline 100 mg b.i.d. p.o. x5 days.
10. Ativan q.h.s. prn.
11. Darvocet prn.
PHYSICAL EXAMINATION: On exam, the patient did complain of
worsening distance vision, no dysphagia. He did also state
that he had shortness of breath with angina, no palpitations,
and heartburn since he had been on steroids, no melena, or
hematochezia. He had no nocturia. He did state that he had
bilateral lower extremity weakness at the end of the day with
right greater than left, no known varicosities, and histories
of CVA or TIA. His lungs were clear on examination. His
HEENT exam was benign. Heart was regular, rate, and rhythm
without any murmurs, rubs, or gallops. He had positive bowel
sounds with benign abdominal examination. He had no
clubbing, cyanosis, or edema. He was right-hand dominant.
He is alert and oriented times three, and neurologically
appeared to be grossly intact. He had palpable PT and radial
artery pulses, but dorsalis pedis pulses are by Doppler.
His white count was 21.6, hematocrit 42.7, platelet count
321,000. Sodium 140, potassium 3.8, chloride 103, bicarb 26,
BUN 19, creatinine 0.5, with a blood sugar of 103, ALT 109,
AST 16, alkaline phosphatase 45, total bilirubin 0.2. PT
12.9, PTT 24.2 with an INR of 1.1.
Dr. [**Last Name (STitle) **] ordered a MRI and the Cardiac team is waiting for
the results to assist in assessing the bleeding risk of the
metastases and to determine whether or not he was a surgical
candidate for coronary vascularization.
He was examined by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Cardiology, who
assessed his MRI results and allowed Dr. [**Last Name (STitle) 70**] to proceed
with bypass surgery.
On [**12-2**], the patient underwent off-pump coronary
artery bypass grafting x1 with a mediastinal lymph node
dissection upon the discovery of enlarged nodes when his
chest was open, and the patient also had intra-aortic balloon
pump placed in the operating room for hemodynamic
instability. The single bypass was a saphenous vein graft to
the LAD. Please refer to the operative report. Consultation
during was also obtained during Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] of Thoracic
Surgery.
He is transferred to Cardiac ICU in stable condition on a
nitroglycerin drip at 0.5 mcg/kg/minute and titrated
propofol.
The note from postoperative day one appears to be missing
from the chart. On postoperative day two, the patient was
doing fairly well, had to restart his Neo-Synephrine over the
prior evening due to some hypotension. He was in sinus
rhythm in the 90s with a blood pressure of 98/55 at the time
of exam, and in the morning was on a Neo-Synephrine drip at 1
mcg/kg/minute. He was satting 93% on 2 liters nasal cannula.
He had decreased airway movement with left greater than
right. His heart was regular, rate, and rhythm. His balloon
was removed with no evidence of any groin hematoma. Chest
tubes remained in place. He was making good urine with
diuresis and was transfused 2 units of packed red blood cells
for a hematocrit of 25.1.
On postoperative day two, his white count was 17.4 with a BUN
of 13 and creatinine of 0.4.
On the 26th, the patient was reintubted during the evening
for hypoxemia with a pO2 of 47 secondary to thick and copious
tracheobronchial secretions. He was bronched at the same
time in the unit which showed nonpurulent thick secretions
and no collapse of his airways. He also required a chest
tube placement for right sided pneumothorax and he had
received 2 units of packed red blood cells the day prior.
His hematocrit rose to 31.1. He was on a esmolol drip at
150, nitroglycerin at 1, Neo-Synephrine at 2, and propofol.
He remained intubated and sedated. Was sinus rhythm in the
80s on the esmolol drip with a blood pressure of 120/64.
He was bronched again on the [**12-5**] for copious
mucoid secretions in the left upper lobe, lingula, and left
lower lobe. The right airways were clear. He was seen by
Case Management also for evaluation on the 27th and the
Clinical Nutrition team for support.
On postoperative day four, he was started on Levaquin due to
his heavy lung secretions and remained on a Fentanyl drip
with Neo-Synephrine at 1.75. His Dilantin had been
restarted, and the patient continued on Plavix and Lopressor.
He was in sinus rhythm in the 70s with a blood pressure of
116/58, stable BUN and creatinine at 15 and 0.4, hematocrit
of 29.9. His white count dropped slightly to 15. He was
stable and off the esmolol drip, but continued to require
Neo-Synephrine. The plan was to try and D/C his Swan after
extubation, and he continued with good diuresis and his Lasix
was turned off.
He was also seen by Neurology for followup on the 28th. The
patient did have some symptoms of right leg, arm, and face
weakness and right foot numbness with a likely ACA stroke or
hemorrhage in the left parasagittal metastatic lesion. They
recommended a followup MRI brain to look for stroke or
bleeds. Please refer to the report.
On the 28th, the patient was unable to move his right leg
when out of bed and he had right arm weakness which was
noted. Please refer to the Neurology consult note.
On postoperative day five, again it was noted that the right
lower extremity paresis, no improvement on the morning of
postoperative day five with a blood pressure of 94/54. He
was satting 96% on 2 liters nasal cannula. His lungs were
clear bilaterally. His heart was regular, rate, and rhythm.
His right lower extremity had 0/5 strength compared to full
strength in his left lower extremity, but was grossly intact
to sensation. Incisions were clean, dry, and intact with his
sternum being stable. His white count dropped to 10.9 and
his hematocrit, BUN, and creatinine remained stable also.
The head CT that was repeated showed a 3 cm mass in the
posterior aspect of his left frontal lobe with no evidence of
acute hemorrhage and a small amount of surrounding edema.
Please refer to the final CT report. He continued on his
beta blocker and antibiotics, and was diuresing well. He
continued to be monitored by the Neurology Stroke service.
On postoperative day six, he continued on decadron. He was
slightly tachycardic at 106. He also continued with his
Levaquin, Plavix, and Dilantin as per prior days. His right
sided paresis with increased weakness continued. He was also
seen by Neurosurgery, who recommended continuing his IV
decadron and Dilantin, and patient was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
about the possibility of having surgery to remove the
metastatic lesion in his brain, which was discussed with the
patient.
On postoperative day seven, his right toes had some movement.
His left apical pneumothorax was stable. His lungs were
clear bilaterally with faint breath sounds. He did have
flexion in his right toes, but no strength in his right leg.
His Lopressor was increased to 100 t.i.d. to bring his heart
rate down from 102. His Foley was pulled with continuing
good output and he was transferred to [**Hospital Ward Name 121**] 2, where he was
evaluated by a physical therapist, and he was transferred to
[**Hospital Ward Name 121**] 2 on the [**12-9**].
He was seen daily by the Stroke Service with noted
improvement on the 31st in his right facial droop and his
right upper extremity arm weakness now increased to [**5-14**] for
strength. His right lower extremity was unchanged and he was
only able to wiggle his toes.
Throughout the day the goal continued to getting his Dilantin
therapeutic and he continued on his IV decadron therapy.
Physical Therapy continued to work with him. On
postoperative day nine, he continued to move his toes. He
was hemodynamically stable. His lungs were clear. Incisions
were clean, dry, and intact. He continued with Physical
Therapy and Occupational Therapy to improve the movement on
the right side of his body. He remained in sinus rhythm. He
was using his incentive spirometer, and was seen again by the
Case Management team. He had a bone scan performed on the
evening of the 3rd, on postoperative day 10. He was alert
and oriented. Talking about his desire to go home, he had a
stable blood pressure. His BUN was 11, creatinine 0.5 with a
K of 3.9, hematocrit of 29.2. His white count was stable at
13.8.
He had an approximately [**4-14**] right leg strength. He continued
to improve slightly. A bone scan was to be done for
completion of his Oncology workup and starting to plan for
his discharge. He was also seen by the social worker on the
3rd, and was recommended by Neurology that he continue with
his outpatient Physical Therapy and noted his slowly
improving right leg flaccidity. The plan was for the patient
to go home with VNA on the 4th.
On postoperative day 10, he was down 4 kg. His heart rate
was 100 in sinus rhythm with a blood pressure of 99/60 and
was satting 95% on room air. He was alert and oriented times
three. He had right lower extremity paresis. His lungs were
clear bilaterally. His heart was regular, rate, and rhythm.
His abdominal examination was benign as was his extremity
examination other than the right lower extremity with limited
motor function, but continued improvement from the week
prior. Please refer to the final Radiology report of his
bone scan.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Dilantin 200 mg p.o. t.i.d.
4. Metoprolol 100 mg p.o. b.i.d.
5. Decadron 4 mg q.i.d.
6. Percocet 5/325 1-2 tablets p.o. prn q.4h. for pain.
FOLLOW-UP INSTRUCTIONS: He was instructed to followup with
Dr. [**Last Name (STitle) 50948**] of Neurosurgery this week, and to see Dr. [**Last Name (STitle) 7047**]
or Dr. [**Last Name (STitle) 6700**] in [**3-14**] weeks and to make an appointment for
followup with his cardiac surgeon, Dr. [**Last Name (STitle) 70**] at six weeks
and to see Dr. [**Last Name (STitle) 50949**] in [**3-14**] weeks.
DISCHARGE DIAGNOSES:
1. Status post off-pump coronary artery bypass grafting x1.
2. Lung cancer with brain metastases.
3. Seizures.
4. Hypercholesterolemia.
5. Right sided paresis.
DISCHARGE STATUS: Patient was dislocation to home with VNA
services on [**2146-12-13**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2147-1-24**] 09:22
T: [**2147-1-27**] 07:14
JOB#: [**Job Number 50950**]
|
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"934.1",
"411.1",
"518.5",
"997.01",
"198.3",
"518.0",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"88.72",
"96.05",
"96.71",
"36.11",
"40.29",
"37.61",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
11784, 12335
|
11147, 11360
|
1870, 11124
|
158, 1138
|
11385, 11763
|
1160, 1331
|
1348, 1847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,112
| 161,990
|
44978
|
Discharge summary
|
report
|
Admission Date: [**2172-9-12**] Discharge Date: [**2172-10-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
mental status changes, hypoxia
Major Surgical or Invasive Procedure:
colonoscopy
TEE guided cardioversion
intubation X 3
bronchoscopy
central line placement (right internal jugular)
History of Present Illness:
86 yo F with MMP including [**First Name3 (LF) 1291**] (on coumadin), afib, colon cancer
s/p resection, multiple C diff infections, recurrent Klebsiella
UTI, who presented to [**Hospital1 18**] on [**9-12**] with tachypnea, tachycardia
and low grade temp. Per ED chart, pt was felt to have mental
status changes at her NH and was 85% on 2L by nc. She was
transferred to the [**Hospital1 18**] ER for evaluation of her hypoxia. In
the ED, 85% RA which improved to 100% on NRB and blood pressure
91/59. A RIJ was placed emergently for access and she was
transferred to the medical ICU for further management of
hypoxia.
Past Medical History:
1) AF - has h/o of afib w/ RVR, on coumadin
2) colon cancer s/p colectomy in [**5-7**] - no XRT or chemotherapy
3) C-diff, recurrent - d/c [**2172-8-18**] w/ 2nd bout, to complete 4 wk
course, last dose to be [**2172-9-19**]
4) recurrent pseudomonas UTI's
5) anemia
6) [**Last Name (LF) 1291**], [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] - on coumadin, goal INR 2.5 to 3.5
7) infrarenal AAA - per [**Doctor First Name **], not surgical candidate; last U/S
during [**9-6**] admission found size increased to 5.1cm (from 4.5 in
[**5-6**])
8) s/p repair of type I aortic dissection
9) CAD s/p CABG
[**76**]) CRI
11) s/p R TKR
Social History:
Came from rehab (had been at [**Hospital1 882**] from [**9-2**] - [**9-9**]). Former
food service director, previously lived with her children in
[**Location 1268**]. No ETOH/tobacco/drugs.
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission
T 97.5, Tm 99.1, BP 88/63, HR 94, RR 22, sats 97% on 3L
Gen - Pleasant elderly female in NAD. Answers questions
appropriately, flat affect.
HEENT - PERRL, EOMI, sclera anicteric. Dry MM. OP clear, no
exudates or erythema.
Neck - Unable to assess JVP 2/2 RIJ in place.
Chest - Coarse upper airway sounds, but no wheezing.
CV - Irreg irreg, normal S1, audible click. No murmurs.
Abd - Soft, nontender, minimally distended, with normoactive
bowel sounds
Back - [**Name8 (MD) **] RN report, multiple stage II ulcers on her sacrum
and coccyx.
Extr - No c/c. + edema, but nonpitting. 2+ DP, radial pulses
bilaterally.
Neuro - AAO x3 (month and year). Moves all 4 extremities.
Skin - No rash.
Pertinent Results:
Laboratory studies on admission:
[**2172-9-12**]
WBC-10.5 RBC-4.06 HGB-11.3 HCT-35.6 MCV-88 RDW-16.9 PLT
COUNT-177
NEUTS-75.8 LYMPHS-20.6 MONOS-3.4 EOS-0.1 BASOS-0.1
PT-19.1 PTT-28.7 INR(PT)-1.8
GLUCOSE-111 UREA N-24 CREAT-1.0 SODIUM-140 POTASSIUM-5.3
CHLORIDE-104 TOTAL CO2-32
CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.0
CK(CPK)-30 cTropnT-0.05 CK-MB-NotDone
LACTATE-1.4
Radiology:
[**9-12**] Head CT without contrast: Extensive periventricular and
deep white matter hyperdensities in the right hemisphere
associated with ex vacuo dilatation of the right lateral
ventricle and prominence of the sulci on the right; these
findings most likely represent sequela of old ischemic infarcts
[**9-12**] CXR: Moderate cardiomegaly with bilateral pleural effusions
moderate congestive heart failure. Left lower lobe atelectasis
versus underlying pneumonia.
[**9-17**] Transthoracic echocardiogram: The left atrium and right
atrium are moderately dilated. Moderate global left ventricular
hypokinesis with EF 30-35%. Mildly dilated right ventrical with
depressed systolic function. Aortic prosthesis is well-seated.
Trivial MR, moderate TR, mild pulmonary artery systolic
hypertension.
[**9-18**] Abdominal ultrasound: 5-cm abdominal aortic aneurysm for
which inclusion of renal arteries cannot be excluded.
Cholelithiasis. Small ascites and bilateral pleural effusions.
Large bilateral simple renal cysts.
[**9-24**] transesophageal echocardiogram: No intracardiac thrombus
seen. Prosthetic aortic valve appears normal. Moderately
depressed ejection fraction.
Brief Hospital Course:
This 86 year old female w/ [**Month/Year (2) 1291**], colon CA s/p colectomy,
recurrent C. diff was initially admitted to the medical ICU
[**2172-9-12**] with hypoxia due to a CHF exacerbation and low grade
fever attributed to a urinary tract infection (multi-drug
resistent Klebsiella). She was transferred to the general
medical floor [**9-13**], but returned to the ICU [**9-14**] with maroon
stools and hypotension. Colonoscopy [**9-15**] showed >20 non-bleeding
polyps and an ulcer at her colonic anastomotic site. The patient
was transfused with blood, the rectal bleeding stopped, and her
hematocrit stabilized. She was intubated twice while in the
intensive care unit- [**9-19**] due to a CHF exacerbation and [**9-29**] for
mucus plugging/pneumonia. MICU course also notable for lower
extremity cellulitis (resolved following 7 days of vancomycin),
congestive heart failure (EF 30%-35% from 65% earlier this year,
requiring dobutamine drip, digoxin, and gentle diuresis), atrial
fibrillation (s/p TEE cardioversion [**9-25**], atrial fibrillation
recurred), and intermittent hypotension attributed to SIRS in
the setting of pneumonia/urinary tract infection as well as
congestive heart failure. At the time of transfer to the general
medical floor on [**10-5**], she had completed a 4 week course
metronidazole for recurrent C. diff (started prior to admission)
and a 14 day course of meropenem for a Klebsiella UTI. At the
time of transfer, she was on vancomycin/Zosyn/metronidazole for
MRSA pneumonia. On the evening of [**10-5**], she became progressively
less responsive, followed by a PEA arrest that progressed to
asystole. Resuscitative efforts (intubation,
epinephrine/atropine, transcutaneous pacing) were unsuccessful
and the patient died at 7:03 p.m. Her family (at the bedside)
were notified and declined autopsy.
Medications on Admission:
flagyl 500 mg PO tid - last dose on [**9-19**] (4 wk course for C
diff)
megace 400 mg PO tid
questran 1 pkt PO QD
protonix 40 mg PO qd
lopressor 12.5 mg PO tid
celexa 20 mg PO qd
lasix 80 mg PO qd
iron sulfate 325mg PO QD
effexor XR 37.5 mg PO qd
dorzolamide 1 drop OU TID
acetaminophen 650mg PO q6 prn
lactobacillus 2tab PO TID
coumadin 3 mg PO qd
digoxin 0.125mg PO qd
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Primary: systolic congestive heart failure
Secondary: lower gastrointestinal bleed, acute blood loss
anemia, urinary tract infection, bacterial pneumonia,
cellulitis, atrial fibrillation
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2172-10-6**]
|
[
"482.41",
"E912",
"584.5",
"585.9",
"518.81",
"V43.65",
"578.9",
"285.1",
"038.9",
"008.45",
"997.4",
"682.6",
"995.92",
"562.10",
"273.8",
"V45.81",
"V10.00",
"V09.91",
"427.31",
"428.41",
"599.0",
"707.03",
"V58.61",
"785.51",
"933.1",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.69",
"88.72",
"38.93",
"96.34",
"96.04",
"96.6",
"89.64",
"45.23",
"96.72",
"99.07",
"99.04",
"00.17",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6548, 6631
|
4291, 6127
|
293, 407
|
6861, 7022
|
2714, 2733
|
1947, 1965
|
6652, 6840
|
6153, 6525
|
1980, 2695
|
223, 255
|
435, 1054
|
2747, 4268
|
1076, 1724
|
1740, 1931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,059
| 198,015
|
43542
|
Discharge summary
|
report
|
Admission Date: [**2127-7-24**] Discharge Date: [**2127-8-7**]
Date of Birth: [**2051-3-25**] Sex: F
Service: MEDICINE
Allergies:
Gabapentin
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
CVL placement
HD line placement
History of Present Illness:
76yo F with h/o ILD on pred, recent PNA tx w/ ertapenem and
vanco, CVA, COPD (on 4L), CRI, CAD, DMII, Breast Ca p/w from
pulm clinic with decreased mental status. She was found to have
no O2 left in her tank. She recieved O2 and improved. She
states that she hasn't been feeling well past few days.
Reporting increase cough, productive of sputum that she states
is intermittently bloody. Increased SOB and lower extremity
swelling. +CP since this AM, intermittent, substernal, pressure
like, nonradiating. No diaphoresis. No fever, chills.
.
In VS: 97.6 82 91/58 20-30 95% (on non-rebreather). Physical
exam was notable for guaiac pos, brown stool. Labs were notable
for hct 31 (hct 37), Cr at baseline 2.2, Trop elevated to 0.12,
BNP [**Numeric Identifier 30501**] (without baseline), and blood cx were sent. She
underwent an EKG which showed NSR at 91, NA/NI, TWI in III, AVF,
V3-V5 (new changes). CXR which showed increased interstitial
opacities acute on chronic changes, ? PNA. She was given
ceftriaxone and azithro, lasix, and ASA. She was seen by
cardiology who recommeded that given pain free, with no ST
elevations, no need for cath or further intervention at this
time--> agree with admit to MICU, will follow if requested by
inpatient team. admitted for altered mental status. Vitals prior
to transfer 99.4 80 110/63 18 96% 4L. Access: PIV 20g left.
Past Medical History:
-interstitial lung disease with worsening DOE recently started
on prednisone
- hx of Breast cancer, stage I, status post lumpectomy and XRT
in [**2124**] on brief aromatase inhibitors
- type 2 DM
- hypertension
- GERD
- history of CVA [**2118**] on Plavix.
- CAD
- PVD
- Chronic renal insufficiency
- Hyperlipidemia
- COPD
- Depression
- Spinal stenosis
- Degenerative joint disease
- H/o back surgery
- H/o bilateral knee replacements
- H/o neck surgery
- s/p femoral angioplasty
- Osteoarthritis
- Obesity
Social History:
She lives alone in an apartment. She has a homemaker help her
clean but she does her own cooking and some of her shopping.
Her son helps her with shopping and paying bills. She performs
all other ADLs and administers her own medications. She walks
with a cane but thinks she may need to use a walker.
# Tobacco: Previously smoked 1 PPD for 30 years but quit 6 years
ago
# Alcohol: Used to drink up to a pint every few days, but has
not had alcohol in several years.
# Drugs: Denies drug use.
Family History:
Siblings with blood clots. A sister with breast cancer. Family
members with diabetes.
Physical Exam:
Admission Physical Exam:
Vitals: T: 96.3 BP:103/65 P:89 R:27 18 O2:94% 4L
General: mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles and end expiratory wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs at admission:
[**2127-7-24**] 03:30PM BLOOD WBC-8.5 RBC-3.29* Hgb-11.1* Hct-31.8*
MCV-97 MCH-33.8* MCHC-34.8 RDW-15.4 Plt Ct-118*
[**2127-7-24**] 03:30PM BLOOD Neuts-74.7* Lymphs-19.6 Monos-3.7 Eos-1.6
Baso-0.3
[**2127-7-24**] 03:30PM BLOOD PT-13.2 PTT-19.6* INR(PT)-1.1
[**2127-7-24**] 03:30PM BLOOD Glucose-200* UreaN-39* Creat-2.2* Na-133
K-3.8 Cl-96 HCO3-25 AnGap-16
[**2127-7-24**] 10:05PM BLOOD ALT-30 AST-46* LD(LDH)-544* CK(CPK)-120
AlkPhos-93 TotBili-0.2
[**2127-7-24**] 03:30PM BLOOD cTropnT-0.12* proBNP-[**Numeric Identifier **]*
[**2127-7-24**] 10:05PM BLOOD Albumin-2.9* Calcium-8.8 Phos-4.0 Mg-1.4*
[**2127-7-28**] 04:26AM BLOOD Vanco-7.5*
[**2127-7-24**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-7-26**] 09:08PM BLOOD Type-ART Temp-36.2 Tidal V-400 PEEP-10
FiO2-80 pO2-68* pCO2-44 pH-7.36 calTCO2-26 Base XS-0 AADO2-465
REQ O2-78 Intubat-INTUBATED Vent-CONTROLLED
[**2127-7-24**] 03:42PM BLOOD Glucose-186* Na-132* K-3.6 Cl-95*
calHCO3-27
B/L LENIS
INDICATION: A 76-year-old female with hypoxic respiratory
failure and
hemoptysis, history of lower extremity DVT, evaluate for
interval clot
formation.
COMPARISON: Bilateral leg ultrasound [**2127-7-27**].
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
Occlusive thrombus is again seen within the posterior tibial
veins of the left
calf. These veins do not compress and do not show vascular flow.
Note is
made that the left peroneal veins could not be identified.
Normal flow, compression, and augmentation is seen in the
remainder of the
deep veins of the left leg and all of the veins of the right
leg.
IMPRESSION: Persistent clot in the left posterior tibial veins.
No
progression of the clot is identified and the remainder of the
deep vessels
bilaterally demonstrate no DVT.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2127-7-31**] 8:23 AM
CT head
INDICATION: Question stroke with right facial droop; assess for
intracranial
hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the
brain.
COMPARISONS: None available.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, or
major vascular territorial infarction. THE [**Doctor Last Name 352**]-white matter
differentiation
is preserved. Mild ventricular and sulcal prominence is
compatible with
age-related atrophy. There is no shift of normally midline
structures. There
is extensive atherosclerotic calcification of the carotid
siphons.
There is no fracture. The imaged paranasal sinuses and mastoid
air cells
demonstrate right-sided maxillary, sphenoid, and ethmoid air
cell mucosal
thickening.
IMPRESSION:
1. No acute intracranial process; note that MR is more sensitive
than CT for
assessing for acute ischemic infarction.
2. Bifrontal cortical atrophy and mild sequelae of chronic small
vessel
ischemic disease, as on the MR examination of [**2120-2-7**].
COMMENT: This was discussed with Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) **] at 2:25
a.m. on
[**2127-7-30**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 815**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2127-7-30**] 10:57 AM
TTE [**7-29**]
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color
Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Small LV cavity.
RIGHT VENTRICLE: Dilated RV cavity.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Suboptimal
image quality as the patient was difficult to position.
Suboptimal image quality - ventilator.
Conclusions
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The left
ventricular cavity is small. The right ventricular cavity is
dilated
[**7-28**] TTE
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 2.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.6 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.3 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.43
Mitral Valve - E Wave deceleration time: *282 ms 140-250 ms
TR Gradient (+ RA = PASP): *60 mm Hg <= 25 mm Hg
Findings
This study was compared to the report of the prior study (images
not available) of [**2127-7-25**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm)
with <50% decrease with sniff (estimated RA pressure ([**4-1**]
mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
RIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV
free wall hypokinesis. Abnormal systolic septal motion/position
consistent with RV pressure overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to
moderate [[**11-24**]+] TR. Severe PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - body habitus. Suboptimal
image quality - patient unable to cooperate. Echocardiographic
results were reviewed by telephone with the houseofficer caring
for the patient.
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2127-7-25**], the right ventricular cavity is larger
with more severe free wall dysfunction. Severe pulmonary artery
hypertension is now identified.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-7-28**] 15:25
[**7-27**] LENIS
Final Report
INDICATION: 76-year-old female with known interstitial lung
disease on
prednisone with recent diagnosis of pulmonary embolism, followed
by hemoptysis
necessitating discontinuation of anticoagulation. Monitoring for
DVT.
TECHNIQUE: Bilateral lower extremity ultrasound.
COMPARISON: Ultrasound dated [**2127-7-25**].
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the bilateral
common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins were
performed. On the left, the posterior tibial veins demonstrate
occlusive
clot. The peroneal veins are not seen and cannot be assessed. On
the right,
the peroneal veins are not well seen, which may be due to small
caliber or
additional clot. The remainder of the visualized veins
demonstrates normal
compressibility, flow and augmentation.
IMPRESSION: Occlusive clot within the left posterior tibial
veins. Bilateral
peroneal veins not well seen and the presence of additional clot
cannot be
excluded.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 12562**] [**Last Name (NamePattern1) **]
DR. [**Last Name (STitle) 8087**] M. DIDOLKAR
Approved: MON [**2127-7-28**] 1:56 PM
[**7-25**] CTA
INDICATION: 76-year-old woman with interstitial lung disease, on
INH for
presumed latent TB with hypoxia and altered mental status, found
to have RV
dysfunction on transthoracic echocardiogram concerning for PE.
COMPARISON: High-resolution chest CT [**2127-6-2**].
TECHNIQUE: MDCT data were acquired through the chest before and
after the
administration of intravenous contrast. Images were displayed in
multiple
planes.
FINDINGS: Contrast bolus timing is adequate for assessment of
the pulmonary
vasculature to the segmental level. Acute pulmonary emboli are
seen in the
right upper lobar pulmonary artery extending into the apical
posterior
segmental arteries and their branches. Thrombus is seen at the
bifurcation of
the right interlobar artery (402B:34). Thrombus is seen in the
medial and
lateral middle lobe segmental arteries in a more linear fashion
and may be
slightly more chronic. Thrombus is seen in the proximal right
lower lobar
pulmonary artery and extends into the artery to the superior
segment. Small
amount of thrombus is seen in the basal lateral lower lobe
segmental pulmonary
artery (3:61, 402B:36) and its branches. A small amount of
thrombus is seen
in the left posterior upper lobe segmental pulmonary artery
(3:40, 403B:50) as
well as in the left lower lobe segmental pulmonary artery
(3:70).
The main pulmonary artery is enlarged and measures approximately
3.5 cm. Aorta
is of normal caliber. No dissection. Diffuse soft and calcified
plaque is seen
throughout the aortic arch and descending aorta with numerous
areas of
penetrating ulceration in the soft atheromatous plaque. The
right ventricular
cavity size is mildy enlarged which correlates with the right
ventricular
strain visualized on transthoracic echocardiogram. The right
atrium is
enlarged and the interatrial septum slightly bows towards the
left (3:67).
The trachea and central airways are patent. Honeycombing,
interlobular and
intralobular septal thickening, and areas of ground glass
opacities are again
seen right greater than left, with diffuse traction
bronchiectasis and
bronchiolectasis, consistent with known pulmonary fibrosis.
These have
increased bilaterally. The ground glass opacities are more
prominent than on
the prior. Some of the right upper lobe anterior changes may
again in part be
due to radiation changes. A clip is seen within the right
breast, unchanged.
Mediastinal lymphadenopathy is similar in appearance. Prominent
pretracheal
nodes measuring 1.6 and 1 cm in short axis (3:37). A node under
the left main
pulmonary artery measures 9 mm from (3:37). A 1 cm
paraesophageal node (3:28)
has increased in size since [**Month (only) 205**] when it only measured 7 mm. No
axillary or
hilar or supraclavicular lymphadenopathy is present. The thyroid
enhances
homogeneously.
The exam was not specifically tailored to evaluate
subdiaphragmatic region.
Adrenal glands are grossly unremarkable. Visualized portions of
the liver,
spleen and right kidney appear unremarkable.
No aggressive osseous lesions. Mild degenerative changes of the
thoracic
spine.
IMPRESSION:
1. Extensive bilateral lung pulmonary emboli, as described
above.
2. Enlarged main pulmonary artery and findings suggesting mild
right heart
strain.
3. Diffuse atherosclerotic disease of the aorta with soft tissue
and
calcified atheromatous plaques and foci of penetrating
ulceration.
4. More prominent ground-glass opacities, perhaps reflecting a
degree of
edema. Possible superinfection is not excluded.
5. Progression of pulmonary fibrosis, right greater than left,
as described
above, likely UIP or fibrotic subtype of NSIP.
6. Persistent likely reactive mediastinal lymphadenopathy with a
pre-esophageal node increased in size.
Findings were discussed with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] via telephone at
6 p.m. on
[**2127-7-25**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**Last Name (STitle) 8087**] M. DIDOLKAR
Approved: SAT [**2127-7-26**] 1:08 PM
LENIS [**7-25**]
Final Report
INDICATION: A 76-year-old female with hypoxia, evaluate for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
Normal flow,
compression, and augmentation is seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name (STitle) 8913**] SUN
Approved: FRI [**2127-7-25**] 5:09 PM
[**7-25**] TTE
This study was compared to the prior study of [**2127-1-17**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis. Abnormal septal motion/position
consistent with RV pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. No MS.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild to moderate [[**11-24**]+] TR. Moderate PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus. The referring
physiician's office was notifed of the echocardiographic
results.
Conclusions
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 is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis (there is RV apical sparing of systolic
function or McConell's sign suggestive of acute RV strain from
pulmonary embolism). There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**7-25**] CXR
INDICATION: Evaluation of patient with pain.
COMPARISON: Chest radiograph from [**2127-6-25**] and chest CT
from [**2127-6-2**].
FINDINGS: PA and lateral chest radiographs were obtained. There
are
increased interstitial opacities involving the right upper,
right lower, and
left lower lobes. These findings are likely suggestive of an
acute process
overlying the patient's chronic interstitial changes. Otherwise,
the
cardiomediastinal silhouette remains stable with stable
mediastinal widening.
bilateral pleural effusions may be present.
IMPRESSION:
Increased interstitial opacities involving the right upper,
right lower, and
left lower lobes, likely representative of an acute interstitial
process
overlying chronic interstitial changes.
The study and the report were reviewed by the staff radiologist.
CXR [**8-6**]
IMPRESSION: AP chest compared to [**8-3**] through 13:
Extensive heterogeneous pulmonary opacification progressed
substantially
between [**8-3**] and [**8-5**] with particularly dense
consolidation in
the left lower lobe. Today pulmonary edema has worsened, and if
there is left
lower lobe pneumonia, it is less readily visible, but probably
not improved.
Small bilateral pleural effusions have increased. Cardiac size
is difficult
to assess because of the left heart border is persistently
obscured.
Mediastinal veins are dilated. ET tube is in standard placement,
left
internal and right internal jugular lines both end in the SVC
and a
nasogastric tube passes below the diaphragm and out of view. No
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2127-8-6**] 3:08 PM
Micro
[**2127-8-3**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT
[**2127-8-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2127-8-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2127-7-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2127-7-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2127-7-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2127-7-30**] URINE URINE CULTURE-FINAL INPATIENT
[**2127-7-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2127-7-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2127-7-27**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; RESPIRATORY CULTURE-FINAL; GRAM STAIN-FINAL
INPATIENT
[**2127-7-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2127-7-26**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2127-7-25**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-FINAL INPATIENT
[**2127-7-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2127-7-25**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2127-7-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2127-7-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2127-7-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
76yo F with h/o ILD on pred, recent PNA tx w/ ertapenem and
vanco, CVA, COPD, CRI, CAD, DMII, Breast Ca p/w from pulm clinic
with decreased mental status and dyspnea.
.
# Altered mental status: likely secondary to her lack of O2
transiently. Though, could be related to her underlying ILD
with pna, she is on high dose steroid concern for pna/pcp. [**Name10 (NameIs) **]
was started on ceftriaxone and azithromycin to treat for
infection given concerning imaging and sputum production which
could cause her AMS. Her MS continued to improve once she
reached the ICU until she was intubated.
.
On [**7-28**] she had a right facial droop, concerning for stroke.
Heparin for PE was stopped. Because of hemodynamic instability
with labile BPs, she was unable to have a head CT until the
evening of [**7-29**]. At that point, head CT was negative for acute
hemorrhagic stroke and heparin drip was started without bolus at
previous dose.
.
# Hypoxia: Initially thought ILD vs. CHF vs cardiogenic vs
infection. TTE showed RV dysfunction concerning for acute
pulmonary HTN and possible PE. Inital LENIS were obtained and
showed no evidence of deep vein thrombosis in either leg. CTA
chest was obtained and showed extensive bilateral lung pulmonary
emboli, enlarged main pulmonary artery and findings suggesting
mild right heart strain, more prominent ground-glass opacities,
perhaps reflecting a degree of edema. Progression of pulmonary
fibrosis, right greater than left, likely UIP or fibrotic
subtype of NSIP. She was placed on IV heparin gtt but was forced
to come off it due to significant hemoptysis. For this she was
intubated on [**7-26**] and asparin/plavix were held. A repeat LENIs
were performed and showed calf DVT. She also developed
transient hypotension and was placed on levophed for pressure
support. IR and vascular surgery were consulted and deferred
IVC filter due to the lack of evidence of DVTs in the
higher/larger blood vessels. Patient was bronched and noted
clean airways without significant bleed. Given this finding,
she was placed on a very conservative heparin sliding scale for
a target PTT of 60-80 with the understanding of her bleeding
history and her clots in her pulmonary arteries.
.
Given the initiation of steroids pre-INH initiation, it was felt
that although unlikely, this could be a reactivation of TB given
hemoptysis. Her INH was continued and she underwent 3 AFB
induced sputums which were negative. Serum glucan and
galactomannan were negative. She was diuresed with IV lasix
drip. Her home prednisone was continued (40mg daily). Other
culture data obtained includes blood, urine, and legionella
which were negative with the exception of a sputum culture which
had gram negative rods. She was continued on Vancomycin,
Ceftriaxone and Azithromycin and completed a course for
pneumonia. It was thought that most of her limiting hypoxia was
due to pulmonary embolism which was treated with a heparin drip
for the majority of her course.
.
# Interstitial Pulmonary Fibrosis: The patient has a history of
interstitial pulmonary fibrosis, recently diagnosed as
autoimmune based on positive [**Doctor First Name **] and elevated CRP. She was
started on 60 mg of prednisone daily on [**6-12**] (+bactrim for PCP
[**Name Initial (PRE) 1102**]) and was decreased to 40 mg on [**6-26**]. She was
continued on prednisone. She was placed on broad spectrum
antibiotics as above.
.
# Hypotension: Soon after intubation, patient developed
hypotension, thought due to PE. Sepsis was also considered and
she was started on Vancomycin, Zosyn and Azithromycin and
completed a course for pneumonia. She was on up to three
vasopressors and two within the last days of her course required
high dosing of levophed and vasopressin. Her hemodynamics were
difficult to manage, and she was persistently hypotensive,
thought due to her large PE burden.
.
# Acute Renal Insufficiency: Patient with acute on chronic renal
insufficiency likely due to ATN in part. She was started on CVVH
in an attempt to better manage her volume status however still
required vasopressors with both the addition of volume/fluids
and with diuresis.
.
# CAD: The patient has a history of CAD, controlled on
medication at home. started carvedilol 6.25 mg [**Hospital1 **] at the
previous hospitalization. Continued on aspirin 325 mg daily and
atorvastatin 40 mg daily. Aspirin was stopped due to
hemoptysis. Echo showed [**Last Name (un) **] sign of RV strain
concerning for PE.
.
# type 2 DM: She was placed on an ISS then an insulin drip.
.
# hypertension: Held home medications given hypotension.
.
# CVA: on plavix, held due to hemoptysis.
.
# Hyperlipidemia: on atorvastatin
.
# Depression: Continued duloxetine 20 mg daily.
.
# GERD: continued on home omeprazole 40 mg daily.
# Prophylaxis: Heparin gtt
# Access: CVL was placed, arterial line was placed
# Communication: Patient, grand-daughters, son
# [**Name2 (NI) 7092**]/goals of care: Patient's code status and goals of care
were discussed with her prior to intbubation. Over the course
of her ventilation-dependent hospitalization, the patient's son
and his wife and the patient's grand-daughters were updated on
her course. It was decided with the son, to focus on
comfort-focus care. Vasopressors were stopped and she was
extubated on [**2127-8-7**] and died at 9:15 pm of hypoxic respiratory
failure due to pulmonary embolism. Her son [**Name (NI) **] was contact[**Name (NI) **]
and declined autopsy.
Medications on Admission:
Refresh Tears 0.5 % Eye Drops
cetirizine 10 mg Tab
1 Tablet(s) by mouth once a day for allergies
Lipitor 40 mg Tab
1 Tablet(s) by mouth DAILY (Daily)
Diovan 320 mg Tab
1 Tablet(s) by mouth once a day
carvedilol 12.5 mg Tab
1 Tablet(s) by mouth twice a day (this is an increase in your
dose)
Plavix 75 mg Tab
1 (One) Tablet(s) by mouth once a day
Centrum Silver Tab
1 (One) Tablet(s) by mouth once a day
Novolog 100 unit/mL Sub-Q
4 units [**Hospital1 **], with breakfast and dinner [**Last Name (un) **] changed this dose.
Cymbalta 60 mg Cap
1 Capsule(s) by mouth qam
Humulin N 100 unit/mL Susp, Sub-Q Inj
as directed 18 units qAM, 9 units qHS
inhaler, assist devices, accessories
attach to your inhaler as directed
clonidine 0.3 mg/24 hr Weekly Transderm Patch
apply one patch to skin weekly (this is an increase in your
dose)
sulfamethoxazole-trimethoprim 400 mg-80 mg Tab
1 Tablet(s) by mouth daily 1 tablet daily while on prednisone
aspirin 325 mg Tab, Delayed Release
1 Tablet(s) by mouth once a day
isoniazid 300 mg Tab
1 Tablet(s) by mouth daily
calcitriol 0.25 mcg Cap
1 Capsule(s) by mouth once a day
albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler
1-2 puffs inhaled up to qid
furosemide 20 mg Tab
1 Tablet(s) by mouth daily
omeprazole 40 mg Cap, Delayed Release
1 Capsule(s) by mouth once a day
prednisone 20 mg Tab
2 Tablet(s) by mouth daily Take 3 tablets (60 mg) daily for two
weeks, then decrease to 2 tablets (40 mg) daily
zolpidem 5 mg Tab
1 Tablet(s) by mouth once a day at bedtime as needed for if
needed
tramadol 50 mg Tab
1 Tablet(s) by mouth up to three times a day as needed for pain
aware of low dose of duloxetine in conjunction with low dose
tramadol.
Colace 100 mg Cap
2 Capsule(s) by mouth once a day
ferrous sulfate 325 mg (65 mg iron) Tab
2 Tablet(s) by mouth once a day as needed
amlodipine 10 mg Tab
1 Tablet(s) by mouth daily
pyridoxine 50 mg Tab
1 Tablet(s) by mouth daily
lidocaine 5 % (700 mg/patch) Adhesive Patch
1 patch daily as needed for for pain
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary embolism
Secondary:
Interstitial Lung Disease
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"785.59",
"416.8",
"414.8",
"V12.54",
"515",
"V43.65",
"250.00",
"403.90",
"V10.3",
"584.5",
"585.4",
"453.42",
"415.19",
"428.0",
"276.4",
"278.00",
"V46.2",
"287.5",
"276.1",
"311",
"530.81",
"496",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"33.23",
"33.24",
"96.72",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
30121, 30130
|
22552, 22731
|
292, 326
|
30231, 30237
|
3415, 22529
|
30289, 30296
|
2788, 2875
|
30093, 30098
|
30151, 30210
|
28049, 30070
|
30261, 30266
|
2915, 3396
|
231, 254
|
354, 1726
|
22746, 28023
|
1748, 2258
|
2274, 2771
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,684
| 141,923
|
10565
|
Discharge summary
|
report
|
Admission Date: [**2118-7-12**] Discharge Date: [**2118-7-15**]
Date of Birth: [**2058-8-29**] Sex: M
Service: [**Location (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with metastatic pancreatic cancer who is status post
Whipple procedure in [**2116-9-30**], status post
chemotherapy with cisplatin, gemcitabine, Xeloda, Taxol, who
presented to the [**Hospital1 **] [**First Name (Titles) 151**] [**Last Name (Titles) 16169**]
gastrointestinal bleeding.
The patient had his first episode of bleeding in [**2116-5-30**]. The patient was found on hospitalization at that
time to have a hematocrit from 32 to 23.9. An
esophagogastroduodenoscopy performed at that time showed a
duodenal mass without active bleeding, as well as grade 1
esophageal varices. A colonoscopy was negative. The patient
was transfused and discharged to home where he was stable
until [**2118-7-4**], when he was found to have a hematocrit
drop to 21. The patient was transfused at that time and then
discharged.
On [**2118-7-12**], the patient presented to the [**Hospital1 **] with complaints of coffee-grounds emesis, and
bright red blood per rectum, as well as clots in his stools.
He also complained of an episode of syncope. His hematocrit
upon admission was found to be 19.6. A gastric lavage
returned bilious material as well as blood clot. The patient
was given packed red blood cells and intravenous fluids and
stabilized to a hematocrit of 30. Esophagogastroduodenoscopy
on [**2116-7-12**] showed varices in the lower third of the
esophagus, but no active bleeding.
The patient was maintained in the Intensive Care Unit until
[**7-14**], when he was transferred to the care of the
[**Hospital **] Medical Firm. At the time of being transferred to
the Medicine Service, the patient had no complaints. He had
no chest pain, syncope, nausea, or vomiting. His stools were
described as dark, but not grossly bloody.
PAST MEDICAL HISTORY:
1. Pancreatic cancer diagnosed in [**2115**]; status post
choledochojejunostomy, gastrojejunostomy, percutaneous
endoscopic jejunostomy.
2. Diabetes mellitus secondary to pancreatic resection.
3. Pancreatic abscess diagnosed in [**2117-3-30**].
4. Right foot drop.
5. Depression.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Zoloft 100 mg p.o. q.d.
2. Creon two pills p.o. q.i.d.
3. Insulin NPH 7 units q.a.m. and 7 units q.p.m.
4. Protonix p.o. b.i.d.
5. Reglan.
6. Taxotere (first cycle on [**2118-7-11**]; cycles weekly).
SOCIAL HISTORY: The patient is a retired policeman who lives
with his wife. [**Name (NI) **] tobacco, ethanol, or intravenous drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.4,
blood pressure was 114/72, heart rate was 72, respiratory
rate was 16. In general, the patient was awake, alert, and
well-nourished. Pupils were equally round and reactive to
light. Extraocular muscles were intact. There was no
scleral icterus. Mucous membranes were moist. There was no
jugular venous distention. No lymphadenopathy. The chest
was clear to auscultation bilaterally. Heart was regular in
rate and rhythm, with no murmurs, rubs or gallops. The
abdominal examination revealed a right upper quadrant
incisional scar as well as a percutaneous endoscopic
jejunostomy tube scar in the left upper quadrant. Otherwise,
the abdomen was soft, nontender, and nondistended, with
positive bowel sounds. Extremity examination revealed 2+
dorsalis pedis pulses bilaterally with no clubbing, cyanosis,
or edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Upon his
admission to the [**Location (un) **] Medicine Service, the patient's
laboratories were significant for a hematocrit of 29.2. His
white blood cell count was slightly low at 3.3. Coagulation
studies and Chemistry-7 values were normal.
RADIOLOGY/IMAGING: The patient had an AP chest film on
[**7-14**] which was normal.
HOSPITAL COURSE: While on the Medicine Service, the patient
had no symptoms of gastrointestinal bleeding, chest pain, or
abdominal pain. His hematocrit remained stable at
roughly 30. He was maintained on all of his outpatient
medications. A peripherally inserted central catheter line
was placed as per the instructions of his oncologist,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DISCHARGE DISPOSITION: He was discharged to home on
[**7-15**] with instructions to follow up with his oncologist
(Dr. [**First Name (STitle) **] on [**2118-7-18**] for his next cycle of
Taxotere chemotherapy.
MEDICATIONS ON DISCHARGE: (He was discharged on his original
medications which included)
1. Zoloft 100 mg p.o. q.d.
2. Creon two pills p.o. q.i.d.
3. Insulin NPH 7 units q.a.m. and 7 units q.p.m.
4. Protonix p.o. b.i.d.
5. Reglan.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES: Upper gastrointestinal bleed.
[**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**]
Dictated By:[**Name8 (MD) 34768**]
MEDQUIST36
D: [**2118-7-18**] 14:41
T: [**2118-7-25**] 00:03
JOB#: [**Job Number 34769**]
|
[
"578.9",
"197.4",
"285.1",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4376, 4564
|
4885, 5211
|
4591, 4812
|
2325, 2535
|
3955, 4352
|
4827, 4863
|
178, 1953
|
1975, 2299
|
2552, 3937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,593
| 175,852
|
51094
|
Discharge summary
|
report
|
Admission Date: [**2111-2-16**] Discharge Date: [**2111-2-20**]
Date of Birth: [**2057-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
hypotension, weakness, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53W w/HIV (CD4 217), HepC (1,1), ESRD on HD, CHF (EF 30-35%, E/A
1.2, 3+MR, 3+TR, moderate [**Last Name (un) 6879**] on TTE [**2-6**]) presented to HD this
morning weak and dizzy after missing last HD. No HD was
performed b/c of hypotension to SBP60 and the patient was
transferred to the ED.
.
In the ED, the patient was afebrile w/VS 95.0 58 75/50 25
99%2L. Following 750cc and peripheral dopamine at 10ug/min, SBP
rose to 110. She was SOB, at her baseline and could not lie
flat. ECG demonstrated TWI in V2, flat T in V3. K was 6.8 and
phos 13. BNP was 31,000. Bedside TTE was negative for
tamponade. She was given vanco, ctx, flagyl, dex 10mg,
dextrose, Cagluconate, insulin. Nephrology was consulted; they
reported 8kg weight gain and indicated a desire to initiate
gentle HD in the MICU.
.
ROS notable for cough X 2 associated w/straining abdominal
discomfort and 1 episode emesis. At this time, she denies
fevers, chest pain, back pain, urinary symptoms. She says that
she forgets her HAART about once per week.
Past Medical History:
HIV (CD4 Ct in [**1-7**] was 217)
ESRD on HD
HTN
AVNRT diagnosed at [**Hospital1 2177**]
Recent vaginal bleed s/p conization
HCV
ESRD on hemodialysis
Asthma/COPD (on 4L O2 at home)
Cardiomyopathy w/ echo on [**8-6**] EF>55%, mild MR
[**First Name (Titles) 106113**] [**Last Name (Titles) 106114**] pneumonitis followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **]
at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
.
PSurgH:
C-section
R knee surgery
Ovarian cysts removed
Social History:
Lives with her 17 year old son; has been medically handicapped
for many years. She has 4 children; one son is incarcerated. 45
pack years tobacco history, reports having quit for last 1
weeks. Denies alcohol, or drug use. History of crack use.
Family History:
Her mother had a stroke and has DM, Her Daughter only has one
kidney and has a thyroid problem.
Physical Exam:
Gen: well appearing, in no acute distress,
HEENT: NC AT, mouth dry, PERRL, EOMI
CV: RRR, holosystolic murmur, +S3
Lungs: generally clear to auscultation bilaterally with
occasional faint rhonchi throughout
Abd: soft NT ND + BS
Ext: no cyanosis clubbing or edema
Neuro: alert and oriented x3, 5/5 strength of all four
extremities, nl sensation, CN II-XII intact
Brief Hospital Course:
53W w/hypotension and renal failure after having had more than 5
days since last HD. also she had stopped her low dose prednisone
since she did not like its side effects.
.
#Hypotension- Likely multifactorial: initially thought to be
related to adrenal insufficiency b/c patient had self d/ced
steroids which she was on for [**Telephone/Fax (1) **] [**Telephone/Fax (1) 106114**]
pneumonitis as well as in the ED she responded to minimal
interventions including a small fluid boluses, IV dex and
antibiotics. However, pt had a single cortisol
result(29.4)within normal levels. No evidence sepsis: lactate
3.4 but trended down to 1.8 w/HD, Abx were held; ruled out MI-
three sets of cardiac enzymes:(0.12,0.11,0.11); TTE [**2-17**]:
Compared with the prior study (images reviewed) of [**2111-2-6**],
findings are similar except that the effusion is now smaller. In
MICU, periperal dopa was successfully weaned during dialysis and
pt maintained BP's of 110-140.
steroids for two reasons: seemed to improve her condition
dramatically in ED, assume partial adrenal insufficiency;
asthma/ CPOD exacerbation that is helped with steroids.
anti-hypertensives were held, and pt's BP stabilized HD2.
.
ESRD- AG metabolic acidosis, high K, high Phos, and uremia [**3-6**]
missed HD- underwent HDx2 in ICU (first time w/high bicarb bath
w/small amount of dopamine support) last [**2111-2-18**], plan to repeat
in AM [**2111-2-19**]. ABG on admission showed bicarb of 8, improved on
labs first morning after admission so no repeat ABG obtained.
Lactate improved w/HD from 3.4 on admission to 1.8 [**2111-2-18**].
Renal followed, HD Friday [**2111-2-20**] before d/c. continued
nephrocaps, calcium acetate throughout admission.
.
[**Name (NI) 15197**] pt w/COPD/asthma, history of chronic cough and [**Name (NI) 106113**]
[**Name (NI) 106114**] pneumonitis, CHF w/worsening of EF over the past
year exacerbated by fluid overload from missed HD. Currently
lungs are clear, saturating well on RA. completed course of
Azithromycin because of leukocytosis w/left shift and pt's good
clinical response to ABx. continued albuterol nebs and started
pt on prednisone taper from doses of steroids pt received while
in the ICU.
.
HIV- CD4 count just above 200. Cont ppx with bactrim DS and
HAART as above.
.
Hep C- stable.
Medications on Admission:
Bactrim DS QD
Imdur 60mg PO QD
Cozaar 50mg PO QD
Lopressor 37.5 PO BID
Cardizem 120mg PO QD
Nephrocaps QD
Phoslo 4 tabs tid
Seroquel 25mg QHS
Didanosine 125mg after each HD
Nevirapine 400 QD
Abacavir 600mg [**Hospital1 **]
Benadryl 50 QHS
Claritin 10mg PO QD
Spiriva 18ug PO QD
Ibuprofren PRN
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Didanosine 125 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: please hold for
sbp<100.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 1 days.
Disp:*2 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD
Discharge Condition:
stable
Discharge Instructions:
Please present to your outpatient hemodialysis as scheduled. It
is very important to your health that you do not miss [**First Name (Titles) **] [**Last Name (Titles) 106116**]s.
Please call your primary care physician or present to the
hospital if you have chest pain or shortness of breath, fever or
chills, headache or dizzyness.
Please follow up with your appointments and take your
medications as directed.
Followup Instructions:
You have the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2111-3-9**] 8:40
You should follow up with your primary care physician-
[**Telephone/Fax (1) 3581**]
|
[
"428.0",
"070.54",
"585.6",
"255.4",
"493.22",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6539, 6545
|
2710, 3394
|
350, 357
|
6594, 6603
|
7063, 7338
|
2212, 2309
|
5359, 6516
|
6566, 6573
|
5042, 5336
|
6627, 7040
|
2324, 2687
|
3410, 5016
|
278, 312
|
385, 1420
|
1442, 1933
|
1949, 2196
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,674
| 144,272
|
21105
|
Discharge summary
|
report
|
Admission Date: [**2148-5-2**] Discharge Date: [**2148-5-21**]
Date of Birth: [**2102-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Severe Mitral Regurgitation
Major Surgical or Invasive Procedure:
[**2148-5-4**] cardiac catheterization
[**2148-5-5**] Intra-aortic Balloon pump placement
[**2148-5-6**] CABGx1, MV repair (28mm ring)
History of Present Illness:
46yo with known coronary artery disease (STEMI [**2147-6-26**] LAD TO)
apical anuerysm and severe mitral regurgitation admitted to
[**Hospital1 18**] for cath prior to valve surgery. Patient had MI last year.
Initially he had trivial MR [**First Name (Titles) 6643**] [**Last Name (Titles) 28495**] over time. Surgery
was initially planned in febuary but postponed due to dental
procedure.
Past Medical History:
1. Low back pain.
2. Anterolateral ST segment elevation myocardial infarction in
04
3. Congestive heart failure.
4. Left ventricular aneurysm.
5. Atrial Flutter
6. Hypertension
7. Hypercholesterolemia
8. Severe mitral valve regurgitation
Social History:
The patient works as a roofer. He is married and has three
children. He had a one pack per day smoking history x25 years.
He has a history of drinking
beer, however, he states that he currently only drinks
approximately [**3-14**] glasses of wine every two weeks or so.
There is no history of illicit drug use or cocaine use.
he quit smoking 4 years ago
Family History:
Father: History of CVA at age 72.
Mother passed away at age 62 from lung cancer.
Patient has three brothers and one sister with no known history
of heart
disease.
Physical Exam:
wt 240lb Ht 5 10'
Gen-NAD, very pleasant obese caucasian gentleman
HEENT-PERRL, anicteric
CV-irregularly irregular, 2/6 systolic murmur radiating from
apex to axilla
resp-CTAB(anterior)
[**Last Name (un) 103**]-soft, NT/ND
ext-warm, DP 1+ b/l
Pertinent Results:
[**2148-5-2**] 08:00AM PT-14.9* PTT-29.3 [**Month/Day/Year 263**](PT)-1.4
[**2148-5-2**] 09:30AM PLT COUNT-168
[**2148-5-2**] 09:30AM ALT(SGPT)-29 AST(SGOT)-26 LD(LDH)-263*
CK(CPK)-183* TOT BILI-1.3
[**2148-5-2**] 03:26PM HGB-13.8* calcHCT-41 O2 SAT-63
[**2148-5-2**] Cardiac Catheterization
1. One vessel coronary artery disease.
2. Severe pulmonary hypertension and elevated filling pressures,
which
improved by the end of the case.
3. Successful stenting of the mid LAD with two overlapping Drug
Eluting
Stents.
[**2148-5-3**] ECHO
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. The left ventricular cavity is moderately dilated. There is
an apical left ventricular aneurysm. Overall left ventricular
systolic function is severely depressed.
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed.
4. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen.
5. Compared to the findings of the prior study of [**2147-6-27**], the
severity of mitral regurgitation has increased.
[**2148-5-4**] Abdominal Ultrasound
1. Diffusely heterogeneous and coarsened echotexture to the
liver consistent with fatty infiltration. Likely areas of focal
fatty sparing, however a short term follow-up study (approx 3
months) is recommended to exclude space occupying lesions. If
there is clincal concern, further work-up with MRI may be
performed.
2. Splenomegaly.
3. Ectatic aorta, although no evidence of aneurysmal dilatation.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname **] was admitted to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
on [**2148-5-2**] for a cardiac catheterization and surgical
management of his mitral valve disease. The cardiac
catheterization was significant for severe left main disease, a
95% stenosed left anterior descending artery, a moderately
disease circumflex artery and severe mitral valve regurgitation.
Stenting was performed to the left anterior descending artery
with improvement in his hemodynamics. Milrinone was started for
a low cardiac index however as this caused tachycardia
vasopressin was used with good effect. an Echocardiogram was
obtained which showed an ejection fraction of 25%, an apical
left ventricular aneurysm, 3+ mitral regurgitation and a
moderately dilated left ventricular cavity. Mr. [**Known lastname **] was
worked-up in the usual preoperative manner by the cardiac
surgery service. A prophylactic intra-aortic balloon pump was
placed prior to surgery given his low ejection fraction. As Mr.
[**Known lastname **] was in atrial flutter, he was cardioverted on [**2148-5-4**]
under transesophageal guidance back into normal sinus rhythm. On
[**2148-5-6**], Mr. [**Known lastname **] was taken to the operating room where he
underwent coronary artery bypass grafting to one vessel and a
mitral valve repair utilizing a 28mm [**Last Name (un) **] [**Known firstname **] ring.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 26228**] neurologically intact and was extubated. He was transfused
for postoperative anemia. His intra-aortic balloon pump was
weaned and removed without complication. He again developed
rapid atrial fibrillation which was rate controlled with beta
blockade. Coumadin was started for anticoagulation. On
postoperative day three, Mr. [**Known lastname **] was transferred to the
cardiac surgical step down unit for further recovery. He was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. His drains and epicardial
pacing wires were removed per protocol. Heparin was started for
anticoagulation until his [**Known lastname 263**] was within therapeutic range.
Plavix was continued given his recent coronary stents. Mr.
[**Known lastname **] developed some slight sternal serous drainage from the
inferior aspect of his sternotomy. Betadine occlusive dressings
were applied and vancomycin as well as levofloxacin were started
prophylactically. Cultures of his sternal wound were negative
and the vancomycin was discontinued. Beta blockade was adjusted
for appropriate rate control of his atrial fibrillation. His
medications were adjusted due to Mr. [**Known lastname 5024**] financial
concerns. Slowly his sternal drainage slowed and ceased. On
postoperative day fifteen, Mr. [**Known lastname **] was discharged home with a
visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) 263**] on discharge was 2.0. Mr. [**Known lastname **] will
follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary
care physician as an outpatient.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily-last dose on [**5-1**] prior to valve replacement
per Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**]
Lipitor 80mg daily
Toprol 100mg daily
Lisinopril 10mg daily
Coumadin 5/5/2.5 last dose 3/20
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**5-15**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once a
day.
Disp:*75 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p CABG x 1 (SVG-OM)
s/p MV repair(#28 annuloplasty ring)
AF, HTN, ^chol, Sleep apnea, s/p PTCA
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as directed.
You should take your coumadin daily.
Call if you experience increasing shortness of breath, worsening
chest pain, or light-headedness/fainting.
Call if your incision becomes increasingly red or painful, or if
you experience drainage from the wound.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 33330**] Call to schedule
appointment in [**4-12**] weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Call to schedule
appointment in [**3-14**] weeks
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Call to schedule
appointment for 4 weeks.
Completed by:[**2148-5-21**]
|
[
"427.32",
"998.89",
"428.0",
"414.01",
"287.5",
"424.0",
"412",
"414.11",
"285.9",
"401.9",
"272.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.04",
"35.33",
"37.23",
"39.61",
"99.62",
"36.01",
"88.72",
"36.07",
"36.11",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
8354, 8409
|
305, 442
|
8550, 8556
|
1954, 3528
|
8899, 9406
|
1511, 1676
|
7223, 8331
|
8430, 8529
|
6936, 7200
|
8580, 8876
|
1691, 1935
|
3579, 6910
|
238, 267
|
470, 861
|
883, 1123
|
1139, 1495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,334
| 170,088
|
32277
|
Discharge summary
|
report
|
Admission Date: [**2154-11-5**] Discharge Date: [**2154-11-29**]
Date of Birth: [**2085-11-6**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
68yo F transferred for acute onset of speech difficulty
Major Surgical or Invasive Procedure:
Intubated for airway protection in the setting of delerium
tremens.
History of Present Illness:
68yo RH F h/o EtOH abuse, heavy smoking, HTN, CAD s/p MI in
[**2150**] and h/o MS who was well until last night. Her daughter came
home and discussed the hospitalization of the patient's brother
around 6pm. The patient then went upstairs and was in her room
for the rest of the night. Around 9:30pm, the patient first had
difficulty speaking in that her speech was slightly slurred. She
did not report this to her daughter and is able to offer this
information to multiple yes/no questions at this time. Details
of
the history were provided by her daughter, as the patient has
severe difficulty articulating her words.
The patient woke this morning and walked downstairs. The
patient's daughter noticed a new right facial droop (that the
patient says was not present last night). She was only able to
say a few words and what she said was so slurred as to be
incomprehensible. She was taken to [**Hospital3 2783**] and
transferred here. Her speech difficulties were far worse than
last night. She denies visual disturbances or diplopia and
denies
other deficits such as gait difficulty, dizziness,
incoordination, headache, neck pain or manipulation,
numbness/tingling.
ROS: On review of systems, the pt denied recent fever or chills.
No night sweats or recent weight loss or gain. 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. Denied rash.
Past Medical History:
CAD s/p MI in [**2150**] (no stents or surgery)
HTN
MS: diagnosed decades ago. Details are hard to come by; it seems
that her previous flares consisted of gait difficulty and
possibly the left hand (which she points to). She was on
betaseron until a few years ago and sees Dr. [**Last Name (STitle) **]. She
denies
h/o blurry vision with her attacks and definitely had no flares
like this before.
Social History:
drinks heavily (5 martinis a night). Long-time heavy smoker
as well. Retired computer worker.
Family History:
Father had DM2, mother had breast cancer
Physical Exam:
VS 97.4 124/83 62 12 97%
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Awake, alert. Fully oriented (when asked yes/no to multiple
choice). Attentive to exam. Speech is mostly non-fluent and
severely dysarthric. She is able to point to my thumb and pinky
finger when asked to; she points to a pen and a stethoscope as
well. Repetition seems relatively preserved. Comprehension seems
intact. Normal prosody. Able to follow both midline and
appendicular commands. No apraxia. Interprets cookie theft
picture appropriately.
CN
CN I: not tested
CN II: VFF to confrontation, no extinction. Pupils 3->2 b/l.
Fundi clear
CN III, IV, VI: EOMI no nystagmus or diplopia
CN V: intact to LT throughout
CN VII: severe R facial droop that may also affect the upper
right face mildly, as I can break orbicularis oculi on that side
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**4-20**] and symmetric
CN XII: tongue midline and agile
Motor
Normal bulk and tone. No pronator drift
D B T WE FE FF IP Q H DF PF TE
R 4+ 5 4+ 5- 4+ 5---------------->
Sensory intact to LT, PP, JPS, vibration throughout. No
extinction.
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2+ 2+ 2+ 2+ 2+ down
R 2+ 2+ 2+ 2+ 2+ down
Coordination FTN, HTS normal; [**Doctor First Name **]/FFM's slightly slowed on her
right, which is her dominant side
Gait stands without assistance. Walks steadily but with slightly
wide based gait.
Pertinent Results:
[**2154-11-12**] 02:59AM BLOOD WBC-10.4 RBC-2.60* Hgb-9.5* Hct-27.4*
MCV-105* MCH-36.5* MCHC-34.7 RDW-13.7 Plt Ct-257
[**2154-11-5**] 12:45PM BLOOD WBC-5.7 RBC-3.54* Hgb-13.2 Hct-38.4
MCV-109* MCH-37.3* MCHC-34.3 RDW-13.2 Plt Ct-265
[**2154-11-12**] 09:30AM BLOOD PT-20.1* PTT-49.3* INR(PT)-1.9*
[**2154-11-12**] 02:59AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-134
K-4.1 Cl-104 HCO3-23 AnGap-11
[**2154-11-11**] 05:23PM BLOOD ALT-13 AST-22 AlkPhos-63 TotBili-0.4
[**2154-11-8**] 08:57PM BLOOD Lipase-17
[**2154-11-5**] 12:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-11-6**] 04:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-6**] 09:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-11-6**] 11:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-6**] 06:23PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-12**] 02:59AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0
[**2154-11-6**] 09:10AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.3* Cholest-173
[**2154-11-6**] 09:10AM BLOOD %HbA1c-4.8
[**2154-11-6**] 09:10AM BLOOD Triglyc-59 HDL-79 CHOL/HD-2.2 LDLcalc-82
[**2154-11-11**] 09:48AM BLOOD TSH-0.74
[**2154-11-5**] 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2154-11-6**] CTA with perfusion:
1. Hypodense areas in the left frontal lobe, including
involvement of the anterior sylvian region, compatible with
acute infarction. Increased mean transit time is visualized on
the perfusion images along the superior margin of this area,
also supportive of recent ischemia and/or infarction. No
significant mismatch between blood volume, flow and MTT is noted
to suggest significant salvageable tissue or penumbra.
2. Non-occlusive filling defect in a sylvian branch of the left
middle cerebral artery, although the area of recent infarction
is probably not primarily supplied by the vessel containing the
filling defect.
3. Prior left cerebellar infarct.
4. Emphysema.
5. Lucency about the lateral root of [**Doctor First Name **] 3, which could
represent a periodontal abscess or dentigerous cyst. When
clinically appropriate, dental consultation is recommended.
[**2154-11-6**] ECHO
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No cardiac source of embolism seen. Normal
biventricular systolic function.
[**2154-11-9**] CT-head without contrast.
IMPRESSION: Evolution of the left-sided anterior division middle
cerebral artery infarct. No hemorrhage. No other significant new
abnormalities since the previous CT of [**2154-11-5**].
[**2154-11-11**] MRI head:
IMPRESSION: Acute infarcts of the left frontal lobe and insula
not significantly changed in extent compared to CT scans.
Moderate degree of chronic microangiopathic changes and an old
infarct of the left cerebellum.
The previously seen filling defect of a branch of the left MCA
is not definitively seen on the MRA.
[**2154-11-7**] ECG:
Atrial fibrillation, average ventricular rate 129. Compared to
previous
tracing cardiac rhythm is now atrial fibrillation.
Brief Hospital Course:
The patient was admitted to the floor on [**2154-11-5**]. On [**2154-11-6**]
the patient had new onset afib with rapid ventricular response
(HR to 156) and blood pressures dropping into the low 100s. The
patient was transferred to the ICU so that pressors could be
hung as we were concerned that her low blood pressure might put
her at further risk for ischemic injury in the setting of her
recent stroke. Furthermore it was felt likely that the
patient's stroke was caused by the afib itself, as this was new
onset and the patient was not previously anticoagulated. The
patient was placed on Neo-Synephrine to maintain systolic blood
pressure over 120. She was also started on a diltiazem drip to
facilitate rate control, but this was felt not to be ideal as
the blood pressure effects of the diltiazem was counteracting
the effects of the Neo-Synephrine. Therefore the patient was
started on an amiodarone gtt for rate control and the diltiazem
was stopped. The patient still required the neo gtt to maintain
adequate pressures. She was eventually transition to PO
amiodarone. Unfortunately she was still in and out of atrial
fibrillation and a cardiology consult was required.
On the morning of [**2154-11-8**] the patient began to withdraw,
showing the first signs of delirium tremens - she was agitated,
disoriented, and combative. These behaviors were in [**Doctor Last Name 29943**]
contrast to her otherwise perfectly pleasant demeanor. The
patient was initially started on a CIWA scale but was requiring
large doses. She was started on a lorazepam gtt.
The patient was felt to be at risk of not protecting her airway
and shortly after being started on the Ativan gtt she was
intubated. She was briefly on a propofol gtt and receiving
regular ativan as the SICU team felt that she was at high risk
for withdrawal related MI or seizures and as she was also very
combative. This was explained to her family.
Regarding the patient's stroke, this was seen both in the CTA
perfusion performed on the day of admission and in the MRI
performed on [**11-11**]. An ECHO did not demonstrate a cardiac
source for the embolus. The carotids had no significant
stenosis on the CTA of the neck. A hemoglobin A1C was 4.8.
The total cholesterol was 173 and the LDL fraction was 82.
Simvastatin 40mg daily was started. Given the likelihood that
the patient's stroke was cause by her atrial fibrillation the
patient was started on a heparin gtt and Coumadin was given as
well.
A urine culture was positive for E.coli and Stenotrophomonas.
The patient was started on Ciprofloxacin on [**2154-11-10**] and
completed a 3 day course. Her repeat UA was negative.
The patient was noted to be increasingly anemic with a HCT of
27.4 on [**2154-11-12**] from 38.4 on admission. The MCV was noted to
be elevated. Folate and B12 were normal or elevated.
The patient was maintained on an insulin sliding scale.
The patient was given famotidine and tube feeds were initiated
while she was intubated. After a prolonged intubation, she was
gradually weaned off sedation. She then took several days before
waking up enough to be extubated. After extubation, she was also
noted to have large bilateral pleural effusions. She therefore
had an IR guided thoracentesis which showed a transudate, with
negative gram stain and culture. She was therefore not treated
with antibiotics.
She has had persistent expressive aphasia with aphonia. She was
evaluated by Speech who noted a possible L vocal cord
paralysis. She was then seen by ENT who noted that her vocal
cords are mobile, but she had large posterior gap and
significant laryngeal edema. She was therefore started on [**Hospital1 **]
Protonix. She was also re-evaluated multiple times for
aspiration and failed. A J-G tube was therefore placed
surgically as IR was unsuccessful. During this time she was off
Coumadin, reversed with FFP and on a heparin drip. Her INR on
discharge was 2.1 and she was on Coumadin. She was discharged to
rehab and will follow-up with Neurology as an outpatient. Her
LDL should be maintained less than 70 and HbA1c less than 7.
Medications on Admission:
ASA 325
HCTZ 25
Metoprolol 25mg [**Hospital1 **]
Hydrochloroquine 200
B12
long-term use of cod liver oil
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day).
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
8. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q12H PRN () as
needed for aggitation.
13. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QDAY ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
chronic renal failure
hyperlipidemia
hypertension
coronairy artery disease
Atrial Fibrilation
DT's
Anemia
Discharge Condition:
Expressively Aphasic and dysphonic, moving all extremities
Discharge Instructions:
Please follow up as instructed below.
.
If you experience new symptoms of weakness, numbness, double or
blurry vision, or clumsiness, please contact your doctor or come
to the nearest ED.
.
Please have your INR checked regularly and followed up by your
primary care doctor
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2154-12-16**] 3:30.
.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
[
"292.81",
"511.9",
"291.0",
"438.12",
"340",
"041.4",
"285.29",
"438.11",
"305.1",
"434.11",
"348.30",
"414.01",
"412",
"787.22",
"427.31",
"303.91",
"599.0",
"401.9",
"E939.4",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"99.04",
"43.11",
"34.91",
"38.93",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13520, 13592
|
7926, 12041
|
373, 442
|
13742, 13803
|
4435, 7903
|
14124, 14347
|
2560, 2603
|
12199, 13497
|
13613, 13721
|
12067, 12174
|
13827, 14101
|
2618, 4416
|
278, 335
|
470, 2011
|
2033, 2432
|
2448, 2544
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,906
| 111,126
|
18402
|
Discharge summary
|
report
|
Admission Date: [**2101-9-1**] Discharge Date: [**2101-9-3**]
Date of Birth: [**2020-8-24**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Dyazide
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is an 81 yo f with a history of diverticulosis and 2
recent episodes of GIB who had another GIB on [**2101-8-31**] prompting
her admission to [**Hospital 8**] Hospital. In the AM of [**8-31**], patient
had mild incontinence followed by a bloody bowel movement,
accompanied by clots. She described a dark hue to the contents
of her BM. Then, on the AM of [**9-1**], she had another bloody BM.
She denied any lightheadedness, changes in vision, abdominal
pain or chest pain with these episodes. (Though, a note from the
[**Hospital1 8**] ED notes that the patient had a syncopal type episode
while in the ED) She had a tagged RBC scan which was unable to
identify the source of bleeding. Hence, she is being transferred
here with the objective of IR guided embolization. On admission
to [**Hospital 8**] hospital, her Hct dropped from 30->22. She was
transfused with 2U PRBC and given 2 PIVs. Her Hct rose from 22
to 25.4 and thus she was transfused another 2 units PRBCs.
Past Medical History:
- LGIB w/ [**Month (only) **] HCT [**7-/2099**]
- Diverticulosis - diagnosed after 1st GIB
- HTN - on Lisinopril, Procardia, metoprolol
- CVA - in the [**2054**]
- Ulcer operation ? in the [**2054**]. Apparently surgery was done on
a part of her stomach.
- S/P TAH-BSO
- gastritis - s/p trt for duodenitis, PUD and H Pylori [**2098**], tx
w/ Prevpack
- Subarachnoid hemorrhage - per OSH report
Social History:
Lives alone. 32 pack yr history smoking. Social EtOH use.
Closest relatives are a son and a sister.
Family History:
NC
Physical Exam:
T: BP: 155-195/53-67 P:72-80 RR:18-20 O2 sats: 100% on 2L
Gen: alert, thin elderly woman
HEENT: dry MM
CV: 3/6 SEM RUSB and L apex, RRR
Resp: rales R lung base, no wheezes, no rhonchi
Abd: Soft NT ND, NABS
GU: per ED admit note last night guaic +
Ext: mild RUE non-pitting swelling, rt ankle mildly swollen
Neuro: AOx3.
Pertinent Results:
Laboratory Data:
.
[**2101-9-1**] 08:06PM WBC-9.8 RBC-3.83* HGB-12.1 HCT-33.2* MCV-87
MCH-31.6 MCHC-36.5* RDW-15.1
[**2101-9-1**] 08:06PM NEUTS-77.2* LYMPHS-15.0* MONOS-3.9 EOS-3.6
BASOS-0.4
[**2101-9-1**] 08:06PM PLT COUNT-309
[**2101-9-1**] 08:06PM PT-12.0 PTT-25.4 INR(PT)-1.0
[**2101-9-1**] 08:06PM GLUCOSE-120* UREA N-27* CREAT-1.5*
SODIUM-146* POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-28 ANION
GAP-14
[**2101-9-1**] 08:06PM ALT(SGPT)-11 AST(SGOT)-21 LD(LDH)-228 ALK
PHOS-66 TOT BILI-0.6
[**2101-9-1**] 08:06PM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-4.4
MAGNESIUM-1.8
.
Urinalysis:
.
[**2101-9-1**] 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2101-9-1**] 11:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2101-9-1**] 11:27PM URINE HOURS-RANDOM UREA N-151 CREAT-18
SODIUM-152
.
Imaging:
[**9-1**]: CXR: No evidence of focal consolidation.
.
[**2101-9-2**]: RUE ultrasound: No evidence of right upper extremity
DVT. Cephalic vein not visualized.
.
[**2101-9-3**]: Renal ultrasound: 1. No evidence of hydronephrosis or
kidney stones.
2. Increased echogenicity of the right kidney may represent
medical-renal disease.
3. Bilateral pleural effusions.
.
[**2101-9-3**]: Echo
Measurements:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.7 m/sec
Mitral Valve - E/A Ratio: 0.65
Mitral Valve - E Wave Deceleration Time: 205 msec
TR Gradient (+ RA = PASP): *44 to 54 mm Hg (nl <= 25 mm Hg)
.
Official read pending. Prelim report of normal EF and
obstructive hypertrophic cardiomyopathy
.
OSH records:
OSH Colonoscopy: [**2101-8-24**]: Done to cecum.
- Severe L sided diverticulosis. No active bleeding.
.
EGD: [**2101-8-24**]:
- benign appearing gastric mucosa and duodenal mucosa (to the
3rd portion of the duodenum
.
[**2101-8-31**]: Tagged RBC scan: 2 areas of increased activity in the
deep pelvis - There was no evidence of GI Bleed.
Brief Hospital Course:
# GIB: 81 yo f with PMH diverticulosis and history of GIB was
transferred from OSH with recent GIB. Per report, source was
identified on tagged RBC at OSH and she was transferred here for
IR embolization. We obtained records from [**Hospital 8**] Hospital
which showed that the tagged RBC scan didn't reveal any source
of bleeding. Pt had a previous colonoscopy which showed severe
left sided diverticulosis. Pt's source of recent GIB was most
likely secondary to diverticulosis. During this hospitalization,
pt didn't have any bowel movements. Serial hematocrits remained
stable. Pt was evaluated by IR and surgery who didn't feel that
any immediately intervention was indicated. Pt was evaluated by
GI who recommended a repeat colonoscopy. If pt were to re-bleed,
she will need a repeat tagged RBC scan and possible
embolization. Please continue to check serial [**Hospital1 **] hematocrits.
Pt has not had a BM in 4 days - please titrate bowel
medications, for a BM.
.
# CRI: Lisinopril was held in setting of elevated creatinine.
Further data revealed that baseline creat is around 1.8, and pt
was restarted on Lisinopril. Urine lytes showed low FeNa and
FeUrea, suggestive of pre-renal state; however, urine Na was not
low. Clinically pt appears to be volume overloaded.
.
# CHF: Pt noted to be in mild CHF, likely in setting of volume
rescusitation. Pt has bilateral pleural effusions. Pt was
diuresed with IV Lasix. Pt needs to continue with diuresis. Echo
was performed - final read is pending. Prelim tech read is
normal EF with evidence of obstructive hypertrophic
cardiomyopathy.
.
# HTN: - Initially BP meds were held in setting of GIB. Then, pt
was restarted on lopressor and lower dose of nifedipine.
Lisinopril was initially held in setting of elevated creatinine,
and pt was put on IV hydralazine. Further data revealed that
creatinine is at baseline, so Lisinopril was restarted. Pt was
also restarted on home dose of nifedipine.
.
# RUE swelling: Pt was noted to have RUE swelling, which is most
likely secondary to IV infilatration. RUE U/S was negative for
DVT.
.
# Hypercholesterolemia: Pt was continued on lipitor.
.
# Code: DNR/DNI - confirmed with patient.
.
# Contacts: Sister - [**Name (NI) 50665**] [**Name (NI) 50666**]: [**Telephone/Fax (1) 50667**]
Medications on Admission:
Lisinopril 40 QD
Metoprolol 100mg TID
Procardia XL 90mg QD
Lasix 10mg QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
GIB (likely [**12-23**] diverticulosis)
RUE swelling
.
Secondary diagnoses
HTN
CRF
Hyperlipidemia
Discharge Condition:
Stable, no further GIB, stable Hct
Discharge Instructions:
Please continue doing the following:
1. Daily hematocrits
2. Diurese with IV Lasix
3. Titrate BP meds
3. Please titrate bowel medication to BM (last BM on [**8-31**])
Followup Instructions:
Follow up with your primary care doctor within 2 weeks of
discharge from the hospital.
|
[
"428.0",
"729.81",
"403.90",
"272.0",
"585.9",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8068, 8083
|
4804, 7087
|
282, 288
|
8244, 8281
|
2209, 4781
|
8497, 8587
|
1849, 1853
|
7211, 8045
|
8104, 8223
|
7113, 7188
|
8305, 8474
|
1868, 2190
|
239, 244
|
316, 1298
|
1320, 1716
|
1732, 1833
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,201
| 149,143
|
55169
|
Discharge summary
|
report
|
Admission Date: [**2107-7-8**] Discharge Date: [**2107-7-8**]
Date of Birth: [**2024-3-6**] Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
[**2107-7-8**] Endovascular Abdominal Aortic repair
History of Present Illness:
83 year old male who presented with question of STEMI. He had 4
days of abdominal pain and back pain now status post a syncopal
episode while shaving.
He he did hit his head and was out for seconds. He denied any
headache neck pain chest pain or shortness of breath, he is
having ongoing abdominal back pain.
Past Medical History:
Unkonwn
Social History:
Unknown
Family History:
Unknown
Physical Exam:
HR: 66 BP: 117/73 Resp: 22
Exam in the emergency room / per ED team
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact C. collar in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Mildly distended diffusely tender palpable
pulsatile mass
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent alert and oriented x3 moving all
extremities
Pertinent Results:
[**2107-7-8**] 02:14PM BLOOD WBC-2.2*# RBC-2.67* Hgb-8.2* Hct-24.8*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.9 Plt Ct-26*#
[**2107-7-8**] 11:30AM BLOOD WBC-15.0* RBC-3.43* Hgb-11.2* Hct-34.0*
MCV-99* MCH-32.7* MCHC-33.1 RDW-13.1 Plt Ct-241
[**2107-7-8**] 02:14PM BLOOD Plt Ct-26*#
[**2107-7-8**] 11:30AM BLOOD PT-10.8 PTT-23.5* INR(PT)-1.0
[**2107-7-8**] 02:14PM BLOOD Fibrino-117*
[**2107-7-8**] 11:30AM BLOOD Glucose-146* UreaN-17 Creat-1.3* Na-141
K-3.5 Cl-105 HCO3-24 AnGap-16
[**2107-7-8**] 11:30AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.6
[**2107-7-8**] 02:15PM BLOOD Type-ART pO2-430* pCO2-36 pH-7.15*
calTCO2-13* Base XS--15
[**2107-7-8**] 02:15PM BLOOD Glucose-369* Lactate-7.0* Na-147* K-4.6
Cl-103
[**2107-7-8**] 02:15PM BLOOD Hgb-7.2* calcHCT-22 O2 Sat-98
[**2107-7-8**] 02:15PM BLOOD freeCa-LESS THAN
[**2107-7-8**] 01:09PM BLOOD freeCa-0.47*
Pt underwent CT torso at OSH / Ruputred 10cm AAA
Brief Hospital Course:
Pt was seen in the ED for possible NSTEMI. He had been
complaining of abdominal pain and back pain status post a
syncopal episode while shaving. He he did hit his head and was
out for seconds. He denied any headache neck pain chest pain or
shortness of breath, he was having ongoing abdominal back pain.
We were called to see the pt emergently. He had OSH imaging
that demonstrated a ruptured 10cm AAA. We attempted to obtain a
CTA torso as the OSH imaging was non contrasted. He lost his
blood pressure while on the CT table and was brought emergently
to the operative suite. He underwent an emergent EVAR with
rapid transfusion protocol intstituted. Decompressive
laparotomy performed with evacution of hematoma and noted
ongoing exsanquination. He went into PEA arrest multiple times
and responded to resuscitative efforts. Additional stent grafts
placed proximally to obtain hemmorhage econtrol, covering the
mesenertic vessels transiently. Ventricular thrombus and aortic
thrombus noted on ECHO and angiogram despite aortic control.
A decision was made to discontinue aggressive resuscitative
efforts and the patient expired. His family was updated during
the procedure and then again after his passing.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
ruptured AAA
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2107-7-8**]
|
[
"410.71",
"568.81",
"444.1",
"444.09",
"785.59",
"780.2",
"441.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.71",
"88.47",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
3567, 3576
|
2257, 3480
|
295, 348
|
3632, 3641
|
1339, 2234
|
3694, 3728
|
760, 769
|
3538, 3544
|
3597, 3611
|
3506, 3515
|
3665, 3671
|
784, 1320
|
243, 257
|
376, 688
|
710, 719
|
735, 744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,917
| 192,671
|
27695
|
Discharge summary
|
report
|
Admission Date: [**2166-6-10**] Discharge Date: [**2166-6-23**]
Date of Birth: [**2091-3-26**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Throat Swelling
Major Surgical or Invasive Procedure:
ENT scope
History of Present Illness:
75 yo F who noted tongue numbness followed by tongue swelling on
[**6-9**]. She had had 2 prior episodes of tongue numbness, her 1st
episode on [**3-/2166**] without notable consequences and did not tell
anyone of these prior episodes. On [**6-9**] she was concerned about
her tongue numbness and called her grandaughter whom noticed the
patient was dysarthric, with a hoarse voice over the phone. Her
granddaughter arrived to her home and noticed cheek swelling,
with some drooling and took her grandmother to [**Hospital3 **].
The pt denied any difficulty breathing, no throat pain. She
denies any new medications or new foods. She did state that she
had bought new organic brand eggs, but has eaten eggs on a
regular basis in the past. At [**Hospital3 **] she received
Solumedrol and Ceftriaxone. She was transferred to [**Hospital1 18**] for ENT
workup. ENT scoped pt which showed angioedema.
Past Medical History:
- gout
- HTN
- increased cholesterol
- s/p R hip replacement x 5 yrs ago
- s/p CEA x 4 years ago
- s/p ectopic pregnancy
Social History:
Lives alone. Drinks 5-6 drinks of whiskey per day. Smoked on and
off from age 16 - ~60
Family History:
No family history of throat swelling
Physical Exam:
T: 97.1 BP: 168/52 P: 77 RR: 21 O2 sats: 92%RA
Gen: Well appearing in NAD
HEENT: PERRL, EOMI, Anicteric sclera, normal appearing tongue,
some cheek swelling and soft tissue supraclavicular swelling, no
thyromegaly, no supraclavicular LAD
RESP: Inspiratory Bibasilar crackles b/l, no wheezing, no
stridor
CV: Reg, nml s1,s2, no M/R/G
ABD: Soft, somewhat distended/NT, +BS, no rebound, no guarding
EXT: No C/C/E, warm, 2+DP pulses B/L
NEURO: A&OX3, CNII-XII intact
Pertinent Results:
ENT was consulted in the ED and had an ENT scope which showed:
- no airway narrowing between back of throat and post pharyngeal
wall
- R>L Aryepiglottic folds with edema
- arytenoids with edema
- false cords with watery edema
- no hypopharyngeal masses
[**2166-6-10**] Per ENT review of OSH CT scan w/o contrast:
- R>L asymmetry below level of epiglottis c/w arythenoid and AE
fold edema
- mild stranding in anterior neck R>L
- no abscesses appreciated
.
[**2166-6-10**] CXR -
1. Cardiomegaly and diffuse interstitial abnormality. Left lower
lobe atelectasis.
2. Widening of the left paraspinal line. PA and lateral chest
radiography is recommended for further assessment.
.
[**2166-6-11**] Per ENT scope:
-Marked improvement in supraglottic edema, airway widely patent,
AE folds R>L still w/edema, erythema, post-cricoid w/erythema
.
[**2166-6-12**] CXR:
PA AND LATERAL CHEST RADIOGRAPHS:
Unchanged cardiomegaly. Within the left lower lobe, there is
obscuration of the left hemidiaphragm with opacities seen
throughout the lower portion of the left lower lobe. Findings
are consistent with pneumonia. No additional opacity are seen
throughout the lungs. Surrounding osseous and soft tissue
structures are unremarkable.
.
[**2166-6-12**] Renal U/S:
RENAL ULTRASOUND: The right kidney measures 10.6 cm. The left
kidney measures 10.2 cm. No hydronephrosis, stones, or masses
are seen bilaterally. A Foley catheter is seen within a
collapsed bladder.
IMPRESSION: No hydronephrosis or stones bilaterally.
.
[**2166-6-12**] ECHO:
Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The inferior vena cava is
dilated (>2.5 cm). There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
LABS:
AT DISCHARGE:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2166-6-23**] 06:10AM 10.0 2.66* 8.8* 26.3* 99* 33.2* 33.5
16.0* 295
[**2166-6-12**] 07:00AM 16.5*# 2.76* 9.3* 27.8* 101* 33.5* 33.3
15.5 190
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2166-6-23**] 06:10AM 90 28* 2.0* 143 4.0 109* 21* 17
[**2166-6-17**] 04:05PM 132* 56* 2.4* 139 4.61 106 19* 19
PT PTT Plt Smr Plt Ct INR(PT)
[**2166-6-23**] 06:10AM 35.3* 36.9* 3.9
.
ADMISSION:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2166-6-10**] 11:00PM 10.8 2.94* 10.0* 29.5* 100* 34.1* 34.0
15.3 167
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2166-6-10**] 11:00PM 176* 46* 1.6* 1341 4.5 97 15* 27
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2166-6-17**] 06:10AM 33
[**2166-6-10**] 11:00PM 31 44* 211 80 0.5
.
CARDIAC:
CK-MB cTropnT
[**2166-6-17**] 06:10AM 2 0.02
[**2166-6-12**] 07:00AM 0.02
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2166-6-12**] 07:00AM 224* 771 149 1.5 60
.
HEME:
calTIBC VitB12 Folate Ferritn TRF
[**2166-6-12**] 07:00AM 229* 433 3.5 549* 176
.
ENDO:
%HbA1c
[**2166-6-23**] 09:23AM 6.0
PTH
[**2166-6-18**] 04:35PM 136
.
VITAMIN D 25 HYDROXY
Test Result Reference
Range/Units
25-HYDROXY VITAMIN D 11 L 20-100 NG/ML
.
SPEP
Protein Electrophoresis
NO SPECIFIC ABNORMALITIES SEEN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
.
.
TOXICOLOGY:
SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr
Tricycl
[**2166-6-10**] 11:00PM NEG NEG1 NEG NEG NEG NEG
.
[**2166-6-10**] 11:00PM
MUMPS VIRUS ANTIBODY (IGM) Results Pending
.
.
MICROBIOLOGY:
[**2166-6-10**] 11:30 pm THROAT CULTURE
**FINAL REPORT [**2166-6-14**]**
THROAT - R/O BETA STREP (Final [**2166-6-14**]):
NO BETA STREPTOCOCCUS GROUP A FOUND.
RESPIRATORY CULTURE (Final [**2166-6-12**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
.
[**2166-6-10**] 11:00 pm SEROLOGY/BLOOD
**FINAL REPORT [**2166-6-11**]**
MUMPS IgG ANTIBODY (Final [**2166-6-11**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
.
[**2166-6-10**] 11:00 pm BLOOD CULTURE
**FINAL REPORT [**2166-6-16**]**
AEROBIC BOTTLE (Final [**2166-6-16**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2166-6-16**]): NO GROWTH.
.
[**2166-6-11**] 5:17 pm URINE
**FINAL REPORT [**2166-6-13**]**
URINE CULTURE (Final [**2166-6-13**]): NO GROWTH.
Brief Hospital Course:
75 year old woman presented with angioedema of unclear
precipitant at time of admission.
MICU COURSE:
The patient was admitted to the MICU for closer airway
monitoring. She was treated with benadryl 50mg IV q4 and
decadron 10mg IV q8. She was also started on clindaymycin for
possible infectious etiology but this was discontinued after 24
hours. The patient's edema improved. She was scoped by ENT on
admission which showed right greater than left aryepiglottic
folds with edema, arytenoids with edema, false cords with watery
edema, no hypopharyngeal masses. Her O2 was continously
monitored overnight and kept with HOB>30 degrees. A repeat
scope by ENT the morning after admission showed a "dramatic
improvement in supraglottic swelling likely secondary to
resolving edema". Her antibiotics were stopped and she was
switched to PO steroids (should get medrol dose pack). The
cause of her angioedema was unclear, but a likely source was her
ACEI and/or ASA which were held. She was continued on Prednisone
60mg, Benadryl and Famotidine.
.
# Angioedema: She was initially weaned from O2 with sats sats
92-96%[**Last Name (LF) **], [**First Name3 (LF) **] ENT patent airway and no evidence of tongue edema
when called out of the MICU, tolerating POs. However, etiology
most likely to ACE-I. Possibly related to ASA, no recent NSAID
use. ? infection - from cellulitis, parotiditis, mouth organisms
or Mumps, Mumps IgG AB + but viral IgM pending. ? allergic rxn:
she has had 2 episodes in the past but could not relate them to
particular food intakes or new medications. ? C1 esterase
inhibitor deficiency: no family history of angioedema like
symptoms. An alergy consult was called and agreed that most
likely related to ACE-I. ASA was not entirely ruled out and if
wanted to continue ASA she would require desensitization and
monitoring in ICU setting. This process was deferred and she was
not restarted on her home ASA. She was continued on Famotidine
20mg daily, Benadryl 25mg q6hr and Prednisone 60mg daily. Pt
was more delirius on [**2166-6-13**] requiring a sitter, her steroids
were throught to be the cause and were d/c'd. ENT had signed off
at that point for no further angioedema issues without any
airway edema, no tongue edema and tolerating POs without
incident. Her famotidine and benadryl were also d/c'd on [**2166-6-13**].
Allergy to ACE-I documented in chart.
.
#. RESP: Pt had been stable with continuous O2, however started
to require more O2 after receiving fluids for ARF, and for gap
acidosis. CXR notable for pulm edema and LLL PNA, ECHO with
severe pulmonary HTN with severe TR and moderate MR. She also
has underlying COPD. She was agressively diuresed with Lasix
20mg IV throughout the course of 3 days, followed by more
aggressive diuresis w/40mg IV x2-3 for 1 week. She was also
started on Levofloxacin day 1=[**2166-6-12**] and Flagyl day 1=[**2166-6-14**] for
Aspiration PNA to complete a 10day course. Her respiratory
status improved and remained stable on RA at time of discharge
with 3-4kg weight loss. Her home lasix dose 40mg daily was
restarted at discharge w/improved Cr.
.
#. CHF Exacerbation: ECHO notable for severe pulm HTN, mod MR
and severe TR with hyperdynamic EF 70%. Her CXR notable for
pulmonary edema. Her Tn-T was .02 and no EKG changes to suggest
ischemia as cause of CHF exacerbation. She had been on high dose
steroids and her home dose of lasix held while she had
angioedema, which may have precipitated CHF exacerbation as well
as PNA. She was diuresed with lasix for the course of 1 week
with improvement in peripheral edema as well as respiratory
status.
.
#. AF: New onset AF started on [**2165-12-18**]. She was started on Hep
gtt, Coumadin 5mg daily, increased to 7.5mg. She was started on
Dilt on [**6-18**] in addition to Toprol XL. She self converted to NSR
on [**6-19**]. Her dilt was titrated for better rate control to 240mg
SR daily. Her coumadin was held for INR 4.0 and at time of
discharge was held with VNA to draw blood at home and follow INR
closely. She was referred to the coumadin clinic at [**Company 191**]. She
remained in NSR with PACs at time of discharge.
.
#. HTN: Pt with known HTN on Atenolol 100mg daily and lisinopril
as outpatient. Her SBP was in the 180s while her lisinopril was
d/c'd. With her worsening renal fxn, she was switched to
Metoprolol and titrated to Toprol XL 400mg daily as well as
started on Nifedipine 30mg daily. Her SBP was better controlled
130s-140s at discharge with Toprol XL 400mg daily, Dilt SR 240
and Nifedipine 30mg daily.
.
#. ARF: Baseline Cr 1.7 per PCP and daughter. Cr [**Name2 (NI) **] here 1.6
with peak at 2.4 back down to 2.2. Pt known to have CRI.
Worsening Cr unclear as to etiology as no nephrotoxic meds given
and no contrast during this admission. However, did receive
contrast at an OSH prior to transfer. Her FeNa was .27% and was
hydrated intially. Her Cr did initially improve with lasix. Her
Cr was closely followed while she was diuresed. Her UOP remained
wnl, no casts seen in her urine. Her Cr trending down at
discharge 2.0.
.
#. Secondary Hyperparathyroidism: PTH level was checked per
renal and found to be elevated. Per renal followed Vit D levels
which were pending at discharge. If Vit-D level low would
increase Vit D with 50,000U q week. If wnl would start
calcitriol 0.25mcg 2x/week. Will f/u results as outpt per PCP.
[**Name10 (NameIs) **] [**Name11 (NameIs) **] she was started on Vit D 400U daily.
.
#. Hyperglycemia: Pt had persistently elevated BS throughout her
hospital course. She's not a known Diabetic, most likely related
to the high dose steroids she was on for her angioedema. She
remained on an ISS with improvement in her BS. On last day of
admission her BS was well controlled, w/FS 116, 117, however did
have persistently elevated FS 170s-190s. She was started on
glipizide 2.5mg daily with teaching for BS monitoring at home.
Will f/u her FS as outpatient and adjust glipizide if needed and
possible referral to [**Last Name (un) **] for new dx of DM.
.
#. Gap acidosis: most likely from hyperglycemic osmolar gap
acidosis with ketones in urine (DKA) vs. CRI. Negative tox
screen, normal lactate however +UA therefore infectious most
likely UTI, also with PNA. She was initially given IVF, gap
closed, glucose improved with Insulin and Abx.
.
#. UTI: +UA, She was started on Cipro, however was d/c'd after 3
days since WBC persistently elevated and Uculture with no
growth. Abx switched to flagyl/levoflox for Aspiration PNA as
noted above. She did have hematuria in setting of pulling out
foley during delirium. She remained HD stable without further
hematuria.
.
#. Anemia: HCT remained stable throughout her hospital course
with slow [**Last Name (un) **] from 29 to 25. Iron studies were sent and c/w
anemia of chronic disease. Pt also known to have extensive ETOH
intake and anemia attributed to ETOH intake as well as renal
insufficiency. Her hct remained stable and did not require
transfusions throughout her course. She was started on Epogen
4,000U M,W,F. VNA was to do injection teaching for home.
.
#. Mental Status changes: Pt became delirius when transferred
from MICU to floor. She had not had any new medications, no
benzos. She did have a UTI and PNA which may have triggered her
delirium but most likely related to high dose steroids. She
required a sitter for a few days, was also placed on a CIWA
scale given her ETOH history. She only required benzos 1 day and
only 1 time. Her MS [**First Name (Titles) 21299**] [**Last Name (Titles) 7151**] once steroids were d/c'd.
She was back to her baseline at discharge.
.
#. ETOH use: Pt with known h/o ETOH intake of >5 drinks of
Whisky per day per daughter. Pt was placed on a CIWA scale but
did not show any signs or symptoms of ETOH withdrawal. A tox
screen was sent which was negative. She was started on thiamine
and MVI. She remained stable without signs of withdrawal
throughout her hospital course.
.
# CODE: FULL
.
- PCP at [**Hospital3 4107**] is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] transfer
care to [**Company 191**]-new PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Medications on Admission:
Lisinopril 30mg daily
ASA 81mg daily
Lovastatin 40mg daily
Atenolol 100mg daily
Allopurinol 100mg daily
Lasix 40mg daily
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily) as
needed for for HTN.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*90 injections* Refills:*2*
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*90 Capsule, Sustained Release(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): take
[**12-9**] tablet daily with breakfast. .
Disp:*90 Tablet(s)* Refills:*2*
8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
9. Glucometer Elite Classic Kit Sig: One (1) Miscell. once
a day: please check finger sticks three times per day.
Disp:*1 glucometer* Refills:*0*
10. Glucometer Dex Test Sensors Strip Sig: One (1) Miscell.
three times a day.
Disp:*90 strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
-Angioedema due to Lisinopril
-Hypertension
-Acute Renal Failure
-CHF exacerbation
-Aspiration PNA
-Secondary Hyperparathyroidism
-Urinary Tract Infection
-Atrial Fibrilation
-Anemia
-Diabetes Mellitus
Discharge Condition:
Stable
Discharge Instructions:
Please take all of your medications and keep all your follow up
appointments.
.
Please keep a diary of your daily weights, if your weight
increases by 3 pounds in one day please call the clinic.
Restrict your diet to low salt and low sugar.
.
Please check your blood sugar three times a day but more
importantly before taking your sugar medication-Glipizide.
.
If you have chest pain, shortness of breath, notice any
lip/tongue or throught swelling, are lightheaded or dizzy please
call your physician and go to the emergency room.
.
Please note the following changes in your medications:
-You should never take Lisinopril due to your allergy
-You were started on Toprol XL 400mg daily
-You were started on Diltiazem SR 240mg daily
-You were started on Nifedipine CR 30mg daily
-You were started on Coumadin but will have it restarted as an
outpatient
-You were started on a Multivitamin
-You were started on Epogen injections for your anemia
Followup Instructions:
You have an appoitment with your new Primary Care
Physician-[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2166-7-15**] 2:30
.
You also have an appointment with the Kidney Physician,
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2166-7-31**] 3:00
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2166-9-11**] 4:00
Completed by:[**2166-6-25**]
|
[
"599.0",
"995.1",
"507.0",
"428.0",
"251.8",
"584.9",
"403.91",
"427.31",
"274.9",
"416.8",
"585.4",
"496",
"276.2",
"E932.0",
"285.9",
"E942.9",
"588.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
17275, 17332
|
7515, 15754
|
289, 300
|
17578, 17587
|
2029, 4631
|
18579, 19199
|
1493, 1531
|
15925, 17252
|
17353, 17557
|
15780, 15902
|
17611, 18556
|
1546, 2010
|
4668, 7492
|
234, 251
|
328, 1228
|
1250, 1373
|
1389, 1477
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,036
| 106,404
|
47101
|
Discharge summary
|
report
|
Admission Date: [**2183-11-20**] Discharge Date: [**2183-12-3**]
Date of Birth: [**2129-9-14**] Sex: F
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal Distention
Vomiting
Anorexia
Major Surgical or Invasive Procedure:
Exploratory laparotomy, abdominal colectomy,
sigmoid mucous fistula and end ileostomy, transgastric
gastrojejunostomy tube placement and splenic flexure
takedown
History of Present Illness:
54F with h/o recurrent metastatic ovarian cancer s/p TAH/BSO
[**4-/2180**], on Taxol (last RX [**11-12**]), who presents to oncology
clinic with a 2 day history of progressive abdominal distention,
anorexia, vomiting and decreased bowel function.
Past Medical History:
Recurrent Ovarian cancer
Asthma
Obesity
Social History:
She has one son who is 28 years old. She works as a financier
and is self employed. She lives in the [**Location (un) 5583**] area. She
does not drink or smoke.
Family History:
She had a grandmother who at the age of 83 developed colon
cancer. There is no other cancer in her family. She is not of
Ashkenazi [**Hospital1 **] descent.
Physical Exam:
Admission Physical Exam - [**2183-11-20**]
97.6 100 159/89 18 100%RA
AOx3, nontoxic
RRR, CTAB
Obese, markedly distended/tympanitic
+BS, mild right sided abdominal tenderness
Rectal- normal brown guaic (-) stool, no strictures
1+ edema
Pertinent Results:
Admission Labs
-------------------
[**2183-11-20**] 01:34PM BLOOD WBC-8.3# RBC-4.32 Hgb-11.5* Hct-35.3*
MCV-82 MCH-26.6* MCHC-32.6 RDW-20.6* Plt Ct-429
[**2183-11-20**] 02:20PM BLOOD Neuts-72.2* Lymphs-21.5 Monos-5.5 Eos-0.4
Baso-0.3
[**2183-11-20**] 02:20PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Microcy-2+
[**2183-11-20**] 01:34PM BLOOD Plt Ct-429
[**2183-11-20**] 01:34PM BLOOD Gran Ct-6080
[**2183-11-20**] 02:20PM BLOOD Glucose-159* UreaN-16 Creat-0.7 Na-134
K-3.2* Cl-96 HCO3-27 AnGap-14
[**2183-11-20**] 02:20PM BLOOD estGFR-Using this
[**2183-11-20**] 02:20PM BLOOD ALT-67* AST-39 AlkPhos-99 TotBili-0.5
DirBili-0.2 IndBili-0.3
[**2183-11-20**] 02:20PM BLOOD Albumin-4.2 Phos-2.9 Mg-1.9
Discharge Labs
-------------------
[**2183-11-27**] 09:55AM BLOOD WBC-10.5 RBC-3.47* Hgb-9.8* Hct-29.4*
MCV-85 MCH-28.2 MCHC-33.3 RDW-18.2* Plt Ct-356
[**2183-11-27**] 09:55AM BLOOD Plt Ct-356
[**2183-12-1**] 05:10AM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-139
K-3.8 Cl-108 HCO3-23 AnGap-12
[**2183-11-23**] 03:05AM BLOOD ALT-19 AST-21 AlkPhos-47 Amylase-28
TotBili-0.6
[**2183-12-1**] 05:10AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9
[**2183-11-26**] 06:32AM BLOOD Triglyc-218*
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: CT with RECTAL contrast to rule out distal obstructive
proce
Field of view: 46 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
54F with large bowel obstruction
REASON FOR THIS EXAMINATION:
CT with RECTAL contrast to rule out distal obstructive process
CONTRAINDICATIONS for IV CONTRAST: IV dye allergy
INDICATION: Plain film concerning for large bowel obstruction.
COMPARISON: CT scan dated [**2183-10-30**] and plain films dated
[**2183-11-20**].
TECHNIQUE: MDCT acquired images of the abdomen and pelvis were
obtained after the administration of IV, oral, and rectal
contrast. Multiplanar reformatted images were also obtained.
CT OF THE ABDOMEN WITH IV CONTRAST
The imaged portions of the lung bases are clear. There is
diffuse fatty infiltration of the liver. There is a gallstone
within the gallbladder. The pancreas and spleen are
unremarkable. The adrenal glands are normal. There are multiple
left renal cysts and a right renal lesion that is too small to
characterize, that probably represents a cyst.
There is dilatation of the cecum with diameter measuring up to
12.3 cm. Oral contrast is present within the cecum. No dilated
loops of small bowel are seen. Note is made of subtle
pneumatosis of the cecum with no wall edema. The transverse
colon measures up to 7.8 cm, only mildly dilated by size
criteria with no wall edema or pneumatosis. There is a focal
narrowing of the lumen of the sigmoid flexure with adjacent
peritoneal metastasis producing a low-grade obstruction at this
location. The descending colon is of normal size. There is an
inflammatory mass located at the mid-upper pelvis (series 5,
image 69). Rectal contrast material passes freely through the
rectum and sigmoid colon to the level of this inflammatory mass
(series 7, image 24). Approximately 1 liter of contrast was
given. There is no intra-abdominal free air. There is no
mesenteric or portal venous gas. The superior mesenteric artery,
celiac artery, and inferior mesenteric arteries all appear
patent.
CT OF THE PELVIS WITH IV CONTRAST: The bladder is unremarkable.
The patient is status post TAHBSO. There is no pelvic free
fluid. Rectum is unremarkable with rectal tube in place.
Bone windows reveal no suspicious lytic or sclerotic lesions.
There are degenerative changes.
IMPRESSION:
1) Dilatation of the cecum with measurement up to 12.3 cm, and
only mild dilatation of the transverse colon, with the
descending colon being of normal diameter. There is a focal area
of mild luminal narrowing at the splenic flexure with adjacent
mesenteric/serosal metastasis. More inferiorly, in the mid
pelvis there is an ill-defined mesenteric metastatic lesion,
with rectal contrast noted to clearly pass from the rectum
through the sigmoid colon up to the level of this mass. No
rectal contrast could be passed through this level. Notably,
there is residual stool present within the rectum and sigmoid
colon. Taken together, findings are suggestive of at least a
partial large bowel obstruction. Complete or high-grade
obstruction cannot be excluded as rectal contrast material was
not noted to pass through the level of this inflammatory mass.
Further evaluation could be performed with a barium enema to
assess for passage of contrast through this level.
2) Pneumatosis is noted of the cecum, without associated wall
edema. The significance of this finding is not certain. It is
not felt to be likely due to ischemia. Correlate clinically.
KUB
-------
Compared to CT torso of [**2183-10-30**]. There is diffuse distention of
the large bowel to the level of the distal sigmoid colon, at
which point there appears to be an abrupt cut off which
corresponds to an area of serosal implant seen on the prior CT
of [**2183-10-30**]. Overall, the findings are highly concerning for
distal large bowel obstruction. The large bowel measures up to
10 cm in maximum diameter involving the transverse and hepatic
flexure. No evidence of free intraperitoneal air.
IMPRESSION: Findings highly suspicious for distal large bowel
obstruction. Findings discussed with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] after the
study.
Portable TTE
---------------
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W057-1:08
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.46 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 210 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Suboptimal technical quality, a focal LV wall motion
abnormality
cannot be fully excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Borderline
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal
image quality - bandages, defibrillator pads or electrodes.
Suboptimal image
quality - body habitus.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is
borderline pulmonary artery systolic hypertension. There is a
prominent
anterior fat pad.
IMPRESSION: Preserved global and regional biventricular systolic
function.
CLINICAL IMPLICATIONS:
Based on [**2173**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Chest Xray
--------------
Admission [**2183-11-21**]
Portable AP chest radiograph compared to [**2183-3-2**]. The
heart size is mildly enlarged but stable. The mediastinal
contours are unchanged. The lungs are clear. There is no
sizeable pleural effusion. The left subclavian line tip is in
mid SVC.
IMPRESSION: No evidence of acute cardiopulmonary process.
[**2183-11-30**] Chest Xray
FINDINGS: Compared with [**2183-11-22**], there has been partial interval
clearing of the left lower lobe atelectasis/infiltrate/effusion.
No infiltrates are seen in the left mid/upper and right lung
fields.
Brief Hospital Course:
[**Known firstname 636**] [**Known lastname **] was admitted to the surgery service under the care
of Dr. [**First Name (STitle) 2819**] on [**2183-11-20**]. CT scan and KUB showed evidence of
large bowel obstruction. She was taken to the operating room on
HD 1 where she underwent an exploratory laparotomy, abdominal
colectomy, sigmoid mucous fistula and ileostomy, transgastric
gastrojejunostomy, tube placement and splenic flexure takedown.
She was transferred to the ICU intubated postoperatively. At
POD 1 she was tachycardic and with low urine output. She was
treated with fluid resuscitation and 1 unit PRBCs. She was on
day 2 of Kefzol/Flagyl.
At POD 2 she was extubated. Urine output was improved and she
was afebrile. Her antibiotics were discontinued. Hct was stable
at 29.6. Tube feeds were started at jejunostomy. Lasix was
started for diuresis. Blood glucose was evaluated and treated
with RSSI.
At POD 3 an ECHO was performed which was WNL with LVEF>55%. She
was transferred to the floor. Blood pressure was elevated and
continued to be controlled with IV metoprolol.
At POD 4 tube feedings continued with reports of high residuals.
A KUB was completed without evidence of obstruction. NGT
remained in place. Blood pressure was elevated. Diuresis
continued. Physical therapy was consulted.
At POD 5 there was return of bowel function. NGT was removed.
Diet was advanced to sips. She was febrile to 101.4 Urinalysis
was negative. Urine and blood cultures were sent. RIJ was
removed and tip sent for culture. CXR was negative.
At POD 6 she complained of nausea. Reglan was started and her
diet was advanced as tolerated. She was started on PO
medications.
At POD 7 she had high ostomy output. C. difficile was sent and
was negative. Fluid placement was provided to accommodate
output. Tube feeds were held to decrease output. She was
afebrile.
At POD 8 the ostomy output continued to be high at >4000cc.
Imodium and Metamucil were started. IV fluids were provided to
accommodate output. Blood, urine and line tip cultures from
POD5 were negative. Tube feeds were restarted.
At POD 11 she was doing well. Ostomy output remained high at
1575cc but was certainly improved from initial post operative
bowel function recovery. Metamucil and Imodium dosing was
increased. The tube feeds were at goal at 60cc/hr. She was
discharged in good condition to an acute rehabilitation center.
She was to follow up with Dr. [**First Name (STitle) 2819**] in clinic in [**12-23**] weeks.
Medications on Admission:
Taxol
Effexor XR 37.5
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for slow ostomy output.
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain.
4. Erythromycin 5 mg/g Ointment Sig: One (1) 1cm ribbon
Ophthalmic TID (3 times a day) for 5 days: Left eye.
5. Psyllium 1.7 g Wafer Sig: [**12-23**] Wafer PO TID (3 times a day).
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): 40mg SC daily.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for htn: Please hold for SBP <110 and
HR <65.
8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Ovarian Cancer
Large Bowel Obstruction
Postoperative Fever
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Persistent or worsening abdominal pain
* Increased or decreased output from ostomy
* Inability to urinate or dark urine
* Nausea or vomiting
* Redness or drainage at incision
* Any other concerns
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in clinic on [**2183-12-11**] 1:00pm.
The clinic is located on the [**Location (un) 470**] of the [**Hospital Unit Name **]
near the [**Hospital Ward Name 517**]. You may call ([**Telephone/Fax (1) 6347**] for any
questions for concerns.
Completed by:[**2183-12-3**]
|
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"V10.43",
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icd9cm
|
[
[
[]
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[
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14177, 14184
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,464
| 195,910
|
22553
|
Discharge summary
|
report
|
Admission Date: [**2132-8-6**] Discharge Date: [**2132-8-20**]
Date of Birth: [**2078-6-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
transferred for further care of hypoxic respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Mr. [**Known lastname **] is a 54 year-old male, recent ex-smoker, with a
history of ALL Ph chromosome positive on Gleevec status post
allo MUD BMT in [**11/2130**] with subsequent complete remission, also
with a history of COPD and probable CAD, being transferred from
[**Hospital3 5365**] for further management of above issues.
*
He presented to [**Hospital1 392**] on [**8-5**] with a 4-day history of fever up
to 102 at home, chills and shortness of breath. Per records, He
denied increased cough, but endorsed increased wheezing, and
reported right-sided pleuritic chest pain, mostly posterior. +
Orthopnea, no PND, no lower extremity swelling. On the night of
admission, he was reportedly found by his wife in the bathtub,
confused with possible slurred speech. He was brought by EMS to
[**Hospital1 392**].
*
At [**Hospital1 392**], initial vitals with BP 109/69, HR 133, RR 22, Sat 93%
on RA, up to 97% on 2L NC. Temperature not recorded. Labs were
remarkable for WBC 17.5 with bands 11%, neutrophils 82%, hct 36,
plt 109K. Sodium 131, creatinine 2.2. CK 1502, MB 4.12, troponin
0.33. ABG 7.44/28/64 on supplemental oxygen. CXR with probable
RLL pneumonia, and questionable effusion. He was started on CTX
and Azithromycin IV. While in the ED, he developed SVT with HR
to 190s, and was given Adenosine 6 mg IV X1, and Diltiazem IV
bolus with subsequent return to NSR in 90s. He was subsequently
placed on Diltiazem drip 5mg/hour. He later became hypotensive
with SBP to 70s systolic, drip was stopped, and he was given IVF
boluses. His antibiotic coverage was broadened with Vancomycin,
Levofloxacin and Flagyl. His blood pressure responded to the low
100s. A CT head without contrast was also obtained in the ED,
initially read as normal but an addendum made note of "acute to
subacute left upper anterior corona radiata hypodensity with
compression of the left lateral ventricle". He was started on
Heparin IV, and plan was made to proceed with a head MRI, which
was deferred pending rule out of a metallic foreign body. In
addition to he above, subsequent labs showed drop in platelets
to 71 and hematocrit to 26, INR 1.7, cardiac enzymes trending
down. He was transferred for further care.
Past Medical History:
1) pre-B-cell type ALL, Ph+: presented w/ fatigue [**6-3**]. found to
have ALL 90% cellularity w/ cytogenetics Ph +. Immunophenotyping
+ for CD34, HLA-DR, CD10, CD19, and dim CD4 consistent with
pre-B
-cell type ALL.
ECOG-E2993 protocol.
-phase I [**2130-6-29**]: w/ daunorubicin, vincristine,
prednisone,L-asparaginase, and then intrathecal methotrexate
-phase II [**2130-8-4**]: intrathecal methotrexate, cyclophosphamide,
cytarabine and 6- mercaptopurine.
-Induction: gleevac [**9-3**]
-[**11-3**]: MUD allo-BMT, donor CMV +, course c/b Grade II GVHD of
skin and GI tract tx w/ solumedrol
2) Alcohol abuse
3) Left hip synovial cyst
4) Bipolar disorder
5) Arthritis
6) ECHO: [**2130-11-2**]: EF 60% trivial MR
7) PFTs [**2130-11-2**]: FVC 74% of predicted, FEV1 68% of predicted,
FEV1/FVC ratio 92%, TLC 98% of predicted
8) HIV neg [**10-4**]
9) Several stable-appearing, tiny noncalcified pulmonary
nodules seen on CT scan [**11-3**], benign appearing
10) Emphysema
11) Mild sinus mucosal disease on CT scan [**12-6**]
Social History:
Mr. [**Known lastname **] is married and has 2 sons who live at home with him
in [**Name (NI) 392**] and 3 sons with his previous wife. [**Name (NI) **] admits to
alcoholism and says that he has not had a drink since [**2130-6-1**].
He smoked 2-4 packs per day for 36yrs but quit in [**2130-11-1**].
He did recently start smoking cigarrettes again. He admits to a
remote hx of polysubstance abuse including cocaine, downers,
marijuana, and crystal meth but denies IVDU. Works in a
hardware store in [**Location (un) 577**]. He used to work in maintenance and
was exposed to metal cleaning solvents a few years ago.
Family History:
Maternal aunt w/ cancer of unknown type.
Brother with cardiac dx.
Physical Exam:
Upon arrival to [**Hospital1 18**]:
VITALS: Tm 102 at OSH, BP 90s/60s, HR 80s, RR 26, Sat 93% on 3L
NC.
GEN: In moderate respiratory distress.
HEENT: Acessory muscle use. Dry MM.
NECK: JVP 3-4 cm ASA. No carotid bruit.
RESP: Right basilar dullness to percussion. Bronchial breathing
at right base, with egophony, whispered pectoriloquy. Diffuse
expiratory wheezing.
CVS: RRR. Normal S1, S2. No murmur appreciated.
GI: BS NA. Abdomen soft, non-tender. No hepatosplenomegaly.
EXT: Without edema, no calf tenderness.
NEURO: CN intact. Strenght 4+-[**4-4**] in all extremities, no focal
abnormality. Sensation to light touch intact. Speech intact,
good recall. Normal cerebellar exam.
Pertinent Results:
From [**Hospital3 5365**] in ED [**8-5**]:
WBC 17.5, bands 11%, Hct 36.1%, Plt 109, MCV 103.
Na 131, K 3.8, Cl 99, HCO3 20.3, BUN 30, Creat 2.2, glucose 163
AST 65, ALT 39, Alb 3.5, ALP 69, T bili 1.0.
*
RELEVANT IMAGING DATA:
CXR in ICU: RLL opacity with air bronchogram, probable right LL
effusion.
*
[**8-5**] CT HEAD without contrast: Initially read as normal, then
addendum: "Fluid densities in both middle ear cavities
consistent with low grade OM. No mastoiditis. Low density area
in left anterior upper corona radiata with compression of the
anterior [**Doctor Last Name 534**] left lateral ventricles. no midline shift, no
parenchymal hemorrhage. Impression: Ischemic infarction
involving upper anterior left [**Male First Name (un) 4746**] with associated compression of
the left lateral ventricle characteristic of acute or possibly
subacute event.
*
[**2132-8-5**] CXR 0100: Pathy RLL airspace disease. Addendum with
moderate-sized pleural effusion.
*
[**2132-8-5**] CXR 1100: Right pleural effusion, appears loculated.
Airspace disease in RLL, most consistent with atelectasis.
Probable COPD.
*
ECHO [**2132-8-5**]: Normal LV/RV size and function. Normal atria.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]/AS. Normal PV. No pericardial effusion.
*
Legionella Urinary Antigen (Final [**2132-8-6**]):
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
*
[**2132-8-10**]: MRI/A head: T2 hyperintensity involving the left
frontal white matter suggestive of old infarction. No abnormal
enhancing lesions are seen within the brain. T2 hyperintensity
within the mastoid sinuses suggestive of mastoiditis of
uncertain chronicity. Unremarkable Circle of [**Location (un) 431**].
.
[**2132-8-20**]: ECHO: Compared with the findings of the prior study
(images reviewed) of [**2132-8-6**], there is an improvement in LV
function
Brief Hospital Course:
In brief, the patient is a 54 year-old male with AML in
remission status post allo-BMT, COPD on chronic prednisone
therapy, and probable CAD, who presented with hypoxemic
respiratory failure.
.
1) Hypoxemic respiratory failure: The patient developed hypoxic
respiratory failure thought secondary to severe pneumonia with
exacerbation of COPD. At [**Hospital3 5365**] he was found to have a
RLL pneumonia. He was started on ceftriaxone and azitrhomycin
for community acquired pneumonia and steroids for COPD
exacerbation. After he developed hypotension, his antibiotics
were broadened to levofloxacin/metronidazole/vancomycin. These
antibiotics were continued at the time of transfer to [**Hospital1 18**].
After the legionella urine antigen resulted positive, his
antbiotics were tailored appropriately. Following transfer, he
did develop respiratory distress and was intubated. His chest
xray was concerning for cavitary lesion so sputum culture and
AFB samples were sent; these were negative. He underwent a
bronchoscopy while intubated that revealed normal airways. He
was successfully extubated after his agitation on the vent was
managed. Upon transfer to the BMT unit, his RR was 20 and O2 sat
99% on 50% face mask. He remained afebrile on the BMT floor and
his oxygen requirements were steadily reduced. By time of
discharge, he had normal oxygenation on room air. His steroids
were tapered down and he was discharged on 7.5 mg of prednisone
daily.
.
2) Delta Mental status: The patient initially presented with
reportedly slurred speech and had a head CT that was intially
concerning for an infarct. He was started on heparin drip. An
repeat head CT performed following transfer to [**Hospital1 18**] was
concerning for an infectious process and he was treated with
vancomycin/zosyn. A follow-up MRI revealed no evidence of
abscess formation, so the antibiotics for this indication were
discontinued. A neurology consult was obtained and thought the
brain lesion was more consistent with an old stroke however in
the abscence of confirmatory prior imaging this diagnosis could
not be proved definitely. The patient was more agitated since
extubation/off sedation. This was likely a delirium in the
setting of prolonged effects of sedating medications (both from
intubation), and infection in the setting of organic brain
disease. The patient required 1:1 supervision after extubation.
His mental status gradually cleared. By time of discharge he
was alert and oriented and able to appropriately discuss his
medical care. He was discharged to follow-up with neurology and
to have a repeat MRI to assess for stability of the brain
lesion.
.
3) Labile blood pressure: Following extubation the patient had
labile blood pressure. Initially he had SBPs to the 190s off of
sedation. He was treated with prn beta blockers. After
transfer, his blood pressure was 90/60 but was asymptomatic from
it. The hypotension was thought secondary to adrenal
insufficieny however, he underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test with an
post-stim change of ~13 units. He continued on a mild dose of
predinsone. There was no evidence of infection and an TTE prior
to discharge showed notable improvement from the intial study.
.
3) Acute on chronic RF: On [**Hospital 18**] hospital day 2 he developed
acute on chronic renal failure and a nongap acidosis so he was
started on bicarb [**Doctor First Name **] IVFs. His baseline creatinine was
1.2-1.6. There was no significant finding in the urine
sediment. His creatinine slowly improved, however, his
creatinine improvement stalled and upon discharge was 2.5 He
received supplemental free water to correct hypernatremia. He
will follow-up with nephrology upon discharge and to have his
serum chemistries checked at the [**Hospital Ward Name 1826**] 7 clinic.
.
4) COPD: The patient had a long smoking history prior to
undergoing BMT. He did resume smoking approximately 2 weeks
prior to discharge. He received Atrovent and Albuterol during
this hospital stay along with increased dose of steroids. He
was discharged on 7.5 mg of prednisone daily with plans to
ultimately resume his home dose of 5 mg daily.
.
5) Thrombocytopenia: On presentation to [**Hospital3 5365**] his
platelet count was >100,000. He was started on heparin for the
potential stroke and 13 hours later had a platelet count of
71,000. The heparin was stopped. After transfer, his platelets
continued to trend down reaching a nadir of 31,000. HIT
antibody was negative. Anti-platelet agents were held. His
platelet count gradually recovered reaching 73,000 prior to
discharge. The most likely cause of his thrombocytopenia was a
combination on non-immune heparin induced thrombocytopenia and
sepsis induced marrow suppression. If his platelet count does
not recover appropriately after discharge, a bone marrow biopsy
would be considered.
*
6) Anemia: The patient has a baseline chronic anemia that may be
secondary to Gleevec. He developed no evidence of acute blood
loss except for some trace guaiac positive stools. His Hct was
supported with occasional transfusions and was stable prior to
discharge.
*
7) Cardiac arrhythmia: The patient developed SVT while in [**Hospital1 **]. This was broken with diltiazem gtt. He remained in
sinus rhymth will on the BMT floor.
*
8) ALL in remission: The patient had no evidence of relapsed ALL
on peripheral blood samples. With concern for the
thrombocytopenia that developed in the hospital, a bone marrow
biopsy will be considered as an outpatient if his platelets do
not recover appropriately. Upon discharge he was re-started on
the Gleevec.
*
9) FEN: Following a successful swallowing evaluation after his
mental status cleared his diet was advanced as tolerated. His
hypernatremia was managed with free water boluses and his
electrolytes were repleted as needed.
.
10) Ppx: Pneumoboots, PPI, bowel regimen prn. PT consult
recommended that the patient receive home PT services.
.
11)Access: PIV, PICC
.
12) Code: Full.
.
13) Dispo: discharged to home with home PT services with
followup in hematology clinic, neurology clinic, and nephrology
clinic.
Medications on Admission:
Prednisone 5 mg PO QOD
Advair 250/50 1 inh [**Hospital1 **]
Spiriva
Albuterol inhaler prn
Fluconazole 200 mg PO QD
Gleevec 400 mg PO QD
Klonopin 0.5 mg Po QD to [**Hospital1 **]
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
3. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-3**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
6. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
Legionella Pneumonia
Acute Renal Failure
.
Secondary:
Delerium
Leukemia s/p bone marrow transplant
Discharge Condition:
good. ambulating with walker. afebrile. vital signs stable.
tolerating oral medications and nutrition.
Discharge Instructions:
You have been evaluated and treated for pneumonia, acute renal
failure and delerium all of which were improved by time of
discharge.
.
Please attend your follow-up appointments as scheduled. You
should have the MRI before your neurology appointment.
.
If you experience any concerning symptom particularly fevers to
> 100.5F, worsening cough or shortness of breath, please call
Dr.[**Name (NI) 14047**] office at [**Telephone/Fax (1) 3237**].
.
Please return to the [**Hospital Ward Name 1826**] 7 clinic on Friday [**2132-8-22**] at 10am
be seen and to have your blood drawn.
.
You need to schedule a follow-up appointment in [**Hospital 878**] Clinic
with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4638**] please call [**Telephone/Fax (1) 541**] to be seen
within one month.
Followup Instructions:
You have the following appointments scheduled for you:
1) Hematology/[**Hospital **] clinic: with Dr. [**First Name (STitle) **] on [**2132-8-26**] at
11:30am
2) Neurology: with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4638**] within one month -
see phone number above.
3) MRI of brain: [**2132-9-19**] please call [**Telephone/Fax (1) 327**] to confirm
4) Nephrology: with Dr. [**Last Name (STitle) 1366**] on [**2132-9-11**] at 4pm
5) [**Hospital Ward Name 1826**] 7 Clinic: [**2132-8-22**] at 10am
|
[
"204.01",
"491.21",
"518.81",
"482.84",
"V42.82",
"287.5",
"585.9",
"276.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14109, 14160
|
6988, 8465
|
358, 383
|
14312, 14417
|
5099, 6965
|
15253, 15769
|
4315, 4382
|
13407, 14086
|
14181, 14291
|
13204, 13384
|
14441, 15230
|
4397, 5080
|
259, 320
|
411, 2616
|
8480, 13178
|
2638, 3664
|
3680, 4299
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,422
| 125,387
|
36720
|
Discharge summary
|
report
|
Admission Date: [**2150-6-20**] Discharge Date: [**2150-6-26**]
Date of Birth: [**2110-12-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Increased seizure frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 39 year old left handed man with a history
of seizure disorder with recent increased frequency of
generalized convulsions, alcoholism, and prior head injuries who
presents to the ED with a total of [**5-24**] seizures in 1 day, 4 of
which were in the ED.
The history is obtained from the ED staff and the patient, as
the
EMS sheet has not yet been faxed to the [**Hospital1 18**] ED. The patient
drank 1 quart of vodka today (which is baseline), and was at the
Esplanade. The patient himself reports that he noticed an aura
described as a colored box which he could see out of both eyes,
then he was not sure what happened next (he says he thinks other
people would tell him he went "straight up"). He had [**12-19**]
generalized convulsions while at the Esplanade, and bystanders
called EMS since he was unresponsive and shaking his arms and
legs. EMS arrived, and the patient had 1 seizure while in the
ambulance associated with difficulty breathing, and he was
briefly bagged. It is not clear how long these seizures lasted,
or how much time elapsed between seizures. In the ED, the ED
staff witnessed a seizure (unclear duration) with decreased
responsiveness, and were about to intubate the patient when he
became more responsive and woke up. A Neurology Consult was
obtained.
Of note the patient was awake and able to relay a coherent
history initially despite having [**2-18**] seizures up to this point.
During the Neurology history taken by this author, at 4:15 pm
the
patient had his eyes roll in the back of his head with decreased
responsiveness and tonic extension of his back. He then rolled
over on his left side and then on to his stomach, with his head
and body between the gurney and the side rail. The patient was
immediately rolled back over, with upward right gaze deviation
and right beating nystagmus. He was not responsive to sternal
rub
or to his name. He did not have any rhythmic movements of his
upper or lower extremities. This lasted for approximately 3
minutes. He was given Ativan 2 mg IV x1, Ativan 4 mg IV x1, and
reloaded with Dilantin 1 gm IV. After this event, he was very
sleepy, but still oriented. Head CT was obtained which showed no
hemorrhage, but the ED staff reported that he had a 2 minute
seizure while in the scanner. Then, when back in his room, the
patient had another seizure associated with desaturation, and
the
patient was intubated by the ED staff.
Of note the patient was admitted to [**Hospital1 18**] [**Date range (3) 83036**] for 4
seizures in one day. Per the admission note, he felt unwell at
lunchtime, had his aura (see below), then did not remember
further events. He had 4 generalized seizures lasting [**12-19**]
minutes
with a few minutes between each seizures. He was taken to the
[**Hospital1 18**] ED, where he had 2 more seizures lasting 1-2 minutes each,
and was given Ativan 2 mg IV x2. Upon admission, he was on
Dilantin and Tegretol (unclear doses, likely Dilantin 100 mg tid
and Tegretol 200 mg [**Hospital1 **] or tid), but his Dilantin level was <0.6
and his Tegretol level was 1.6, EtOH level was 243. He was
loaded
with Dilantin 1 gm IV x1. Head CT showed no acute intracranial
abnormality. He was admitted to Neurology, and per Dr.[**Name (NI) 83037**] note on [**6-15**], "He had one event witnessed by a
nurse on the floor of what she described as a functional
seizure."
LTM on [**6-16**] showed no pushbutton events and no epileptiform
discharges. He was seen by Psychiatry during that admission, who
recommeded increasing his Fluoxetine to 40 mg daily. He was
instructed to discontinue Tegretol, and continue Dilantin 100 mg
tid. He was seen again by Neurology in the ED [**2150-6-17**] (the day
after discharge) for 2 seizures in one day lasting approximately
2 minutes. He had drunk 1 quart of liquor, and his EtOH level
was
317. His Dilantin level was subtherapeutic at 6.2, so he was
reloaded with 1 gram IV and discharged on Dilantin 100 mg tid.
He
was seen again for seizures in the [**Hospital1 18**] ED on [**2150-6-19**], but the
ED
notes that the patient "is not post-ictal and awake, alert
during
episodes."
Per Dr.[**Name (NI) 83038**] previous admission note, he has had a
seizure disorder since a teenager, which started after falling
off a horse. He described a similar aura of a colored box in
front of his eyes (see above), but said that he would have a
seizure approximately 30 minutes later. His seizure frequency is
generally one seizure every 3 weeks, but he has had a much
higher
seizure frequency recently for unclear reason.
Past Medical History:
-seizures as above
-EtOHism, denies hx of DT's but has had multiple
hospitalizations
for EtOH
-head injuries: 1 from falling off a horse, 2 from assault with
scar over L eyebrow
-L foot fx
-L hip frx from fall from horse with "steel bars" in place
-depression, anxiety, denies SI or prior SI attempts
-pancreatitis
-HTN
Social History:
Social History: He denies ciagerette, IV drug, cocaine, or
marijuana use. He has a history of alcoholism, and started
drinking at age 13 or 14. He drinks a pint of EtOH (vodka)
daily,
but has previously drank more. He has been in jail before for 3
DWIs and attempted burning of a dwelling. Homeless, previously
living [**Street Address(1) 32165**] Inn. Recently was served a restraining
order from his father. Currently unemployed, last worked in [**2140**]
in a warehouse.
Family History:
-mother: polysubstance abuse (heroine, EtOH, and cocaine)
-father: MI
Physical Exam:
(prior to intubation, and before the seizure witnessed by
Neurology in the ED-see above)
VS: temp 98.2, HR 81, bp 134/69, RR 11, SaO2 98% on RA
Genl: Awake, breath smells like alcohol, left posterior eyelid
hematoma (which is apparently old), agitated
HEENT: Sclerae anicteric, + conjunctival injection
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, intermittently uncooperative
with
exam (for example, when asked to squeeze hands bilaterally, he
squeezes this examiner's hands so hard that I had to ask the ED
staff to help pry his hand off of mine). Appears intoxicated.
Oriented to name, place ([**Hospital 86**] hospital), initially says he
does
not know the date but then knows it is the [**6-20**] holiday.
Speech is fluent, + dysarthria likely due to intoxication.
Follows commands to squeeze hands bilaterally.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
3 mm bilaterally. Blinks to threat bilaterally. Extraocular
movements intact bilaterally, does not follow finger in the
vertical plane, no nystagmus. Sensation intact V1-V3. Facial
movement symmetric. Palate elevation symmetric. Tongue midline.
Motor/Sensation: No observed myoclonus, asterixis, or tremor.
Keeps his bilateral upper extermities extended against gravity.
Will not keep his bilateral lower extremities raised against
gravity, but does follow command to cross his legs bilaterally.
Withdraws bilateral upper extremities to noxious, internally
rotates bilateral lower extremities to noxious.
Reflexes: 2+ and symmetric in biceps, brachioradialis, knees. 1+
and symmetric in triceps. No ankle clonus bilaterally. Toes
equivocal bilaterally.
Gait: Deferred
Pertinent Results:
Admission Labs:
[**2150-6-20**] 04:20PM
PLT COUNT-318
NEUTS-51.8 LYMPHS-38.5 MONOS-4.8 EOS-4.1* BASOS-0.8
WBC-7.0 RBC-3.96* HGB-13.3* HCT-39.7* MCV-100* MCH-33.5*
MCHC-33.4 RDW-14.7
ASA-NEG ETHANOL-403* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-2.1
[**Month/Day/Year **](SGPT)-35 AST(SGOT)-43* LD(LDH)-231 ALK PHOS-82 TOT BILI-0.2
DIR BILI-0.1 INDIR BIL-0.1
GLUCOSE-109* UREA N-7 CREAT-0.9 SODIUM-146* POTASSIUM-3.2*
CHLORIDE-98 TOTAL CO2-28 ANION GAP-23*
[**2150-6-20**] 06:00PM URINE
RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0
BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
[**2150-6-20**] 07:20PM CEREBROSPINAL FLUID (CSF)
WBC-0 RBC-4* POLYS-32 LYMPHS-48 MONOS-18 EOS-2
<ALBUMIN>-20.9
PROTEIN-30 GLUCOSE-72 LD(LDH)-21
MRI of head w/ wo contrast:
1. Heterogeneous enhancing lesion within the right tonsil could
represent
abscess or malignancy such as squamous cell carcinoma.
2. Mild-to-moderate diffuse parenchymal volume loss. This can be
seen in
patients with AIDS dementia complex.
CT Neck with contrast [**2150-6-23**]
IMPRESSION: Right palatine tonsil lesion incompletely assessed
on this study
as the degree of extension and enhancement is difficult to
assess. The
parapharyngeal fat in the region however, is normal and there
are no
abnormally enlarged lymph nodes. Would recommend MRI of the neck
without and
with contrast for further evaluation and characterization.
EEG: 07 05:
IMPRESSION: No evidence of electrographic status. This is an
abnormal
EEG due to the absence of normal awake pattern. Instead, the
record was
a mixture of beta and delta rhythms that were symmetric. This
appearance is most consistent with an iatrogenic-induced
encephalopathy.
No electrographic seizure activity was seen.
Brief Hospital Course:
Mr [**Known lastname 83035**] is a 39 year old left handed homeless man with a
history of seizure disorder with recent increased frequency of
generalized convulsions, alcoholism, and prior head injuries
admitted on [**6-20**] in the ED status post multiple witnessed
seizures.
# Seizures: The patient was initially admitted to the ICU,
intubated and sedated with propofol. His initial dilantin level
was noted to be sub-therapeutic on dilantin and tegretal. MRI
of the head was unremarkable. He was intubated for
approximately 24 hours until the morning of [**6-22**]. He did not
experience episodes of tachycardia and hypertension nor did he
require benzodiazepines during his time in critical care unit.
Over the remaining hospital course, he had no identified
seizures. Due to his known alcohol abuse and his reports of
non-compliance with medications which are required more than
once a day, it was felt that the patient would benefit from a
simpler medication regimen. He was subsequently weaned from his
dilantin and started on Zonisimide. He tolerated the transition
well. He was discharged with instructions to follow up with his
primary care doctor in the next few weeks. Additionally, he was
scheduled for follow-up in [**Hospital 878**] Clinic.
# Tonsil Mass: An enhancing lesion on the right tonsil was
incidentally identified on MRI scan. A dedicated CT scan of the
neck was unable to exclude any mass but there was little
evidence to suggest any pathologic mass. ENT was consulted and
did not identify any abnormalities on physical exam. It was
suggested that the patient follow-up in the [**Hospital **] clinic in the
month.
# Ethanol Abuse: Mr. [**Known lastname 83035**] has a long, documented history
of alcohol abuse. At the time of admission, his EtOH level was
400. Over the course of his hospitalization, he had no signs of
withdrawal. The patient was seen by social work but declined
any intervention. He was informed that continued alcohol abuse
could be fatal, especially in the setting of his seizure
disorder.
# Anxiety/Depression: Treatment with fluoxetine and trazedone
was continued.
Medications on Admission:
Dilantin 100 mg tid
Trazodone 50 mg qhs
Amylase-Lipase-Protease 30,000-8,000- 30,000 unit [**Unit Number **] tablet tid
with meals
Pantoprazole 40 mg Tablet daily
Fluoxetine 40 mg daily
Thiamine HCl 100 mg daily
Folic Acid 1 mg daily
(however, his bag in the ED contains):
Dilantin 100 mg tid (filled [**2150-6-16**])
Carbamazepine 200 mg [**Hospital1 **]
Fluoxetine 20 mg and 40 mg daily
Diltiazem ER 120 mg daily
Metformin 500 mg daily
Campral 666 mg tid
Trazodone 50 mg daily
Viokase 8 or 16, 1 tablet before meals
Omeprazole 20 mg daily
Vitamin B1 100 mg daily
Folic Acid 1 mg daily
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
2. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig:
One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
4. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Dilantin Extended 100 mg Capsule Sig: As directed Capsule PO
once a day: 2 tablets once a day for the next 4 days, then 1
tablet daily for 7 days. Last dose to be on [**2150-7-7**].
8. Zonisamide 100 mg Capsule Sig: As directed Capsule PO once a
day: Take 3 tablets once a day for the next 2 days, then take 4
tablets daily to prevent seizures.
Disp:*120 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder
Ethanol Intoxication
Anxiety/Depression
Discharge Condition:
The patient was hemodynamically stable and without evidence of
focal deficit on neurologic examination.
Discharge Instructions:
You were admitted after having seizures. It was felt that your
seizures were related to a combination of you not taking your
medications and to drinking alcohol. Because you reported
difficulty taking medications multiple times a day, we have
switched you over to a new anti-seizure medication called
Zonisimide, which is taken once a day. You will need to taper
down your dilantin over the next 2 weeks. Please follow the
instructions provided.
It is extremely important that you take your medications as
directed. It is also important that you avoid alcohol. By
doing these things, you can prevent further seizures and the
risks of harm that they cause.
You were found to have an abnormality on your right tonsil and
were evaluated by the ear nose and throat doctors. It is
recommended that you follow up in the [**Hospital **] clinic in 1 month to
re-evaluate.
You should follow-up with your primary care doctor to discuss
your medication changes. Call your doctor or seek medical
attention if you develop any new or concerning symptoms.
Followup Instructions:
PCP:[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 70076**]
Follow-up Next week as you have planned
ENT: To evaluate the finding on your tonsil
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38669**]
[**7-29**], 12pm
Neurology:
Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 44**]
[**8-10**], 4:00pm
*******PLEASE CALL AND RESCHEDULE IF YOU CANNOT ATTEND AN
APPOINTMENT*********
Completed by:[**2150-6-29**]
|
[
"474.9",
"577.1",
"V60.0",
"291.81",
"345.3",
"300.4",
"303.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13399, 13405
|
9713, 11850
|
345, 351
|
13506, 13612
|
7713, 7713
|
14713, 15235
|
5790, 5861
|
12488, 13376
|
13426, 13485
|
11876, 12465
|
13636, 14690
|
5876, 6329
|
278, 307
|
379, 4938
|
6871, 7694
|
7729, 9690
|
6368, 6855
|
6353, 6353
|
4960, 5282
|
5314, 5774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,541
| 168,683
|
14258
|
Discharge summary
|
report
|
Admission Date: [**2121-7-5**] Discharge Date: [**2121-7-12**]
Date of Birth: [**2084-1-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Leukine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Right Lower extremity weakness
Major Surgical or Invasive Procedure:
[**7-7**]: T11 Vertebrectomy
History of Present Illness:
Mrs. [**Known lastname 42367**] is a 37 y/o female who underwent excision of a 0.7
mm thick superficial spreading melanoma from her right shoulder
in [**2112**]. In [**2115-5-6**], she developed a recurrence in the right
mandible and staging CT scan revealed multiple nodules in the
lung, liver and spleen which were FDG avid on PET scan. Biopsy
revealed metastatic melanoma. She was enrolled in the [**First Name8 (NamePattern2) **]
[**First Name5 (NamePattern1) 25368**]
[**Last Name (NamePattern1) 42368**] protocol in [**2115-6-5**] and received four cycles
of iochemotherapy and twelve months of maintenance IL-2 therapy
completed [**2116-9-4**]. In [**2117-12-6**], she developed spinal
cord compression in the thoracic and lumbar spine due to a large
soft tissue mass presumed to be melanoma treated with radiation
therapy. This was followed by one cycle of high-dose IL-2
completed on [**2118-4-10**]. In late [**2118**], she had radiation to a hip
lesion. In [**2119**], she then had radiation to one of her spine
lesions. She then developed a new spine lesion, which was
causing cord compression. She had extensive spinal surgery with
rods placed and reconstruction of her T11-T12 vertebrae. She did
well for the next 1-2 years. In [**11-11**], she noted a soft tissue
nodule in her right side with torso CT on [**2121-4-5**] showing a right
superior pelvic subcutaneous enhancing nodule worrisome for a
metastatic focus. FNA on [**2121-6-4**] reveals poorly differentiated
carcinoma consistent with melanoma. Spine MRI and radiation
therapy records were reviewed by Dr. [**Last Name (STitle) 3929**] of radiation
oncology and Dr. [**Last Name (STitle) 548**] of neurosurgery with conscensus being
that she has spinal cord compression without neurologic
compromise. She cannot have further radiation and would need
surgical decompression is she develops symptoms. Over the past
3-4 days she has noted increasing weakness in the right leg;
however, she
denies falls or bowel/bladder incontinence. She also describes
a vague numbness over the right leg below the knee. She returns
to the ED for evaluation of these symptoms.
Past Medical History:
metastatic melanoma s/p IL-2 therapy, radiation therapy, and
recent start of CTLA-4 antibody compassionate use trial
PSH:
[**2119**] spinal metastatic lesion resection and placement of
thoraco-lumbar fusion construct
[**2112**] melanoma resection
Social History:
LIVES WITH HUSBAND / PARENTS IN TOWN FOR ASSISTANCE
Family History:
non-contributory
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-6**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5- 4+ 4+ 5-
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally except mild numbness to light touch below
the right knee
Reflexes: B T Br Pa Ac
Right 2+---------
Left 2+---------
Propioception intact; negative hoffmans; no clonus
Toes downgoing bilaterally
Rectal exam: normal sphincter control; no saddle anesthesia
Pertinent Results:
Head CT([**7-5**]):IMPRESSION:
1. No significant change in the 1.3 x 0.9 cm enhancing lesion in
the left occipital condyle, presumed metastatic lesion in the
left occipital condyle.
2. Osseous integrity of this lesion is not well assessed on the
present study.
3. No new lesions are noted.
MRI, T-Spine([**7-5**]):IMPRESSION:
1. Study severely limited due to hardware artifacts.
2. Within these limitations, there is a large mass, with
compression fractures involving the T11 and T12 vertebral
bodies, causing severe canal stenosis and severe cord
compression. As before, accurate assessment in change is limited
due to artifacts.
CT Torso([**7-6**]):CT OF THE CHEST WITH IV CONTRAST: The heart and
great vessels are unremarkable. There is no mediastinal, hilar,
or axillary lymphadenopathy. Within the lungs, there are a few
scattered small nodules. Specifically, within the right upper
lobe, there are two 2 mm subpleural nodule (2:15), and (2:27).
Within the left lower lobe, there is a 6 mm somewhat linear
appearing opacity (2:28). There is also a 3 mm nodule within the
left lower lobe (2:45). Within the left upper lobe, there is a 2
mm pulmonary nodule (2:33). These findings are unchanged from
[**2121-4-5**]. Studies further back are not available for
comparison. There is no pleural effusion. Airways are patent to
the subsegmental level.
CT OF THE ABDOMEN WITH IV CONTRAST: Area of hypodensity adjacent
to fissure of ligamentum teres likely reflects perfusion
differences. The liver is enlarged, without a focal lesion. The
spleen, pancreas, adrenal glands, and gallbladder are
unremarkable. Within the kidneys, there is an ill-defined low
attenuation within the medial upper poles bilaterally, right
greater than left, similar in appearance to [**2121-4-5**], which
likely reflects renal cortical atrophy. Assessment is slightly
limited due to streak artifact from adjacent hardware. The
stomach and bowel are unremarkable. There is no intra- abdominal
lymphadenopathy, free fluid, or free air.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, uterus,
and rectum are unremarkable. Multiseptated left ovarian cyst is
again noted, measuring up to 3 cm in maximum dimensions. There
is a trace amount of free fluid within the pelvis.
OSSEOUS STRUCTURES AND SOFT TISSUE STRUCTURES: Spinal rods are
present throughout the thoracic spine, with bipedicular screws
spanning T5-6, T8-10, and L1-2. Evaluation is slightly limited
due to metallic streak artifact. Again noted is an abnormal soft
tissue density within the T11-T12 vertebral bodies, extending
into the central canal, better assessed on MRI of the thoracic
spine obtained concurrently. Additionally, there is destruction
of the vertebral bodies at these levels.
Left T11 pedicle screw appears to terminate within the medial
pleural region.
There continues to be a trabecular irregularity of the right
sacral ala as well as within the superior aspect of the right
acetabulum and adjacent ilium. Sclerotic focus within the left
ilium is also unchanged.
Within the soft tissues, there is a 1.8 cm x 1.8 cm enhancing
nodule located within the subcutaneous tissues of the right
pelvis (2:86), immediately superior to the right iliac [**Doctor First Name 362**].
Additionally, there is irregular stranding of the right axillary
soft tissues, similar in appearance to [**2121-4-5**].
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
RADIOLOGY Final Report
MR [**Name13 (STitle) **] W &W/O CONTRAST [**2121-7-8**] 10:52 AM
MR [**Name13 (STitle) **] W &W/O CONTRAST
Reason: please scan T7-L1, s/p vetebrectomy for tumor
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with malignant melanoma with mets
REASON FOR THIS EXAMINATION:
please scan T7-L1, s/p vetebrectomy for tumor
CONTRAINDICATIONS for IV CONTRAST: None.
MR THORACIC SPINE
HISTORY: 37-year-old woman with malignant melanoma, spinal
metastasis, status post tumor resection.
TECHNIQUE: Sagittal pre- and post-gado T1, T2, STIR, and axial
post-gado T1- and T2-weighted images of the thoracic spine were
obtained.
FINDINGS: Comparison is made to CT of the thoracic spine from
the same date as well as the preoperative MR of the thoracic
spine from [**2121-7-5**].
This study is markedly limited due to patient motion and
artifacts from the posterior cervical spinal fusion
instrumentation. Air is seen within the T11 vertebrectomy
defect. No large residual tumor is identified, but the
evaluation again is markedly limited.
There are bilateral moderate-sized pleural effusions with
adjacent atelectasis.
IMPRESSION: Post-surgical changes at the T11/12 level. No
definite gross tumor residual remaining, although the evaluation
is markedly limited by patient motion and artifacts from
instrumented fusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2121-7-8**] 3:25 PM
X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
RADIOLOGY Final Report
CT T-SPINE W/O CONTRAST [**2121-7-8**] 10:07 AM
CT T-SPINE W/O CONTRAST
Reason: Please evaluate T7-L1; post-op vertebrectomy.
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with
REASON FOR THIS EXAMINATION:
Please evaluate T7-L1; post-op vertebrectomy.
CONTRAINDICATIONS for IV CONTRAST: None.
CT THORACIC SPINE
HISTORY: 37-year-old female post-upper vertebrectomy.
TECHNIQUE: CT of the thoracic spine was obtained with 3.75-mm
axial and 2-mm coronal and sagittal reconstructions.
FINDINGS: Comparison is made to a spinal arteriogram from
[**2121-7-7**], CT of the chest from [**2121-7-6**] and MR of the thoracic spine
from [**2121-7-5**].
There is a new air-fluid level within the T11 vertebrectomy
defect. The previously seen large mass in this region is no
longer visualized, although the evaluation is somewhat limited
due to streak artifacts from the adjacent spinal hardware.
New subcutaneous staples are seen in the midline. There are also
small areas of subcutaneous emphysema of the posterior soft
tissues.
Again seen is posterior instrumented fusion with a left-sided
pedicle screw at T5, bilateral pedicle screws at T6, T8, T9,
T10, L1 and L2. There is a crossbar at the T6 and T12/L1 levels.
The right T8 pedicle screw extends minimally into the right
spinal canal. The left T10 pedicle screw is located
inferolateral to the pedicle. There are two metallic bars
extending from the T11 to the L1 vertebral bodies. The T11 and
T12 vertebral bodies show areas of destruction/surgical
resection with a bone graft material within the vertebrectomy
defect.
There is no abnormal angulation of the thoracic spine. No other
suspicious lytic lesions are seen.
There is a right internal jugular central line whose tip is in
the superior vena cava. The visualized lungs show bilateral
moderate-sized pleural effusions and scattered band-like
densities which may represent atelectasis or scarring.
IMPRESSION: Status post surgical resection of large T11 mass,
now with postoperative air-fluid level in this region. There are
no gross tumor residual although the evaluation is limited due
to streak artifact from the adjacent orthopedic hardware.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2121-7-8**] 3:25 PM
X
X
X
X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[**2121-7-9**] 01:45AM
Report Comment:
Source: Line-tlcl
COMPLETE BLOOD COUNT
White Blood Cells 6.4 K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.01* m/uL 4.2 - 5.4
PERFORMED AT WEST STAT LAB
Hemoglobin 9.3* g/dL 12.0 - 16.0
PERFORMED AT WEST STAT LAB
Hematocrit 27.5* % 36 - 48
PERFORMED AT WEST STAT LAB
MCV 91 fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 30.8 pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 33.7 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 13.3 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 154 K/uL 150 - 440
PERFORMED AT WEST STAT LAB
[**2121-7-9**] 01:45AM
Report Comment:
Source: Line-tlcl
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 13.3 sec 10.4 - 13.4
PERFORMED AT WEST STAT LAB
PTT 29.9 sec 22.0 - 35.0
PERFORMED AT WEST STAT LAB
INR(PT) 1.1 0.9 - 1.1
PERFORMED AT WEST STAT LAB
Test Name Value Units Reference Range
[**2121-7-9**] 01:45AM
Report Comment:
Source: Line-tlcl
RENAL & GLUCOSE
Glucose 109* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 9 mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.8 mg/dL 0.4 - 1.1
PERFORMED AT WEST STAT LAB
Sodium 136 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.1 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 100 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 30 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 10 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 8.3* mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 2.6* mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 1.7 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
Brief Hospital Course:
Pt was seen and admitted through the emergency room for c/o of
progressive weakness to RLE x 3-4 days. This was not associated
with any bowel or bladder incontinence. She is know to have
metestatic melenoma to the spine and has had RT to this area in
the past. She comae into the ED for eval of the new symptoms.
MRI of the Thoracic spine was obtained and it was noted that she
had involvement of the T11 body with cord compression. She was
pre-op'd and scheduled for surgery for the following am.
She underwent the procedure and awoke from anesthesia without
complication. She was placed in the ICU overnight [**Doctor Last Name **] #1. PCA
was placed for pain management and this was discontinued on
[**Doctor Last Name **]#2 as well as her foley catheter. The foley needed to be
replaced due to urinary retention and a liter was drained after
the catheter was replaced. On [**2121-7-10**] she had bladder training
all day. The catheter was removed in the am of [**2121-7-11**] and the
patient was able to void on her own that evening.
She was seen by PT for ambulation and safety eval's. They
continued to see her daily. As of [**2121-7-11**] they felt that she
would require home PT. They re-evaluated her on [**2121-7-12**] and
recommended>>>>>>>>>>>>>>>>>
Post operatively she had a CT scan of the T spine for eval of
instrumentation as well as an MRi to evaluate residual tumor
burden. Those results are listed in this summary. CT torso was
perfomed for staging.
The remainder of her stay was uneventful. Her diet and activity
were advanced.
Medications on Admission:
HYDROCODONE-ACETAMINOPHEN [VICODIN] - 5 mg-500 mg Tablet - [**2-5**]
Tablet(s) by mouth q4-6h as needed for pain
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
Dosage uncertain
CALCIUM - (Prescribed by Other Provider) - Dosage uncertain
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider)
-
Dosage uncertain
IBUPROFEN [ADVIL] - (OTC) - 200 mg Tablet - 2 Tablet(s) by
mouth
three times a day as needed for pain
MULTIVITAMIN - (OTC) - Dosage uncertain
VITAMIN E - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Metastatic Melanoma to Thoracic Spine / T11
Urinary Retention
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**11-18**] days for removal of your
staples.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in [**5-11**] weeks.
??????You will need x-rays prior to your appointment.
THE APPOINTMENTS LISTED BELOW ARE WERE PREVIOUSLY SCHEDULED AND
ARE LISTED FOR YOUR CONVENIENCE
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-7-29**] 2:00
Provider: [**Name10 (NameIs) 22181**] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-7-29**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-7-29**] 2:00
Completed by:[**2121-7-12**]
|
[
"788.20",
"198.3",
"198.5",
"E878.8",
"V10.82",
"997.09",
"336.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.59",
"03.4",
"80.99",
"88.49",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
15454, 15501
|
12763, 14329
|
301, 332
|
15607, 15616
|
3743, 7364
|
17001, 17868
|
2861, 2879
|
14941, 15431
|
8928, 8951
|
15522, 15586
|
14355, 14918
|
15640, 16978
|
2894, 2894
|
231, 263
|
8980, 12740
|
360, 2505
|
2908, 3104
|
3119, 3724
|
2527, 2776
|
2792, 2845
|
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