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7,752
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22225
|
Discharge summary
|
report
|
Admission Date: [**2168-6-1**] Discharge Date: [**2168-6-2**]
Date of Birth: [**2137-3-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a very unfortunate 31 yo male who had an initial
diagnosis of metastatic poorly differentiated carcinoma
w/lesions in the gallbladder, biliary tree, and hepatic
metastasis in [**2167-8-26**]. Initial workup demonstrated an
abnormal pancreatic drainage, which
likely lead to the development of his malignancy. Onc felt
gallbladder was primary site.
.
Patient was treated initially w/ 5 cycles of gemcitabine and
cisplatin (last dose [**2168-1-26**]), requiring dose reductions due to
cytopenias. Imaging from [**2-/2168**] showed increased disease. The
patient was switched to Xeloda in [**2168-2-23**] x1, complicated by
ascites and sbp. [**2168-4-24**] CT showed new pulmonary nodules,
increased size and number of multiple hepatic metastasis with
occlusion of the portal vein as well as the superior mesenteric
vein due to lymphadenopathy and worsening ascites. Over his
chemotherapy course, he had evidence of progressive portal
hypertension, esophageal varices, requiring multiple banding and
at least three admissions for upper GI bleeds and hyponatremia.
.
Last admit was [**2168-5-7**] for sepsis and positive blood cultures
w/enterococcus. TEE showed thickening of the aortic valve and
endocarditis. Patient sent to rehab on penicillin and gentamicin
were for four weeks. Onc team has tried to switch patient to
palliative care, but family wants all atempts at treatment and
in fact got a second opinion at [**Hospital1 4601**]. Per onc notes,
[**Hospital1 **] staff have talked to family multiple times about
patients terminal status and expressed that he is atively dying.
Family wants "more chemotherapy, Liver transplant"
.
At [**Hospital1 **], pain progressed and patient placed on PCA pump. He
has required weekely large volume paracentesis of [**3-30**] liters for
relief. Over the past week patient has become more obtunded and
had a Na of less than 120. He also developed worsening renal
failure with a Cr over 5 concerning for hepatorenal syndrome.
.
In the ED, found to be lethargic. Had diarrhea today for first
time. Hypotensive to 90/60, responded quickly to 500 cc IVF.
Blood cultures from [**Hospital1 **] were positive for GNR and GPC in
clusters. He had Cipro and Vanco dosed prior to arrival at ED.
Put on vanc, levo, flagyl, ceftriaxone in the ED. In the ED got
cx, FFP and paracentesis (diagnostic only). Started on 1U prbc.
Abdominal US done, per radiology there is so much tumor they
cannot assess liver or portal vein. Lab data concerning for wbc
of 33, lactate of 9, INR 2.5, greatly elevated LFTs, Cr of 5.4,
albumin 1.9.
.
Past Medical History:
Past Medical History:
1. Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes. With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most
recently [**2168-1-21**]). On Gemcitabine/Cisplatin, last dose [**2168-2-4**].
Most recently received Xeloda x1 [**2-27**].
2. Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6. HBV, low viral load, with varices in lower 1/3 esophagus
Social History:
Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Lived with his brothers until last admit, at
rehab since then. Per report, brother is POA.
Family History:
DM in both parents, no cad, cancer. 10 siblings, none with
cancer
Physical Exam:
PE: 98.0 112/60 72 16 100% RA
Gen: Lethargic, cachectic, arousable
HEENT: +scleral icterus, jaundice, mmd, neck supple
CV: rrr 1/6 murmer rusb
Pulm: ant clear, dull at bases
Abd: + caput madusa, huge ascites w/fluid wave, tender
throughout, more over RUQ. hypoactive bs
Ext: 4+ edema to knees, thin throughout. PICC in place,
non-tender.
Rectal: (Per ED) red blod from visible hemorrhoids mixed w/brown
stool.
Pertinent Results:
CBC:
[**2168-6-1**] 05:20PM BLOOD WBC-33.6*# RBC-3.66* Hgb-8.4* Hct-27.8*
MCV-76* MCH-23.0* MCHC-30.3* RDW-17.9* Plt Ct-165
[**2168-6-2**] 04:30AM BLOOD WBC-26.6* RBC-4.23* Hgb-10.6*# Hct-33.1*
MCV-78* MCH-25.0* MCHC-32.0 RDW-17.7* Plt Ct-125*
[**2168-6-1**] 05:20PM BLOOD Neuts-85* Bands-9* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2168-6-1**] 05:20PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-1+ Target-1+
[**2168-6-2**] 04:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Burr-2+ Tear
Dr[**Last Name (STitle) 833**]
[**Name (STitle) 2591**]:
[**2168-6-2**] 04:30AM BLOOD Plt Ct-125*
[**2168-6-2**] 04:30AM BLOOD PT-20.6* PTT-39.2* INR(PT)-2.8
[**2168-6-1**] 05:20PM BLOOD PT-18.9* PTT-60.4* INR(PT)-2.4
Chemistries:
[**2168-6-1**] 05:20PM BLOOD Glucose-92 UreaN-68* Creat-5.4*# Na-121*
K-5.6* Cl-86* HCO3-15* AnGap-26*
[**2168-6-2**] 04:30AM BLOOD Glucose-60* UreaN-71* Creat-5.4* Na-122*
K-6.4* Cl-92* HCO3-10* AnGap-26*
Calcium-7.7* Phos-7.2*# Mg-1.7
[**2168-6-2**] 04:30AM BLOOD Calcium-8.1* Phos-8.5* Mg-1.9
[**2168-6-1**] 05:49PM BLOOD Lactate-9.0*
LFTs:
[**2168-6-1**] 05:20PM BLOOD ALT-412* AST-1140* AlkPhos-463*
Amylase-90 TotBili-5.3*
[**2168-6-2**] 04:30AM BLOOD ALT-376* AST-967* LD(LDH)-949*
AlkPhos-464* TotBili-6.2*
[**2168-6-1**] 05:20PM BLOOD Albumin-1.9*
CXR:Left pleural effusion and left lower lobe atelectasis,
improved
since the last examination.
.
RUQ US:Heterogeneous and nodular liver consistent with
metastatic disease. No definite intrahepatic biliary ductal
dilatation. Large ascites.
Brief Hospital Course:
1. Sepsis: This 31 yo M with poorly differentiated metastatic
GB carcinoma presents with progressive liver failure, acute
renal failure, active GI bleeding, SBP, bacteremia, possible
endocarditis, and profound 3rd spacing. At presentation he was
in Sepsis with a lactate of 9, the etiology was thought to be
secondary to peritonitis (~400 polys in peritoneal fluid) from
erosions of mets into bowel. Pt also had diarrhea concerning
for C. diff given recent ABX and severe leukocytosis. Recent
endocarditis and new bacteremia make it likely patient may have
endocarditis again. PICC line does not appear infected however
may be source. On admission his Hypotension was initially
treated with fluid boluses. He was continued on Vanco dosed by
levels given severe renal failure, ceftaz, levo, and flagyl. IV
hydration was held overnight given the concern for severe third
spacing into his abdomen. The morning after admission he was
hypotensive and appeared moribund. He was treated with IV
fluids with no improvement. His electrolytes were markedly
abnormal. Several family meetings were held to discuss
prognosis and it was explained that he was extremely ill and
prognosis was extremely poor. The family and medical team
agreed that CPR was not medically indicated with advanced
carcinoma and organ failurs. All agreed that comfort was most
important goal. Care then shifted to primary goal of comfort.
He was started on a PCA for pain control. He was comfortable
throughout the day. He developed increased hypotension and
bradycardia. He passed away at 6:45 PM. The family members
were present.
2. Renal failure: This was felt to be secondary to hepatorenal
syndrome. His medications were all renally dosed. His
electrolytes were markedly abnormal
.
3. GIB: BRBPR likely secondary to known varices and tumor
eroding through stomach. Received FFP and 2 units prbc's upon
admission. His HCT was followed during his admission.
4. Liver failure/possible biliary obstruction: U/S done in the
ED unable to asses portal vein or ducts given extensive tumor
burden as per radiology. LFTs much worse than prior. Felt that
he might have portal vein thrombosis.
.
5. Hypervolemic Hyponatremia secondary to liver failure/ascites.
Urine lytes were sent. He was bolused as needed for
hypotension.
.
6. Pain: He was treated with a Dilaudid PCA which was titrated
up to control his pain.
.
7. Social Work: Palliative care and social work were involved
to help with end of life issues.
.
8. Communication: There was continual communication with the
patient and his family. His Brother is the HCP.
.
Medications on Admission:
Meds at rehab: Fentanyl patch; Prevacid; Mg Oxide; remeron;
nadolol; Dilauded PCA; cipro; vanco;
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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"567.2",
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icd9cm
|
[
[
[]
]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,529
| 187,654
|
53800
|
Discharge summary
|
report
|
Admission Date: [**2184-3-9**] Discharge Date: [**2184-4-2**]
Date of Birth: [**2112-5-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
MVC, b/l ankle fractures
Major Surgical or Invasive Procedure:
[**2184-3-9**] - ex-fix L ankle; closure scalp lac
[**2184-3-11**] - ORIF R ankle, washout L ankle
[**2184-3-18**] - Trach
[**2184-3-24**] - PEG
[**2184-3-26**] - Debridement L foot/heel. Longer trach
History of Present Illness:
71M s/p MVC vs guard rail as unrestrained driver, swerved with
significant intrusion and prolonged extrication of 45-minutes.
Patient was GCS at scene with significant bleeding from scalp
noted and large blood loss at scene. Patient was brought to
[**Hospital1 18**] by [**Location (un) **] with ancef given en route, hemodynamically
stable. GCS was 15 on arrival to ED. Surveys and radiographic
workup revealed a right closed ankle fracture, left open ankle
fracture
with significant deformity, and large scalp laceration actively
bleeding. Patient's left foot was mildly cooler than the right
with only a DP doppler signal (baseline exam unknown).
Past Medical History:
PMH: HTN, HL, ? OSA
PSH: Umbilical hernia repair
Social History:
married, has daughter, occasional EtOH
Family History:
NC
Physical Exam:
Admission Physical:
T 99.1 P 98 BP 118/44 RR 18 O2 94% 4L
anxious, in pain, AOx3
airway intact, breathing stable, HD stable
superficial scalp laceration
trachea midline without crepitus
chest wall stable, no crepitus
abdomen soft/nontender/nondistended
pelvis stable
no gross deformity upper extremities
Severe deformity of left ankle, with foot angled ~90 degrees
medially with respect to leg. Extensive open area on lateral
aspect with exposed muscles and tendons. DP by Doppler. Unable
to
assess PT due to deformity. Deformity of right ankle, closed.
DP
and PT by Doppler. Remainder of extremities nontender and with
full ROM.
Discharge Physical:
Interactive, usually following commands
tracheostomy in place, on trach mask
lungs CTAB
RRR, no r/m/g
abd
Pertinent Results:
Imaging:
-[**3-9**] Trauma CXR and Pelvic XR: No abn
-[**3-9**] Bilateral ankle fx: Dislocation of the right ankle with
lateral displacement of the talus in relation to the tibia.
There is a distal fibular fracture with a distal fragment
displaced posteriorly. There is a talonavicular dislocation and
mild widening at the calcaneocuboid joint. There is also likely
a medial malleolus fracture. There is a displaced proximal fifth
metatarsal fracture. The left ankle is dislocated with the talus
displaced medially compared to the tibia. There is also
displaced fracture of the medial malleolus. There is likely
less-well visualized fracture of the lateral malleolus as well
as the distal fibula. There are proximal and distal fifth
metatarsal fractures.
-[**3-9**] CT Head: Small right vertex subgaleal hematoma
-[**3-9**] CT Cspine: No fracture
-[**3-10**] CTA chest/abd/pelvis: no PE, no obvious abnormality
-[**3-10**] TTE: unremarkable, LVEF>55%, RV wnl
-[**3-13**] CXR: Lsided opacities
-[**3-13**] CT Head: No acute intracranial process
-[**3-15**] MRI/MRA: 1. Few small white matter infarcts seen
bilaterally, suggestive of embolic disease. No evidence of
anoxic brain injury. 2. Patent carotid and vertebral arteries.
-[**3-17**] Chest CT: 1. Multiple peripheral pulmonary opacities could
represent septic emboli. Aggressive search for a source of
infection is recommended. 2. Increased bibasilar consolidation
of the dependent lungs, most likely representing atelectasis,
though an infectious process is possible. 3. New small bilateral
pleural effusions.
-[**3-18**] TEE: No valvular vegetation, abscess, or intracardiac
mass/thrombus visualized
-[**3-23**] LENI: negative for DVT
-[**3-23**] Bilateral ankle xrays: Hardware well aligned, no
dislocations
-[**3-28**] Overall appearance is similar. Possible very slight
interval improvement in the CHF findings.
Admission Labs -
[**2184-3-9**] 12:55PM WBC-23.0* RBC-3.91* HGB-11.9* HCT-36.3*
MCV-93 MCH-30.5 MCHC-32.9 RDW-13.0
[**2184-3-9**] 06:00PM GLUCOSE-192* UREA N-27* CREAT-1.5* SODIUM-143
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-20* ANION GAP-18
[**2184-3-9**] 12:55PM LIPASE-25
Brief Hospital Course:
71 M s/p MCV with bilateral ankle fractures admitted to the TICU
intubated. In brief, he made steady improvements over his 24 day
stay and was discharged to a ventilator rehabilitation on
[**2184-4-1**]. Below is his hospital course through his stay in the
Trauma ICU:
He was taken emergently to the OR for wash out and splinting of
his fractures and repair of his scalp laceration. Intraop, he
required phenylephrine with 3L crystalloid and 3U PRBC given to
wean off. In PACU, he was noted to be very agitated with mild
hypotension. On arrival to TICU, he was hemodynamically stable
but confused. Subsequently, had hypoxic event leading to PEA s/p
CPR and epi x 2, difficult intubation.
N: Following intubation the pt was kept sedated on fentanyl and
propofol. He was administered PRN haldol due to agitation. It
was difficult to establish an adequate neuro exam because of
sedation and agitation and on HD 4 a continuous EEG was ordered.
The EEG was significant for periodic epileptiform discharges,
concernign for seizure activity. A neurology consult was
obtained and the patient was started on keppra. An MRI was
obtained which was significant for a few small white matter
infarcts seen bilaterally, suggestive of embolic disease. There
was no evidence of anoxic brain injury and the carotid and
vertebral arteries were patent. Final read on EEG was
encephalopathy with no focal or epileptiform features. It was
felt that the Keppra was adequately treating previously recorded
epileptiform activity and it was recommended he stay on Keppra
until follow-up in one month with Dr [**Last Name (STitle) **]. He continued to
be agitated and over the course of the remaider of his ICU stay
he was tried on various regimens of haldol, ativan, precedex,
ativan, clonidine, and seroquel for his agitation. Ultimately
the patient's mental improved by the end of his first week and
he was kept on a stable dose of seroquel and clonidine for
intermitent agitation. He continued to improve and by discharge
was interactive, following commands though still mildly
agitated. He requires Trazodone to sleep some nights.
CV: He had a brief PEA arrest post-op. Due to continued fevers a
CTA Chest was done on HD 9. The read was concerning for septic
emboli. A formal TEE was obtained and was significant for no
valvular vegetation, abscess, or intracardiac mass/thrombus
visualized. He otherwise had no cardiovascular issues.
Pulm: Following PEA arrest immediately post op the patient was
intubated. The patient was initially weaned to CPAP but due to
respiratory distress he was placed on APRV and CMV through
various portions of his initial hospitalization. He was placed
on a prolonged course of vancomycin and inhaled tobramycin.
Given his inability to wean from the vent he had a tracheostomy
performed on [**2184-3-18**]. Following the procedure he was slowly
weaned to CPAP and then to trach color which he was tolerating
well at the time of discharge.
GI: On HD 5 tube feeds were initiated through an OGT. The
patient was able to tolerate full feeds and they were only
discontinued prior to procedures. On [**2184-3-24**] the patient
underwent a percutaneous gastrostomy tube placement as a more
permanent solution to long term feeding. He was able to tolerate
full feeds via the PEG through the rest of his hopitalization.
He will be discharged on Isosource 1.5 Cal Full strength;
Additives: Beneprotein, 35 gm/day, Goal rate: 45 ml/hr.
GU: No active issues. His urine output was adequate throughout
hospitalization. He was on a Lasix drip HD [**3-13**] as he mobilized
the fluid from his admission resuscitation. He then was given
intermittent lasix for several days and transitioned to
lisinopril. His Foley catheter was removed [**2184-4-2**].
Heme: He had a persistent mild anemia. This was believed to be
due to anemia of chronic disease. He was transfused a total of
14 units PRBC: 11 units peri-operatively, and a subsequent 3
units over the following 3 weeks. He was started on iron
supplementation.
ID: He was treated for two weeks with broad spectrum antibiotics
as he was spiking fevers and had a rising WBC. His BAL from
[**2184-3-16**] showed
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.
MORGANELLA MORGANII. 10,000-100,000 ORGANISMS/ML.
It was unclear if he was spiking fevers from this pneumonia or
from his left leg, which had shown signs of worsening necrosis.
Following debridement of his left leg on [**2184-3-26**], his fevers
subsided and he was narrowed to Ancef for coverage.
Extrem:
He presented with bilateral lower extremity fractures. His right
lower extremity underwent ORIF on admission and has done well.
His left leg had significantly more soft tissue damage and a
more impressive fracture pattern. He was placed in an an
external fixator on that side and underwent several debridements
during his stay. His final debridement was [**2184-3-26**] by Dr [**First Name (STitle) 1022**] at
which time he was left with an exposed gastroc tendon and
calcaneous. The prospect of a BKA was discussed with his family,
and the decision was made to continue dressing changes and have
him see Dr [**First Name (STitle) 1022**] in follow-up for consideration of flap coverage.
Per orthopedic surgery, he is to be non-weight bearing on both
lower extremities.
Medications on Admission:
Lisinopril 40', Simvastatin 20' HS, Metoprolol tartrate 150'',
Diltiazem ER 240
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 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
3. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
6. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day): Continue until follow-up with neurology.
13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia .
15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
18. cefazolin 10 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Respiratory failure
Traumatic brain injury with delerium
Bilateral lower extremity fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of bed with assistance. NWB bilateral lower
extremities.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*New chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*Vomiting and cannot keep down fluids or your medications.
*Dehydration due to continued vomiting, diarrhea, or other
reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*Blood or dark/black material when you vomit or have a bowel
movement.
*Burning when you urinate, blood in your urine, or urinary
discharge.
*Your pain doesn't improve in [**7-18**] hours or is not gone within
24 hours. Call or return immediately if your pain becomes
severe, changes location or moves to your chest or back.
*Shaking chills or fever greater than 101.5F or 38C.
*An acute change in your symptoms, or new symptoms that concern
you.
*Increased pain, swelling, redness, or drainage from any
incisions you may have.
*Any of the warning signs listed below.
Followup Instructions:
* Neurology - Please follow-up with Dr [**Last Name (STitle) **] on [**5-4**] 3:00pm.
[**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
COGNITIVE NEUROLOGY-TESTING (SB). Call [**Telephone/Fax (1) 1690**] if there are
any questions.
* Plastic Surgery - Please follow-up with Dr [**First Name (STitle) 1022**] in one week,
call
([**Telephone/Fax (1) 36264**] to schedule.
|
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icd9cm
|
[
[
[]
]
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[
"43.11",
"78.17",
"86.59",
"33.22",
"79.36",
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"31.1",
"78.58",
"79.66",
"79.06",
"84.72",
"96.72",
"86.22",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
11471, 11518
|
4330, 9619
|
326, 528
|
11655, 11655
|
2155, 2921
|
12848, 13291
|
1352, 1356
|
9750, 11448
|
11539, 11634
|
9645, 9727
|
11843, 12825
|
1371, 2136
|
262, 288
|
556, 1207
|
3169, 4307
|
11670, 11819
|
1229, 1280
|
1296, 1336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,745
| 159,596
|
51497
|
Discharge summary
|
report
|
Admission Date: [**2169-11-23**] Discharge Date: [**2169-11-29**]
Date of Birth: [**2109-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2169-11-23**] Coronary artery bypass graft surgery x 3 (Left internal
mammary artery > left anterior descending, Saphenous vein graft
> RAMUS, saphenous vein graft > posterior descending artery)
[**2169-11-23**] re operation for bleeding
History of Present Illness:
60 year old gentleman with hyperlipidemia, diabetes and
hypertension who developed epigastric pain over labor day
weekend. He underwent a stress test which was positive showing
left anterior descending coronary artery ischemia. He
subsequently underwent a cardiac catheterization on [**2169-10-31**]
which revealed significant two vessel coronary artery disease
with normal left ventricular function. He is now referred for
surgical revascularization.
Past Medical History:
Hypertension
Diabetes mellitus
Dyslipidemia
GERD
Remote history of GI bleed (? Dieulafoy lesion)
Degenerative disc disease
Attention deficit disorder
Anxiety disorder - Lifelong and significant
Poor oral/dental health
s/p 3 corneal transplants
s/p Hemorrhoidectomy
Social History:
Lives with: Alone. Divorced with 2 grown children.
Occupation: Self Employed
Cigarettes: Smoked no [X]
ETOH: < 1 drink/week [X]
Illicit drug use: None
Family History:
no Premature coronary artery disease
Physical Exam:
General: Well-developed male in no acute distress- appearing
slightly disheveled.
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] poor dentitian
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: NO Left: NO
Pertinent Results:
ECHO:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results at time of surgery.
Admisssion Labs:
[**2169-11-23**] 09:48AM HGB-12.6* calcHCT-38
[**2169-11-23**] 01:30PM FIBRINOGE-226
[**2169-11-23**] 01:30PM PT-14.3* PTT-24.7 INR(PT)-1.2*
[**2169-11-23**] 01:30PM PLT COUNT-224
[**2169-11-23**] 01:30PM WBC-13.1*# RBC-3.93* HGB-11.3*# HCT-33.3*
MCV-85 MCH-28.9 MCHC-34.0 RDW-12.8
[**2169-11-23**] 02:29PM UREA N-19 CREAT-1.0 SODIUM-139 POTASSIUM-4.7
CHLORIDE-108 TOTAL CO2-24 ANION GAP-12
Discharge Labs:
[**2169-11-29**] 03:38AM BLOOD WBC-7.3 RBC-3.82* Hgb-11.2* Hct-32.1*
MCV-84 MCH-29.3 MCHC-34.8 RDW-14.1 Plt Ct-281
[**2169-11-29**] 03:38AM BLOOD Plt Ct-281
[**2169-11-25**] 02:18AM BLOOD PT-16.3* PTT-28.1 INR(PT)-1.4*
[**2169-11-29**] 03:38AM BLOOD Glucose-120* UreaN-28* Creat-1.0 Na-133
K-4.3 Cl-99 HCO3-25 AnGap-13
[**2169-11-25**] 09:29AM BLOOD TotBili-1.2 DirBili-0.5* IndBili-0.7
Radiology Report CHEST (PA & LAT) Study Date of [**2169-11-28**] 10:14
AM
Final Report : PA and lateral chest compared to post-operative
chest radiographs since [**11-23**]:
Pulmonary edema has cleared since [**11-26**]. Moderate
enlargement of the
post-operative cardiomediastinal silhouette has been stable
since [**11-23**] following the preceding drainage of hematoma.
Small bilateral pleural
effusions are probably unchanged since most recent prior
studies. There is no pulmonary or mediastinal vascular
engorgement, no pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 106773**] was a same day admission scheduled to be admitted
and taken to the operating room on [**2169-11-23**]. At that time he and
underwent Coronary artery bypass grafting x3, please see the
operative report for details, in summary he had: left internal
mammary artery grafted to left anterior descending, reverse
saphenous vein graft to the ramus intermedius and to the
posterior descending artery. He tolerated the surgery well and
post-operatively was transferred to the cardiac surgery ICU in
stable condition. Later on POD#0 he was taken back to the
operating room for post-operative bleeding, no source was
identified. Post-operatively he was again admitted to the ICU
intubated and sedated. He awoke neurologically intact and was
weaned from the ventilator and extubated. After having a stable
hematocrit post-operatively he was noted to have a hematocrit
drop, GI was consulted since he had a history of
gastrointestinal bleeding in the past, they found no evidence of
GI bleeding. His HCT remained stable there after. All tubes,
lines and temporary pacing wires were removed per cardiac
surgery protocol. The remainder of his hospital stay was
uneventful, he was started on aspirin, beta blockers, and
statin. He was diuresed toward his pre-operative weight. He was
evaluated by physical therapy for strength and [**Hospital 106774**]
rehab was recommended. On POD 6 he was discharged to
rehabilitation at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab and Nursing Center in
[**Location (un) 47**]. All appointments and instructions were advised.
Expected length of stay at rehab is less than 30 days
Medications on Admission:
Atenolol 150mg twice daily
Zocor 20mg daily
Omeprazole 20mg twice daily
Metformin 500mg twice daily
Adderall 20mg three times daily
Clonazepam 1mg at bed time
Cymbalta 120mg daily
Eye drops: Restasis and Pilocarpine
Aspirn 81mg daily
Fenofibrate 134mg daily
Diazepam 5mg as needed
Discharge Medications:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic HS (at bedtime): right eye.
6. atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): right eye.
14. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for congestion.
15. Adderall 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
16. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Anxiety disorder
Attention deficit disorder
Hypertension
Diabetes mellitus type 2
Dyslipidemia
Gastroesophageal reflux disease
Degenerative joint disease
s/p 3 corneal transplants
s/p Hemorrhoidectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, mild erythema, no drainage
Leg Right - healing well, no erythema or drainage, ecchymosis in
thigh area
Edema trace bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2169-12-27**] 1:30 in the [**Hospital **]
medical office building [**Hospital Unit Name **], [**Doctor First Name **]
Wound check cardiac surgery office [**Telephone/Fax (1) 170**] on [**2169-12-5**]
10:45
Cardiologist: Dr [**Last Name (STitle) 32255**] [**Telephone/Fax (1) 6256**] [**12-20**] at 3:00pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 106775**] [**Telephone/Fax (1) 106776**] in [**5-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2169-11-29**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.15",
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icd9pcs
|
[
[
[]
]
] |
9462, 9602
|
5821, 7484
|
292, 535
|
9880, 10155
|
2175, 4852
|
10995, 11765
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1491, 1530
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7816, 9439
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9623, 9859
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4868, 5798
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1545, 2156
|
242, 254
|
563, 1017
|
1039, 1306
|
1322, 1475
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,814
| 134,054
|
33803
|
Discharge summary
|
report
|
Admission Date: [**2145-4-9**] Discharge Date: [**2145-4-15**]
Date of Birth: [**2064-8-29**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Lisinopril / Morphine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
hepatic mass
Major Surgical or Invasive Procedure:
[**2145-4-9**] L hepatectomy, gold fiducial seed placement [**2145-4-9**]
History of Present Illness:
80-year-old male who underwent a routine chest x-ray and
subsequently
CT scan of the chest that demonstrated a mass in the liver
precipitating a CT scan of the abdomen. This demonstrated a
5.4 x 4.9 cm poorly marginating heterogeneous mass. A CT
guided liver biopsy on [**2-22**] demonstrated infiltrating
poorly differentiated adenocarcinoma. A chest CT scan
demonstrated no evidence of pulmonary metastases. A
colonoscopy, upper GI and small-bowel follow-through did not
demonstrate any abnormal lesions. He is completely
asymptomatic and was referred for evaluation. A triphasic CT
scan of the abdomen at [**Hospital1 18**] demonstrated a mass as primarily
in the medial segment of the left lobe (segment 4) but does
extend into the left lateral segment more superiorly. There
is encasement of the left and middle hepatic veins. The
lesion extends close to the bifurcation of the right anterior
and left portal vein. There is an early branch of the right
posterior portal vein, however, the portal vein does not
appear to be involved. The tumor appears to be more cephalad
to the portal vein. There is no evidence of extrahepatic
spread. The lesion did appear to be resectable with a left
hepatic lobectomy and measured approximately 5.4 x 4.9 cm.
His AFP was 4.7, CA19-9 10 and CEA less than 1. He has
provided informed consent for hepatic resection. He underwent
a thorough cardiac evaluation preoperatively and was cleared
for surgery. He is now brought to the operating room for left
hepatic lobectomy.
Past Medical History:
diverticulitis, hyperlipidemia, cardiac murmur,, CAD s/p MI in
his 50s. PSH: CABG [**2123**], knee surgery [**2136**],partial colectomy
[**2141**] with temporary colostomy with subsequent reversal. States
this was not for a malignancy
Social History:
He is a widower and retired carpenter. He has six children. One
has polio, one has had an MI, and the third has type I DM, and
the other three children are healthy
Family History:
Mother died of a stroke at age 83, father died of heart failure
at age 89. Strong family history of cardiac disease.
Physical Exam:
97.7 62 152/70 20 99%RA, 5'3", 85.4kg
A&O, no scleral icterus
Neck free range of motion. no carotid bruits
Lungs bibasilar rales
Cor RRR, 2/6 sem loudest @ rsb radiating to bilat neck.
abd obese, normal bowel sounds, no HSM or masses,
ext venostasis changes, no edema\
Neuro: no asterixis
Pertinent Results:
On Admission: [**2145-4-9**]
WBC-18.1* RBC-4.29* Hgb-13.1* Hct-38.9* MCV-91 MCH-30.6
MCHC-33.7 RDW-13.1 Plt Ct-241
PT-14.8* PTT-28.6 INR(PT)-1.3*
Glucose-125* UreaN-17 Creat-0.8 Na-142 K-4.3 Cl-108 HCO3-23
AnGap-15
ALT-246* AST-293* AlkPhos-53 TotBili-1.5
Albumin-3.3* Calcium-7.8* Phos-3.8 Mg-1.9
On Discharge: [**2145-4-13**]
WBC-12.1* RBC-3.66* Hgb-11.1* Hct-33.3* MCV-91 MCH-30.4
MCHC-33.4 RDW-13.3 Plt Ct-171
Glucose-108* UreaN-18 Creat-0.5 Na-138 K-3.9 Cl-104 HCO3-30
AnGap-8
ALT-98* AST-34 AlkPhos-62 TotBili-0.7 Albumin-2.5*
Brief Hospital Course:
On [**2145-4-9**] he underwent left hepatic lobectomy, caudate lobe
resection, placement of gold fiducials and intraoperative
ultrasound for intra-hepatic cholangiocarcinoma. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative report for further
details. A JP drain was placed. EBL was 1200cc and this was
replaced with crystalloid. He was extubated in the OR then
transferred directly to the SICU for monitoring. On POD 1, the
patient was transferred to the floor from the SICU with no
adverse events.
Neuro: An epidural was in place for pain control. When
appropriate, the epidural was removed, and the patient was put
on IV Dilaudid. When the patient was tolerating PO pain
medications, he was transitioned to oral medication with good
relief of his pain.
CV: The patient was monitored on telemetry throughout his stay.
He received perioperative beta blockade. When the patient
complained of nausea, EKGs were obtained, which were stable.
The patient was put on home medications when he was tolerating
adequate oral intake.
Pulm: Good pulmonary toilet and early ambulation were
encouraged.
GI/GU/FEN: The patient's intake and output were closely
monitored throughout his stay. The patient's IVF were adjusted,
and the patient was bolused when appropriate post operatively to
maintain adequate urine output and vital signs. On POD1, the
patient received sips of clears, which was advanced to clears on
POD2. The patient's Foley was removed when the patient was
urinating adequately. On POD 3, the patient was transitioned to
a regular diet, whcih he tolerated well, and was restarted on
most home medications (except cholesterol lowering medications,
which were to be started on discharge given the patient's
transaminitis). The patient's JP drain was left in place as the
output was bilious. He was instructed on home JP care and how
to record outputs for follow up, as the patient will be
discharged to rehab with the JP in place. On POD 5, the patient
complained of nausea briefly, for which an EKG was obtained, and
was stable. A JP bilirubin was obtained as well, which was
34.7.
Heme: The patient's CBC was routinely followed; the patient did
not require a post operative transfusion
ID: The patient's fever curve and white blood count were
closely examined for signs of infection. The patient's wound
was monitored as well, without signs of infection.
Other: A physical therapy consult was obtained, who recommended
that the patient be discharged to a rehabilitation facility;
both the patient and his family were in agreement. On POD 5,
the central venous line was removed.
Path report as follows: Portal lymph node (A):Fragments of
lymph node(s): No tumor.
II. Liver, left lobe (B-G):Cholangiocarcinoma, Mild steatosis.
Liver: Resection Synopsis MACROSCOPIC
Specimen Type: Left lateral segmentectomy.
Focality: Solitary
Tumor Size:Greatest dimension: 7.5 cm. Additional dimensions:
7.0 cm x 4.4 cm.
MICROSCOPIC
Histologic Type: Cholangiocarcinoma, intrahepatic.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Solitary tumor with no vascular invasion.
Regional Lymph Nodes: pNX: Cannot be assessed.
Lymph Nodes None in specimen 2
Distant metastasis: pMX: Cannot be assessed.
Margins:Parenchymal margin: Involved by invasive carcinoma.
(Less than 0.5 mm).
Bile duct margin: Cannot be assessed. Other margins: Cannot be
assessed
Clinical: Liver lesion; cholangiocarcinoma. Specimen
submitted-1. Portal lymph node 2. Liver lobe. Prior biopsy
outside showed tumor immunostains positive for CK-7, negative
for CK20, HepPar and TTF-1.
On discharge, the patient was doing well, tolerating a regular
diet. His vital signs were stable, and the patient was
afebrile. He was ambulating and voiding without difficulty.
The patient was discharged to a rehabilitation facility for
further care.
Medications on Admission:
simvastatin 40 mg', Zetia 10 mg', atenolol 25 mg', zantac 300
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Per Insulin Flowsheet.
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
5. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. 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
8. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
9. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Cholangio CA
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to eat, increased abdominal pain,
incision redness/bleeding/drainage or jaundice.
Continue JP drain care as instructed. Please record all daily
drain outputs, and bring information to your follow up
appointment with Dr. [**Last Name (STitle) **]. Please call Dr[**Name (NI) 1369**] office if
drainage increases in volume, develops purulence or foul odor.
It is currently bilious (greenish/yellow) in appearance due to
bile leak which is expected to decrease over time
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-Your staples will be removed during at your follow up
appointment.
-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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-17**] lbs) until your follow up appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 78154**] Call to schedule
appointment
Please follow up with Dr. [**Last Name (STitle) **] Wednesday [**4-21**] @ 4:20pm; call
his office at ([**Telephone/Fax (1) 3618**] for any questions or changes.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"412",
"155.1",
"272.4",
"788.5",
"997.5",
"V45.81",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.3"
] |
icd9pcs
|
[
[
[]
]
] |
8467, 8560
|
3376, 7336
|
302, 378
|
8617, 8624
|
2819, 2819
|
10816, 11255
|
2374, 2492
|
7448, 8444
|
8581, 8596
|
7362, 7425
|
8648, 9234
|
9250, 10793
|
2507, 2800
|
3131, 3353
|
250, 264
|
406, 1919
|
2833, 3117
|
1941, 2177
|
2193, 2358
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,228
| 103,379
|
51076
|
Discharge summary
|
report
|
Admission Date: [**2170-12-15**] Discharge Date: [**2170-12-24**]
Date of Birth: [**2112-10-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2170-12-20**]: PICC line placement
History of Present Illness:
58yo F well-known to Hepatobiliary / Transplant / West 1
surgical service from recent admission [**Date range (1) 106084**] for
obstructive jaundice ultimately leading to a new diagnosis of
cholangiocarcinoma with metastatic disease to her sigmoid colon.
She was treated with biliary stenting, currently with two bare
metal stents within CBD / L hepatic duct (placed endoscopically)
and within R hepatic duct (placed percutaneously), as well as
colonic stent. She was discharged two days ago to begin
outpatient chemotherapy. Overnight she experienced a fever to
102, presented to an OSH ED, was noted to be hypotensive and
bolused 3L of IVF, then transferred here for resumption of care.
In the ED here, she was persistently hypotensive and
tachycardic,
and bolused ~5 add'l liters of IVF, with marginal response
90s/50s.
ROS: Pt denies abdominal pain except for low-grade pain along
RUQ
which she has had since last admission. Denies nausea, emesis,
diarrhea, constipation. Denies chest pain, shortness of breath,
or cough. Denies dysuria or frequency.
Past Medical History:
PMH: Cholangiocarcinoma, Hypothyroidism, R Kidney stones
PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,
Tonsillectmy and adenoidectomy, Colonoscopy many years ago
Social History:
Lives alone, sister who lives out of state and a brother.
Reports some friends near her home. Negative ETOH/tobacco
Family History:
Mother had lung cancer (+tob). father is alive. No significant
history of colon, liver, gallbladder, pancreas cancer.
Physical Exam:
102.1, 149, 115/57, 24, 94 on NRB
A&Ox3, slightly dyspneic
coarse BS BL, no rales
RRR except tachy. no murmurs.
soft, slightly distended. non-tender to palpation. no masses.
WWP, no C/C/E.
Foley in place (scant med-yellow urine), PIV x2.
Pertinent Results:
[**11-30**]: Colon, distal sigmoid, "mass at 20 cm"; biopsy
(A):Comment: The tumor is present within the lamina propria, and
is without a recognizable precursor lesion. The malignant cells
are immunoreactive for cytokeratin 7 and are non-reactive for
cytokeratin 20 and CDX-2. The immunophenotype and the lack of a
precursor lesion are not characteristic of a primary colonic
carcinoma. Given the imaging findings metastatic
pancreaticobiliary carcinoma is likely though other primary
sites, including gastric and gynecologic, could be considered
[**11-26**] ERCP: ADENOCARCINOMA.
Labs on Admission: [**2170-12-15**]
WBC-41.9*# RBC-3.15* Hgb-9.4*# Hct-27.6* MCV-88 MCH-29.9
MCHC-34.2 RDW-14.0 Plt Ct-376
PT-17.2* PTT-29.6 INR(PT)-1.6*
Glucose-115* UreaN-11 Creat-0.8 Na-138 K-3.4 Cl-103 HCO3-24
AnGap-14
ALT-58* AST-52* AlkPhos-479* TotBili-1.1 Lipase-38
Albumin-2.2* Calcium-6.1* Phos-2.7 Mg-1.0*
On Discharge: [**2170-12-24**]
WBC-16.9* RBC-2.76* Hgb-8.3* Hct-24.2* MCV-88 MCH-30.2 MCHC-34.4
RDW-14.5 Plt Ct-595*
Glucose-86 UreaN-7 Creat-0.6 Na-138 K-3.8 Cl-103 HCO3-28
AnGap-11
ALT-13 AST-12 AlkPhos-185* TotBili-0.6
Calcium-8.2* Phos-3.5 Mg-2.0
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**12-15**] with concerns for
septic shock. She is a 58 yo female with cholangiocarcinoma,
likely metastatic to the colon (with a colonic mass s/p stent
placement) and s/p multiple biliary stents, currently with two
bare metal stents within CBD / L hepatic duct (placed
endoscopically) and within R hepatic duct (placed
percutaneously) on [**12-11**]. She was transferred from an OSH with
temperature of 102.
The patient was admitted to the ICU, given multiple fluid
boluses, and found to have 2/2 blood cultures growing Gram
Negative Rods, later E Coli sensitive to zosyn. She was placed
on pressors until her blood pressure stabilized. She was
started on cipro, vanco, flagyl, and zosyn presumptively; the
vanc and cipro discontinued following results of the blood
cultures. She was continued on the zosyn for the bacteremia and
flagyl for presumptive C. difficile colitis.
She underwent a CT scan of the abd to search for a presumed GI
source of her bacteremia. It revealed persistent and unchanged
hepatic lesions compatible with metastatic disease, colitis of
the right ascending colon and the distal transverse /splenic
flexure (thickened colonic wall), a small amount of ascites and
free pelvic fluid, and a RML infiltrate.
On [**12-17**] she was awoke tachycardic, tachypneic, hypertensive and
with rigors w/fever 101 presumed to be still septic, that
resolved w/zopenex nebulizer and demerol. CXR revealed
increasing b/l opacities concerning for pulmonary edema. ABG
7.38/32/62/20. She underwent a CTA of that chest that revealed
bilateral multifocal consolidations, worsening pleural
effusions, now moderate on the left and large on the right,
Anasarca, ascites, persistent hepatic lesion compatible with
metastatic cholangiocarcinoma, lucency in vertebral body of L1,
worrisome for metastasis.
The likely source of her bacteremia is either pneumonia or
colitis. She was treated empirically for both with zosyn and
flagyl; follow up blood cultures on [**12-17**] were without growth.
Following normalization of her hemodynamics and control of her
pneumonia, the patient was aggressively diuresed for b/l pleural
effusions (thought secondary to fluid resuscitation vs
parapneumonic vs malignant, though no tap performed). Her
effusions improved over time, and on [**12-23**] she was without any
oxygen requirement at rest and ambulating.
The patient also complained of loose stool; she was tested for C
dif that was negative x5, though was treated empirically with
flagyl. The diarrhea has decreased in frequency over her
hospitalization.
The patient diet was steadily advanced; she underwent a
nutrition consult who recommended a regular diet with
supplements. By the time of discharge she was tolerating a
regular diet, though remained with some residual nausea treated
well with zofran PRN.
She developed a superficial thrombophlebitis of her right upper
extremity that resolved with heat packs.
She had a PICC line placed on [**12-15**] in the RUE for antibiotic
delivery.
At the time of dictation the patient is without pain, on room
air both at rest and while ambulating, has documented negative
blood cultures ([**12-17**]), is tolerating a regular diet, urinating
well and without other complaints. The patient does remain with
a leukocytosis today of 16.9 down from a high of 41.9 on [**12-15**],
though she appears clinically stable. She is being discharged
on Ceftrixaone x 1 week and flagyl for 14 days since documented
negative blood cultures. Switched to Ceftrixaone prior to
discharge.
Finally, the patient does have metastatic cholangiocarcinoma to
the sigmoid colon, and so further symptoms are likely to occur
in the future. The patient is scheduled to begin outpatient
chemotherapy at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital.
Medications on Admission:
cipro 500' (x2wk), actigall 300'', protonix 40', levothyroxine
25', senna 8.6'', phenergan 5 q6:prn, dilaudid [**5-6**] q3:prn,
colace 100'', ambien 5'prn
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous every eight (8) hours as needed for line flush:
after flushing picc with normal saline 10ml.
Disp:*50 doses* Refills:*1*
2. Saline Flush 0.9 % Syringe Sig: One (1) Injection every
eight (8) hours for 1 weeks.
Disp:*50 * Refills:*1*
3. Picc Line Supplies
supply 1 week of tubing, dressing kits, pump
4. CeftriaXONE 1 gram Recon Soln Sig: One (1) unit Intravenous
Q24H (every 24 hours) for 7 days.
Disp:*7 unit* Refills:*0*
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Phenergan 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Septic shock with E coli bacteremia
Pneumonia
Cholangiocarcinoma
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever greater
than 101, chills, nausea, vomiting, diarrhea, increased
abdominal apin, yellowing of skin or eyes, inability to take
adequete food and fluids.
Drink enough fluids to keep urine light yellow
Continue Ceftriaxone once daily through [**2170-12-31**] using Right
PICC
No Heavy lifting
No Driving if taking narcotic pain medication
Continue warm packs to right arm PRN comfort at PICC insertion
site
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2171-1-9**]
3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2170-12-24**]
|
[
"008.45",
"197.7",
"197.5",
"285.9",
"038.42",
"486",
"785.52",
"244.9",
"995.92",
"156.1",
"451.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8706, 8755
|
3375, 7241
|
322, 362
|
8864, 8878
|
2195, 2788
|
9422, 9741
|
1801, 1921
|
7447, 8683
|
8776, 8843
|
7267, 7424
|
8902, 9399
|
1936, 2176
|
3114, 3352
|
277, 284
|
390, 1455
|
2802, 3100
|
1477, 1651
|
1667, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,721
| 155,413
|
48486
|
Discharge summary
|
report
|
Admission Date: [**2164-4-17**] Discharge Date: [**2164-5-22**]
Date of Birth: [**2096-6-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Oxaliplatin / Iodine; Iodine Containing / Fluconazole /
Ace Inhibitors
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Fever, blood per ostomy
Major Surgical or Invasive Procedure:
Indwelling Port Removal
PICC line placement
History of Present Illness:
Ms. [**Known lastname 69629**] is a 67 y.o woman with metastatic colon cancer (lung,
peripancreatic) on palliative chemotherapy - C33D8
5FU/Leucovocin, last received [**2164-3-23**], who presents to the ED
with fever at rehab to 100.4, poor po intake, and recurrent
bloody enterocutaneous fistula outpt. She was started the
evening of [**2164-4-16**] on empiric coverage with IV vancomycin and
meropenem.
Of note, she was recently discharged on [**3-6**] from [**Hospital1 18**]
(including ICU stay for hypotension) and treated for GNR (E.
coli) bacteremia, diarrhea, and bloody per enterocutaneous
fistula. During that hospitalization, fondaparinux was
discontinued given concern for bleeding. She was discharged back
to rehab after this stay and tolerated additional doses of
chemotherapy. She then represented to the ED on [**4-22**] both
from bleeding at fistula site. On [**4-1**] this was felt to be
superficial and treated with silver nitrate, and on [**4-10**] there
was no apparent bleeding at the time of surgical evaluation.
On this presentation she reports feeling badly overall for the
past several weeks. She has decreased appetite, and reports
getting TPN. She denies chills, sweats, headache, neck pain,
abdominal pain, dysuria or diarrhea. All of her stool is
eliminated through her enterocutaneous fistula. She reports
intermittent nausea, but not more than usual. She has a port in
place (not accessed), and a PICC line through which she receives
TPN and IVFs.
In the ED her initial VS were T 100.7 HR 127 BP 134/74 RR 20
O2 94% on RA. She received 2L of NS for SBPs in the 80s with
tachycardia (120s). With this her MAPs increased to >65. She
underwent CXR which showed pulmonary edema, effusions, cannot
r/o PNA and she was given one dose of Cefepime 2gm, and Tylenol
650mg. VS on transfer were HR 98 O2 97% BP 96/50 RR 15 T 100.7
--> 98.7.
Past Medical History:
Metastatic colon cancer to lung and peripancreatic mass.
0riginally diagnosed in [**3-/2156**] with a T3 N0 M0 ulcerating colon
adenocarcinoma of the ascending colon. [**9-14**]: developed
metastatic disease in porta hepatis
Pulmonary Embolism
Recurrent SBO
SVC syndrome
DM
.
PAST SURGICAL HISTORY:
s/p Small bowel resection, resection of mass, lysis of
adhesions [**5-20**]
s/p right cataract [**1-21**] s/p port [**7-16**]
s/p repair of incarcerated incisional hernia w/mesh [**5-16**]
s/p ORIF right ankle distal fibular fracture with plate and
screws [**3-15**]
s/p right colectomy [**3-13**]
.
ONCOLOGIC HISTORY:
Prior chemotherapy and history:
[**2158-2-12**] Oxaliplatin/xeloda- discontinued after 1 dose because of
allergic reaction to oxaliplatin
[**2158-3-18**] Ankle fracture (admitted to hospital)
[**2158-3-15**]- [**2158-11-22**] Irinotecan/Xeloda for 9 cycles.
discontinued because of rising CEA
[**2158-12-27**] Erbitux/Irinotecan weekly started, baseline CEA 45
She received a total of 7 combined Erbitux/irinotecan
treatments. CEA fell to 7 ([**2159-3-14**])
[**2159-4-11**] Begin single [**Doctor Last Name 360**] Erbitux, baseline CEA [**2159-5-4**] Repair of surgical hernia
[**2159-6-6**]- [**2159-10-3**] Erbitux/irinotecan, discontinued
because of allergic reaction to Erbitux (see below)
[**2159-10-24**] Begin [**Month/Day/Year 49565**]/irinotecan, CEA rose to 43
[**2159-12-25**] Begin 5-FU/LCV/[**First Name9 (NamePattern2) 49565**]
[**2160-1-13**] Cyberknife treatment (radiation therapy)
[**2160-12-12**] Begin [**Year (4 digits) 102068**]
[**Date range (3) 102071**] Hospitalization for pneumococcal mastoiditis
and meningitis
[**2161-3-12**]- [**2161-5-12**] Begin 5-FU/Leucovorin/[**First Name9 (NamePattern2) 49565**]
[**2161-6-12**] Cyberknife (radiation treatment)
[**2161-9-12**] 5-FU/Leucovorin/[**Year (4 digits) 49565**]
[**5-20**]-present: 5FU/Leucovorin
Social History:
Husband died of cancer recently on [**2163-9-22**]. She immigrated from
[**Country 5976**] in [**2127**]. lives alone now. has 3 sons (1 in ME, 1 in UT, 1
in [**Location (un) 86**]). Currently on disability secondary to cancer;
formerly worked housekeeping for [**Hospital3 1810**].
EtOH: none
Tobacco: none
Family History:
Non contributory
Physical Exam:
VITALS: T 98.7 HR 91 BP 116/51 RR 24 O2 95%
GEN: NAD, comfortable, answering questions appropiately.
HEENT: no icterus, or conjunctival injection, MM moist, EOMI
LYMPH: no cervical, clavicular LAD
NECK: neck veins not dilated, JVP not seen
CAR: s1s2 rrr no m/r/g, no murmurs appreciated
RESP: Clear to auscultation bilaterally
ABD: soft, nontender, not distended, enterocutaneous fistula
with small volume liquid red/brown stool. Per patient--normal in
appearance.
EXT: no LE edema, RUE increased swelling compared to R.
SKIN: no rash
BACK: no midline, paraspinal or CVA tenderness
NEURO: CN II-XII intact, alert/oriented X 3, MAE normally
Pertinent Results:
[**2164-4-17**] 02:25PM BLOOD WBC-10.9# RBC-3.03* Hgb-9.5* Hct-28.9*
MCV-95 MCH-31.2 MCHC-32.7 RDW-15.9* Plt Ct-348
[**2164-4-17**] 02:25PM BLOOD Neuts-91.9* Lymphs-3.5* Monos-3.7 Eos-0.7
Baso-0.2
[**2164-4-17**] 02:25PM BLOOD Glucose-103* UreaN-27* Creat-0.7 Na-135
K-4.5 Cl-102 HCO3-25 AnGap-13
[**2164-4-17**] 02:25PM BLOOD ALT-11 AST-21 AlkPhos-98 TotBili-0.6
[**2164-4-17**] 11:07PM BLOOD Calcium-7.8* Phos-3.4 Mg-1.7
[**2164-4-17**] 02:25PM BLOOD Albumin-2.5*
[**2164-4-17**] 02:40PM BLOOD Lactate-1.1
CXR: IMPRESSION: Limited study. There are findings suggestive of
volume overload including pulmonary edema and bilateral pleural
effusions. In addition, there is confluent opacity at the right
lung base, which may represent confluent edema, aspiration, or
pneumonia. Correlate clinically. Repeat radiography after
appropriate diuresis may be beneficial to assess for underlying
infection.
RENAL U/S: Limited renal ultrasound without evidence of
hydronephrosis.
[**2164-4-23**] CT Chest/Abdomen/Pelvis:
1. Oral contrast pooling on the surface of the lower abdominal
wall directly above the ileocolic anastomosis representing an
enterocutaneous fistula.
2. Enhancing soft tissue mass within the abdominal wall near the
fistula,
concerning for disease recurrence.
3. Peripancreatic mass, slightly increased in size from previous
study,
occluding the SMV.
4. Bilateral pleural effusions with bilateral lower lobe
collapse, and an
increase in size of the right lower lobe metastasis.
[**2164-5-10**] CT Chest/Abdomen/Pelvis
1. No evidence for discrete abscess collection along the left
anterior
abdominal wall.
2. Interval progression of mass in the mid abdominal wall at the
site of
enterocutaneous fistula, concerning for local tumor progression,
despite the short interval follow-up and confounding factor or
superimposed debris along its surface. Correlation with direct
inspection is recommended.
3. Stable midline abdominal mass causing encasement of the
superior
mesenteric arteries and veins.
4. Enterocutaneous fistula as previously documented without
bowel
obstruction.
5. Hypodensities in the liver, spleen, and kidneys, unchanged.
6. Bilateral pleural effusions, unchanged.
[**2164-5-12**] Chest Xray: Pleural effusions are difficult to compare
due to positional differences, but a large right and
small-to-moderate left pleural effusion are again demonstrated
with adjacent basilar lung opacities. The latter probably
reflect atelectasis, but underlying infectious consolidation
cannot be excluded. There are no new areas of lung opacification
in areas that are not immediately adjacent to the pleural
effusions to suggest a new site of pneumonia.
Other Studies:
Blood Culture, Routine (Final [**2164-5-14**]):
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2164-5-11**] 12:37 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2164-5-12**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2164-5-12**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
67 year old female with metastatic colon cancer s/p
5-FU/Leucovorin who presented with fever, hypotension and blood
per enterocutaneous fistula found to have E. coli bacteremia
thought secondary to her fistula, s/p 14 day course for
ceftriaxone. Course also complicated by cellulitis, fistula
bleeding, and recurrent bacteremia with Enterobacter.
#. E. Coli Bacteremia and Sepsis - Patient was found to have SBP
to 80s in the ED with little initial improvement after 2L NS.
She was started on pressors but was quickly weaned off of this
within 24 hours. She mentated well throughout her ICU stay with
no documented period of hypotension. The presumed etiology was
sepsis, as her blood cultures drawn at [**Hospital1 **] [**Hospital1 8**] (her
rehab) were positive for E. coli. The antibiogram indicated
that it was Zosyn, CTX-sensitive, and FQ/Bactrim resistant. She
was initially started on Zosyn on admission to the ICU and
switched to CTX after sensitivities were available. She
completed a total 14 day course.
#. Enterobacter bacteremia: On [**5-12**], she again spiked a fever and
became bacteremic. This time her blood cultures grew
Enterobacter. She was initially started on Zosyn but this was
stopped upon speciation and she was switched to cefepime as her
Enterobacter was resistent to Zosyn. She will complete a total
14 day course to end [**2164-5-26**]. It was felt that the source of
her bacteremia was likely her enterocutaneous fistula as it was
bleeding and seeding her bloodstream. Her port was also
discontinued and her PICC line was resited. Subsequent blood
cultures were all negative but she continued to have low-grade
fevers to 100.0-100.5 in the evenings.
#. Cellulitis: She was found to have a large cellulitis on her
left lower quadrant/flank and thigh. Ultrasound was performed
which showed no abscess formation. CT abdomen and pelvis also
showed no abscess. She was started on vancomycin given her
extensive hospital course. She was monitored closely. She
completed a 10 day course. Her skin remained erythematous and
indurated in her LLQ but it remained stable.
#. Decreased UOP - The patient's UOP precipitously dropped to
10-20 cc/hr on ICU day 2. Urine electrolytes indicated FeNa <
1% but she had little improvement in UOP to fluid challenge.
Renal was consulted and advised a renal ultrasound, which showed
no evidence of hydronephrosis. Her serum creatinine remained
stable, and her urine output spontaneously improved after 24-48
hours. Her urine sediment was bland for casts and UA was
remarkable for yeast only. She was treated for her yeast with
fluconazole but she quickly developed a rash and this was
stopped. Her urine output increased to normal range.
#. Bloody fistula drainage ?????? She required intermittent
transfusions due to slow bleeding from her fistual. She
initially had visible bleeding from her fistula which dropped
off during the majority of her hospital stay. Patient did have
an episode of oozing from her fistula in the setting of
vomiting. She also later had an unprovoked episode Bleeding
was controlled with silver nitrate and Surgi-seal. Topical
thrombin was the next step if these interventions did not cease
bleeding. Her bleeding was always responsive to these measures.
#. Metastatic colon cancer: Now followed by Dr. [**Last Name (STitle) **]
(heme/onc) and Dr. [**Last Name (STitle) **]. Power PICC placed for a CT Torso
to be performed with desensitization protocol.
Full report showed progression of disease despite chemotherapy.
Further management will be deferred to outpatient oncology but
she may be a candidate for panitumimab as an outpatient. She was
continued on opium tincture and loperamide. It was discussed
with her multiple times that her prognosis is poor and further
chemotherapy is unlikely to help her disease course.
# H/O PE/SVC syndrome/port-related clots: Fondaparinaux
initially held due to recent fistula bleeding. Since hematocrit
was stable, this was restarted prior to discharge. One dose
held in setting of oozing fistula, however restarted once stasis
was achieved.
# [**Last Name (STitle) 409**]: Ostomy nurse followed closely. No signs of infection.
Continued topical therapies and local care. She had multiple
episodes of bleeding from her fistula site. These episodes were
controlled with Silver Nitrate, surgi-seal, and thrombin gel as
needed.
# Leukocytosis: Mildly elevated on admission, decreased in
setting of antibiotics. Increased to 15 in setting of three
doses of prednisone. Prednisone was given prior to CT as patient
is allergic to the dye.
# Access: Patient had a port in place as well as PICC on right
on admission. Due to recurrent bacteremia, her port was pulled
and her PICC line was resited.
# Nutrition: TPN initially held while hypotensive in ICU.
Restarted without incident.
# Rash: She had yeast in her urine culture and was started on
fluconazole. She immediately developed a rash on her upper and
lower extremities as well as her chest. Her rash improved when
her fluconazole was stopped.
#. Tachycardia: She remained tachycardic which was sinus on ECG.
She was not orthostatic and it was felt that her tachycardia
was related to her underlying disease.
# Code: Full code. Despite extensive discussion to patient about
her poor prognosis, she would like to continue cancer treatment
and remain full code.
Medications on Admission:
- Acetaminophen 650mg po q4hr prn
- Fentanyl 100 mcg/hr patch q72hr
- Heparin 5,000 units sc daily
- Fluticasone nasal spray (50)
- Lorazepam 0.5 mg PO bid prn nausea
- Pantoprazole 40 mg po daily
- Rifaximin 400 mg po tid
- Miconazole Nitrate 2 % Powder QID as needed for groin area.
- Ferrous Gluconate 325 mg po bid
- Codeine Sulfate 30 mg po tid
- Sodium Bicarbonate 650 mg po tid
- Ascorbic Acid 500 mg po bid
- Compazine 10 mg po q6hr prn
- Magnesium hydroxide 30mL daily prn
- Meropenem 1gm q8hr
- Mirtazapine 22.5mg po qhs
- Tincture of opium 1mL [**Hospital1 **]
- Loperamide 2mg po q4hr
- Vancomycin 1gm IV q12hr
- Regular insulin sliding scale.
Discharge Medications:
1. Mirtazapine 15 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime).
2. Fentanyl 100 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: Two (2)
Spray Nasal DAILY (Daily).
4. Lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for anxiety/nausea.
5. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
6. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Indwelling Port (e.g. Portacath), non-heparin dependent: Flush
with 10 mL Normal Saline daily, PRN, and when de-accessing, per
lumen.
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO three times a day.
10. Sodium Bicarbonate 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
11. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
12. Codeine Sulfate 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Compazine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6)
hours as needed for nausea.
14. Opium Tincture 10 mg/mL Tincture [**Hospital1 **]: One (1) mL PO Q12H
(every 12 hours) as needed for diarrhea.
15. Loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q4H (every 4
hours) as needed for diarrhea.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Fondaparinux 5 mg/0.4 mL Syringe [**Hospital1 **]: Five (5) mg
Subcutaneous DAILY (Daily).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: [**4-19**] Injection
Q8H (every 8 hours) as needed for nausea.
19. Acetaminophen 325 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
20. Silver Nitrate Applicators Misc [**Month/Day (3) **]: One (1) Misc
Topical Q15MIN () as needed for bleeding fistula.
21. Megestrol 400 mg/10 mL (40 mg/mL) Suspension [**Month/Day (3) **]: One (1)
PO BID (2 times a day).
22. Cyanocobalamin 250 mcg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
23. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day (3) **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
24. Cefepime 2 gram Recon Soln [**Month/Day (3) **]: Two (2) gram Intravenous
twice a day: Continue through [**2164-5-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
E. coli and Enterobacter Bacteremia
Metastatic Colon Cancer
Cellulitis
Anemia
Enterocutaneous Fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted because you had an infection in your blood.
This made you very sick and you had to be closely monitored in
the ICU for several days. Once you were stable, you were
monitored on the oncology floor. You were found to have a skin
infection as well as multiple infections in your blood. You were
started on antibiotics for this. Your port was also removed and
your PICC line was changed. After close monitoring, it was felt
safe for you to go to a rehab facility.
Your new medications include:
ADDED Fondaparinux 5 mg subcutaneous injection DAILY
ADDED Zofran 4-8 mg every 8 hours as needed for nausea
ADDED cefepime 2g IV Q12H for total of 14 day course, last day
[**2164-5-26**]
STOPPED miconazole
ADDED vitamin B12 250mcg by mouth daily
It is important you keep all of your doctor's appointments.
Followup Instructions:
You have the following appointments scheduled in follow-up:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Oncologist
Date/Time: [**2164-6-6**] at 2:30pm
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) 24**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,217
| 114,785
|
31616
|
Discharge summary
|
report
|
Admission Date: [**2136-8-14**] Discharge Date: [**2136-8-24**]
Date of Birth: [**2058-3-25**] Sex: F
Service: SURGERY
Allergies:
Demerol / Epinephrine / Fosamax / Latex / Dilaudid
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Right lower extremity rest pain/nonhealing ulcer
Major Surgical or Invasive Procedure:
[**2136-8-20**]: Right common femoral to anterior tibial artery
bypass with nonreversed saphenous vein graft.
History of Present Illness:
Mrs. [**Known lastname 33172**] has a history of severe degenerative spine disease
and also carotid artery disease. She recently has developed
increasing pain in her foot. She is very disabled by her back.
She does walk but uses a wheelchair a lot and is having severe
pain in her right foot. This is bad at all times but
particularly severe at night and she has now developed some
small ulcerations. She saw Dr. [**Last Name (STitle) **] at [**Hospital6 33**]
who did some noninvasives and told that her circulation was
really poor and suggested that she see Dr. [**Last Name (STitle) **]. It was
recommended that she be admitted to the hospital for an
arteriogram.
Past Medical History:
history of b/l hip and ankle ulcers
Chronic diarrhea / constipation of unclear etiology
Colonic polyps
PUD with hx of GIB
HTN
Fibromyalgia
Hypothyroidism
Glaucoma
Cataracts
"Irregular heartbeat"
h/o benign fallopian tumor, removed [**2085**]
SBO [**3-7**] adhesions [**2117**]
IBS
Gastritis
s/p multiple spinal fusions amd kyphoplasty
Osteoarthritis
h/o R hip fracture
frequent falls
h/o L CEA for "93% blockage" per pt
hx MRSA
35% burn s/p skin grafting
Social History:
She does smoke at least [**2-7**] pack per day, and has a 50 year
smoking history but does not drink alcohol. She has spent most
of the past several months in rehab. Needs assistance with ADLs.
Family History:
Mother with breast cancer and osteoarthritis. Father with
diabetes type 2. Her family history is negative for colorectal
cancer or inflammatory bowel disease.
Physical Exam:
On discharge:
Tm 98.0, Tc 96.0, HR 87, BP 98.58, RR 16, 93% on RA
AAO x3, in no acute distress
chest clear to auscultation bilaterally, heart rate regular.
abdomen soft, nontender, nondistended.
Right lower extremity warm, with palpable DP pulse, surgical
incision healing, with areas of serosanguinous drainage. Small
nonhealing ulcer at right lateral malleolus.
No clubbing, cyanosis, or edema.
Pertinent Results:
[**2136-8-24**] 04:53AM BLOOD WBC-5.0 RBC-3.06* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.3 Plt Ct-216
[**2136-8-24**] 04:53AM BLOOD Glucose-92 UreaN-15 Creat-0.6 Na-142
K-3.9 Cl-112* HCO3-26 AnGap-8
[**2136-8-23**] 04:49AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
[**8-21**] UCx: no growth (FINALIZED)
[**8-21**] U/A: >182 WBC, no epis, large leuks, no nitrites
[**8-21**] MRSA swab: positive
Brief Hospital Course:
Ms. [**Known lastname 33172**] [**Last Name (Titles) 1834**] a diagnostic angiography of her right lower
extremity on [**2136-8-14**], which revealed moderate to severe stenosis
in the SFA with complete occlusion distally, reconstituting into
the popliteal, but occluding again at the PT, with moderate to
severe stenosis of a diminutive DP. No intervention was
attempted. She went back to the operating room on [**2136-8-20**] for a
right femoral-AT bypass with nonreversed saphenous vein. Please
see operative report dictated [**2136-8-20**] for full details of the
operation.
Postoperatively, she was somewhat hypotensive and anemic, so a
fluid bolus was given and a blood transfusion attempted.
However, soon after starting the blood transfusion she became
rigorous, acutely hypotensive, and temporarily developed stridor
with decreased O2 sats that resolved spontaneously. She was
transferred to the ICU for closer monitoring. The blood bank
was notified of a possible transfusion reaction, and a complete
workup was performed which turned out negative for transfusion
reaction. She was transfused two more units of blood the next
day without issue.
She was transferred back to the VICU on [**2136-8-21**], and her
hematocrits stabilized. her foley catheter and arterial line
were discontinued, and she was started on a regular diet. Her
right foot was much warmer postsurgery, and she developed a
strong palpable pulse of her right foot, as well as a
dopplerable PT signal. She got out of bed to a chair on POD 2
and ambulated minimally with full assistance on POD3. By POD4
she was tolerating a regular diet, her pain was controlled, and
her incisions were healing nicely. She was discharged to an
extended care facility for intensive rehabilitation.
Medications on Admission:
amytriptyline 75''' PRN anxiety
Amlodipine 5'
Clonazepam 1-2 mg QHS PRN insomnia
Cosopt 0.5-2% 1gtt OU daily
Latanoprost 0.005% 1gtt OU QPM
Synthroid 100'
Lidocaine patch
Lovastatin 1 QPM
mesalamine 800'''
Oxycodone PRN
Oxycodone extended release 40''
protonix 40'
KCl
Promethazein 25''
Vitamin C
Colace
Vitamin D
Iron
Loperamide 2mg PRN diarrhea
MVI
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. amitriptyline 75 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for anxiety.
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. insulin aspart 100 unit/mL Solution Sig: Zero (0) units
Subcutaneous QACHS: adjust sliding scale as needed.
16. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): LAST DAY [**2136-8-26**].
17. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
19. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
20. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab
Discharge Diagnosis:
right lower extremity nonhealing ulcer
right lower extremity bypass
Discharge Condition:
Alert and oriented x3
ambulating with [**Last Name (LF) **], [**First Name3 (LF) **] assist
Full weight bearing
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-8**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-9-6**] 1:45
Completed by:[**2136-8-24**]
|
[
"458.9",
"440.23",
"365.9",
"285.9",
"707.15",
"729.1",
"401.9",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.29",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
6893, 6943
|
2898, 4670
|
359, 471
|
7055, 7169
|
2473, 2875
|
9911, 10083
|
1880, 2040
|
5071, 6870
|
6964, 7034
|
4696, 5048
|
7193, 9478
|
9504, 9888
|
2055, 2055
|
2069, 2454
|
271, 321
|
499, 1172
|
1194, 1651
|
1667, 1864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,452
| 118,310
|
34074
|
Discharge summary
|
report
|
Admission Date: [**2147-6-16**] Discharge Date: [**2147-6-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
88 yo F with h/o alzheimer's dementia, HTN, and DM2 transferred
from OSH for evaluation by neuro out of concern for ICH. She
was found in her bed today at NH diaphoretic, somnolent,
lethargic, dysarthric and hypoxic to 80% on 3L NC at which time
she was transferred to Good Samiritan ED for further evaluation.
She underwent head CT at OSH ED which revealed ? of basal
ganglia bleed. She was then intubated for increasing
unresponsiveness (only to painful stimuli) and for airway
protection in setting of ? head bleed for transfer to [**Hospital1 18**].
Prior to intubation, she received lidocaine 100mg, etomidate
20mg, succinylcholine 100mg and cerebyx 1gm.
.
En route, she was hypotensive, initially 94/60 -> 64/31 at
9:50am. This came up with IVF to 97/69, but fell again to 83/44
and thus neosynephrine was started.
.
In the ED here, initial vitals were T: none recorded BP: 111/72
HR: 76 RR: 14 O2 sat: 100% on AC (settings unclear). She was
continued on neosynephrine for SBPs in the 70s and had only
received 600cc IVFs prior to transfer to [**Hospital1 18**]. Here, she
received 2L IVFs in the ED and SBPs improved to 100s-110s off
pressors. UA was positive for >50 WBCs and many bacteria (no
squams) and she received levofloxacin 750mg IV x1. CXR was
negative for infiltrate. She received 1mg ativan prior to
neurology consult. Per RNs, she was moving all extremities, with
good strength in both arms, prior to the ativan (received 1mg IV
x2). On review of OSH head CT, neurology felt that basal
ganglia finding was more consistent with calcification as
opposed to bleed and recommended repeat imaging here. Repeat
imaging showed no evidence of acute intracranial process on
NCHCT and CTA head and neck.
.
ROS: Unable to obtain given patient intubated.
Past Medical History:
-HTN (per tx records however NOT per daughters EVER)
-Alzheimer's disease - at baseline talks, interacts normally,
but has delusions
-Diabetes mellitus; type 2
-Neuropathy
-CAD s/p angioplasty at [**Hospital1 2025**] approx. 10 yrs ago per daughter
-Recurrent UTIs
-s/p Cataract surgery
-Hard of hearing; wears hearing aides
Social History:
Lives at nursing home (Guardian [**Name (NI) **]) in [**Name (NI) 1474**]. Quit
tobacco 10+ years ago, but prior heavy history per daughter. [**Name (NI) **]
Etoh. Walks with walker at baseline.
Family History:
Noncontributory
Physical Exam:
98.6 92/43 67 14 100% AC 450x14 PEEP 5 FiO2 0.5
GEN: Intubated, non on sedating meds however unresponsive.
HEENT: Pinpoint pupils nonreactive to light, symmetric,
conjuctival injection, anicteric, OP clear, dry MM, Neck supple,
no LAD
CV: RRR, distant HS, no m/r/g appreciated
PULM: Clear anteriorly
ABD: soft, ND, + BS, no HSM appreciated
EXT: cool b/l however palpable peripheral pulses including DP/PT
NEURO: Rarely moves both lower extremities minimally. Does not
follow commands.
Pertinent Results:
[**2147-6-16**] CXR (from OSH): Increase of right basal lung markings
possibly representing a small infiltrate. Otherwise relatively
clear lungs. Chronic changes.
.
[**2147-6-16**] head CT (from OSH)--no official report: Per transfer
notes, ? basal ganglia bleed.
.
[**2147-6-16**] CXR: Adequate position of ET and NG tubes. No acute
intrathoracic process.
.
[**2147-6-16**] CTA head/neck:
1. Findings consistent with internal globus pallidus
calcifications bilaterally. No evidence of acute intracranial
process on non contrast head CT.
2. CTA shows moderate internal carotid artery stenosis
Brief Hospital Course:
88yo F with h/o CAD, recurrent UTIs, DM2, alzheimer's dementia
presents with altered mental status and sepsis. The following
issues were investigated during this hospitalization:
.
# Sepsis/Hypotension/Respiratory Failure: Resolved hypotension
and was probably mostly due to hypovolemia on presentation. Did
meet criteria for sepsis given WBC count and tachycardia (at
OSH) with source of infection, clearly positive UA (culture sent
on second sample after received abx and was negative) and had
blossomed pneumonia on CXR. CSF seemed like an unlikely source,
particularly for bacterial meningitis. However, patient was
treated for HSV encephalitis with Acyclovir given RBCs in CSF.
This was later discontinued once cultures came back negative.
Sputum eventually grew MRSA which was treated with Vancomycin
and a 14 day course was completed on discharge. Given a sudden
decline in clinical status and increased sputum production,
Cefepime was also added for possible hospital acquired PNA and
was completed on the day of discharge. Patient was difficult to
wean from the vent given copious secretions which were not
controlled even with Scopolamine and frequent suctioning. For
this reason, a trach was pursued after one failed extubation.
.
# Altered mental status: Most likely due to metabolic insult of
infection (pneumonia/UTI) on already demented baseline. Improved
markedly with lightening of sedation. Initial OSH CT head
concerning for basal ganglia bleed for which she was transferred
however review of that imaging and repeat imaging here negative
for bleed. Initially covered for bacterial and viral
meningitis/encephalitis with ctx/vanco/amp/acyclovir however CSF
cultures negative and by counts on CSF unlikely bacterial.
Again, HSV cultures were eventually negative and empiric
meningitis regimen was discontinued. Patient was otherwise
continued on her dementia medications and upon discharge, was
awake and communicative at her baseline.
.
# CAD: No acute issues
.
# DM: Maintained on Insulin sliding scale
Medications on Admission:
Atenolol 25mg daily
Aricept 10mg daily
Oscal 500mg daily
ASA 81mg daily
Memantine [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Vitamin B12 500mcg [**Hospital1 **]
Seroquel 25mg 1mg 6x/wk, 0.5mg qSun
Loperamide 4mg q6hrs prn
Robitussin 5ml prn
Bisacodyl 10mg prn
Milk of magnesia 30ml prn
Acetaminophen 650mg prn
Maalox 30ml q6h prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
5. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection [**Hospital1 **] (2
times a day).
11. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary
MRSA PNA
CHF
.
Secondary
HTN
Alzheimer's Disease
Diabetes mellitus; type 2
Neuropathy
CAD s/p angioplasty at [**Hospital1 2025**] approx. 10 yrs ago per daughter
Recurrent UTIs
s/p Cataract surgery
Hard of hearing; wears hearing aides
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated for respiratory failure, which was
felt to be due to pneumonia. You have received treatment for
this pneumonia, however, it was difficult to remove the
breathing tube that you needed while you were treated. For this
reason, we performed a tracheostomy to assist with your
breathing. Since you cannot eat with this tracheostomy in place,
you also had a gastric feeding tube placed in your stomach. You
are now being discharged to a rehabilitation facility where you
will continue to be treated.
Followup Instructions:
You will be followed by physicians at your rehabliitation
facility
|
[
"276.0",
"331.0",
"038.8",
"288.60",
"276.2",
"518.81",
"428.0",
"038.11",
"507.0",
"427.31",
"V09.0",
"250.00",
"599.0",
"401.9",
"995.92",
"414.00",
"294.10",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.21",
"43.11",
"96.6",
"96.04",
"96.72",
"38.93",
"93.90",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
7191, 7263
|
3871, 5123
|
284, 316
|
7550, 7559
|
3248, 3848
|
8129, 8199
|
2701, 2718
|
6284, 7168
|
7284, 7529
|
5922, 6261
|
7583, 8106
|
2733, 3229
|
223, 246
|
344, 2122
|
5138, 5896
|
2144, 2470
|
2486, 2685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,306
| 134,980
|
31262
|
Discharge summary
|
report
|
Admission Date: [**2188-12-12**] Discharge Date: [**2189-1-7**]
Date of Birth: [**2106-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
Rhabdomyolysis, EKG changes
Major Surgical or Invasive Procedure:
Intra-aortic balloon pump
Central line
CVVHD
Arterial Line
History of Present Illness:
CCU HPI on [**12-16**]:
82 yo M w/ CAD s/p BMS--> RCA [**2176**], PVD s/p [**Doctor Last Name **] atherectomy,
TIA, carotid artery stenosis, RAS s/p stent, DM2, HTN, prostate
CA s/p brachytherapy w/ recent admission in [**2188-11-12**] for
chest pain, s/p cath showing diffuse 3vd, LMCA 60% stenosis.
Decision was made to proceed with medical management since poor
distal coronary targets and not a good surgical candidate. Pt
sent home on atorvastatin 40mg -->80mg. Few weeks later pt noted
leg cramps. Went to [**Hospital1 882**] on [**12-8**] for likely statin induced
myopathy and found to have elevated CK (8,000), hypertension to
200s, ARF (Cr=3 which is up from baseline 1.7), and
myoglobinuria. Pt was diagnosed with Rhabdomyolysis and given
several liters of fluid. He was then noted to have EKF changes
in lateral leads and rising cardiac enzymes. He was transfered
to [**Hospital1 18**] Cardiothoracic Surgical service for plan of urgent
CABG. Upon arrival to [**Hospital1 18**], cardiac enzymes continued to
increase (Trop 0.03-->0.5-->0.75-->0.6-->0.9) with lateral EKG
changes. In addition, pt was not oxygenating well and CXR showed
pulmonary edema. He was intubated for pulm edema and and
intra-aortic balloon pump placed to improve coronary perfusion.
Pt was stable until yesterday morning when he became hypothermic
(T=34) and bradycardic, he was pan-cultured for concern of
sepsis. Cultures are pending. He was also started on milrinone
for low cardiac index and poor urinary output with goal of
improving forward flow and perfusing kidneys. He was also give
lasix 40mg IV once with no response. This morning, he was found
to be in A. fib and was started on amiodarone bolus and drip. Pt
also on heparin gtt for balloon pump and possible ACS event.
.
Unable to obtain ROS since pt is sedated and intubated.
Past Medical History:
1. CARDIAC RISK FACTORS:
(+) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: BMS to RCA [**2176**]
- PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
CAD, s/p NSTEMI in [**2187**], s/p ?RCA stenting
Chronic renal insufficiency (b/l creatinine unknown - peak creat
[**2188-12-8**] 2.96)
PVD, s/p popliteal and SFA arthrectomy.
TIA in [**2173**],
Carotid Stenosis
Gout
Sick Sinus Syndrome
H/o Inguinal Hernia
Plantar Fasciitis
Glaucoma
Diverticulitis
GERD
Anemia (Hct 35 in [**2185**], per records)
H/o Kidney Stones
H/o prostate CA s/p brachytherapy in [**2175**]
Syncope in [**2185**]
Surgical History:
-Bilateral hernia repair
Bilateral thoracentesis for recurrent PTX
Social History:
Lives with wife. Retired. [**Name2 (NI) **] recently, worked as a counselor
with the Department of Mental Health.
-Tobacco history: Former smoker ([**7-7**] cigarettes a day), quit in
[**2158**].
-ETOH: Occasional
-Illicit drugs: None
Family History:
(per OMR): (-) for premature cardiac disease
Physical Exam:
CCU [**12-16**] Vitals:
VS: T=36.9 BP=123/15 (IABP) HR=82 RR=15 O2 sat= 9
Vent: AC TV 500, FiO2 50, RR 15, PEEP 10
GENERAL: Intubated, sedated
HEENT: Pupils reactive
CARDIAC: normal S1, S2. systolic murmur appreciated in setting
of balloon pump. No thrills, lifts. No S3 or S4.
LUNGS: bilateral breath sounds, scattered rhonchi.
ABDOMEN: Soft, non distended
EXTREMITIES: No femoral bruits. 2+ pedal edema bilateally,
swelling of bilateral hands
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: distal pulses Doppler detected bilaterally
Pertinent Results:
Admission labs:
[**2188-12-12**] 05:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2188-12-12**] 05:08PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-12-12**] 05:08PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2188-12-12**] 05:08PM URINE HYALINE-0-2
[**2188-12-12**] 05:08PM URINE MUCOUS-FEW
[**2188-12-12**] 01:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2188-12-12**] 01:53PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-12-12**] 01:53PM URINE RBC-[**4-4**]* WBC-[**7-10**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2188-12-12**] 01:53PM URINE GRANULAR-0-2 HYALINE-0-2
[**2188-12-12**] 01:53PM URINE MUCOUS-FEW
[**2188-12-12**] 05:08PM WBC-11.5*# RBC-3.01* HGB-9.4* HCT-27.3*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.5
[**2188-12-12**] 05:08PM PT-13.2 PTT-36.2* INR(PT)-1.1
[**2188-12-12**] 05:08PM ALBUMIN-3.4* CALCIUM-8.5 PHOSPHATE-4.1
MAGNESIUM-2.0
[**2188-12-12**] 05:08PM CK-MB-22* MB INDX-2.5 cTropnT-0.53*
[**2188-12-12**] 05:08PM ALT(SGPT)-202* AST(SGOT)-123* LD(LDH)-377*
CK(CPK)-864* ALK PHOS-82 TOT BILI-0.4
[**2188-12-12**] 05:08PM GLUCOSE-258* UREA N-50* CREAT-2.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17
[**2188-12-12**] 08:07PM PT-12.7 PTT-36.5* INR(PT)-1.1
[**2188-12-12**] 09:59PM TYPE-ART PO2-103 PCO2-31* PH-7.43 TOTAL
CO2-21 BASE XS--2
.
[**2188-12-15**] Renal ultrasound
Limited vascular exam due to artifact from balloon pump.
However, there is little, if any parenchymal flow in arcuate
arteries of both kidneys which may be related to insufficient
perfusion pressure. Flow is detected in the main renal arteries
and veins bilaterally, but there is no appreciable diastolic
flow.
.
[**2188-12-15**] Echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with inferior and infero-apical severe
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. with depressed
free wall contractility. There is no aortic valve stenosis. 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 no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2188-12-13**],
RV systolic function is less vigorous. The LVEf is similar
on/off IABP.
.
[**2188-12-15**] Carotid study:
1. Near occlusion of the right internal carotid artery,
presenting with a
string sign.
2. 40-59% stenosis of the left internal carotid artery. These
results were posted in the radiology critical results
communication dashboard on [**12-11**] at 6:00 p.m.
.
[**2188-12-18**] CT head w/o contrast
1. No acute intracranial hemorrhage, mass effect or shift of
normally midline structures. While there is no obvious hypodense
area to suggest an acute infarct, MR of the head can be
considered if there is continued clinical concern and if not
contraindicated. Other details as above.
2. Paranasal sinus and mastoid disease as described above.
Fullness of the nasopharyngeal soft tissues, can be correlated
with ENT examination.
.
.
Ultrasound S/P Balloon Pump [**12-24**]: No fluid collection within
the right groin. No pseudoaneurysm or fistula.
.
[**12-30**]: Liver Ultrasound: IMPRESSION: 1. Normal Doppler
evaluation of the liver. 2. Cholelithiasis and gallbladder
sludge, without evidence of cholecystitis. 3. Right pleural
effusion. 4. Pulsatie portal vein flow may be seen in right
heart failure.
.
[**12-31**] CXR: 1. Worsening opacity at left lower base is fluid,
atelectasis, and possible pneumonia. 2. Worsening pulmonary
venous congestion. 3. Right upper lung opacity, likely artifact.
.
12.03 CXR: FINDINGS: In comparison with the study of [**1-1**], there
is little change in the appearance of the monitoring and support
devices. The cardiac silhouette is essentially within normal
limits on this study. Right pleural effusion is unchanged. The
patchy opacification at the left base may be increasing.
Although this could merely reflect atelectasis, though
possibility of supervening pneumonia would have to be considered
in the appropriate clinical setting. Elevation of pulmonary
venous pressure is suggested.
.
.
[**1-5**] ECHO:Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 15-20%). The right ventricular cavity is mildly
dilated with depressed free wall contractility. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion. IMPRESSION: Severely depressed LV
systolic dysfunction with inferior/inferolateral akinesis and
severe hypokinesis of all other segments (apart from basal
anterior and anteroseptal segments which have relatively
preserved function). Moderate mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2188-12-15**], overall LV systolic function and the
degree of mitral regurgitation have worsened.
Brief Hospital Course:
CCU Course:
82 yo M w/ CAD- diffuse 3 vessel disease and 60% left main, PVD,
TIA, carotid artery stenosis, RAS s/p stent, DM2, HTN, who
presented to OSH for statin induced rhabdomyolisis; hospital
course complicated by pulmonary edema in setting of aggressive
hydration, and resultant demand myocardial ischemia, VAP, acute
on chronic kidney injury, eventually made comfort measures only.
.
# RESPIRATORY: Respiratory distress secondary to pulmonary edema
in setting of aggressive hydration (received total of 16 L
fluids prior to transfer to CCU) for management of rhabdo. Pt
with Echo LVEF 35-40%. Pt was intubted and vented. He was placed
on lasix drip for diuresis. Attempts to extubate were thwarted
by patient's inability to protect airway and he was re
intubated. Given need for longterm ventilation interventional
pulmonology was consulted and a tracheostomy tube was placed.
The patient had a bilateral infiltrate on Chest X-ray (see
below) and was treated with a course of antibiotics for a
possible respiratory source (see septic shock below).
.
# Septic shock: After admission, patient developed leukocytosis
hypotension and spiking fevers. Chest X-ray showed a bilateral
infiltrate. At the time, the patient was already being treated
with cefepime, vancomycin, and flagyl for aspiration pneumonia.
The patient was started on pressors and given fluid
resuscitation. ID was consulted and antibiotics were switched to
[**Last Name (un) 2830**], linezolid, tobramycin. He was treated with for 8 days of
Meropenem and Linezolid ([**Date range (1) 73754**]). He was afebrile for 8 days
and again spiked fevers. CT Torso was ordered which showed BL
infiltrates and loculated pleural effusions. He was started on
on Metronidazole, Cefepime, and Vancomycin for VAP coverage.The
patient was re-started on a course of antibiotics several times
due to a concern of worsening sepsis. He also started to have
diarrhea and was covered with PO vancomycin, his C.diff stool
studies came back negative.
.
# CORONARIES: Pt has 3 vessel disease along with Left Main
disease. Per CT surgery, pt is a poor surgical candidate since
poor distal targets. On this admission, pt with elevated
troponins (peak trop 1.8) and EKG showing lateral lead changes
concernign for ACS. He had IABP placed to improve coronary
perfusion and heparin was administed for 48 hrs in setting of
acute event. IABP was removed.Repeat ECHO was performed on [**1-5**],
showing worsening systolic function, (LVEF= 15-20%) worsening
MR.
.
# RHYTHM: In A. fib as of [**2188-12-16**]. Started on amiodarone
drip, and patient reverted to NSR. Metoprolol also started and
continued when patient's blood pressure could support. The
patient continued to be in and out of atrial fibrillation, so
amiodarone was continued as 400mg PO.
.
# Rhabdomylosis/ARF: Statin induced rhabdo with elevated CK
(highest was 8,000 from OSH), Cr, myoglobinuria at OSH. Was
aggressively hydrated resulting in pulmonary edema. Pt was given
bicarb drip early during hospitalization. Cr continued to
increase 3.1-->4.0, then reached a plateau in the low 4s. Renal
recommended continued diuresis. The patient was also started on
desmopression. CVVHD was started and discontinued prior to
expiration. See goals of care discussion below.
.
# Neurologic function: On HD 20 patient was weaned temporarly
from vent and placed on a 48 hour sedation holiday to evaluate
neurologic function and patient remained responsive only to
pain. He was evaluated by neurology who noted a non-focal exam,
and recommended head CT to evaluate an intracranial process.
Head CT was negative for mass or hemorrhage. 20min EEG was
ordered to evaluate status epilepticus and showed normal
subcortical activity.
#Thrombocytopenia: Admission PLT was 190-200. Pt's platelets
dropped as of [**12-14**], coinciding with few days after heparin
admisnistration as well as IABP placement. HIT panel returned
negative twice. Heparin was stopped for concern of possible HIT
and argatroban was started. Following the second HIT panel
negative, the argatroban was stopped. Heparin was held, though,
due to concern for GI bleed. Thrombocytopenia likely attributed
to IABP since plt trended up after removal.
.
# GI bleeding: Patient had coffee ground liquid suctioned from
OG tube. Hematocrit went steadily downward until transfusion of
2 units PRBCs necessary. GI was consulted. The patient was
placed on a pantoprazole drip and transitioned to Q12h dosing.
Endoscopy was thought to be needed once patient is stable. The
patient was intermittenly transfused when his hematocrit was
low.
.
# Goals of care: Prior to admission, patient had a relatively
high functional status. Family was initially hopeful of
recovery. However, the patient continued to do poorly and
eventually a decision was made to start him on CVVHD to see if
that helps to clear up the mental status. CVVHD brought down his
BUN and creatinine, however the patient continued to be
minimally responsive throughout his stay and eventually was
Trach/PEGd. Multiple family meetings were held throughout his
ICU stay to address the goals of care continuously. Another
family meeting with Dr. [**First Name (STitle) **], [**First Name3 (LF) **] (SW), RN, CCU res/intern and
[**Name (NI) 11805**], wife, daughter, son-in-law, and neurology was held on
[**1-6**] to discuss whether CVVHD was helpful in his case given
extensive and rapidly deteriorating function of multiple organ
systems (this included unlikely recovery of his kidney function,
unlikely recovery of his mental status, worsening sepsis on top
of [**Last Name (un) **] worsening cardiac function). Family was aware that we do
not think he will recover, and the decision was made to provide
supportive care with comfort measures only on [**2189-1-7**]. Decision
was made to discontinue norepinephrine drip at 1230 on [**2189-1-7**].
The patient was then started on morphine drip for comfort. He
expired on [**2189-1-7**] at 7:05pm.
.
# DM2: Glucose was controlled with insulin drip and ISS.
Medications on Admission:
Glipizide 10mg PO
Januvia 25 mg PO daily
Levemir 14 units sc qAM
Novolog SS
Ranitidine HCl 150 mg PO daily
Multivitamin
Clopidogrel 75 mg PO daily
Isosorbide mononitrate 120 mg PO daily
Metoprolol 25 mg PO bid
Nicardipine 20mg PO bid
Aspirin 81 mg PO DAILY
Ranexa 500 mg PO BID
HCTZ 25 mg q AM
NTG SL prn
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Acute on chronic renal failure
2. Congestive heart failure
3. Rhabdomyolysis
4. Ventilator-associated pneumonia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
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icd9cm
|
[
[
[]
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[
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[
[
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15927, 15936
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3928, 3928
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,078
| 138,121
|
6831
|
Discharge summary
|
report
|
Admission Date: [**2171-10-31**] Discharge Date: [**2171-11-6**]
Date of Birth: [**2089-1-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / morphine / Lipitor / Lopid /
Pradaxa
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue/Shortness of breath
Major Surgical or Invasive Procedure:
[**2171-11-1**]
Redo sternotomy and mitral valve repair with a 26-mm [**Doctor Last Name 405**]
annuloplasty band
Tricuspid valve repair with the 28-mm Contour 3-D annuloplasty
ring
History of Present Illness:
This is an 82yo female with known coronary artery disease s/p
CABGx3 in [**2159**]. Recently she had an episode of congestive heart
failure and subsequently underwent a cardiac catheterzation
revealing a patent internal mammary but occluded vein grafts.
She was first noted to have mitral and tricuspid disease in
Septmember [**2170**] when an echocardiogram was notable for moderate
to severe mitral regurgitation and moderate to severe tricuspid
regurgitation. A repeat transesophageal echocardiogram [**2171-9-10**]
showed severe mitral and tricuspid regurgitation. She is
symptomatic with fatigue and dyspnea on exertion however she
does maintain her daily activities without any hindrance. Given
the severity of her disease, she was referred for surgical
consultation.
Past Medical History:
Coronary artery disease s/p CABG c/b persistent effusions
Mitral and tricuspid Regurgitation
Chronic Atrial Fibrillation since [**2159**]
Hypertension
Dyslipidemia
History of Migraine HA
History of GI Bleed [**2-6**] peptic ulcer disease/Pradaxa
AV malformations of small intestine
Elevated Homocysteine
Varicose Veins
History of Pancreatitis
Lactose Intolerance
Breast Cancer treated with Surgery/XRT.
Past Surgical History:
s/p CABG [**2159-4-5**] Dr. [**Last Name (STitle) 1537**] [**Hospital1 18**]
s/p Pericardial Window/Pigtail drain [**2159**]
s/p RCA stent [**2159-7-5**]
s/p Pacemaker [**2168-12-5**]
s/p Breast Cancer Lumpectomy
s/p Hysterectomy
s/p Arthroscopic Knee Surgery
s/p Cholecystectomy
s/p Spinal Tumor [**2110**]'s
s/p Tonsillectomy
s/p Appendectomy
s/p Mastectomy (R)
Past Cardiac Procedures:
- Surgery: CABGx3 Date: [**2159-4-5**]
- Pacemaker: St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 10550**]: 5625 Serial: [**Numeric Identifier 25841**]
Social History:
Race: Caucasian
Last Dental Exam: [**2171-7-5**]
Lives with: single, widowed. Lives in [**Location **].
Contact: Phone #
Occupation: unemployed, retired
Cigarettes: Smoked no [] yes [X] Hx: 1ppd x 40 years
Other Tobacco use:
ETOH: < 1 drink/week [X] [**2-11**] drinks/week [] >8 drinks/week []
Illicit drug use: None
Family History:
Denies premature coronary artery disease - None
Physical Exam:
Pulse: 63 Resp: 16 O2 sat: 99%
B/P Right: - Left: 164/76
Height: 66" Weight: 147
General: WDWN in NAD
Skin: Warm, Dry and intact. Well healed sternotomy, subxiphoid
inc.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
good repair. Left total knee incision.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: Irregular rate and rhythm, III/VI systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] 1+ LE Edema
bilaterally. Bruising noted on arms.
Varicosities: Open vein harvest incison from right knee to ankle
and open harvest from left ankle to mid claf. Appears suitable
in
thighs (B)
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Question right bruit. Transmitted murmur to both
carotids.
Pertinent Results:
Chest CT [**10-31**]: 1. Thoracic aortic calcifications, most
prominent in the aortic arch and descending thoracic aorta.
These images are available for review for preoperative planning.
2. Status post previous coronary bypass surgery with diffuse
calcification of the native coronary arteries. 3. Cardiomegaly.
4. Mild interstitial lung abnormality with basilar predominance.
Such findings can sometimes be observed in the elderly
population in the absence of symptoms or pulmonary function
abnormalities, but the appearance overlaps with nonspecific
interstitial pneumonia (NSIP). 5. Single enlarged mediastinal
lymph node is of uncertain clinical significance.
.
Carotid U/S [**10-31**]: Right ICA <40% stenosis. Left ICA 40-59%
stenosis.
.
TTE [**2171-11-1**]: PRE-BYPASS: The left atrium is markedly dilated.
The left atrium is elongated. The coronary sinus is dilated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
Severe [4+] tricuspid regurgitation is seen. The tricuspid
annulus diameter is 4.3 mm. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is V paced. The patient is on
epinephrine and milrinone infusions. Left ventricular function
is mildly depressed (EF 50-55%). There is mild hypokinesis of
the mid inferior wall. Right ventricular function is mildly
depressed. There is a well-seated mitral annuloplasty ring in
place. No mitral regurgitation is seen. There is a mean gradient
of 4 mmHg across the mitral valve at a blood pressure of 125/63.
There is a well-seated tricuspid annuloplasty ring in place.
Mild (1+) tricuspid regurgitation is seen. No tricuspid stenosis
is seen. The aorta is intact post-decannulation.
.
CXR [**11-4**]: Small right pleural effusion. Stable pulmonary edema
and
cardiomegaly. Possible left 7th rib fracture which could be
better seen on
dedicated rib radiographs.
[**2171-10-31**] 04:00PM BLOOD WBC-3.2* RBC-3.21* Hgb-9.4* Hct-29.2*
MCV-91# MCH-29.4 MCHC-32.3 RDW-13.7 Plt Ct-124*#
[**2171-11-6**] 06:30AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.7* Hct-29.2*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.3 Plt Ct-106*
[**2171-10-31**] 04:00PM BLOOD PT-14.5* PTT-24.9 INR(PT)-1.3*
[**2171-11-4**] 08:50AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.2*
[**2171-11-5**] 05:55AM BLOOD PT-17.0* INR(PT)-1.5*
[**2171-11-6**] 06:30AM BLOOD PT-18.2* INR(PT)-1.6*
[**2171-10-31**] 04:00PM BLOOD Glucose-154* UreaN-47* Creat-1.6* Na-141
K-4.2 Cl-103 HCO3-27 AnGap-15
[**2171-11-6**] 06:30AM BLOOD Glucose-110* UreaN-47* Creat-1.4* Na-138
K-4.1 Cl-100 HCO3-27 AnGap-15
[**2171-11-4**] 08:50AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.3
Brief Hospital Course:
The patient was admitted to the hospital on [**10-31**] (day before
surgery) since she was on Coumadin and admitted for Heparin and
pre-op work-up. She was brought to the operating room on
[**2171-11-1**] where the patient underwent Redo sternotomy and mitral
valve repair with a 26-mm [**Doctor Last Name 405**] Annuloplasty band and
tricuspid valve repair with the 28-mm Contour 3-D Annuloplasty
ring. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and titrated up. The patient was gently diuresed
toward the preoperative weight. CXR showed pulmonary edema and
Lasix was subsequently increased. She was restarted on Coumadin
at her home dose for chronic atrial fibrillation and her INR was
slowly increasing towards goal of 2.0-2.5. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 5 the patient was ambulating with assistance, the wound
was healing well and pain was controlled with oral analgesics.
The patient was discharged [**Hospital **] Nursing and Rehab in good
condition with appropriate follow up instructions.
.
Pacemaker interrogation [**11-1**]:
-Presenting rhythm: AV asynchronous pacing
-Intrinsic Rhythm: AF with controlled ventricular response
-Ventricular sensitivity decreased to 0.5mV
-Rate increased to 70 bpm at request of primary team
Medications on Admission:
ALLOPURINOL 150 mg Tablet once a day
ALOSETRON [LOTRONEX] - (Prescribed by Other Provider) - 0.5 mg
Tablet - 1 Tablet(s) by mouth as directed
CARVEDILOL - (Prescribed by Other Provider) - 12.5 mg Tablet -
1
Tablet(s) by mouth twice a day
COLESEVELAM [WELCHOL] - (Prescribed by Other Provider) - 625 mg
Tablet - 2 Tablet(s) by mouth twice a day
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg/mL Solution - 1000mcg q monthly
DIPHENOXYLATE-ATROPINE - (Prescribed by Other Provider) - 2.5
mg-0.025 mg Tablet - 1 Tablet(s) by mouth prn
FENOFIBRATE NANOCRYSTALLIZED - (Prescribed by Other Provider) -
145 mg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
METAXALONE [SKELAXIN] - 800 mg Tablet - 1 Tablet(s) by mouth
three times a day
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually [**Name8 (MD) **] MD [**First Name (Titles) **]
[**Last Name (Titles) 25842**] [ACIPHEX] - (Prescribed by Other Provider) - 20 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a
day
as needed for prn
SUCRALFATE - (Prescribed by Other Provider) - 1 gram Tablet - 2
Tablet(s) by mouth three times a day as needed for prn
WARFARIN as directed
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
2 Tablet(s) by mouth prn as needed
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. colesevelam 625 mg Tablet Sig: Four (4) Tablet PO q HS ().
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
9. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Lotronex 0.5 mg Tablet Sig: One (1) Tablet PO daily () as
needed for ibs.
13. Ativan 0.5 mg Tablet Sig: 0.5 Tablet PO three times a day as
needed for anxiety for 1 months.
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take as directed for INR goal 2-2.5 for Atrial fibrillation.
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
17. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Health & Rehabilitation Center - [**Location (un) 745**]
Discharge Diagnosis:
Mitral Regurgitation s/p repair
Tricuspid valve regurgitation s/p repair
Past medical history:
Coronary artery disease s/p CABG c/b persistent effusions
Chronic Atrial Fibrillation since [**2159**]
Hypertension
Dyslipidemia
History of Migraine HA
History of GI Bleed [**2-6**] peptic ulcer disease/Pradaxa
AV malformations of small intestine
Elevated Homocysteine
Varicose Veins
History of Pancreatitis
Lactose Intolerance
Breast Cancer treated with Surgery/XRT
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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
Surgeron: Dr [**Last Name (STitle) **] on [**2171-12-4**] at 1:45 PM
Cardiology: Dr. [**Last Name (STitle) 2912**] on [**11-25**] at 3:45 PM
Please call to schedule appointments with your Primary Care Dr.
[**Last Name (STitle) 1437**] in [**1-6**] weeks [**Telephone/Fax (1) 25843**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2171-11-6**]
Coumadin follow up to be arranged upon discharge from rehab
Completed by:[**2171-11-6**]
|
[
"416.8",
"E878.2",
"428.0",
"401.9",
"414.02",
"397.0",
"998.2",
"V70.7",
"V53.31",
"424.0",
"272.4",
"427.31",
"V58.61",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.57",
"39.61",
"35.12",
"35.14"
] |
icd9pcs
|
[
[
[]
]
] |
12314, 12418
|
7267, 9077
|
365, 548
|
12923, 13091
|
3807, 7244
|
14014, 14710
|
2760, 2809
|
10808, 12291
|
12439, 12512
|
9103, 10785
|
13115, 13991
|
1799, 2388
|
2824, 3788
|
298, 327
|
576, 1351
|
12534, 12902
|
2404, 2744
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,100
| 107,988
|
17833
|
Discharge summary
|
report
|
Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-14**]
Date of Birth: [**2139-2-28**] Sex: F
Service: MEDICINE
Allergies:
Zocor
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
permenant tunneled line placement
picc placement
temporary dialysis line placement
EGD x 2
History of Present Illness:
39 yo F with PMH significant for ESRD on HD [**3-12**] diabetic
nephropathy, type I DM, HTN, hypercholesterolemia who presents
today with fever at dialysis. The pt states she was in USOH when
she went to dialysis today at [**Hospital1 3494**]. She reports she was
"just hooked up to the machine" when she had a fever to 103 F
associated with rigors and myalgias. Given Vancomycin 1 gm X 1
at HD and transferred to ED for further evaluation. The pt
denies pain, redness, swelling, discharge from R SCV HD line
which she has had for 7 months after her AVF "stopped working".
Denies recent sick contacts, travel, headache, nausea, vomiting,
diarrhea, abominal pain, chest pain, shortness of breath.
.
In the ED, T 104.2, BP 172/68, HR 112, RR 20, O2 sat 98% on RA.
Given 2L IVF, 1 gm tylenol and motrin 600 mg X 1 with
defervescence, ciprofloxacin 400 mg IV X 1, and gentamicin 30 mg
IV X 1. Seen by renal and transplant surgery. Admitted to
medicine for likely line infection and treatment with IV abx.
Past Medical History:
1. Type 1 DM
2. Hypercholesterolemia
3. HTN
4. ESRD [**3-12**] DM - pre-op for renal transplant
5. blindness in Right eye
6. Left leg weakness
7. Goiter
Social History:
Lives at home with her mother, stepfather and sister. She denies
tobacco, alcohol, and IVDU.
Family History:
Multiple family members on father's side with DM II. Denies
family h/o CAD, CA.
Physical Exam:
PE: Tm 104.2 Tc 98.9 BP 125/62 HR 95 RR 18 100% on room air FS
417
Gen: thin female, laying comfortably in bed. No acute
distress. Alert and
oriented to person, place, and date.
HEENT: Yellow dentition. Left pupil reactive to light. Sclerae
anicteric. Right eye blind. MMM, OP clear, neck supple, no LAD,
R SCV permacath with dressing c/d/i, no overlying warmth,
erythema, non-tender to palpation, no drainage.
CV: RRR. Normal S1 and S2. II/VI systolic murmur heard over
LSB (not documented on prior d/c summary)
Chest: CTA bilaterally. no w/r/r.
Abd: Soft, NT, ND, normoactive BS
Ext: no LE edema, + 2 DP pulses b/l, no palpable thrill over
site of L arm AVF, no bruit appreciated.
Pertinent Results:
Initial labs:
[**2178-12-30**] 01:20PM WBC-10.3# RBC-4.45 HGB-12.1 HCT-34.8*#
MCV-78* MCH-27.1 MCHC-34.7 RDW-16.1*
[**2178-12-30**] 01:20PM NEUTS-93.0* BANDS-0 LYMPHS-4.8* MONOS-1.7*
EOS-0.4 BASOS-0
[**2178-12-30**] 01:20PM PLT SMR-NORMAL PLT COUNT-257
[**2178-12-30**] 01:20PM PT-13.4* PTT-47.9* INR(PT)-1.2*
[**2178-12-30**] 01:20PM CALCIUM-7.9* PHOSPHATE-1.8*# MAGNESIUM-1.6
[**2178-12-30**] 01:20PM GLUCOSE-245* UREA N-19 CREAT-3.2*# SODIUM-137
POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-29 ANION GAP-17
[**2178-12-30**] 01:39PM GLUCOSE-241* LACTATE-1.5 NA+-137 K+-5.6*
CL--99*
[**2178-12-30**] 09:21PM POTASSIUM-3.5
.
EKG: NSR @ 86 bpm, nl axis, nl intervals, LVH, TWI I, aVL,
V2-V6, no peaked T waves. (new TWI V4-V6 compared to prior EKG
[**8-13**])
.
Imaging:
[**12-30**] CXR - There has been interval placement of a large bore
dual lumen
catheter from right internal jugular approach. The distal tip
is near the cavoatrial junction. The lungs are clear. The
mediastinum is otherwise unremarkable. No pleural effusion or
pneumothorax is seen. The visualized osseous structures are
unremarkable.
TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF 60%). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
No masses or vegetations are seen on the aortic valve. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve.
There is moderate pulmonary artery systolic hypertension. No
vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
TEE
1. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
2. The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen. There are multiple, mobile, very thin,
fibrinous
strands on the mitral annulus and valve, which probably do not
represent
infective endocarditis.
3. Compared with the prior study (images reviewed) of
[**2179-1-1**], there is no
significant change.
[**1-7**] CXR:
1. No free air.
2. New small left lower lobe opacity, most likely atelectasis,
although pneumonia cannot be excluded.
3. Appearance suggesting a small new left loculated pleural
effusion.
Findings discussed with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **].
RUQ US
1. Cholelithiasis without cholecystitis
2. Large right pleural effusion.
3. Echogenic and small right kidney consistent with the given
history of renal failure.
[**1-13**] CXR
1. New patchy left lower lobe opacity, concerning for infectious
process such as pneumonia.
2. Right-sided PICC line croses midline into the left
brachiocephalic vein.
.
Micro:
Blood culture drawn off HD line at HD center - 4/4 bottles Staph
Aureus sensitive to naficillin
Blood culture [**12-30**] on admission - 1/4 bottles MSSA
Blood cultures 11/23, [**1-1**] negative
Blood culture [**1-2**]: CAPNOCYTOPHAGA SPECIES}; ANAEROBIC
BOTTLE-FINAL {LACTOBACILLUS SPECIES, VEILLONELLA SPECIES,
PREVOTELLA SPECIES}
Blood cultures: [**Date range (1) 49484**], [**1-11**], [**1-12**]: negative
Discharge labs:
wbc 11.6 hgb 10.5 hct 30 plt 225
141 101 15
-----------< 106
4 29 3.5
Brief Hospital Course:
39 yo F c ESRD on HD with R SCV permacath HD line X 7 months, DM
type I, HTN presents with fevers to 104.2 at dialysis, here with
line infection and MSSA bacteremia.
.
1) Fever - Pt with elevated temperature, tachycardia, and
relative hypotension on admission concerning for peri-septic
picture. Was placed on IV Vancomycin, dosed by level, IV Cipro,
and IV Gentamicin dosed at HD for broad-spectrum coverage. BP
meds were held on admission. Seen by both transplant surgery and
renal consult in ED who recommended that HD line be kept in the
interim until blood cultures positive off line. [**Name (NI) **] pt's
HD center who confirmed that blood cultures drawn at HD center
off HD line significant for 4/4 bottles of staph aureus
sensitive to oxacillin, 1/2 blood cultures also positive here
for staph aureus sensitive to oxacillin. As BPs stable, AF, and
WBC stable, line was kept and pt dialyzed through line on the
third hospital day to maintain her usual HD schedule. At HD,
spiked temperature to 101.5 and became tachycardic and BPs
elevated. Given dose of IV Vancomycin. The following day, blood
cultures on admission with MSSA and vancomycin switched to IV
Nafcillin. On [**1-2**] surveillance cx were positive for
prevotella, lactobacillus, capnocytophagia and speciations were
not done. Patient was already on zosyn which was continued for
total of 14 days. Meropenem was briefly added for 1-2 doses when
pts blood pressure dropped, but zosyn was resumed. Multiple
surveillance cx were negative thereafter. Patient had a new
permenant dialysis catheter placed.
.
2) ESRD on HD - Seen by renal and transplant [**Doctor First Name **] consult. Pt
usually on M/W/F HD schedule. Was dialyzed on third hospital day
as above with spike in temperature. Given blood cultures off
line at HD center and blood cultures on admission here positive
for MSSA, R SCV tunneled line d/c'd. Patient had temporary line
placed and then a permenant tunneled line. Pt with L AVF and per
op note [**6-13**], thrombectomy of thrombosed AVF performed; however
pt has had tunneled HD cath since [**6-13**] and reports her HD center
being unable to access graft.
.
3) DM type I - HbA1c 7.9 [**11-13**]. Reports taking lantus 8 U qam at
home with HISS. Initially had a very elevated FS in 400s on
admisison without anion-gap metabolic acidosis which resolved
with 14 U Humalog. Placed on 10 U lantus qam for increased
glycemic control in setting of infection, FS qid, and HISS. As
infection cleared, patient had low blood sugars on this regimen
and lantus was decreased to 5 units.
.
4) HTN - Pt with relative hypotension on admission and BP meds
held. During hospital course, BPs increased and BP meds were
restarted, including metoprolol 100 mg [**Hospital1 **], lisinopril 40 mg qd,
and nifedipine 60 mg qd. ASA continued. After TEE, pt had
esophagitis and upper GI bleed which caused hypotension. All BP
meds were again stopped. After bleeding was under control,
metoprolol, nifedipine, lisinopril and diovan were restarted.
.
5) Hypercholesterolemia - Pt refused lipitor stating that
lipitor was "killing her liver" and her MD told her to d/c it.
Deferred to outpt management and d/c lipitor.
.
6) Anemia - Baseline Hct mid 30s. Hct currently at baseline.
Iron studies suggest anemia of chronic disease. On epo at HD.
.
7.) UGIB- this occurred in setting of elevated coags (DIC labs
negative) and TEE trauma. Patient was hypotensive and had
several episodes of hemoptysis. Transferred to unit. Given FFP,
PRBCs, DDAVP, and protamine. Patient had EGD which showed
erosive esophagitis and clot, but no active bleeding. Protonix
[**Hospital1 **] started. Follow-up EGD showed no active bleeding. Patient
should have EGD in one month. Hematocrit stable after 2nd EGD.
Medications on Admission:
Sevelamer 800 mg tid
Calcium Acetate 667 mg tid
Pravastatin 40 mg qd
Ursodiol 500 mg [**Hospital1 **]
Nifedical 60 mg qd
Metoprolol 100 mg [**Hospital1 **]
Lisinopril 40 mg qd
Losartan 25 mg qd
Aspirin 325 mg qd
Folic Acid 1 mg qd
Docusate Sodium 100 mg [**Hospital1 **]
Multivitamin,Tx-Minerals 1 tab qd
Pantoprazole 40 mg qd
Lantus 8 U qam
Epogen 3700 qHD
Hectoral 5 mg qHD
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: take in am.
Disp:*qs qs* Refills:*2*
12. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: see sliding scale.
Disp:*qs qs* Refills:*2*
13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Line sepsis
2. UGIB [**3-12**] esophagitis
3. HTN
4. DM
5. ESRD
Discharge Condition:
HD stable and afebrile.
Discharge Instructions:
You were admitted with fever and elevated white count and found
to have an infection of your dialysis line. You were treated for
14 days with antibiotics IV. While in the hospital, you had a GI
bleed from your esophagus requiring protonix therapy twice daily
and a follow-up EGD in 1 month. Your blood counts have been
stable. In addition, you have a small infiltrate on chest xray
which may suggest pneumonia. You were already on antibiotics and
Dr. [**Last Name (STitle) 4888**] wants to follow you closely and not add additional
antibiotics at this time.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Please return to the ED or call Dr. [**Last Name (STitle) 4888**] if you experience
fevers, chills, shortness of breath, cough, chest pain,
worsening diarrhea or any other concerning symptoms.
Please be sure to take the protonix twice a day and avoid spicy
foods for the next few weeks.
Please take to Dr [**Last Name (STitle) 4888**] about scheduling a bilateral upper
extremity venogram to assess your veins for dialysis access.
Followup Instructions:
Dr [**Last Name (STitle) 4888**] would like to see you in her office tomorrow, Friday
[**2179-1-15**] at 1:45.
Please see Dr. [**Last Name (STitle) 4888**] on Monday [**1-18**] at 1:30. Her
phone number is [**Telephone/Fax (1) 6820**].
.
You also need a follow-up EGD in one month. Please go to your
appointment on [**3-1**] and arrive at 7am on the [**Location (un) **] of
the [**Hospital Ward Name 121**] Building with Dr. [**First Name (STitle) 2643**].
.
Please go to dialysis tomorrow. ([**Doctor First Name **] please call her unit and
tell them she will be back tomorrow).
|
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256
| 188,869
|
43791
|
Discharge summary
|
report
|
Admission Date: [**2170-6-15**] Discharge Date: [**2170-6-27**]
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
intermittant abdominal and back pain for 10 days
Major Surgical or Invasive Procedure:
Abdominal Aortic Aneurysm S/p repair [**2170-6-14**]
History of Present Illness:
83 yo M s/p EVAR in [**7-/2163**] by Dr. [**Last Name (STitle) 18835**] for an infrarenal
AAA. He has been lost to follow up since that time. He has been
c/o intermittant abdominal and back pain for the last 10 days,
with an acute increase in pain at around 6PM this evening. He
was
seen by his PCP [**Last Name (NamePattern4) **] [**6-11**] and a NC CT was obtained, showing
enlargement of the AAA from ~ 5x5 to ~ 7x7. His symptoms were
thought to be due to constipation and he was sent home
recommendations to see Dr. [**Last Name (STitle) 22426**] in [**Hospital **] clinic ASAP.
A
repeat NC CT was done this evening, due to his CRI, which showed
the enlarged AAA with extravasation of high-density fluid
anteriorly. The AAA also appears to now involve the renal
arteries B. He arrived in the ED hypertensive with SBP >200. We
have since given him Labetalol and he is now on a Nitro gtt for
BP control, goal SBP <100. He is currently mentating. We have
discussed the gravity of this situation and he wishes us to
proceed with an attempt at operative repair.
Past Medical History:
1. Coronary artery disease, status post MI in [**2166**]. 2 vessel
disease s/p successful PCI to mid-RCA
2. Hypertension.
3. Hyperlipidemia.
4. Paroxysmal atrial fibrillation.
5. History of abdominal aortic aneurysm.
6. History of deep venous thrombosis.
7. Chronic obstructive pulmonary disease.
8. Peptic ulcer disease.
9. History of esophagitis.
10. History of gastrointestinal bleeding.
11. Diverticulosis.
12. Renal insufficiency.
13. Lumbosacral radiculopathy.
14. Depression.
15. History of hip fracture.
PAST SURGICAL HISTORY:
1. Status post stent graft surgery for abdominal aortic
aneurysm.
2. Status post [**Location (un) 260**] filter placement for history of DVT.
3. Status post hip replacement.
Social History:
Home: lives with wife of 60 years at home; supportive family
with 1 daughter, 2 granddaughter and great-granddaughters
[**Name (NI) **]: retired math professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 532**]
Denies tobacco, etoh, drugs
Family History:
noncontributory
Physical Exam:
VS: T 98.8 HR 56 BP 100/56
Gen: NAD. A&Ox3.
Heart: [**Last Name (un) **], [**Last Name (un) **]. Now brady in the 50's.
Lungs: Diminshed bases b/l.
Abdomen: + Guarding. TTP diffusely. + Palpable mass mid-abdomen.
Pulses: Palpable femoral pulses B. No peripheral edema.
Labs:
Trop-T: <0.01 CK: 35 MB: Notdone
144 109 23 /
------------- 109
4.5 26 1.7 \
Ca: 9.8 Mg: 2.2 P: 2.6
ALT: 5 AP: 62 Tbili: 0.5 Alb: 3.9 AST: 12 Lip: 17
143 103/
------- 100
4.2 27 \
freeCa:1.18
Lactate:1.3
pH:7.42
Hgb:13.4
CalcHCT:40
PT: 13.4 PTT: 30.6 INR: 1.1
Abd./Pelvis CT: New stranding and high-attenuation fluid
surrounding large abdominal aortic aneurysm, which is slightly
increased in size since very recent exam of [**2170-6-11**]. Of note,
the stent endograft has migrated significantly inferiorly since
previous contrast-enhanced scan of [**2167-2-25**]. While no evidence of
intramural hemorrhage, active endoleak or extravasation of
contrast is seen, these findings are concerning, and may
represent impending leak or rupture. Alternatively, the
inflammation surrounding the aortic aneurysm could represent a
process such as aortitis (though no evidence of such was seen as
recently as three days before).
Pertinent Results:
[**2170-6-25**] 07:20AM BLOOD WBC-7.9 RBC-3.51* Hgb-9.8* Hct-30.8*
MCV-88 MCH-28.1 MCHC-32.0 RDW-15.1 Plt Ct-257
[**2170-6-24**] 04:51AM BLOOD WBC-8.0 RBC-3.31* Hgb-9.6* Hct-28.6*
MCV-86 MCH-29.0 MCHC-33.5 RDW-15.3 Plt Ct-251
[**2170-6-23**] 04:52AM BLOOD WBC-6.8 RBC-3.43* Hgb-9.8* Hct-29.7*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.0 Plt Ct-222
[**2170-6-22**] 02:10AM BLOOD WBC-7.5 RBC-3.69* Hgb-10.5* Hct-31.7*
MCV-86 MCH-28.4 MCHC-33.0 RDW-14.8 Plt Ct-235
[**2170-6-21**] 03:00AM BLOOD WBC-8.6 RBC-3.56* Hgb-10.3* Hct-30.7*
MCV-86 MCH-28.8 MCHC-33.4 RDW-14.9 Plt Ct-219
[**2170-6-20**] 02:42AM BLOOD WBC-9.4 RBC-3.60* Hgb-10.7* Hct-31.0*
MCV-86 MCH-29.8 MCHC-34.5 RDW-14.9 Plt Ct-206
[**2170-6-19**] 03:11AM BLOOD WBC-8.3 RBC-3.41* Hgb-9.9* Hct-29.4*
MCV-86 MCH-29.1 MCHC-33.8 RDW-15.1 Plt Ct-168
[**2170-6-18**] 01:08AM BLOOD WBC-8.6 RBC-3.21* Hgb-9.1* Hct-28.2*
MCV-88 MCH-28.4 MCHC-32.3 RDW-14.8 Plt Ct-126*
[**2170-6-17**] 04:24AM BLOOD WBC-10.4 RBC-2.97* Hgb-8.6* Hct-26.7*
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.3 Plt Ct-124*
[**2170-6-16**] 02:05AM BLOOD WBC-10.7 RBC-3.43* Hgb-10.0* Hct-29.6*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.3 Plt Ct-155
[**2170-6-15**] 08:30AM BLOOD WBC-12.1* RBC-3.63* Hgb-10.6* Hct-31.3*
MCV-86 MCH-29.3 MCHC-34.0 RDW-13.6 Plt Ct-197
[**2170-6-15**] 03:18AM BLOOD Hgb-9.4*# Hct-27.9*#
[**2170-6-15**] 12:50AM BLOOD WBC-9.8 RBC-4.42* Hgb-12.6* Hct-37.7*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.3 Plt Ct-229
[**2170-6-15**] 12:50AM BLOOD Neuts-69.3 Lymphs-23.6 Monos-4.8 Eos-1.4
Baso-0.8
[**2170-6-25**] 07:20AM BLOOD Plt Ct-257
[**2170-6-25**] 07:20AM BLOOD PT-13.2 PTT-28.6 INR(PT)-1.1
[**2170-6-24**] 04:51AM BLOOD Plt Ct-251
[**2170-6-23**] 04:52AM BLOOD Plt Ct-222
[**2170-6-22**] 02:10AM BLOOD Plt Ct-235
[**2170-6-21**] 03:00AM BLOOD Plt Ct-219
[**2170-6-20**] 02:42AM BLOOD Plt Ct-206
[**2170-6-20**] 02:42AM BLOOD PT-12.7 PTT-31.1 INR(PT)-1.1
[**2170-6-19**] 03:11AM BLOOD Plt Ct-168
[**2170-6-19**] 03:11AM BLOOD PT-12.1 PTT-34.3 INR(PT)-1.0
[**2170-6-18**] 09:45AM BLOOD PT-12.2 INR(PT)-1.0
[**2170-6-18**] 01:08AM BLOOD Plt Ct-126*
[**2170-6-17**] 04:24AM BLOOD Plt Ct-124*
[**2170-6-17**] 04:24AM BLOOD PT-14.7* PTT-38.8* INR(PT)-1.3*
[**2170-6-17**] 04:24AM BLOOD PT-14.7* PTT-38.8* INR(PT)-1.3*
[**2170-6-16**] 02:05AM BLOOD Plt Ct-155
[**2170-6-16**] 02:05AM BLOOD PT-15.7* PTT-41.1* INR(PT)-1.4*
[**2170-6-15**] 08:30AM BLOOD Plt Ct-197
[**2170-6-15**] 08:30AM BLOOD PT-16.1* PTT-35.8* INR(PT)-1.4*
[**2170-6-15**] 03:18AM BLOOD PT-15.1* PTT-40.9* INR(PT)-1.3*
[**2170-6-15**] 12:50AM BLOOD Plt Ct-229
[**2170-6-26**] 10:05AM BLOOD Glucose-125* UreaN-34* Creat-1.8* Na-141
K-4.1 Cl-104 HCO3-32 AnGap-9
[**2170-6-25**] 07:20AM BLOOD Glucose-112* UreaN-38* Creat-2.0* Na-141
K-4.0 Cl-105 HCO3-30 AnGap-10
[**2170-6-24**] 04:51AM BLOOD Glucose-124* UreaN-45* Creat-2.2* Na-141
K-3.5 Cl-106 HCO3-29 AnGap-10
[**2170-6-23**] 04:52AM BLOOD Glucose-92 UreaN-47* Creat-2.3* Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
[**2170-6-22**] 02:10AM BLOOD Glucose-104 UreaN-49* Creat-2.5* Na-142
K-3.9 Cl-111* HCO3-25 AnGap-10
[**2170-6-21**] 03:00AM BLOOD Glucose-98 UreaN-49* Creat-2.6* Na-142
K-4.2 Cl-112* HCO3-21* AnGap-13
[**2170-6-20**] 04:38PM BLOOD Creat-2.7*
[**2170-6-20**] 02:42AM BLOOD Glucose-141* UreaN-45* Creat-2.8* Na-141
K-4.6 Cl-111* HCO3-22 AnGap-13
[**2170-6-19**] 03:11AM BLOOD Glucose-116* UreaN-40* Creat-2.6* Na-140
K-4.2 Cl-113* HCO3-21* AnGap-10
[**2170-6-18**] 01:08AM BLOOD Glucose-79 UreaN-34* Creat-2.6* Na-139
K-4.1 Cl-112* HCO3-19* AnGap-12
[**2170-6-17**] 04:24AM BLOOD Glucose-76 UreaN-32* Creat-2.2* Na-140
K-4.5 Cl-115* HCO3-20* AnGap-10
[**2170-6-16**] 02:05AM BLOOD Glucose-91 UreaN-28* Creat-2.2* Na-142
K-4.4 Cl-116* HCO3-22 AnGap-8
[**2170-6-15**] 08:30AM BLOOD Glucose-198* UreaN-22* Creat-1.6* Na-142
K-4.7 Cl-114* HCO3-23 AnGap-10
[**2170-6-15**] 12:50AM BLOOD Glucose-109* UreaN-23* Creat-1.7* Na-144
K-4.5 Cl-109* HCO3-26 AnGap-14
[**2170-6-18**] 09:45AM BLOOD ALT-4 AST-20 LD(LDH)-229 AlkPhos-37*
TotBili-0.6
[**2170-6-15**] 08:30AM BLOOD CK(CPK)-65
[**2170-6-15**] 12:50AM BLOOD ALT-5 AST-12 CK(CPK)-35* AlkPhos-62
TotBili-0.5
[**2170-6-15**] 12:50AM BLOOD Lipase-17
[**2170-6-15**] 08:30AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2170-6-15**] 12:50AM BLOOD cTropnT-<0.01
[**2170-6-15**] 12:50AM BLOOD CK-MB-NotDone
[**2170-6-26**] 10:05AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
[**2170-6-25**] 07:20AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0
[**2170-6-24**] 04:51AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.2
[**2170-6-23**] 04:52AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2170-6-22**] 02:10AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.2
[**2170-6-21**] 04:32PM BLOOD Mg-2.2
[**2170-6-21**] 03:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3
[**2170-6-20**] 02:42AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
[**2170-6-19**] 03:11AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.9
[**2170-6-18**] 09:45AM BLOOD Albumin-2.2*
[**2170-6-18**] 01:08AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
[**2170-6-17**] 04:24AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.7
CHEST (PORTABLE AP) [**2170-6-15**] 12:47 AM
FINDINGS: Single portable upright chest radiograph is reviewed
without comparison. Cardiomediastinal silhouette is unchanged,
with lobulated contour to the descending thoracic aorta which
appears to correlate to thoracic saccular aneurysm seen on prior
CT from [**2166-10-29**]. Minimal scarring in the right mid lung is
unchanged. Emphysema is unchanged. There is no new airspace
opacity. There is no pleural effusion or pneumothorax, though
note, a portion of the left hemithorax and costophrenic sulcus
is excluded.
IMPRESSION:
1. Increased prominence of lobulated contour of the descending
aorta, suggestive of interval growth of known saccular aneurysm
at this site.
2. No evidence of pneumonia.
CT PELVIS W&W/O C [**2170-6-15**] 1:04 AM
COMPARISON: [**2170-6-11**] and [**2167-2-25**].
CT ABDOMEN: Bullous emphysematous changes at the lung bases,
right greater than left are unchanged. Right basilar atelectasis
has increased.
Liver and gallbladder are normal. There is mild dilatation of
the extrahepatic common bile duct, measuring up to 13 mm. No
sign of stone or other obstructing lesion is seen. Pancreas is
fatty replaced, and atrophic. Spleen is normal. The stomach and
intra-abdominal loops of bowel are normal. There is no sign of
bowel obstruction. Kidneys are atrophic bilaterally, with
unchanged small cystic lesions too small to definitively
characterize. Contrast is excreted symmetrically. There is no
hydronephrosis.
Large infrarenal abdominal aortic aneurysm is again seen. The
aneurysm has slightly increased in size, measuring 7.3 x 6.9 cm.
The endovascular stent graft is again identified below the renal
arteries, with limbs extending into both common iliac arteries.
Stent graft is unchanged in position from [**2170-6-11**]. However,
note is made that when compared to previous contrast- enhanced
study of [**2167-2-25**], the stent has shifted significantly in
position, at least 3 cm inferiorly. While there is no definite
evidence of leak or extravasation of contrast from the stent,
and there is no increased density seen within the aneurysm sac,
there is now a moderate amount of inflammatory stranding seen
around the aneurysm sac. There is also dense fluid (48 [**Doctor Last Name **] on
non-contrast imaging) seen tracking along the left aspect of the
aneurysm sac (2:47).
There is no free intraperitoneal air, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Pelvic loops of large and small bowel are normal,
though lower pelvis evaluation is limited by streak artifact
from right hip prosthesis. There is no free pelvic fluid or
abnormal pelvic or inguinal lymphadenopathy. Aneurysm coil in
the right internal iliac artery is unchanged.
OSSEOUS STRUCTURES: Right hip prosthesis is unchanged.
Ill-defined sclerotic lesion in the right iliac bone is
unchanged. Mild degenerative changes in the lumbar spine are
stable.
IMPRESSION: New stranding and high-attenuation fluid surrounding
large abdominal aortic aneurysm, which is slightly increased in
size since very recent exam of [**2170-6-11**]. Of note, the stent
endograft has migrated significantly inferiorly since previous
contrast-enhanced scan of [**2167-2-25**]. While no evidence of
intramural hemorrhage, active endoleak or extravasation of
contrast is seen, these findings are concerning, and may
represent impending leak or rupture. Alternatively, the
inflammation surrounding the aortic aneurysm could represent a
process such as aortitis (though no evidence of such was seen as
recently as three days before).
ECG Study Date of [**2170-6-18**] 9:22:24 AM
Artifact is present. Sinus rhythm. There are non-diagnostic Q
waves in the
inferior leads. Diffuse non-specific ST-T wave changes. Compared
to the
previous tracing early transition is no longer present.
CHEST (PORTABLE AP) [**2170-6-20**] 3:46 PM
INDICATION: Dobbhoff placement.
COMPARISON: [**2170-6-15**].
FRONTAL CHEST RADIOGRAPH: There has been interval removal of the
endotracheal tube. The Dobbhoff tube is seen with tip projecting
over the proximal duodenum. Right-sided central venous line is
in unchanged position. Otherwise, no significant change seen
compared to prior study with persistent bibasilar opacities and
small bilateral pleural effusions.
IMPRESSION: Dobbhoff tube seen with tip projecting over the
proximal duodenum. Otherwise, no significant change from prior.
ECG Study Date of [**2170-6-20**] 11:45:24 AM
Sinus rhythm. Non-specific inferolateral T wave flattening.
Compared to the previous tracing of [**2170-6-18**] the Q wave is absent
in lead III and less
pronounced in lead aVF. T wave flattening is new.
Brief Hospital Course:
83 yo M s/p EVAR in [**7-/2163**] by Dr. [**Last Name (STitle) 18835**] for an infrarenal
AAA. He has been lost to follow up since that time. He has been
c/o intermittant abdominal and back pain for the last 10 days,
with an acute increase in pain at around 6PM this evening. He
was
seen by his PCP [**Last Name (NamePattern4) **] [**6-11**] and a NC CT was obtained, showing
enlargement of the AAA from ~ 5x5 to ~ 7x7. His symptoms were
thought to be due to constipation and he was sent home
recommendations to see Dr. [**Last Name (STitle) 22426**] in [**Hospital **] clinic ASAP.
A
repeat NC CT was done this evening, due to his CRI, which showed
the enlarged AAA with extravasation of high-density fluid
anteriorly. The AAA also appears to now involve the renal
arteries B. He arrived in the ED hypertensive with SBP >200. We
have since given him Labetalol and he is now on a Nitro gtt for
BP control, goal SBP <100. He is currently mentating. We have
discussed the gravity of this situation and he wishes us to
proceed with an attempt at operative repair. Patient was
admitted for open AAA repair and further management.
HD1 [**2170-6-15**] Patient was taken to OR by Dr. [**Last Name (STitle) 14533**] for repair
of ruptured AAA. Patient tolerated procedure well.
Post-operatively patient was transfered to the ICU for recovery.
Patient sedated and intubated. Patient rousable and responsive.
Patient placed on levo and cipro for antibiotics. NPO. On RISS
for blood sugar control. Vitals signs stable on pressors
(Levophed gtt.), low dose beta blocker. Labs stable.
POD1 [**6-16**] Remains in ICU, intubated, sedated on Propofol and
Fentanyl drips. Antibiotics switched to Ancef and cipro.
Afebrile. Remains NPO. Poor urine output- hydrated. Plans to
wean to extubate, wean off drips.
POD2 [**6-17**] Remains in ICU, intubated but weaning, sedated.
Continues to require IVF. Given 1 unit of PRBC. Afebrile. NPO.
POD3 [**6-18**] Remains in ICU, intubated-continues to wean, minimally
sedated. Diuresed with Lasix. Remains on Cipro. Transfused 1
unit PRBC. Adequate UOP. Afebrile. RISS.
POD4 [**6-19**] Remains in ICU. Vent weaned and extubated. Reamins on
Fentanyl drip for pain management. Hypertensive- increased beta
blocker.Good UOP. Continues on Cipro.
POD5 [**6-20**] Remains in ICU. Awake, extubated, afebrile. Diuresed
with Lasix-adequate uop. Resumed some home meds. Tube feeds via
NGT. Cipro d/c'd. RISS.
POD6 [**6-21**] Remains in ICU, hypertensive- started on Nitro gtt,
increased antihypertensives. Afebrile. Dob off placed, tube
feeds increased- well tolerated. Gentle diuresis. Plan to
transfer to stepdown. Resumed most home meds. RISS.
POD7 [**6-22**] Speech and swallow eval-OK to start POs as tolerated,
thickened liquids. Remains in ICU. Nitro gtt for hypertension.
Diuresed with lasix. Afberile. Physical therapy referral.
Transferred to VICU [**Hospital Ward Name 121**] 5.
POD8 [**6-23**] VICU status, VSS, afebrile. Diuresed. Pulmonary
toilet. No acute events.
POD9 [**6-24**] VICU status, VSS, afberile. Increasing diet. No acute
events.
POD10 [**6-25**] VICU staus, VSS, afberile. DAT. PT re-consult,
ambulate. Diuresed. Dispo planning.
POD11 [**6-26**] Floor status, VSS, afebrile. D/c foley. Rehab screen
for dispo.Afebrile. no acute events. Restarted Cipro for
CITROBACTER FREUNDII COMPLEX that grew from urine Cx on [**6-22**].
POD12 [**6-27**] Discharged to Rehab ([**Hospital1 599**] of [**Location (un) 55**]) in good
condition. Will D/c on Cipro for 2 wks. FU for Dr. [**Last Name (STitle) 14533**]
already set up.
Medications on Admission:
oxycodone 5mg q4prn
amlopidine 5mg QD
lisinopril 25 (20 + 5) mg QD
metoprolol 12.5 mg [**Hospital1 **]
alprazolam 1 mg QHS
gabapentin 300/200 mg
omeprazole 20 mg QD
simvastatin 20 mg QD
venlafaxine xr 225 mg qhs
senokot [**2-7**] tab QHS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q AM ().
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Abdominal Aortic Aneurysm S/p repair [**2170-6-14**]
CAD
HTN
hyperlipidemia
pAF
h/o DVT with IVC filter
COPD
PUD with GIB
esophagitis
diverticulosis
renal insufficiency
lumbosacral radiculopathy
depression
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-15**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-11**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-7-11**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2170-10-22**]
3:20
Completed by:[**2170-6-27**]
|
[
"997.5",
"401.9",
"518.5",
"V12.51",
"285.9",
"996.1",
"584.9",
"412",
"593.9",
"599.0",
"V15.07",
"496",
"441.3",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18773, 18845
|
13315, 16884
|
261, 316
|
19095, 19102
|
3693, 13292
|
21842, 22173
|
2426, 2443
|
17172, 18750
|
18866, 19074
|
16910, 17149
|
19126, 21389
|
21415, 21819
|
1964, 2140
|
2458, 3674
|
173, 223
|
344, 1407
|
1429, 1941
|
2156, 2409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,660
| 104,430
|
29539
|
Discharge summary
|
report
|
Admission Date: [**2144-5-12**] Discharge Date: [**2144-5-17**]
Date of Birth: [**2093-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine / onions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension, fever
Major Surgical or Invasive Procedure:
Nephrostomy tube exchange
History of Present Illness:
Ms. [**Known lastname 70847**] is a 50 year old woman with h/o rectal ca s/p
radiation, chemotherapy, and surgery, radiation-induced damage
s/p ileostomy, HIV on HAART (last CD4 263 in [**1-26**]), obstructive
renal failure from radiation fibrosis with b/l nephrostomy tubes
and h/o recurrent obstructions, DVTs on Coumadin, sacral
decubitus ulcer with coccygeal osteomyelitis, who was sent to
the ED with Na 115, K 6.3, Cr 4.8 on recent outpatient labs, now
admitted to the ICU with hypotension.
The patient endorses feeling some fatigue, malaise, abdominal
cramping. She has had increased vaginal discharge for the past
couple week. Occasional nausea and vomiting,
nonbloody/nonbilious. She notes increased watery ostomy output
for 1-2 weeks and decreased urine output from her b/l
nephrostomy tubes for 1-2 days. She had decreased PO intake over
the past day. She does receive IV Mg and 1LNS every other night
at home. One fever to 100.8 several days prior to admission, but
no recurrence. Of note, she was started on Ciprofloxacin 5 days
prior for a UTI by her PCP. [**Name10 (NameIs) **] has also been closely monitored
for hyperK and ARF for the past 2 weeks as an outpatient, which
was being treated with Lasix and IVF at home.
In the ED, initial VS were: T 96.9 BP 85/51 HR 98 RR 16 O2sat
100%. She was triggered on arrival for hypotension and was given
2.5L NS, then started on Levophed for persistent hypotension.
Exam notable for b/l nephrostomy tubes and sacral decub ulcer to
the bone. Labs notable for WBC 25.5, Na 118, K 5.6, HCO3 16,
anion gap 19, BUN 61, Cr 5.2, INR 4.2. EKG without peaked T
waves per [**Last Name (LF) **], [**First Name3 (LF) **] they gave Kayexalate, but no Calcium or
Insulin. Cultures sent for [**First Name3 (LF) **], urine, and stool/Cdiff. CXR
unremarkable. CT abd/pelvis with gas/fluid level in the bladder
concerning for pyocystitis, ?SBO, and persistent coccygeal
osteomyelitis. The patient was given Vanc/Zosyn per signout, but
there is no documentation in the chart, and RN-RN signout
confirms that no Abx were given in the ED.
On arrival to the MICU, patient's VS 98.2 106/72 91 20 99%RA.
She is currently feeling ok with no focal complaints. [**First Name3 (LF) 159**]
has been by to place a 14FR Foley catheter without complication.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies shortness of breath, cough, dyspnea or wheezing. Denies
chest pain, chest pressure, palpitations. Denies constipation,
dark or bloody stools. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
ONCOLOGIC HISTORY:
1) Rectal cancer:
- late [**2139**]: 6 months of intermittent rectal bleeding, rectal
pressure and a sensation of incomplete emptying.
- [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and
a 2.5 cm distal rectal mass arising from the anal verge in the
posterior rectum with a large area of induration.
- [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring
4.8 x 3.8 cm, bulging posteriorly into the presacral space and
anteriorly towards the uterus. There were enlarged lymph nodes
in the perirectal fat adjacent to the mass, a 9-mm enhancing
lymph node in the left pelvic sidewall, and enhancing lymph
nodes in the right external iliac region. There was also a 7-mm
hypodensity in the caudate lobe of the liver. Rectal ultrasound
on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3
disease. There were at least four abnormal perirectal lymph
nodes seen on MRI, in addition to multiple bilateral enlarged
pelvic sidewall lymph nodes, concerning for extensive disease.
- [**2141-2-20**]: began chemoradiation
- [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia,
and abdominal cramping
- [**2141-3-13**]: 5-FU was restarted at a reduced dose
- [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal
skin changes, diarrhea, and electrolyte abnormalities.
- [**Date range (3) 70844**]: Radiation was also held
- [**2141-3-27**]: 5-FU was restarted at a further reduced dose
- [**2141-3-31**]: completed radiation
- [**2141-4-3**]: completed chemotherapy
- [**Date range (3) 70845**]: hospitalized for bowel rest and the
initiation of TPN due to presumed radiation enteritis.
- [**2141-5-31**]: found to be HIV positive and began on HAART
- [**Date range (1) 70846**]: required hospitalization for an SBO, underwent
laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed
severe radiation-induced acute ischemic enteritis. She recovered
from this surgery, but continued to require TPN.
- [**7-/2141**]: Once her CD4 count had recovered, she underwent
laparotomy, lysis of adhesions, ileal resection,
proctosigmoidectomy, colonic jejunal pouch to near-anal
anastomosis with EEA, takedown splenic flexure, resection of
ileostomy and creation of new end-ileostomy. Pathology from the
surgical specimen revealed no residual carcinoma and all 14
lymph nodes sampled were free of disease.
- [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis
showed no evidence of recurrence.
- [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen
near the anastomatic site, new since the earlier study. Local
recurrence cannot be excluded, although possibly the appearance
is associated with endoluminal debris."
.
OTHER MEDICAL HISTORY:
2) HIV CD4 count 124 on [**12/2143**]
3) Short gut syndrome secondary to bowel surgery for CA.
4) Obstructive renal failure from radiation fibrosis, in the
past necessitating b/l nephrostomy tubes which have required
multiple revisions.
5) Lower extremity neuropathy, likely secondary to radiation
fibrosis, uses a wheelchair since 4/[**2141**].
6) Pancreatic insufficiency.
7) Anemia.
8) Chronic pain.
9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**].
Social History:
Lives in [**Location 17566**] with her husband and several children. No
tobacco or EtOH use. Used to be account manager, now on
long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], with skilled nursing 1h X
3/week + aid 1h X2/week. She is wheelchair bound.
Family History:
Father died at age 72 from MI. Mother is alive and well. Remote
family history of breast cancer. Daughter with ulcerative
colitis.
Physical Exam:
ADMISSION EXAM
Vitals: 98.2 106/72 91 20 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-distended, bowel sounds present, ileostomy
draining pale brown liquid stool in the RLQ
GU: foley in place; prior to placement, dark green/brown
discharge seen on vaginal pad
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper extremities, unable
to move LE.
.
DISCHARGE EXAM
97.5 HR 70s-90s BP 112/68 RR 14 97% on room air
General: Alert, oriented, no acute distress
Neck: supple, JVP not elevated
CV: RRR, S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally anteriortally
Abdomen: soft, non-distended, bowel sounds present, ileostomy
draining pale brown liquid stool in the RLQ
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] WBC-25.5*# RBC-3.89* Hgb-10.8*# Hct-33.2*
MCV-85 MCH-27.7 MCHC-32.4# RDW-17.6* Plt Ct-562*#
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] Neuts-89.5* Lymphs-7.7* Monos-2.3 Eos-0.2
Baso-0.3
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] PT-43.1* PTT-53.9* INR(PT)-4.2*
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] Glucose-136* UreaN-61* Creat-5.2*#
Na-118* K-5.6* Cl-83* HCO3-16* AnGap-25*
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] ALT-15 AST-13 AlkPhos-159* TotBili-0.1
[**2144-5-12**] 06:20PM [**Month/Day/Year 3143**] Albumin-3.8 Calcium-8.6 Phos-8.1*# Mg-2.5
.
RELEVANT LABS:
[**2144-5-16**] 02:55PM [**Month/Day/Year 3143**] Cortsol-26.2*
[**2144-5-16**] 03:38PM [**Month/Day/Year 3143**] Cortsol-31.5*
[**2144-5-16**] 07:05PM [**Month/Day/Year 3143**] Vanco-33.0*
.
DISCHARGE LABS
[**2144-5-17**] 05:18AM [**Month/Day/Year 3143**] WBC-7.8 RBC-2.58* Hgb-7.5* Hct-23.1*
MCV-90 MCH-29.0 MCHC-32.4 RDW-17.1* Plt Ct-322
[**2144-5-17**] 05:18AM [**Month/Day/Year 3143**] Glucose-80 UreaN-17 Creat-1.0 Na-135
K-5.0 Cl-108 HCO3-19* AnGap-13
[**2144-5-17**] 05:18AM [**Month/Day/Year 3143**] Calcium-7.4* Phos-3.2 Mg-1.6
.
URINE
[**2144-5-12**] 10:10PM URINE [**Month/Day/Year **]-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2144-5-12**] 10:10PM URINE RBC-85* WBC->182* Bacteri-MANY Yeast-MANY
Epi-0 TransE-<1
[**2144-5-12**] 10:10PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2144-5-13**] 10:22AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.010
[**2144-5-13**] 10:22AM URINE [**Month/Day/Year **]-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2144-5-13**] 10:22AM URINE RBC-16* WBC-77* Bacteri-FEW Yeast-NONE
Epi-0
[**2144-5-13**] 03:21AM URINE Hours-RANDOM UreaN-213 Creat-68 Na-37
K-41 Cl-47
[**2144-5-13**] 03:21AM URINE Osmolal-265
.
MICROBIOLOGY
[**2144-5-13**] URINE CULTURE-FINAL {YEAST}
[**2144-5-13**] URINE CULTURE-FINAL {YEAST}
[**2144-5-13**] 4:05 am SWAB PUS FROM FOLEY CATHETER.
GRAM STAIN (Final [**2144-5-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM POSITIVE BACTERIA. MODERATE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**2144-5-13**] STOOL C. difficile -Negative
[**2144-5-12**] SWAB NEISSERIA GONORRHOEAE (GC) Negative; Chlamydia
trachomatis- Negative
[**2144-5-12**] GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY {STAPH
AUREUS COAG +}
[**2144-5-12**] URINE CULTURE-PRELIMINARY {YEAST, STAPHYLOCOCCUS,
COAGULASE NEGATIVE}
[**2144-5-12**] [**Numeric Identifier **] Culture, Routine-PENDING
[**2144-5-12**] [**Numeric Identifier **] Culture, Routine-PENDING
.
STUDIES
EKG- [**2144-5-12**]
Sinus rhythm. Low precordial voltage. Since the previous tracing
of [**2144-2-16**]
the rate is now slower. Otherwise, unchanged.
.
CXR [**2144-5-12**]
IMPRESSION: Bibasilar subsegmental atelectasis.
.
CT abdomen pelvis [**2144-5-12**]
1. Interval development of air-fluid level within the bladder
which is
concerning for infection in the absence of recent
instrumentation,
particularly gas-forming organisms.
2. Gas identified within the renal collecting systems
bilaterally, possibly introduced from the patient's nephrostomy
tubes, though an infectious process/emphysematous pyelitis is
not excluded.
3. Extensive radiation changes within the pelvis including
findings compatible with radiation cystitis and enteritis.
4. Diffuse dilation of the small bowel, without a definite
transition point, which is chronic, and essentially unchanged
from [**2144-2-16**].
5. 4 mm mid left ureteral stone, unchanged. Bilateral
nephrostomy tubes in
place without hydronephroureter.
6. Collapsed gallbladder, containing a small punctate
gallstone.
7. Similar appearance of sacral decubitus ulcer, with erosive
changes at the coccyx concerning for osteomyelitis.
8. Hepatic steatosis.
.
[**5-14**] Nephrostomy Exchange:
CONCLUSION: Uncomplicated bilateral 12 French nephrostomy
catheter exchange over a guidewire.
Brief Hospital Course:
Ms. [**Known lastname 70847**] is a 50 year old woman with h/o rectal ca s/p
radiation, chemotherapy, and surgery, radiation-induced damage
s/p ileostomy, HIV on HAART (last CD4 263 in [**1-26**]), obstructive
renal failure from radiation fibrosis with b/l nephrostomy tubes
and h/o recurrent obstructions, DVTs on Coumadin, sacral
decubitus ulcer with coccygeal osteomyelitis, who was admitted
to the ICU with hypotension.
#. Septic shock: Patient was hypotensive on admission with e/o
end-organ damage (renal failure), likely from infectious
etiology given leukocytosis and several possible sources.
Urinary tract was felt to be the most likely at this time --
dirty UAs from b/l nephrostomy tubes, as well as gas/fluid level
in the bladder concerning for pyocystitis. CXR was without
evidence of pneumonia. Foley placed by [**Date Range **] drained scant
purulent material culture from which grew S.aureus. Cultures of
bilateral nephrostomy tube output grew only yeast. There was
initial concern for C diff given increased ostomy output however
PCR was negative. [**Date Range **] cultures were pending at the time of
discharge. She was started on broad spectrum antibiotics with
linezolid (given history of [**Date Range **]) and zosyn. She initially
required pressor support with norepinephrine to maintain MAP >
65. Given concern for urinary tract infection she underwent
exchange of bilateral nephrostomy tubes under general
anesthetic. She tolerated the procedure well. [**Date Range **] pressures
improved with volume rescucitation and she was weaned from
pressors. ID was consulted regarding antibiotic course and
recommended two weeks of cetriaxone and vancomycin. [**Date Range 159**]
recommended 5 day treatment with fluconazole.
#. [**Last Name (un) **]: Patients creatine on admission was elevated at 5.2 from
a baseline of 1.0-1.5. This was felt to likely be prerenal
etiology, as patient is infected and has had increased watery
stool output from ileostomy. Fe Urea was consistent with a
pre-renal etiology. Even on day before discharge, pt's urine
sodium was <10, indicating a dry state. Less likely obstructive,
as b/l nephrostomy tubes in place and draining, and no e/o
hydronephrosis on CT abd/pelvis. The patient was given NS
boluses with improvement in her Cr to 1.5 at discharge. As
above her nephrostomy were also replaced by IR. Pt's
creatinine was 1.0 at time of discharge after treatment of
urosepsis and aggressive volume rescucitation
#. N/V: Patient with N/V in the ED, which was felt to likely be
[**1-16**] to infection vs renal failure, in addition to dehydration.
CT was without evidence of SBO. She was managed symptomatically
with zofran. Nausea resolved with hydration and the patient was
able to tolerate a regular diet prior to discharge.
# Acute on chronic anemia- On admission the patient's HCT was at
baseline of 23. This fell to 20.7 in the setting of some [**Month/Day (2) **]
loss in her foley.She was transfused 1 unit of PRBCs. Bleeding
resolved and HCT remained stable.
#. Hyperkalemia: Patient was noted to have a potassium of 5.6 on
admission which was attributed her her renal failure. Initial
EKG was notable for slight prominence of Twaves on EKG. She was
given insulin and D50 with improvement in her hyperkalemia as
her renal function recovered.
#. Hyponatremia: Patient was noted to have a sodium of 118 on
admission. Her mental status was intact. The etiology of her
hyponatremia was felt to be hypovolemic hyponatremia due to both
nausea, vomiting and diarrhea. She was given normal saline
boluses with improvement in her sodium to the 130s. On HD 4 pt
continued to be hyponatremic with hypokalemia so a cosyntropin
stimulation test was done which was negative. Urine Na was
still low at that time with FeNa of 0.17%, so she was bolused
with an additional three liters of NaCl.
#. Metabolic acidosis: Patient was noted to have an anion gap
acidosis on admission (AG of 19). This was felt to most likely
be due to renal failure. Acidosis normalized with administration
of IVF.
.
#. b/l DVTs: Patient's INR was supratherapeutic on admission.
Therefore her home coumadin was held. Her INR trended downward
to 1.1 as she was given 5 mg vitamin K and FFP for her
nephrostomy tube exchange and coumadin was restarted at 4 mg
prior to discharge. In the interim between last documented DVT
in [**2142-3-15**], pt had subsequent LE dopplers which were negative
for DVT as well as an MRI pelvis, which showed no DVT. Due to
patient's hct drop requiring 1 unit PRBC, recent nephrostomy
exchange, and no current clinical evidence of DVT, it was
thought most prudent to not bridge the patient. INR monitoring
and coumadin dose adjustment will be transitioned to the
patient's PCP.
STABLE ISSUES
#. HIV: Patient was continued on her home HAART regimen.
#. Peripheral neuropathy/Chronic pain: The patient was continued
on her home lyrica. Pain was controlled initially with IV
dilaudid. Once nausea was improved she was transitioned to her
home PO dilaudid. Nortriptyline was initially held given concern
for interaction with linezolid. This medication was restarted at
discharge. Her home methadone and fentanyl were also held on
admission and restarted at the time of discharge.
#. Rectal ca: No e/o disease per heme/onc progress note in
[**1-25**], but has not been seen in follow-up since that time.
.
TRANSITIONAL ISSUES
-Patient was DNR/DNI throughout this hospitalization
- INR monitoring and coumadin dose adjustment was transitioned
to the patient's PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] cultures pending, urine cx pending
- Patient will follow up with PCP, [**Name10 (NameIs) **] and IR
Medications on Admission:
Abacavir-Lamivudine 600-300mg 1tab PO daily
Darunavir 800mg PO daily
Norvir 100mg PO daily
Albuterol 1neb q4-6h prn
Ciprofloxacin 250mg PO BID (start [**2144-5-5**])
Vitamin D 50,000units PO daily
Fentanyl lozenges 200mcg PO q6h prn
Folic acid 1mg PO daily
Furosemide 20mg IV prn
Dilaudid 32mg PO q2h prn
IVF - NS prn
Lansoprazole 30mg PO daily
Lidocaine-Diphenhydramine-Maalox 10-15mL q4-6h prn
Magnesium sulfate 2g IV 3x/week
Methadone 15mg PO q6h
Mirtazapine 15mg PO qhs
Nortriptyline 50mg PO daily
Zofran 4-8mg PO q6h / 4mg IV q6h prn
Phenytoin 100mg applied to open wound daily
Lyrica 50mg PO TID
Ranitidine 300mg PO qhs
Triamcinolone 0.1% paste TD TID prn
Warfarin as directed
Ascorbic acid 500mg PO daily
Vitamin B12 1000mcg PO daily
Ferrous sulfate 325mg PO daily
Loperamide 4mg PO prn
Miconazole 2% ointment [**Hospital1 **] prn
Discharge Medications:
1. ceftriaxone 2 gram Recon Soln [**Hospital1 **]: Two (2) grams Injection
Q24H (every 24 hours) for 12 days.
[**Hospital1 **]:*24 grams* Refills:*0*
2. vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
every twenty-four(24) hours for 12 days.
[**Hospital1 **]:*12 gram* Refills:*0*
3. IV fluids
1 liter normal saline IV
every other day
run at 125cc/hr
[**Hospital1 **]: 1 month supply
4. magnesium sulfate
magnesium sulfate 16mEq (2g)/500cc NS
Infuse over 4hrs
3 times per week
5. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
6. ritonavir 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation every 4-6 hours
as needed for SOB/wheezing.
8. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. hydromorphone 4 mg Tablet [**Hospital1 **]: Eight (8) Tablet PO Q2HR ()
as needed for pain.
11. fentanyl citrate 200 mcg Lozenge on a Handle [**Hospital1 **]: One (1)
lozenge Buccal every six (6) hours as needed for pain.
12. Vitamin D2 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once
a day.
13. heparin lock flush (porcine) 100 unit/mL Syringe [**Hospital1 **]: Ten
(10) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
14. heparin, porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
15. abacavir-lamivudine 600-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO
once a day.
16. methadone 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO every eight
(8) hours.
17. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
[**Hospital1 **]: Forty (40) mg Intravenous prn as needed for as directed by
PCP.
18. pregabalin 25 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day).
19. ferrous sulfate 300 mg (60 mg iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
20. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
21. ascorbic acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
22. loperamide 2 mg Capsule [**Hospital1 **]: Two (2) Capsule PO QID (4 times
a day) as needed for diarrrhea.
[**Hospital1 **]:*240 Capsule(s)* Refills:*0*
23. nortriptyline 25 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
24. warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM.
25. fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
[**Hospital1 **]:*3 Tablet(s)* Refills:*0*
26. phenytoin sodium Powder [**Hospital1 **]: One Hundred (100) mg
Miscellaneous once a day: apply to open wound daily.
27. Zofran 4 mg Tablet [**Hospital1 **]: 1-2 Tablets PO 4-8mg as needed for
nausea.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
septic shock from pyocystitis
hyponatremia
hyperkalemia
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you. You were admitted to
[**Hospital1 18**] for a severe bladder infection resulting in low [**Hospital1 **]
pressures. We treated your infection with IV antibiotics and
gave you intravenous fluids and IV medications to treat your low
[**Hospital1 **] pressure. During your hospital stay, we also changed out
your nephrostomy tubes without complication. We now think that
you are safe to go home. At home you will need to continue
taking IV antibiotics for at total of 2 weeks.
- start fluconazole for 3 days
- start vancomycin 1g daily and ceftriaxone 2mg daily for 12
days
- change you IV fluids to normal saline
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48223**] at [**Telephone/Fax (1) 3070**] to
schedule a follow up appointment within the next week
Your percutaneous nephrostomy tubes will be replaced at your
regularly scheduled appointment in 8 weeks time. At this time,
Dr. [**First Name (STitle) **], your urologist, plans on seeing you for a follow up.
|
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29,860
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Discharge summary
|
report
|
Admission Date: [**2184-8-11**] Discharge Date: [**2184-9-20**]
Date of Birth: [**2128-9-6**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Lymphoma
Major Surgical or Invasive Procedure:
Chemotherapy
History of Present Illness:
HPI: Mr. [**Known lastname 5395**] is a 55 y/o man with history of non-hodgkin's
lymphoma with recently diagnosed recurrences who re-presents to
the [**Hospital Unit Name 153**] after being found with oxygen saturations of 88% on 6L
NC. The patient was discharged from the [**Hospital Unit Name 153**] to the BMT floor at
approximately 5:00 pm; at that time, the patient's oxygen
saturations were 95% on 2L NC. He was doing well on the floor
until he got up to use his urinal at about midnight. At that
time, tha patient was found to be hypoxic to 88% on 6L NC. His
saturations improved to 90-91% on NRB. He was noted to have
received about 200 cc of IV fluids; on exam, he was diffusely
wheezing. EKG demonstrated NSR at 80, rSr', no significant ST/T
wave changes from prior. CXR at the time demonstrated increased
bilateral opacities, worse since [**2184-8-15**]. The patient received 20
mg IV lasix on the floor and urinated about 550 cc prior to
moving down to the ICU. After receiving lasix, the patient's
saturations improved to 96% on NRB.
.
He was originally admitted on [**2184-8-11**] as a transfer from OSH with
recurrence of disease. At that time, he was initiated on hyper
CVAD chemotherapy. The [**Hospital 228**] hospital course has been
complicated by tumor lysis syndrome which has been treated with
aggressive IV fluids. Bone marrow biopsy done on [**8-12**]
demonstrated large B cell lymphoma; TTE was done on [**8-13**] in
preparation for chemo, which was normal (no LVH, though E wave
decel time upper limit of normal giving ? to diastolic
dysfunction). On [**8-13**], he experienced onset of new AF with RVR.
Metoprolol was gradually uptitrated but he experienced
increasing dyspnea. A chest CT was done, which demonstrated
multifocal bilateral upper lobe, RML, and superior segment LLL
ground glass opacities with diffuse peribronchial thickening.
There was also interlobular septal thickening at the right base,
and small bilateral effusions with ddx including pulmonary
edema, DAH, and infection. He was empirically treated with vanc,
levo, and voriconazole. On the evening of [**8-14**], Mr. [**Known lastname 5395**]
continued to be tachycardic to 140s in AF despite up-titration
of metoprolol to 100mg PO. BP remained stable in 160s/100s. He
was noted to have crackles and elevated JVP on exam, and was
experiencing gradually worsening dyspnea. At that time, he was
diuresed with 20 mg IV lasix and sent to the [**Hospital Unit Name 153**] where
bronchoscopy demonstrated previous pulmonary hemorrhage but no
active bleeding. He was diuresed effectively and actually
converted out of afib while on diltiazem gtt. At the time of
transfer back to the flor, the patient was comfortable on 3 L NC
with oxygen saturations in the mid 90s.
.
On arrival to the [**Hospital Unit Name 153**], the patient states that his breathing is
more comfortable than approximately 30 minutes prior. He also
notes that his bladder feels full and he has to urinate. He
otherwise denies chest pain, abdomina pain, dizziness,
lightheadedness, worsened lower extremity edema, nausea, and
vomiting.
.
Past Medical History:
PMH:
NHL as above
HTN
asthma
cervical disc disease
hepatitis c without cirrhosis
gerd
cad s/p pci
Social History:
SH:
ex smoker, denies alcohol.
Family History:
.
FH:
non-contributory
Physical Exam:
PE:
T 97.5 BP 175/88 HR 81 O2 96% on NRB, 88% on RA
Gen: alert, middle-aged male, slightly cachectic, in slight
respiratory distress with alopecia
HEENT: [**Last Name (un) 2599**] dry, wearing NRB, PERRL, scattered petechiae on
face
Neck: JVP at 10 cm, no lymphadenopathy
Chest: diffuse wheezing throughout, crackles at right base
CV: RRR, no murmur appreciated though heart sounds difficult to
hear due to wheezing
Abd: normoactive bowel sounds, nontender to palpation throughout
Ext: 1+ peripheral edema to the knees, warm & well perfused
throughout
Neuro: grossly intact, face symmetric, moving extremities
without difficulty
Pertinent Results:
Imaging:
[**8-12**] MRI HEAD
HISTORY: 55-year-old man with non-Hodgkin's lymphoma with tumor
lysis syndrome, and now numbness of the right jaw concerning for
cranial nerve involvement.
TECHNIQUE: Sagittal T1; axial post-gadolinium T1, T2, FLAIR,
DWI, DTI of the head as well as axial 3-mm T1, post-gadolinium
T1 with fat sat, T2; coronal T2 with fat-sat and post-gadolinium
T1 with fat-sat images of the skull base were obtained.
FINDINGS: Correlation is made to MR of the cervical spine from
an outside hospital dated [**2184-8-11**].
The visualized skull base appears normal with no areas of
abnormal enhancement. No abnormalities of the mandible,
masticator space, parapharyngeal space, or infratemporal fossa
are seen. The visualized oral cavity, oropharynx, and
nasopharynx are normal. The right inferior turbinate is not
seen, which may be due to prior surgical resection.
There is minimal mucosal thickening involving the maxillary
sinuses and ethmoid air cells.
There is no abnormal enhancement of the visualized cranial
nerves. Meckel's caves and cavernous sinuses appear normal.
There are no areas of slow diffusion. Visualized major flow
voids are normal. The ventricles and extraaxial CSF spaces are
normal.
There are a few scattered T2 hyperintense foci of the
subcortical and deep white matter, which may represent small
vessel ischemic changes.
There is decreased T1 signal of the visualized bone marrow of
the calvarium and cervical spine which is a nonspecific finding
but may represent involvement by lymphoma or marrow
reconversion.
There appears to be a left medial orbital wall blowout fracture.
IMPRESSION: No abnormal enhancement of the visualized cranial
nerves. No abnormalities of the mandible or skull base are seen.
.
[**8-14**] CXR: Progression of bilateral airspace and interstitial
opacities, at least a component of which likely represents
hydrostatic edema given associated cardiovascular changes.
Coexisting infection, hemorrhage or drug reaction is also
possible in the setting of lymphoma.
.
[**8-13**] CT chest w/o contrast: 1. Multifocal ground-glass
opacities involving the both upper lobes, right middle lobe and
superior segment of left lower lobe measuring up to 3.7 cm, with
diffuse peribronchial thickening and pleural effusion and
mediastinal and paraaortic nodes as described above.
Differential diagnosis include alveolar hemorrhage in the
presence of hemoptysis, infectious process in the appropriate
clinical setting, with etiology including both viral and
bacteria, or atypical multifocal pulmonary edema given rapid
appearance and septal
thickening and effusion. Further clinical correlation and close
follow up is recommended.
2. Diffuse high density of the liver, could represent
hemosiderosis or hemachromatosis, or amiodarone accumulation.
3. Bilateral nonobstructing renal stones.
.
[**8-13**] TTE: The left atrium is elongated. 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 root is mildly dilated at the
sinus level. 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. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
.
ECG: NSR at 80s, normal axis, normal intervals, rSr' in V1, no
significant ST-T wave changes compared to two prior EKGS
(however both prior in a fib)
.
[**2184-8-30**] CT CHEST
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with Large B-cell Lymphoma
REASON FOR THIS EXAMINATION:
re-eval s/p chemo r/o infection
CONTRAINDICATIONS for IV CONTRAST: Had ARF
INDICATION: 55-year-old man with large B-cell lymphoma. Evaluate
lung parenchyma, status post chemotherapy.
COMPARISON: CT chest without IV contrast dated [**2184-8-13**].
TECHNIQUE: MDCT imaging of the chest was performed without
intravenous contrast. Images were obtained with 1.25 mm slice
thickness and displayed in soft tissue and lung windows. Coronal
reformatted images were also obtained.
CT CHEST WITHOUT INTRAVENOUS CONTRAST: A right PIC catheter
terminates within the right atrium, and repositioning is
recommended. Multiple mediastinal lymph nodes are decreased in
size. A representative right paratracheal node measures 6 mm in
short axis, previously 9 mm. Additional lymph nodes are equally
decreased in size. Moderate calcifications line the aortic arch
in all three coronary vessels, particularly the left circumflex.
Heart size is normal. There is no pericardial effusion.
Bilateral pleural effusions have resolved. Multifocal areas of
ground-glass opacities seen on the prior CT have largely
resolved. New ground-glass opacities, mainly in the anterior
aspects of both upper lobes and right mid lobe are new, but
appear less dense than those seen previously. Multiple pulmonary
nodules measuring no more than 2 mm in size, and are difficult
to differentiate from the underlying lung disease. Calcified
granulomas in the right lower lobe (3/36, 3/41) are consistent
with prior granulomatous infection.
Limited imaging of the upper abdomen is not sufficient for
diagnosis. The spleen measures upper limits of normal at 13.7
cm. Multiple nonobstructing renal stones are unchanged. There is
an exophytic simple cyst from the interpolar left kidney
measuring up to 3.2 x 2.6 cm in size.
BONE WINDOWS: There are no findings concerning for malignancy
within the imaged bones.
IMPRESSION:
1. Marked interval improvement in multifocal ground-glass
opacities, predominating in the upper lobes. New foci of
ground-glass opacity in the anterior segments of both upper
lobes and right middle lobe are less dense than those seen
previously. Differential diagnosis remains the same, with
infectious etiology most likely.
2. Resolved bilateral pleural effusions.
3. Decrease in mediastinal lymphadenopathy.
4. Right PIC catheter terminates in the right atrium. Retraction
by approximately 3 cm is recommended for positioning in the mid
SVC.
5. Mild splenomegaly.
6. Unchanged nonobstructing bilateral renal stones.
[**2184-8-30**] ECHOCARDIOGRAM
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened (focal thickening of the non-coronary cusp) but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Torn mitral chordae
are present. The tricuspid valve leaflets are mildly thickened.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2184-8-13**], the
patient is no longer tachycardic. Trace aortic regurgitation was
present on the prior study (but not reported). Overall no
significant change.
[**2184-9-4**] CT CHEST WITHOUT CONTRAST
IMPRESSION:
1. New small pleural effusions and diffuse smoothly thickenied
septal lines, most compatible with hydrostatic edema.
2. Increased conspicuity of diffuse centrilobular nodules, but
overall decrease in size in majority of the
previously-visualized ground-glass opacities, some of which are
now consolidative. These findings may be secondary to two
distinct infectious entities, one of which is progressing and
the other of which is improving.
Brief Hospital Course:
A/P. Mr. [**Known lastname 5395**] is a 55 yo male with NHL recently admitted to
[**Hospital Unit Name 153**] for hemoptysis in setting of thrombocytopenia and dyspnea
secondary to A. Fib with RVR, re-admitted for increasing
dyspnea likely secondary to pulmonary edema.
.
1. LYMPHOMA: The patient had had chemo prior to admission and
suffered from tumor lysis syndrome. The patient's heme
malignancy was diagnosed as BURKITTs LYMPHOMA during this
admission, accounting for aggressive tumor turnover. FISH was
carried out and was positive for c-myc rearrangement, as well as
IgH. He received part A of HyperCVAD in the ICU where he had
been transferred for hypoxia. He tolerated the chemo well, but
required close monitoring of his volume status (diastolic HF)
and his oxygenation, as well as tumor lysis status. It was
somewhat challenging to keep his platelets up and he required
numerous transfusions of platelets and RBCs. Upon stabilization
and return to the floor, the patient received prophylactic
intrathecal methotrexate. He did not receive Part B of HyperCVAD
as patient had moderate sized R sided pleural effusions. Upon
return of his counts, patient's LDH also began to escalate,
thought to be secondary to activity of his disease. Therefore
patient was treated with IVAC regimen, day +14 at time of
discharge. He once again became neutropenic and his counts had
not yet recovered by the time patient was transferred.
.
2. SOB. Patient was found to desaturate to 88% on 6L on the
floor but had been previously been 95% on 3L. Etiology of SOB
was initially not clear, but includes pulmonary edema, pneumonia
(aspergillus), PE, and MI, DAH. Pulmonary edema seemed most
likely as oxygen saturation improved with lasix. However, echo
on [**8-13**] showed EF > 55%. Patient had BAL positive for
aspergillus, but was on voriconazole at the time of his hypoxia,
and this would be unlikely to cause acute SOB. CXR showed
bilateral infiltrates. There was no suspicion for PE, and it
would be difficult to anticoagulate patient at that time due to
recent hemoptysis and low platelets. EKG showed no ischemic
changes and enzymes were negative. The patient's respiratory
status improved with an increase in his daily dose of lasix, and
he remained asymptomatic once transferred to the floor, on no
oxygen. He also received nebs. His blood pressure medications
were uptitrated with good response. His peripheral edema was
resolving slowly on his increased dose of lasix.
.
3. A Fib. The patient was initially in A Fib with RVR, which
resolved with monitoring of his volume status and increased beta
blocker. No anticoagulation was indicated in view of his low
platelets and history of bleeding (hemoptysis).
.
4. Hemoptysis. Patient had recent hemoptysis and was found to
have a clot in the carina on bronchoscopy a few days prior.
Hemoptsysis did not recur.
.
5. ARF. The patient developed ARF initially in the setting of
tumor lysis syndrome. Renal was consulted. Creatinine improved
on lanthanum and aluminum hydroxide with resolution of the
syndrome and close monitoring of fluid balance.
.
6. Febrile Neutropenia. Patient was persistently febrile while
neutropenic. Workup included BAL that was positive for
aspergillus. Patient was started on antifungal therapy with
voriconazole and maintained on that regimen until time of
transfer. After treatment with IVAC, patient again developed
neutropenic fever. He also complained of some [**Last Name (un) 940**] stol.
Therefore patient was started on flagyl and three stool samples
had been sent for C. difficile toxin. At time of discharge,
third sample returned negative. Would consider discontinuing
flagyl. Panculture was negative during time of stay.
.
7. Hematuria. One day prior to transfer, patient complained of
painful hematuria. He has a history of kidney stones and
attributed his symptoms to this. UA was positive for 15 RBCs and
5 WBCs. Patient denied further hematuria, frequency or dysuria.
Pain resolved with passage of bloody urine. However had received
ifosfamide with Mesna and cyclophosphamide. Would need further
evaluation for hemorrhagic cystitis vs. BK virus vs
nephrolithiasis.
Medications on Admission:
Meds on transfer:
zofran 24 mg IV q24h with chemo and 4 mg IV q8h prn
lopressor 125 mg TID
vancomycin 1 g IV q12h (premed with benadryl)
voriconazole 200 mg PO Q12H
maalox 20 mg PO q8h
Bactrim DS 1 tab PO three times weekly
levofloxacin 750 mg IV daily
hydralazine 20 mg PO q6h
atrovent nebs q6h prn
dexamethasone 40 mg PO daily X 5 days (starting [**8-13**])
SSI
lanthanum 1000 mg PO TID with meals
ativen 0.5-2 mg PO/IV q4h prn
lactulose 30 ml PO TID
bisacodyl PO daily prn
senna 1 tab PO bid
colace 100 mg PO BID
temazepam 15 mg PO hs prn
reglan 10 mg IV q6h prn
tylenol 325-650 mg PO q6h prn
protonix 40 mg daily
nicotine patch 21 mg daily
benadryl 25 mg IV q6h prn
dilaudid 2-4 mg IV q2h prn
fentanyl patch 25 mcg/hour q72h
folate 5 mg daily
allopurinol 300 mg daily
.
Discharge Medications:
1. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation Q4 prn () as needed for SOB, wheezing.
11. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal
TID (3 times a day) as needed.
17. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
19. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
21. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection
Q24H (every 24 hours).
22. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2
times a day).
23. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed.
24. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
26. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
27. Furosemide 10 mg/mL Solution Sig: One (1) Injection DAILY
(Daily).
28. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
29. DiphenhydrAMINE 12.5 mg IV BEFORE VANCO ADMINISTRATION
Discharge Disposition:
Home
Discharge Diagnosis:
Burkitts Lymphoma
Diastolic Heart Failure
Neutropenic Fever
Pneumonia
Pulmonary Edema
Discharge Condition:
stable
Discharge Instructions:
Admitted with a lymphoma which extensive testing proved to be
BURKITTS. This lymphoma needs frequent chemotherapy. You had a
lung infection and also fluid in your lungs which necessitated
management in the ICU. Your medications have been adjusted to
better deal with this and also your leg edema (swelling). You
underwent several cycles of chemotherapy which resulted in
better control of your disease. You will be transferred to [**Hospital1 336**]
where Dr. [**First Name (STitle) 1557**] has moved his practice.
.
Followup Instructions:
.
You will be followed at [**Hospital 4415**] by Dr.
[**First Name (STitle) 1557**].
|
[
"788.20",
"E947.9",
"401.9",
"428.30",
"253.6",
"200.20",
"486",
"780.6",
"288.00",
"287.5",
"427.31",
"070.54",
"584.8",
"428.0",
"786.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.15",
"38.93",
"33.24",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
19815, 19821
|
12229, 16403
|
279, 294
|
19951, 19960
|
4301, 7998
|
20527, 20615
|
3612, 3636
|
17227, 19792
|
8035, 8078
|
19842, 19930
|
16429, 16429
|
19984, 20504
|
3651, 4282
|
231, 241
|
8107, 12206
|
322, 3426
|
3448, 3548
|
3564, 3596
|
16447, 17204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,120
| 145,835
|
6184
|
Discharge summary
|
report
|
Admission Date: [**2110-4-9**] Discharge Date: [**2110-4-14**]
Date of Birth: [**2056-12-31**] Sex: M
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:
[**2110-4-9**] Emergent Coronary Artery Bypass Graft x 3 (LIMA to LAD,
SVG to OM, SVG to RCA)
History of Present Illness:
53 y/o male with 2 months of worsening chest discomfort
associated with shortness of breath during exercise. Had a
positive ETT on [**4-8**] and referred for cardiac cath. On [**4-9**] had
cath which revealed severe three vessel disease with 90% left
main lesion. Transferred from OSH to [**Hospital1 18**] for emergent surgery.
Past Medical History:
Hypercholesterolemia
Hodgkin's Lymphoma s/p Splenectomy, radiation, chemo
Hypothyroidism
s/p lymph nose dissection and removal (left axillary and bilat
groin)
s/p Tonsillectomy
s/p removal of cancerous nevi from left chest
Social History:
Denies tobacco use. Admits to 2-3 beers/1-2x per wk. Denies
recreational drug use. Lives with wife and 2 children.
Family History:
Non-contributory
Physical Exam:
Gen: WD/WN male in NAD
Skin: W/D -lesions
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2110-4-13**] 04:15AM BLOOD WBC-14.2* RBC-2.29* Hgb-7.7* Hct-22.2*
MCV-97 MCH-33.8* MCHC-34.9 RDW-13.7 Plt Ct-231
[**2110-4-11**] 03:23AM BLOOD PT-12.7 PTT-27.2 INR(PT)-1.1
[**2110-4-13**] 04:15AM BLOOD Glucose-92 UreaN-21* Creat-1.0 Na-138
K-4.4 Cl-102 HCO3-26 AnGap-14
[**2110-4-9**] 11:59AM BLOOD ALT-54* AST-40 LD(LDH)-194 CK(CPK)-246*
AlkPhos-106 Amylase-34 TotBili-0.5
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2110-4-11**] 12:42 PM
CHEST (PORTABLE AP)
Reason: evaluate for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with CAD s/p CABG. ETA to CSRU 45 minutes.
Please page [**First Name8 (NamePattern2) **] [**Doctor Last Name **] with abnormalities at [**Numeric Identifier 8570**].
REASON FOR THIS EXAMINATION:
evaluate for pneumothorax s/p chest tube removal
PORTABLE CHEST OF [**2110-4-11**]
COMPARISON: [**2110-4-9**].
INDICATION: Status post coronary artery bypass surgery.
Following removal of left-sided chest tube, a tiny left apical
pneumothorax has developed. Various other lines and tubes have
been removed with a right internal jugular vascular sheath
remaining in place. Cardiac and mediastinal contours are
slightly widened compared to the recent postoperative radiograph
with associated distention of the azygous vein, probably
reflecting a mild degree of volume overload. Bibasilar
atelectasis has worsened compared to the pre-extubation
radiograph. Small left pleural effusion is without change.
IMPRESSION:
1. Very small left apical pneumothorax following left chest tube
removal.
2. Worsening bibasilar atelectasis and probable mild volume
overload.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Cardiology Report ECHO Study Date of [**2110-4-9**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG
Height: (in) 66
Weight (lb): 165
BSA (m2): 1.84 m2
BP (mm Hg): 134/78
HR (bpm): 56
Status: Inpatient
Date/Time: [**2110-4-9**] at 17:29
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Diastolic Dimension: 3.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 8 mm Hg
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild to moderate
([**11-19**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic 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
Conclusions:
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
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 (3) are mildly thickened but aortic
stenosis is
not present. Mild (1+) aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-19**]+)
mitral regurgitation is seen.
Post bypass
1. Patient is being AV paced and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is preserved.
3. Mild mitral regurgitation persists.
4. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2110-4-9**] 17:56.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 24121**] was transferred for a
emergent CABG. He was brought immediately to the operating room
where he underwent a coronary artery bypass graft x 3. Please
see operative report for details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Inotropes were weaned by
post-op day two and diuretics and beta blockers were initiated.
He was gently diuresed towards his pre-op weight. On post-op day
two his chest tubes were removed and he was transferred to the
telemetry floor for further care. His wires were d/c'd on POD#3
and he was discharged to home in stable condition on POD#5.
Medications on Admission:
Synthroid, Zocor, Aspirin, Toprol, NTG prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. 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*
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Emergent Coronary Artery Bypass
Graft x 3
PMH:
Hypercholesterolemia
Hodgkin's Lymphoma s/p Splenectomy, radiation, chemo
Hypothyroidism
s/p lymph nose dissection and removal (left axillary and bilat
groin)
s/p Tonsillectomy
s/p removal of cancerous nevi from left chest
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. Please shower and wash incisions daily. No bathing or
swimming for 1 month. Use sunscreen on incision if exposed to
sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**].
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 5874**] in [**12-21**] weeks
Dr. [**Last Name (STitle) **] in [**11-19**] weeks
[**Hospital Ward Name 121**] 2 for wound check in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-4-15**]
|
[
"272.0",
"V10.79",
"414.01",
"518.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7735, 7784
|
6025, 6789
|
331, 426
|
8125, 8131
|
1482, 2013
|
8860, 9187
|
1178, 1196
|
6882, 7712
|
2050, 2232
|
7805, 8104
|
6815, 6859
|
8155, 8837
|
3310, 6002
|
1211, 1463
|
281, 293
|
2261, 3284
|
454, 784
|
806, 1030
|
1046, 1162
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,983
| 191,843
|
11912+11913
|
Discharge summary
|
report+report
|
Admission Date: [**2186-1-12**] Discharge Date:
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
white male with a history of CABG [**01**] years ago who presented
to an outside hospital with shortness of breath and CHF. The
patient has a pacemaker for AV nodal disease which was placed
[**2185-11-16**]. The patient then had an echo which demonstrated
severe decrease in left ventricular function with an EF of
10% and moderate MR. The patient also had an ultrasound of
the bilateral carotids which demonstrated bilateral disease
of approximately 80% stenosis on both sides. The patient had
a Persantine stress test which demonstrated ischemia in the
lateral and basilar walls. The patient was noted to be
hyponatremic at the outside hospital as well.
The patient was admitted and treated with diuresis and
Dobutamine for two days with good result. Over that time the
patient ruled in for myocardial infarction with elevated CPKs
but negative troponin. The patient was therefore transferred
to [**Hospital1 69**] for a second opinion
regarding carotid endarterectomy as well as for
catheterization given his history of high risk surgery
candidate.
The outside hospital reported a 7 lb weight loss with
diuretics. His Coumadin was held given his elevated INR of
3.25. At time of transfer the patient denied any shortness
of breath, chest pain, nausea, vomiting, fevers, chills,
diarrhea, constipation.
PAST MEDICAL HISTORY: CABG [**01**] years ago, history of
myocardial infarction, status post cholecystectomy, status
post peptic ulcer disease surgery, ischemic cardiomyopathy,
mitral regurgitation, pacemaker placement secondary to AV
nodal disease, chronic renal insufficiency.
MEDICATIONS: Carvedilol 12.5 mg po bid, Colace 100 mg po
bid, Lasix 40 mg po q d, Aspirin 325 mg po q d, sublingual
Nitroglycerin po prn, Captopril 6.25 mg po tid, Serax 10 mg
po q h.s. prn, Heparin drip.
ALLERGIES: The patient reports an allergy to Erythromycin
and to iodine.
SOCIAL HISTORY: The patient has a positive tobacco history
of 30 years but quit in [**2144**]. He denies any alcohol use.
FAMILY HISTORY: The patient's father died of a cancer at age
[**Age over 90 **]. The patient's mother died of pneumonia at age 86. The
patient reports 10 siblings, one of whom has diabetes and
some of whom have "heart disease". The patient lives with
his wife at home and prior to the last month has helped take
care of his wife. [**Name (NI) **] has four children, two of whom live
close by and are very involved in his care.
PHYSICAL EXAMINATION: Temperature 96.8, blood pressure
153/71, heart rate 40, respiratory rate 16, saturation 94% on
one liter O2, weight 45 kg. HEENT: Pupils equally round and
reactive to light, moist mucus membranes, full dentures,
extraocular movements intact, oropharynx clear. Neck, no
cervical lymphadenopathy, no JVD. Chest, clear to
auscultation bilaterally. Cardiovascular, regular rate and
rhythm, normal S1 and S2, 2/6 systolic ejection murmur.
Abdomen, nontender, non distended, positive bowel sounds,
soft, positive scars, status post cholecystectomy and CABG.
Extremities, trace bilateral edema of the ankle, pulses full,
strength 5/5 bilaterally, trace pedal edema.
LABORATORY DATA: White blood cell count 7.7, hemoglobin
32.4, platelet count 210,000, sodium 130, potassium 4.4,
chloride 92, CO2 31, BUN 19, creatinine 1.3, INR 1.35, PT
13.5, iron 42, TIBC 392.
EKG, old inferior/anterior MI with pacer spikes.
HOSPITAL COURSE: The patient is an 83-year-old male with a
history of CABG, recent pacemaker placement, carotid artery
disease who presents for evaluation for carotid
endarterectomy as well as evaluation for possible
catheterization with stress changes on EKG.
The patient was originally admitted to C-Med firm for
evaluation for possible catheterization and evaluation by
vascular surgery for potential carotid endarterectomy. Given
the patient's history of coronary artery disease he was
continued on his beta blocker, Aspirin and Captopril, as well
as Carvedilol. A discussion was held with the patient's
family who agreed for cardiac catheterization to determine
patency of the patient's graft as well as to evaluate for any
potential intervention. In the meantime an echocardiogram
was obtained on [**1-13**] which demonstrated a severely dilated
left ventricle, mildly dilated left atrium, severe global
hypokinesis of the left ventricle, moderate MR, no effusion.
At this time the patient was started on Digoxin and his ACE
inhibitor was titrated up as tolerated.
Cardiac catheterization was performed on [**2186-1-16**].
Catheterization demonstrated occluded CABG graft, with severe
three vessel coronary artery disease including a 40% stenosis
of the left main, 80% stenosis of the LAD, 50% stenosis of
the left circumflex with 50% stenosis of the diagonal, 100%
stenosis of RCA. The patient had a stent placed in his LAD.
The patient's catheterization was complicated by hypotension
especially during the intervention of the LAD. He briefly
required Milrinone therapy and was then stabilized on
Dopamine as well as an intra-aortic balloon pump.
Hemodynamics during the catheterization study demonstrated a
right atrial pressure of 11, right ventricle 62/5, PA
pressure 62/30 which was then 48/27 post intervention, PA sat
27%, then 62% post intervention, wedge pressure of 39, aortic
pressure 115/40.
Evaluation of catheterization results suggest that patient
did have surgical coronary artery disease, however, he was
not an operative candidate given his history of CABG and the
diffuseness of his disease. Therefore he was admitted to the
CCU for further management post catheterization. The patient
was continued on Aspirin and Plavix as well as his Heparin
drip. A lipid panel was checked and the patient was
continued on Lipitor. No 2B, 3A inhibitors were given
because the patient had demonstrated a low hematocrit over
the course of hospital stay and there had been a question of
some hemoptysis at time of admission.
The patient's LV function was significantly depressed based
on findings on the echocardiogram as well as catheterization.
It is likely that this low EF was not new and that this
revascularization would restore blood flow to hibernating
myocardium thus improving the cardiac function overall. On
admission to the CCU the patient's intra-aortic balloon pump
was continued overnight and the patient was slowly weaned off
Dobutamine.
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2186-1-18**] 10:47
T: [**2186-1-18**] 12:24
JOB#: [**Job Number 37528**]
Admission Date: [**2186-1-12**] Discharge Date: [**2186-1-21**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 83-year-old male with
a history of coronary artery disease, status post coronary
artery bypass graft, with an ejection fraction of around 10%
due to ischemic cardiomyopathy, who presented to an outside
hospital with chest pain and was transferred to [**Hospital1 346**] for catheterization and carotid
evaluation as he was reported to have bilateral critical
carotid artery stenoses.
He arrived at the outside hospital on [**1-9**] with chest
pain, shortness of breath, and congestive heart failure
exacerbation. He developed positive cardiac enzymes with a
peak creatine kinase of 962, and a MB of 24.6, with a MB
index of 2.7. An echocardiogram revealed an ejection
fraction of 10% to 20%. He was also noted to have bilateral
80% carotid stenoses and evidence of lateral ischemia on a
Persantine stress test.
Echocardiogram at [**Hospital1 69**]
confirmed significant left ventricular dilatation and
dysfunction, but carotid Doppler showed no significant
stenoses with 70% to 79% on the left and 40% to 49% on the
right. He was deemed to not be a candidate for carotid
endarterectomy, but was taken to cardiac catheterization for
his non-Q-wave myocardial infarction.
Catheterization revealed significant native 3-vessel disease,
and none of his coronary artery bypass graft grafts were
patent. He underwent percutaneous transluminal coronary
angioplasty and stenting of his proximal left anterior
descending artery lesion and had complications with
hypotension and high filling pressures during the
intervention. He briefly required Milrinone and was
ultimately stabilized on dopamine and an intra-aortic balloon
pump.
After the case, he was transferred to the Coronary Care Unit
for further management. Other positive findings on review of
systems included hemoptysis and anemia of unknown etiology.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2168**] at [**Hospital6 **] with unknown
graft anatomy.
2. Ischemic cardiomyopathy with an ejection fraction of less
than 20%.
3. Peripheral vascular disease.
4. Type 2 diabetes mellitus complicated by chronic renal
insufficiency.
5. His AV nodal disease, status post pacemaker placement.
MEDICATIONS ON TRANSFER:
1. Carvedilol 12.5 mg p.o. b.i.d.
2. Lasix 40 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Captopril 12.5 mg p.o. t.i.d.
5. Colace 100 mg p.o. b.i.d.
6. Heparin drip.
7. Digoxin 0.125 mg p.o. q.d.
ALLERGIES: Allergy to ERYTHROMYCIN, IODINE, and PRONESTYL.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] has four
children including two very involved daughters. [**Name (NI) **] smoked
for 30 years but quit in [**2144**]. There is no alcohol use.
FAMILY HISTORY: His father died at age [**Age over 90 **] of cancer. His
mother died at age 86 of pneumonia. He has one brother with
diabetes and nine of his other siblings are healthy.
PHYSICAL EXAMINATION ON PRESENTATION: This is an elderly man
in no acute distress with a blood pressure of 153/71, a heart
rate of 39, a respiratory rate of 16, and oxygen saturation
of 95% on 1 liter nasal cannula. He is afebrile and weighs
45 kg. His head, ears, nose, eyes and throat examination was
unremarkable. His neck was supple with no jugular venous
distention nor carotid bruits. His lungs were clear except
for bibasilar rales. His heart was regular with no murmurs.
His abdomen was benign. His extremities were warm with no
edema. His neurologic examination showed that he was awake
and oriented times three with intact cranial nerves. He was
moving all four extremities spontaneously and had grossly
intact sensation. His deep tendon reflexes were 1+
bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
presentation included a white blood cell count of 7.7,
hematocrit of 32.4, and platelets of 210. His Chem-7 was
within normal limits except for a blood urea nitrogen of 19
and a creatinine of 1.3.
RADIOLOGY/IMAGING: Electrocardiogram before catheterization
showed a paced rhythm with a left bundle-branch block. There
were no acute changes suggestive of ischemia.
HOSPITAL COURSE: Mr. [**Known lastname **] was kept on aspirin, digoxin,
and captopril. He was started on Lipitor and Plavix after
receiving his stent. He was also placed on a heparin drip
for his low ejection fraction, but given his overall
functional status and that he was a poor candidate for
long-term anticoagulation it was stopped.
He was diuresed as he presented in failure and had great
improvement in his hemodynamics, especially his cardiac
output and his index to the point where he was able to be
weaned off of the balloon pump and off of pressors. His
Swan-Ganz catheter was then removed.
Also of note, he had an increased creatine kinase after
intra-aortic balloon pump placement that peaked at around
5000 with negative MBs. There was a concern for lower
extremity ischemia from the balloon exacerbating his
peripheral vascular disease. This increased creatine kinase
was asymptomatic and continued to trend down during his
entire course.
From a pulmonary standpoint, a single chest x-ray on
[**1-19**] showed evidence of a tiny apical pneumothorax.
This was two days after right internal jugular placement for
a Swan. This pneumothorax was not seen on repeat chest x-ray
on [**1-20**].
From an infectious disease standpoint, he spiked a fever in
the middle of his course and was started on empiric
vancomycin and levofloxacin to cover for line sepsis and
pneumonia. There was a question of a left lower lobe
infiltrate on chest x-ray. Blood and urine cultures were
negative. After his sputum culture grew out Staphylococcus
aureus, his antibiotics were changed to dicloxacillin for a
10-day course. He remained afebrile after initially starting
antibiotics.
For his anemia, he received multiple transfusions with an
increase in his hematocrit to 34 by the time of discharge.
He was briefly placed on Diamox for a metabolic alkalosis
that developed after his intervention. This improved, and
the Diamox was stopped. He was also on a 1.5-liter
restriction for his congestive heart failure.
He had occasional episodes of agitation and sundowning at
night that required Haldol. From time to time he also
required Ativan for extreme agitation.
With regard to code status, he was full code on presentation
but as it became clear how long a recovery he would have and
the new limitations on his function status that were unlikely
to improve significantly with time, a frank discussion was
held with his very supportive family who decided to change
his code status to do not resuscitate/do not intubate/comfort
measures only and have him go home with hospice.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: To home with hospice.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post non-Q-wave
myocardial infarction, status post stent placement.
2. Severe ischemic cardiomyopathy with an ejection fraction
of approximately 10%.
3. Type 2 diabetes mellitus, diet controlled.
4. AV nodal disease, status pacemaker placement.
5. Peripheral vascular disease.
MEDICATIONS ON DISCHARGE:
1. Lasix 80 mg p.o. q.d.
2. Digoxin 0.125 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Lisinopril 10 mg p.o. q.d.
6. Colace 100 mg p.o. b.i.d.
7. Dulcolax 10 mg p.o. q.d. p.r.n. for constipation.
8. Aldactone 25 mg p.o. q.d.
9. Haldol 2.5 mg p.o. q.h.s. p.r.n. for agitation.
10. Ativan 0.5 mg to 1 mg p.o. q.4h. p.r.n. for extreme
agitation.
11. Dicloxacillin 250 mg p.o. q.i.d. times 10 days.
12. Tylenol 650 mg p.o. q.4-6h. p.r.n.
13. Oxygen 3 liters nasal cannula p.r.n.
14. Lasix 80 mg p.o. q.p.m. p.r.n. (weight greater than
52 kg). This Lasix should be used whenever his weight goes
above 52 kg. His weight on discharge was 50 kg. Once his
weight returns to normal, p.r.n. Lasix can be stopped.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2186-1-21**] 15:24
T: [**2186-1-25**] 07:52
JOB#: [**Job Number 37529**]
|
[
"593.9",
"041.10",
"414.01",
"458.9",
"410.71",
"996.72",
"414.02",
"285.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"37.23",
"88.48",
"88.56",
"37.61",
"36.06",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9609, 11000
|
13716, 14034
|
14061, 15092
|
11018, 13602
|
2592, 3505
|
13617, 13695
|
6878, 8705
|
9122, 9387
|
8727, 9097
|
9404, 9592
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,983
| 178,243
|
27862
|
Discharge summary
|
report
|
Admission Date: [**2197-6-25**] Discharge Date: [**2197-7-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Vancomycin weakness
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
84 yo male with h/o HTN, CADs/p CABG was in his USOH until 48
hours ago when he started feeling weak and having dizziness.
Was seen at [**Hospital1 **] [**Location (un) **] and found to have HR in the 30s with a
junctional rhythm on EKG. Was given atropine, and his HR
improved to 40. Found to have new onset renal failure cr 3.6 and
hyperkalemia (5.7) and was given Ca, dextrose, bicarb, insulin,
kayexalate and transferred to [**Hospital1 18**].
.
In the ED here, his HR was in the 40s and he felt better. No CP,
no SOB, no lightheadedness. SBP 140s. HR in upper 40s and lower
50s, Was given glucagon w/ GI upset but w/o improvement in HR.
EKG here w/ ? slow atrial fibrillation. Patient usually receives
lopressor 12.5 9 a.m. and cardizem 240mg XR 9 a.m.
.
The patient denies a change in urination, itchiness, but has had
trouble sleeping recently. Also complains of sinus congestion
and HA for the last few weeks and a week of a nonproductive
cough.
.
PAST MEDICAL HISTORY:
1. CAD s/p CABG ([**2177**])
2. Hypertension
3. Hyperlipidemia
4. Anemia - for the last year, had a transfuion in [**9-26**],
baseline in the low 30's
5. Diverticulitis s/p partial colectomy
6. Mass on the kindey and lung - found last [**Month (only) 321**]; no
current workup, as workup would be too invasive
7. Chronic diarrhea
8. Emphysema
9. History of bowel obstructions
10. s/p Cholecystecomy
11. s/p two hernia repairs
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2177**] anatomy as follows: 3 vessel
disease
.
OUTPATIENT MEDICATIONS:
1. Cardizm XR 240 mg daily
2. Zestril 40 mg daily
3. Metoprolol succinate 12.5 mg daily
4. Norvasc XR 10 mg daily
5. ASA 81 mg daily
6. Zocor 20 mg daily
7. Omeprazole 20 mg daily
8. Trental ZR 400 mg tid
9. Ativan 0.5 mg prn
10. Temazepam 30 - 45 mg qhs
11. Zyrtec 1 tab daily
12. Nasonex 2 sprays q nostril daily
13. Eye drops for runny eyes
14. Miralax once daily
15. B12 shot once monthly
.
ALLERGIES: NKDA
.
SOCIAL and FAMILY HISTORY:
Social history is significant for the a 125 pack year history;
quit 8-10 years ago. There is no history of alcohol abuse. There
is no family history of premature coronary artery disease or
sudden death, however several family members have had [**Name (NI) 5290**].
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. 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. He sleeps
with one pillow.
.
PHYSICAL EXAMINATION:
VS - T 97.6 BP 162/52 P 54 R 20 sat 98% on 3 L
Gen: thin, elderly male lying in bed in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear.
Neck: Supple with JVP of 8 cm.
CV: Midline well-healed scar present; regular and bradycardic,
normal S1, S2. No m/r/g. 2 + radial pulses.
Chest: Wheezing present Left > Rt; crackles present bilaterally
at the bases. Audible wheezing at baseline. Respirations
unlabored, no retractions.
Abd: + BS, distended with gas. No hepatosplenomegaly present.
Ext: No c/c/e.
Skin: Thin skin throughout
.
MEDICAL DECISION MAKING
EKG [**6-25**] - HR 50, irregular,
TELEMETRY demonstrated: bradycardia
2D-ECHOCARDIOGRAM performed on [**10-27**] demonstrated: EF 40-45%,
mild to moderate regional left ventricular systolic dysfunction
with inferior/inferolateral/inferior akinesis.
.
LABORATORY DATA:
Na 14 K 4.9 Cl 109 Bicarb 24 BUN 69 Cr 3.6 Glu 155
WBC 8.7 Hct 30.0 Plt 201 (83.8% N, 11.6% L)
Pt 12.9 Ptt 25.8 INR 1.1
Troponin 0.02
[**1-27**] CT abdomen:
- Cystic renal cell carcinoma left kidney, likely high-grade
papillary type. This has grown since [**2192**].
- Multiple left lower lobe nodules (in the lungs) are new since
[**2197-1-13**]. Though the largest has an appearance concerning for
metastasis, this would be unlikely to have grown to 1 cm in this
short interval and this may represent a small airways infection
or
aspiration as is evident in the right middle lobe.
.
[**6-25**] CXR mild interstital fluid overload without evidence of PNA
or pleural effusion.
.
ASSESSMENT AND PLAN:
84 yo male with pmh of CAD s/p CABG, htn, and renal and
pulmonary masses who presents with ARF and a juntional
bradycardia.
.
#. CAD - patient is s/p CABG, currently without chest pain.
- Continue ASA, statin.
- Are holding B-blocker due to bradycardia.
.
#. Pump - patient has some signs of volume overload - crackles
halfway up his chest and interstial fluid on CXR. Will monitor
and watch his I/Os as he is in renal failure and may become
volume overloaded.
- We will continue BP control with norvasc, but are holding
metoprolol and diltiazem as he is bradycardic. Can consider
starting hydralazine if further BP control is needed.
.
#. Rhythm - patient is currently in a juntional escape rhythm
likely due to his ARF as diltiazem is renally cleared and may be
accumulating causing AV block.
- Continue to monitor on telemetry
- Hold his B-blocker and diltiazem
.
#. Acute renal failure - Differential includes prerenal vs
intrarenal vs postrenal. Unlikey to be prerenal as there is no
history to suggest volume depletion. As for postrenal, he has a
history of RCC which could have metastasized or he may have BPH
which could have caused obstruction. Intrarenal causes included
extension of his RCC, intrinsic golmerular disease, or
interstitial disease.
- Renal US to rule out obstruction
- F/U urinary electrolytes and [**Hospital1 **] electrolytes
- F/U UA amd UCx
- Consider CT abd/ pelvis to evaluate renal mass
.
# Kidney/ lung masses - last CT abd was in [**1-27**]
- Consider CT abd/ pelvis to evaluate renal mass
.
# Wheezing - patient has crackles and interstial fluid on CXR
- albuterol nebs prn
- Will monitor respiratory status
.
# Hx of diarrhea and bowel obstruction - continue home PPI,
ranitidine and miralax.
- As the patient is very gassy, will give simethicone prn
.
# Sinus problems - continue zyrtec and nasonex
.
#. FEN: Follow and replete electrolytes. Cardiac diet. No IVF at
present.
.
#. Access: PIV
.
#. PPx: SQH, bowel regimen.
.
#. Code: full
.
#. Dispo: pending resolution of his junctional rhythm and
diagnosis of the cause of his ARF
.
Past Medical History:
CAD s/p MI and CABG
hx recurrent partial small bowel obstructions
htn
diverticulitis
s/p ccy
s/p sigmoid colectomy
Dengue fever and malaria in WWII
small bowel obstruction in [**2196-1-21**]
colonoscopy [**10-16**] with one polyp removed
EGD [**2196-10-15**] with gastritis
Social History:
Wife died within the 2 months prior to admission. Notes
decreased appetite and endorses depression symptoms. One
daughter lives nearby and is very involved but is also recently
married and has failing in-laws, so is spread thin. Currently
lives alone but daughter frequently in the home. H/o smoking,
but has quit. No EtOH.
Family History:
NC
Physical Exam:
VS - 100.4 95 123/60 16 100% on AC 0.7 500 16 5
Gen: Thin, elderly male. Intubated. Opens eyes and responds to
commands correctly.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear.
Neck: JVP 8cm. Supple. No thyroid enlargement.
CV: Well-healed midline scar; regular and bradycardic, normal
S1, S2. No m/r/g.
Chest: Faint crackles at bases but essentially clear anteriorly.
Abd: OG tube in place. + BS, soft, NT, ND.
Ext: No c/c/e.
Hand grip intact b/l. Tracks and makes eye contact.
Pertinent Results:
[**2197-6-25**] 03:30AM PT-12.9 PTT-25.8 INR(PT)-1.1
[**2197-6-25**] 03:30AM NEUTS-83.8* LYMPHS-11.6* MONOS-3.4 EOS-1.0
BASOS-0.2
[**2197-6-25**] 03:30AM WBC-8.7# RBC-3.23* HGB-9.6* HCT-30.0* MCV-93
MCH-29.7 MCHC-32.0 RDW-14.6
.
RENAL U.S. Study Date of [**2197-6-25**] 12:52 PM
1. Bilateral hypoechoic renal lesions, not meeting son[**Name (NI) 493**]
criteria for simple cyst. In setting of the suspicious left
renal mass previously
described on CT, further characterization of these lesions with
MR is
recommended.
2. The left renal superior pole mass highly suspicious for
pappillary RCC,
seen on CT, [**2197-1-20**] was not demonstrated today. In discussion
with referring physician [**Last Name (NamePattern4) **].[**Last Name (STitle) **] no interim intervention was
undertaken due to decision to pursue non-invasive management
approach. In view of which, this mass could have been obscured
by the rib shadows in that region and MR evaluation is
recommended.
.
Cardiology Report ECG Study Date of [**2197-7-6**] 6:19:00 AM
Sinus rhythm with ventricular premature beats including a slow
triplet.
Consider left atrial abnormality. Left ventricular hypertrophy.
ST-T wave
abnormalities. Since the previous tracing of [**2197-7-2**] the rate
has slowed.
Also, the rate of the ventricular ectopy has slowed. Consider
left atrial
abnormality.
.
CHEST (PORTABLE AP) Study Date of [**2197-7-4**] 3:06 AM
Moderate right pleural effusion layers posteriorly, obscuring
detail in the
right lung but interstitial edema is still present.
Consolidation is
unchanged at the left base since [**6-29**], either atelectasis or
pneumonia.
Heart size is top normal. There is no pneumothorax.
.
Brief Hospital Course:
SUMMARY: Patient is an 84M with a hx of HTN and CAD s/p CABG who
p/w weakness and dizziness. He was found to have renal and
pulmonary masses of unknown significance and also found to have
bradycardia and renal failture. He ultimately underwent
intubation for hypoxic respoiratory failure due to a combination
of NSTEMI and aspiration pneumonia. He was successfully
extubated and improved, thus he was transferred to the floor on
[**2197-7-1**]. He was briefly CMO in the MICU, but was made DNI/DNR
prior to transfer to the floor. He was on 40-50% facemask upon
transfer. He improved to NC 4L on the floor and was stable with
improving pulmonary exam until on [**2197-7-2**], he developed
hypercarbic respiratory failure likely due to mucous plugging
and/or aspiration with blood pH 7.08 and CO2 74. He was sent
back to the MICU to receive CPAP, which he did not tolerate.
However, he improved without CPAP and has been transitioned back
to 4L NC with last ABG on [**7-3**] showing pH 7.26. He was initially
started on vanc/cefepime/flagyl, then the flagyl was
discontinued. He currently feels well with no SOB, CP, abdominal
pain or any other complaints. His current code status remains
DNR/DNI with comfort centered care: cont antibiotics, bp
control, but no escalation of care. As his respiratory function
was improving, he was discharged to home with nursing services
and hospice care. He completed his course of antibiotics, which
was abridged from a 10 day course to a 9 day course (last dose
on day of d/c).
.
# Hypercapneic respiratory failure: This was thought to be
secondary to witnessed aspiration and either pneumonitis or PNA.
He was started on aspiration and hospital acquired PNA
antibiotics. His sputum GS and culture were contaminated
however. Swallow also recommended soft diet with surveillance
while eating. His respiratory function improved and he was
satting 93% on 2L at time of d/c.
.
# NSTEMI: Patient had many PVCs on telemetry but no evidence of
a second infarction. We continued aspirin, beta blocker, and
statin but held the ACE-I b/c of his ARF. We initially held
amlodipine because the patient was bradycardic but restarted it
for better BP control.
.
# Bradycardia: Cause of original admission. HR was initially in
30s due to junctional rhythm and B-blocker, CCB. His
bradycardia resolved and his HR remained in the 60s. Amlodipine
was restarted but diltiazem was held.
.
# Acute renal failure: Cre 2.9 on admission, down to 1.5 at time
of discharge, with a baseline of 1.0 - 1.2. His ARF is likely
[**1-21**] hypoperfusion, probably from bradycardia and/or hypotension
after NSTEMI. His renal function improved with IVF.
A renal U/S showed no hydronephrosis/post-renal obstruction from
mass, but did identify a lesion suspcious for RCC. The family
has chosen not to pursue further w/u.
.
# Hypertension: Patient was hypertensive upon transfer to floor
but improved control with metoprolol. We restarted amlodipine
at the time of d/c.
.
# Hypernatremia: Patient was hypernatremic to 147 but improved
with free water intake and D5W fluid infusion. Sodium was
corrected slowly.
.
# Kidney and lung masses: Had CT abd in [**1-27**] (showed Cystic
renal cell carcinoma left kidney, left lower lobe nodules
largest measures 1 cm). The patient and family do not want
further w/u, however.
.
# Anemia: Patient's baseline hematocrit is low 30s, and he
likely has anemia of chronic disease. We are not working this
up further at this time.
.
# Acute decompensated systolic heart failure: with EF 25-30%.
Previous EF 40%. Patient currently appears euvolemic. Tolerated
IVFs for treatment of ARF which largely resolved. An ACE-I may
be restarted in the future as the patient's renal fxn improves.
.
# Sleep/agitation: Patient was given olanzapine qhs for sleep
and prn haldol 0.25 for agitation. Family members helped with
frequent orientation. Patient tolerated olanzapine and was
weaned off of his home Temazepam. He also was given trazadone
at night to sleep. However, at time of d/c, he requested a
script for his Temazepam, which was restarted.
.
#. FEN: cardiac diet, crushed meds, soft solids w/ thin liquids,
and one-to-one supervision w/ meds. We repleted lytes prn and
d/c'd his foley.
.
#. Access: A PICC was placed during his hospital stay and
removed at time of d/c.
.
#. Code: DNR/I, not CMO, but no escalation in care. Note that
patient did not tolerate CPAP when we transferred him to the
MICU for resp distress. The family spoke with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(palliative care) and the decision was made to discharge the
patient home with hospice care.
.
# Communication: During the hospital stay, we contact[**Name (NI) **] the
patient's sister [**First Name8 (NamePattern2) **] [**Name (NI) **]) at [**Telephone/Fax (1) 67896**] to inform her
of respiratory arrest and intubation; she is the patient's HCP.
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Zyrtec Oral
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Temazepam Oral
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
9. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal once a day.
10. Vitamin B-12 Injection
11. Ativan 0.5 mg Tablet Oral
Discharge Medications:
1. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
2. Zyrtec Oral
3. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed.
4. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal once a day.
5. Vitamin B-12 Injection
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
Disp:*3000 mg* Refills:*2*
9. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H
(every 6 hours) as needed for fever/pain.
Disp:*300 mL* Refills:*0*
10. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane
ASDIR (AS DIRECTED).
Disp:*30 appl* Refills:*2*
11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*240 Puff* Refills:*2*
14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
Disp:*360 puffs* Refills:*2*
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
sleep.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
17. Home supplemental Oxygen at 3 to 4 liters
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
Disp:*30 Tablet(s)* Refills:*2*
19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
20. Home Physical Therapy
Please assist in developing strength and endurance
21. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q2h
as needed for pain or shortness of breath.
Disp:*30 ml* Refills:*0*
22. Temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary
1. Non-ST elevation myocardial infarction
2. Acute renal failure
3. Junctional bradycardia secondary to medication acculmulation
in the setting of acute renal failure
.
Secondary
1. CAD s/p CABG ([**2177**])
2. Hypertension
3. Hyperlipidemia
4. Anemia - for the last year, had a transfuion in [**9-26**],
baseline in the low 30's
5. Diverticulitis s/p partial colectomy
6. Mass on the kindey and lung - found last [**Month (only) 321**]; no current
workup, as workup would be too invasive
7. Chronic diarrhea
8. Emphysema
9. History of bowel obstructions
10. s/p Cholecystecomy
11. s/p two hernia repairs
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to a slow heart rate
accompanied by acute renal failure. You slow heart rate was
found to be due to accumulation of the diltiazem secondary to
your renal failure. You were also found to have suffered a
heart attack and you developed pneumonia. We treated you with
antibiotics and other drugs.
.
We changed several of your medications. Please see the
medications sheet for specific medications and doses.
.
Please contact your primary care physician if you have chest
pain, shortness of breath, fevers, chills, or any other
concerns.
Followup Instructions:
Please schedule an appointment with your primary care doctor in
the next one to two weeks:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]
.
No follow-up with [**Hospital1 18**] Oncology Department for incidental lung
and kidney findings per family's request.
Completed by:[**2197-7-10**]
|
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icd9cm
|
[
[
[]
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[
"96.72",
"38.93",
"96.04",
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icd9pcs
|
[
[
[]
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17940, 17989
|
9753, 14662
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281, 303
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18646, 18655
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8041, 9730
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14688, 15420
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18679, 19256
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7532, 8022
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1942, 2379
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3166, 6854
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222, 243
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331, 1330
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6876, 7151
|
7167, 7497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,677
| 115,839
|
50157
|
Discharge summary
|
report
|
Admission Date: [**2116-12-1**] Discharge Date: [**2116-12-6**]
Date of Birth: [**2041-11-25**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Fosamax / Nsaids / Lisinopril / Astelin /
Hydrochlorothiazide / ipratropium
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ADMISSION NOTE
ADMIT DATE: [**2116-12-1**]
ADMIT TIME: 0400
.
74 yo female with severe end-stage COPD on home oxygen, dCHF, on
treatment for MAC with recent admission for COPD exacerbation
presents to the ED with abdominal pain and constipation.
.
Patient reports [**10-3**] lower quadrant abdominal pain x 1 day.
Also with severe nausea and one episode of vomiting
(non-bloody). Last BM was [**2116-11-16**]. Patient has been taking
miralax, senna and colace daily. Started lactulose yesterday
and glycerin suppository without any effect. Poor po intake
with increasing fatigue. Daughter called patient's palliative
care doctor (for end-stage COPD) who recommended coming to the
ED for further evaluation.
.
Patient was recently hospitalized [**2116-11-17**] - [**2116-11-20**] with
dyspnea from end-stage COPD. Palliative care involved, per note
patient realized she is end-stage however does not wish to be
dnr/dni at this time. Although daughter elaborates that patient
would not want aggressive measures however feels that if she is
dnr/dni she doesn't receive adequate medical treatment in the
hospital.
.
Upon arrival on the floor patient reports she feels slight
better but continues to have significant abdominal pain. NGT is
on intermittent wall suction and is preventing episodes of
vomiting. Denies any cp, lightheadedness or dizziness. SOB
unchanged from baseline. No recent fever or chills.
.
Patient had a fall on Friday ([**2116-11-27**]), tripped over a fan and
has a bruise on left ankle and left arm.
.
ED: 97.6 96P 150/70 20 94%3L NC; 2L NS, morphine 4mg iv x
2, zofran 2mg, dilaudid 1mg iv x 2; CXR stable, KUB dilation of
bowels, NGT placed, CT a/p with contrast no SBO with extensive
fecal loading
.
ROS: as per HPI, 10 pt ROS otherwise negative
Past Medical History:
COPD on home O2 3LNC, chronic steroids (PFT [**10-4**] - FEV1 1.08
(59%), FEV/FVC 48
(70%)
MAC infection initiated on ethambutol, azithromax, levaquin on
[**2116-10-23**]
acquired hypogammaglobulinemia on IVIG / decreased T-cell subset
= idiopathic immune dysfx
Hypertension
Diastolic CHF EF 65% with moderal mitral regurgitation
Pulm Nodules (benign per work up at [**Hospital3 14659**])
GERD
Hyperlipidemia
Hypothyrodism
Osteoporosis with compression fractures (T7/T9/T11)
Osteoarthritis
Chronic Back pain
s/p Appendectomy
s/p partial thyroidectomy for benign thyroid nodule
Social History:
Lives with her husband; 2 daughters help [**Name2 (NI) **]. Retired
banker. Past tobacco with 90 pack year history, no etoh or
illicits.
Family History:
mother with stroke and htn
sister renal cell carcinoma
sister bladder cancer x 2
Physical Exam:
VS: 96.4 108/63 110P 22 93%3LNC
Appearance: tired appearing, NGT in place
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mm very dry, cracked lips, no JVD, neck
supple
Cv: +s1, s2 -m/r/g, L>R 1+ edema, 2+ dp/pt bilaterally
Pulm: diminished throughout, poor air movement, diffuse wheeze
Abd: soft, very distended, tympanic, diffuse mild ttp,
hypoactive bs
Msk: L ankle with hematoma and swelling, left upper arm with
ecchymoses
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Pertinent Results:
[**2116-11-30**] 10:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-8* PH-6.0 LEUK-TR
[**2116-11-30**] 10:35PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
[**2116-11-30**] 07:00PM GLUCOSE-134* UREA N-18 CREAT-1.4* SODIUM-127*
POTASSIUM-3.5 CHLORIDE-88* TOTAL CO2-24 ANION GAP-19
[**2116-11-30**] 07:00PM ALT(SGPT)-23 AST(SGOT)-26 ALK PHOS-66 TOT
BILI-0.9
[**2116-11-30**] 07:00PM LIPASE-21
[**2116-11-30**] 07:00PM CALCIUM-9.8 PHOSPHATE-4.4 MAGNESIUM-2.6
[**2116-11-30**] 07:00PM WBC-24.2*# RBC-4.47 HGB-14.0 HCT-39.9 MCV-89
MCH-31.3 MCHC-35.0 RDW-13.5
[**2116-11-30**] 07:00PM NEUTS-93* BANDS-1 LYMPHS-1* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2116-11-30**] 07:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2116-11-30**] 07:00PM PLT SMR-NORMAL PLT COUNT-248
.
[**2116-11-30**] CT a/p without contrast:
Extensive fecal loading without evidence of obstruction. Small
quantity of
free fluid in the left paracolic gutter is a non-specific
finding. Small 7-mm left renal hyperdensity should be further
characterized with repeat renal ultrasound or MR on a
non-emergent basis.
.
[**2116-11-30**] CXR:
No significant interval change. Stable bibasilar opacities most
likely relate to atelectasis. Pulmonary emphysema.
.
[**2116-11-30**] Humerus xray:
No evidence of acute fracture.
.
[**2116-11-30**] L. ankle xray:
Soft tissue swelling about the lateral malleolus without acute
fracture seen. No dislocation.
.
[**12-2**] Renal ultrasound
1. Numerous cysts within bilateral kidneys. The hyperdense
lesion on CT
corresponds to a simple-appearing cyst on ultrasound
2. No hydronephrosis.
.
Last Chest xray:
[**2116-10-3**]
The interpretation of this study is limited due to rotation of
the patient, the lateral aspect of the left hemithorax was not
included on this radiograph. Left lower lobe atelectasis has
probably increased. Right lower lobe atelectasis is unchanged.
Cardiomediastinal contours cannot be evaluated.
Brief Hospital Course:
74 yo female with severe end-stage COPD on home oxygen, dCHF, on
treatment for MAC with recent admission for COPD exacerbation
admitted with abdominal pain and severe constipation.
She was initially treated for severe constipation, and seen by
GI and palliative care. Despite aggressive bowel regimen, she
continued to have severe obstipation. Gastrograffin enema was
performed on the day of ICU transfer. This also did not relieve
constipation. On the day of transfer to the ICU, she developed
respiratory distress after a renal ultrasound.
.
ICU course:
Pt developed acute respiratory distress shortly after renal
ultrasound while in the waiting room. Unclear cause, though
some iniciting factor that precitpated a COPD exacerbation. She
was transferred to the [**Hospital Unit Name 153**] for evaluation. She was started on
BiPAP and expressly stated she did not want to be intubated.
She was empircally started on broad spectrum antibiotics for PNA
and IV heparin for possible (though unlikely PE). After family
meeting to discuss goals of care, it was decided with inclusion
of the patient in decision making to focus on the comfort of the
patient. IV heparin and antibiotics were discontinued. She
continued with oxygen, steroids, inhalers/nebulizers. She was
transferred to the floor. Palliative care following.
.
She returned to the medical floor on [**12-4**] to my service. She
was comfort measures. She was enrolled in inpatient hospice.
She expired peacefully, with her daughter [**Name (NI) **] at her bedside,
at 9:39 on [**2116-12-6**]. Autopsy was declined.
Medications on Admission:
Advair 500/50 [**Hospital1 **]
spiriva 18 mcg daily
combivent 2 puffs q6h prn
alubterol neb q6h prn
guaifenesin 1200mg [**Hospital1 **]
prednisone
morphine ER 15mg [**Hospital1 **]
morphine 2.5 cc q4h prn
amphoterecin B 50 mg in 1L sterile water, 10 cc swish/spit TID
synthroid 75mcg daily
pravastatin 80mg daily
amlodipine 5mg daily
hctz 12.5mg daily
esomeprazole 40mg [**Hospital1 **]
tums 500mg [**Hospital1 **]
teriparatide 20mcg sc qhs
colace 100mg [**Hospital1 **]
senna 2 caps [**Hospital1 **]
miralax 17gm daily
zofran prn
azithromycin 500mg daily
ethambutol 800mg daily
bactrim ss 1 tab daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Endstage COPD
COPD exacerbation
Obstipation
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
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7990, 7999
|
5748, 7338
|
376, 382
|
8086, 8095
|
3667, 5725
|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,463
| 112,278
|
20463
|
Discharge summary
|
report
|
Admission Date: [**2154-6-7**] Discharge Date: [**2154-6-14**]
Date of Birth: [**2082-7-14**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo F with PMH of CAD, CHF, DM, HTN, CVA who developed acute
onset SOB the night prior to admission. She additionally had an
approximate 5 minute period of chest pain with burning
sensation. During the course of the night she noted difficulty
lying flat. SOB seemed somewhat positional. The day of
presentation, she went to her PCP who then sent her to [**Hospital1 6591**]. There she was found to have elevated Troponin 0.12,
0.13. CXR was not exemplary but CTA with massive pulmonary
embolism. Given Lovenox 80 mg SC at [**2154-6-6**] at [**2161**]. Has history
of R hemorrhagic CVA in [**2148**] with resultant left hemiparesis.
Hemodynamically stable and transferred to [**Hospital1 18**].
.
At [**Hospital1 18**], initial VS 97.7, 128/93, 85, 14 and 97 on unknown
oxygen. Pulmonary exam noted to be clear to auscultation
bilaterally. EKG with SR, multiple PVCs and diffuse new TWI
V2-V6 compared to [**2148**]. Labs revealed hypernatremia, low
bicarbonate to 20 and UA with pyuria and bacteria. She was not
given additional medication but IR was contact[**Name (NI) **] for potential
thrombectomy.
Past Medical History:
Chronic obstructive pulmonary disease.
Systolic CHF, Ef 10-15% [**2148**] (Patient unsure)
s/p Hemorrhagic CVA (left sided hemiparesis) due to right middle
cerebral artery infarction who underwent a craniotomy
Hyperlipidemia
HTN
Diabetes mellitus
Constipation
UTIs
h/o Tracheostomy
Social History:
Lives with husband with daughter upstairs. Previously smoked (20
years x 1.5 ppWeek)
Family History:
No family history of thrombus or bleeding disorders. Father with
history of MIs.
Physical Exam:
VS 98, 79, 125/90, 14, 99/2L NC
GEN: NAD
HEENT: NCAT, PERRL, MMM
PULM: CTAB without w/r/r
CV: RRR without m/g/r
Abd: Soft, NT, active bowel sounds
LE: without e/o edema, symmetric
Pertinent Results:
[**2154-6-7**] 09:25PM HCT-41.5
[**2154-6-7**] 09:25PM PT-14.8* PTT-150.0* INR(PT)-1.3*
[**2154-6-7**] 01:17PM CK(CPK)-114
[**2154-6-7**] 01:17PM CK-MB-6 cTropnT-0.07*
[**2154-6-7**] 01:17PM PT-15.5* PTT-150* INR(PT)-1.4*
[**2154-6-7**] 05:39AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2154-6-7**] 12:01AM GLUCOSE-163* UREA N-15 CREAT-0.8 SODIUM-146*
POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-20* ANION GAP-16
[**2154-6-7**] 12:01AM CK(CPK)-88
[**2154-6-7**] 12:01AM cTropnT-0.11*
[**2154-6-7**] 12:01AM CK-MB-NotDone
[**2154-6-7**] 12:01AM WBC-11.4* RBC-4.91# HGB-15.0# HCT-44.1#
MCV-90 MCH-30.5 MCHC-33.9 RDW-14.7
[**2154-6-7**] 12:01AM PLT COUNT-182
[**2154-6-7**] 12:01AM PT-13.2 PTT-36.4* INR(PT)-1.1
EKG [**6-6**]:
Normal sinus rhythm with occasional ventricular premature beats.
Low voltage in the standard leads and in the precordial leads.
Very poor R wave progression. RSR' pattern in lead V1. QRS
duration of 90 milliseconds. Non-specific ST-T wave changes
throughout the tracing. Compared to the previous tracing of
[**2148-4-25**] the patient has gone from atrial fibrillation at a rate
of 117 to normal sinus rhythm at 86 beats per minute with
occasional atrial premature beats. The T wave inversions in the
lateral leads are new. The poor R wave progression out through
V6 is new. This may be related to altered lead placement.
Consider anterior wall myocardial infarction of undetermined
age.
ECHO [**6-7**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is a very small pericardial effusion.
IMPRESSION: Dilated and hypokinetic right ventricle with
evidence of pressure overload. Small left ventricle with normal
global systolic function. At least mild mitral regurgitation.
Suboptimal study.
Compared with the report of the prior study (images unavailable
for review) of [**2148-4-9**], LV function appears to have improved.
At the same time, there is new RV dilation/dysfunction.
CXR [**6-7**]:
IMPRESSION:
1. No evidence of pneumonia or congestive heart failure.
2. Diminished vascularity in lung, likely due to known large
pulmonary
embolism.
bilateral LE u/s [**6-7**]:
IMPRESSION: Partially occlusive DVT of the left common femoral
vein extending through the entire left superficial femoral vein
where it is nearly completely occlusive and into the left
popliteal vein where again it is partially occlusive. Left calf
veins cannot be seen. Right lower extremity venous structures do
not demonstrate any thrombus.
Brief Hospital Course:
# Pulmonary embolus: Pt was admitted to MICU and started on
heparin gtt. LLE u/s positive for DVT as above. An ECHO showed
moderate RV dilation as above. An IVC filter was placed. She
continued to have borderline blood pressures which were fluid
responsive, likely in part do to her right heart failure, after
transition to regular medicine unit, pt remained normotensive.
Otherwise, she remained HD stable and did not require
significant O2 supplementation. Pt was transitioned to lovenox
and then to coumadin. INR WAS 5 ON THE DAY OF DISCHARGE. Pt had
previously recieved 5mg coumadin x2 days and was held on the day
of discharge. Coumadin was held on the day of discharge. Rehab
facility will continue to adjust coumadin dose as needed. Pt has
no family history or prolonged recumbency, though clot is in
hemiparetic leg. CA screening appears to be mostly uptodate with
colonoscopy in [**2152**], mammogram in [**2151**] though she has not had a
pap recently.
-PT SCHEDULED FOR LOWER EXTREMITY ULTRASOUND ON [**2154-7-8**] FOR
CONSIDERATION OF IVC FILTER REMOVAL.
-Interventional Radiology (Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 6989**] [**Last Name (NamePattern1) 6745**])
to review LENI and [**First Name8 (NamePattern2) 6989**] [**Last Name (NamePattern1) 6745**] will call pt to arrange
for removal of IVC filter at that time.
.
# UTI: pt was noted to have a +UA and initially started on
cipro. However, pt's urine grew esbl e coli s to nitrofurantoin
but not cipro and so pt was switched to nitrofurantoin for total
course of 7 days.
.
# History of hemorrhagic stroke: Review of records indicates
conversion from ischemic to hemorrhagic stroke. Seemingly
minimal risk for recurrent bleeding approximately 6 years
post-event. Pt had been on secondary stroke ppx with plavix but
this was transitioned to coumadin.
.
# CAD/?CHF: Pt reports history of EF 10-15%, however, TTE was
repeated and showed preserved LV function (no LV systolic or
diastolic dysfunction). Metoprolol was initially held for
hypotension and then restarted prior to discharge in setting of
frequent ectopy (including one 16 beat run of NSVT) and normal
blood pressures. Pt is not on aspirin [**2-19**] allergy. Crestor was
continued.
.
# COPD: continued tiotroprium
.
# HTN: Held BBlocker initially in setting of potential HD
instability, restarted prior to discharge.
.
# Hyperlipidemia: Continued home Crestor
.
# Low bicarbonate: felt to be compensatory [**2-19**] elevated
respiratory rate and low pCO2 as pt's VENOUS pCO2 was only 36.
.
Family contact: [**Name (NI) **] (daughter) [**Telephone/Fax (1) 54798**]
Medications on Admission:
Metoprolol Tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily
Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily
Tiotropium Bromide 18 mcg Caps w/Inhalation Device(s) Once Daily
Crestor 20 mg Tab Oral 1 Tablet(s) Once Daily
Glipizide 5 mg Tab Oral 1 Tablet(s) Once Daily
Trazodone 50 mg Tab Oral 1 Tablet(s) QHS
Topamax 200 mg Tab Oral QPM
Topamax 150 mg QAM
Allergies: Aspirin / Penicillins / Sulfa
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
8. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 days: last day [**2154-6-16**].
9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: limit tylenol to less that 4g per
day.
13. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks: apply to rash underneath right knee
and behind right ankle.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks: apply to rash in right axilla.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off. apply to sore
shoulder as needed.
16. Coumadin 2 mg Tablet Sig: as below Tablet PO once a day:
HOLD ALL COUMADIN ON [**6-14**] (INR 5 today).
RECHECK INR TOMORROW ([**4-15**]), IF inr 3.5 OR LOWER WOULD GIVE 2MG.
NP ON CALL DAILY WITH INR TO HELP WITH COUMADIN ADJUSTMENT UNTIL
SHE'S ON A STABLE DOSE OF COUMADIN (JUST STARTED COUMADIN 2D
AGO).
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
primary: pulmonary embolus, UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for a large blood clot in the
lungs. We started you on a blood thinner called lovenox (which
is a shot), but are transitioning you to coumadin (which is a
pill). You will need to get your coumadin levels checked very
closely for the next few weeks to confirm that your your
coumadin levels are not too high (which can cause bleeding) or
low (which can lead to clotting).
You are going to rehab but when you go home, please weigh
yourself every morning, call your primary doctor if your weight
goes up more than 3 lbs.
We have made several changes to your medications. Please ensure
that your rehab gives you a copy of your medicine list when you
go. In brief, we STOPPED your plavix, DECREASED your metoprolol
tartrate (lopressor), STARTED coumadin, STARTED lidocaine patch
Followup Instructions:
Please go to the following appointment which we have arranged
for you:
1. You need to return to [**Hospital3 **] to see if you still have
clot in your leg. It is very important that you go to this
appointment. THe radiologists will call you after they see the
result of the leg ultrasound and arrange a time to take out the
filter they placed in the veins near your heart.
ULTRASOUND APPOINTMENT:
[**Hospital3 **] Hospital, [**Location (un) 86**]
[**Hospital Ward Name **]
Monday [**2154-7-8**] at 12:30 pm in the clinical center on the [**Location (un) **] in the radiology suite
*** After your ultrasound the radiologists should call you to
arrange your next appointment (to get the filter out). If they
don't call within 1 week, please call them at [**Telephone/Fax (1) 8243**]. Your
appointment should be with Dr [**Last Name (STitle) 9441**].
2. We also arranged for you to see a dermatologist for the rash
on your shoulder and knee. If these rashes have disappeared, you
can cancel this appointment.
Department: DERMATOLOGY AND LASER
When: WEDNESDAY [**2154-7-17**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2154-6-15**]
|
[
"438.20",
"276.2",
"401.9",
"285.29",
"599.0",
"041.4",
"453.41",
"496",
"276.0",
"415.19",
"428.0",
"414.01",
"428.22",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
10123, 10219
|
5131, 7754
|
323, 329
|
10295, 10295
|
2185, 5108
|
11312, 12683
|
1887, 1969
|
8197, 10100
|
10240, 10274
|
7780, 8174
|
10478, 11289
|
1984, 2166
|
276, 285
|
357, 1463
|
10310, 10454
|
1485, 1769
|
1785, 1871
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,146
| 169,975
|
23997+57381
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-4-17**] Discharge Date: [**2150-5-16**]
Date of Birth: [**2077-11-8**] Sex: F
Service: CSU
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: A 72-year-old woman with an EF
of 30% and a history of CAD who presented to her PCP's office
complaining of abdominal pain. Recommended to be seen in the
emergency room to rule out a splenic infarct. An abdominal CT
at that time showed a LV thrombus. Labs revealed elevated
cardiac enzymes, and she was admitted to the ICU at an
outside hospital where she was begun on a dopamine infusion
given relative hypotension following which she went into a
sinus tachycardia and was then transferred to [**Hospital **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **] for further workup and evaluation.
PAST MEDICAL HISTORY: Significant for hypertension,
cardiomyopathy, cholecystectomy.
ALLERGIES: Include CEPHALOSPORIN'S and PENICILLIN.
MEDICATIONS ON ADMISSION: Include Neo-Synephrine infusion,
Levophed infusion, aspirin, Zestril, Colace, Lopressor, Zocor
at home.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory.
INITIAL COURSE: The patient was brought to the cardiac
catheterization lab in cardiogenic shock where she was found
to have a 90% left main, a 60% proximal LAD, 70% mid
circumflex, and 100% proximal RCA lesions, as well as 2 to 3+
MR. [**First Name (Titles) 6**] [**Last Name (Titles) 61101**] balloon pump was placed, and the patient
was intubated; following which CT surgery was consulted, and
the patient was brought emergently to the operating room for
high-risk coronary artery bypass grafting.
PHYSICAL EXAMINATION: Physical exam with patient on cardiac
catheterization table sedated at the time. Blood pressure of
80/60, heart rate of 100 (sinus), respirations (ventilated).
Physical exam revealed a height of 5 feet 2 inches, weight of
51 kilograms. Cardiac revealed S1 and S2. Respiratory
revealed coarse rales on anterior examination. The abdomen
was soft, nontender, and nondistended. Pulses revealed 1+
femoral without bruits bilaterally. Extremities with trace
edema.
RADIOLOGIC STUDIES: Echocardiogram showed 2 to 3+ MR [**First Name (Titles) 151**]
[**Last Name (Titles) 61102**] LV function. As stated previously, cardiac
catheterization showed a tight left main with occlusive RCA
disease as well as circumflex and LAD disease.
LABORATORY DATA: Sodium of 142, potassium of 3.5, BUN of 13,
creatinine of 0.6. White count of 13, hematocrit of 40,
platelets of 521. Troponin was 8.15. CK/MB was 12.5.
HOSPITAL COURSE: As stated, the patient was immediately
brought to the operating room for emergent coronary artery
bypass grafting and mitral valve repair. Please see the OR
report for full details. In summary, she had a CABG x 2 with
a vein graft to the LAD and a vein graft to the OM, as well
as mitral repair with a #26 annuloplasty ring. Her bypass
time was 129 minutes with a cross-clamp time of 71 minutes.
It should be noted that the patient suffered cardiac arrest
upon induction in the operating room. The patient tolerated
the operation, was weaned off bypass, and brought to the
cardiothoracic intensive care unit from the operating room.
At the time of transfer the patient was AV paced at 98 beats
per minute with a mean arterial pressure of 95 and a PAD of
26. She had Levophed at 0.15 mcg/kg/min, milrinone at 0.75
mcg/kg/min, epinephrine at 0.5 mcg/kg/min, vasopressin at 3
units per hour, propofol at 20 mcg/kg/min, insulin at 2 units
per hour, and an [**Last Name (Titles) 61101**] balloon pump at 1:1.
Upon arrival in the cardiothoracic intensive care unit it was
noted that the patient had cold lower extremities. At that
time, a vascular surgery consult was called. It was felt that
the cold extremities were related to her [**Last Name (Titles) 61101**] balloon
pump which was then weaned and removed. The patient continued
to have cold lower extremities, and on postoperative day 1
was brought back to the operating room where she underwent
bilateral thrombectomies. Additionally, a neurology consult
was called to rule out stroke due to pupils that were noted
to be fixed and dilated. The patient was brought emergently
to CAT scan which showed no hemorrhage and old lacunar
abnormality. Additionally, the patient was noted to be in
acute renal failure, and a renal consult was called at that
time. CVVHD was also initiated at that time.
The patient continued to do poorly over the next few days
with little, if any, return of blood flow to her lower
extremities. On postoperative day 4, she returned to the
operating room at which time she underwent bilateral
amputations. Following her amputations the patient's
condition improved slowly initially. She was able to be
weaned off some of her pressors. Her acute renal failure
resolved. Her CVVHD was slowly weaned and ultimately
discontinued. Her bilateral amputations were debrided on
multiple occasions, and ultimately revision and flap closure
was done on [**4-26**].
Over the next 2 weeks following flap closure of her
amputations, the patient was slowly weaned from the
ventilator. All of her pressors were being weaned off during
the period between her initial amputations and flap closures.
During that period she did continue to have an elevated white
blood cell count with no known source identified. She was
followed by the infectious disease service throughout this
period and treated with vancomycin, levofloxacin, and Flagyl
empirically with CTs of her chest and abdomen to rule out any
fluid collections or abscesses.
By postoperative day 17, the patient was to the point where
the service was considering extubation. We continued a slow
pressor support wean throughout the next several days, and on
postoperative day 20 the patient was extubated unsuccessfully
- requiring reintubation after a period of only 5 minutes. At
that time, thoracic surgery was consulted for percutaneous
tracheostomy and PEG. On the 13th, the patient had a
percutaneous tracheostomy placed at the bedside. She
tolerated the procedure well. PEG was delayed until a further
date. Unfortunately, the patient's percutaneous tracheostomy
was inadvertently removed on the following day, and she had
to be reintubated.
On the [**5-11**], the patient was brought to the operating
room where she underwent an open tracheostomy as well as a
PEG placement. During the week following the patient's
tracheostomy she was able to wean from the ventilator
successfully to tracheostomy collar during the day with
pressure support ventilation only required at night. At that
time, it was decided that the patient was stable and ready to
be transferred to a rehabilitation center with ventilator
capacity to continue her cardiac rehabilitation as well as
continued weaning from the tracheostomy.
At the time of this dictation, the patient's physical exam
was as follows. Temperature of 97, heart rate of 69 (sinus
rhythm), blood pressure of 92/38, respiratory rate of 17, O2
saturation of 96% on 50% tracheostomy collar. Lab data with a
white count of 12, hematocrit of 39, platelets of 447. Sodium
of 146, potassium of 3.6, chloride of 111, CO2 of 25, BUN of
21, creatinine of 0.4. PT of 17.7, PTT of 68, and INR of 1.4.
Neurologically, alert and responsive. Followed commands.
Moved all extremities. Cardiovascular with a regular rate and
rhythm. S1 and S2. No murmur. The sternum was stable.
Respiratory revealed coarse breath sounds diminished in the
lower lobes. The abdomen was soft and nontender. PEG site was
clean and dry with normal active bowel sounds. Incision sites
with staples. Extremities with bilateral AKA. Suture lines
with staples. Minimal erythema. Otherwise, clean and dry.
Groin incision line with mild erythema and serous drainage;
needs normal saline wet-to-dry dressing.
SUMMARY: In summary, the patient's exam and plan by system:
1. NEUROLOGICALLY: The patient is intact, cooperative,
following commands, requiring intermittent trazodone at
night for sleep.
1. CARDIOVASCULAR: The patient is in a normal sinus rhythm
with an adequate blood pressure. On amiodarone beta
blockade and furosemide at stable doses.
1. PULMONARY: The patient has a #8 tracheostomy that was
placed on [**5-11**]. She has been able to be weaned to a
tracheostomy collar during the day, requiring pressure
support ventilation only a night.
1. INFECTIOUS DISEASE: The patient has a normal white blood
cell count with no source of infection identified. She
continues to be treated with vancomycin and Flagyl which
should continue through [**5-18**].
1. GI: The patient has a PEG that was placed on the [**5-11**], and she is currently tolerating her tube feeds which
are ProMod with fiber at 45 cc per hour (which is her goal
rate).
1. GU: The patient has adequate urine output and a Foley to
gravity.
DISCHARGE DISPOSITION: The patient is to be discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
1. Status post emergent mitral valve repair with a #26
annuloplasty ring and coronary artery bypass grafting x 2
(with a saphenous vein graft to the LAD and a saphenous
vein graft to the OM).
2. Status post bilateral lower extremity amputations on [**5-21**] with multiple debridements and final revision and flaps
on [**4-26**].
3. Status post tracheostomy and percutaneous endoscopic
gastrostomy placement on [**5-11**].
4. Cardiomyopathy.
5. Hypertension.
6. Cholecystectomy.
CONDITION ON DISCHARGE: Good.
DI[**Last Name (STitle) 408**]E FOLLOWUP: She is to have followup with the
vascular surgery department (Dr. [**Last Name (STitle) **] 2 weeks
following her discharge and followup with Dr. [**Last Name (Prefixes) **] (of
cardiothoracic surgery) 4 weeks following her discharge. She
is additionally to have followup with Dr. [**Last Name (STitle) 952**] (of thoracic
surgery) 3 to 4 weeks following her discharge from [**Hospital **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **].
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg daily.
2. Percocet 5/325 (per 5-cc solution) 5 to 10 cc q.4-6h. as
needed.
3. Miconazole powder b.i.d. as needed.
4. Lansoprazole 30 mg daily.
5. Amiodarone 400 mg daily x 2 weeks then 200 mg daily.
6. Lasix 20 mg daily.
7. Lopressor 12.5 mg b.i.d.
8. Trazodone 50 mg at bedtime p.r.n.
9. Warfarin as directed to maintain a target INR of 2 to 2.5
(the patient has been getting 2.5 mg per day for the 3
days prior to discharge).
10. Flagyl 500 mg t.i.d. (through [**5-18**]).
11. Vancomycin 1 gram daily (also through [**5-18**]).
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2150-5-15**] 16:33:55
T: [**2150-5-15**] 17:30:38
Job#: [**Job Number 61103**]
Name: [**Known lastname 62**],[**Known firstname 11090**] Unit No: [**Numeric Identifier 11091**]
Admission Date: [**2150-4-17**] Discharge Date: [**2150-5-19**]
Date of Birth: [**2077-11-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 674**]
Addendum:
Patient has completed her antibiotic course. Please reculture
for any fevers, or significantly elevated WBC.
Major Surgical or Invasive Procedure:
MVR/CABG
Bilat LE amputations
Trach and PEG
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Insulin Regular Human 100 unit/mL Solution Sig: RISS
Injection ASDIR (AS DIRECTED).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) PO once a day.
6. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 2 weeks then 200mg QD.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
10. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: then check INR, and dose for Target INR
2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
s/p Emergent MVR/CABG ([**4-17**])
s/p Bilat LE amputations ([**4-21**])
s/p amputation revision and flaps ([**4-26**])
s/p Trach and PEG ([**5-11**])
Discharge Condition:
stable
Discharge Instructions:
keep wounds clean and dry
take all medications as prescribed
call for any fevers, redness or drainage from wounds
Followup Instructions:
Vascular surgery (Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 11071**] upon discharge
from rehab
Dr [**Last Name (STitle) **] in 4 weeks, or upon discharge from rehab
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2150-5-18**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
] |
12396, 12466
|
11381, 11427
|
12661, 12669
|
12831, 13142
|
1101, 1119
|
8980, 9476
|
11450, 12373
|
12487, 12640
|
10038, 11343
|
979, 1084
|
2595, 8883
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12693, 12808
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1679, 2577
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154, 168
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197, 812
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835, 952
|
1136, 1656
|
9501, 10012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,502
| 178,493
|
14735
|
Discharge summary
|
report
|
Admission Date: [**2181-7-30**] Discharge Date: [**2181-8-2**]
Date of Birth: [**2128-1-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Drug Eluting Stent placement to
distal RCA.
History of Present Illness:
53yoM with h/o CAD (s/p DES to D1 after anterior MI in '[**72**]),
HTN, [**Hospital **] transferred from [**Hospital3 **] with inferior STEMI -
now s/p DES to distal RCA. The patient reports that he was in
his USOH until the last 6-7 days when he began having CP - at
first was fleeting and over last 2-3 days only relieved by SL
nitro. Today, he reports the onset of [**9-19**] SSCP at 4PM that
radiated to his L neck and down both arms. It was associated
with nausea/vomiting. He took ~ 20 SL nitro without relief and
then called 911. At [**Hospital3 7569**], EKG showed large STE
inferiorly - BP on arrival was 146/98. He was Plavix loaded with
600 mg, ASA 325 mg, and started on a heparin gtt. He was not CP
free until revascularization in the cath lab at [**Hospital1 18**] despite
receiving multiple doses of morphine and dilaudid. CP started ~
4 PM, stent placed ~ 9 PM.
.
At [**Hospital1 18**], the patient went straight to the cath lab, which
revealed no flow-limiting disease in LMCA, LAD with diffuse
disease, previous diagonal stent with 50-60% ISR, OM1/OM2 with
60-70% stenosis, and total occlusion in the distal RCA. A DES
was placed in the RCA.
.
On arrival to the CCU, the patient reports [**2-19**] 'twinges' of CP.
He denies recent illness. VS 97.9 107 142/88 16 95% on RA.
Exam significant for multiple circular excoriated lesions on his
arms and legs, CV exam with RR, no murmurs, good distal pulses.
.
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 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:
- PCI w/ stent to first diag in [**2172**] after anterior MI
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Major depression
Hypertension
Hyperlipidemia
Asthma (not on meds)
PUD
Obesity
Social History:
Works in computer repair. Lives alone. Never married, no
children. Not close with his family, no official HCP. [**Name (NI) **] [**Name (NI) 6624**]
(sister) would be first to contact - unsure of phone #.
-Tobacco history: 1 ppd x 40 years (not willing to quit)
-ETOH: None
-Illicit drugs: remote marijuana
Family History:
Father died of lung cancer. MaGpa had MI in 60s.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VS: 97.9 107 142/88 16 95% on RA
GENERAL: 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 not elevated
CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: CTA anteriorlly
ABDOMEN: Obese. Soft, NTND. NABS. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Numerous circular
excoriated lesions w/ scab ~ 5 mm in diameter on bilateral arms
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
.
On discharge:
AVSS
CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: CTA anteriorlly
ABDOMEN: Obese. Soft, NTND. NABS. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Numerous circular
excoriated lesions w/ scab ~ 5 mm in diameter on bilateral arms
Pertinent Results:
[**2181-7-30**] 09:12PM BLOOD WBC-15.4*# RBC-5.01 Hgb-16.2 Hct-45.7
MCV-91 MCH-32.3* MCHC-35.4* RDW-13.8 Plt Ct-247
[**2181-7-31**] 05:26AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0
[**2181-7-30**] 09:12PM BLOOD Glucose-130* UreaN-19 Creat-0.7 Na-139
K-3.6 Cl-106 HCO3-23 AnGap-14
.
[**2181-7-30**] 09:12PM BLOOD CK(CPK)-661*
[**2181-7-31**] 05:26AM BLOOD CK(CPK)-1850*
[**2181-7-31**] 06:48PM BLOOD CK(CPK)-913*
.
[**2181-7-31**] 05:26AM BLOOD CK-MB-223* MB Indx-12.1*
[**2181-7-31**] 10:57AM BLOOD CK-MB-137* MB Indx-10.3* cTropnT-4.39*
[**2181-7-31**] 06:48PM BLOOD CK-MB-68* MB Indx-7.4* cTropnT-3.29*
.
[**2181-7-30**] 10:35PM BLOOD %HbA1c-5.2 eAG-103
.
[**2181-7-31**] 05:26AM BLOOD Triglyc-140 HDL-35 CHOL/HD-4.1 LDLcalc-80
.
[**2181-7-30**] Cardiac Cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel coronary artery disease. The LMCA was
without
significant disease. The LAD had diffuse non-obstructive
disease with
distal 50-60% instent restenosis of the diagonal stent. The LCx
had 70%
stenosis of the origin of OM1 and 70% stenosis of the mid OM2.
The RCA
had a distal total occlusion.
2. There is moderate systemic arterial hypertension with central
aortic
pressure 161/100 with a mean of 99 mmHg.
3. Successful aspiration thrombectomy/direct stenting of the
distal RCA
total occlusion with a Promus Rx 3.0x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with
an NC
3.5 mm balloon. (see PTCA comments)
4. R 6Fr femoral artery Angioseal deployed without complications
FINAL DIAGNOSIS:
1. Three vessel CAD with culprit distal RCA total occlusion
2. Successful aspirtation thrombectomy/direct stenting with a
Promus Rx
3.0x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 3.5 mm balloon (see PTCA
comments)
3. ASA 325 mg daily for six months and then can be decreased to
81 mg
daily indefinitely; plavix (clopidogrel) 150 mg daily for seven
days and
then 75 mg daily
4. High dose statin (atorvastatin 80 mg daily) therapy
5. R 6Fr femoral artery Angioseal closure device deployed
without
complications
.
TTE:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
inferior, inferolateral and distal anterior hypokinesis
(multivessel CAD). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ([**2-11**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction, most c/w multivessel CAD. Mild to moderate aortic
regurgitation. Moderate mitral regurgitation. Mild pulmonary
hypertension.
Brief Hospital Course:
53 year old male with CAD (s/p DES to D1 after anterior MI in
'[**72**]), HTN, [**Hospital **] transferred from [**Hospital3 **] with inferior
STEMI - s/p DES to distal RCA.
.
ACITVE ISSUES:
# Inferior STEMI: The patient presented to [**Hospital3 7569**] with
[**9-19**] CP refractory to ~ 20 SL nitro tablets. EKG there showed
inferior STE. He was transferred to [**Hospital1 18**] for cath, which showed
distal RCA occlusion as well as 3VD. A DES was placed to the
distal RCA. He was started on ASA 325 mg x 6 months, then 81 mg
indefinitely; Plavix 150 mg x 7 days (until [**8-7**])then followed
by 75 mg per day x at least 12 months; atorvastatin 80 mg per
day, metoprolol. A1c returned at 5.4. Lipid panel showed LDL of
80. Captopril was started and he was discharged on lisinopril at
5mg. He was counseled about the importance of aspirin after he
voiced concern about GI side effects. Ranitidine was started to
prevent GI upset. He was also counseled about the importance of
tobacco cessation and was discharged on a nicotine patch.
.
# HTN: He was started on metoprolol 75 mg daily and lisinopril 5
mg daily. BP was at goal of < 130.
.
# PUMP: TTE showed LVEF of 40%. He was euvolemic on exam. He was
discharged on lisinopril and metoprolol. Pt was encouraged to
weight himself daily and eat a low Na diet. He was scheduled
with cardiology f/u.
.
# Depression: The patient reported he had stopped taking his
medications because of depression. His depression and anxiety
has caused severe isolation, inability to work and care for
himself. Social work and psychiatry was consulted and concluded
that the pt was actively suicidal and needs to be treated as an
inpatient. Section 12 paperwork has been started. He was
restarted on Celexa while hospitalized and will need outpatient
counseling and f/u.
.
# RHYTHM: NSR. No abnormal rhythm on telemetry.
.
He remained full code during this admission.
Medications on Admission:
nifedipine 30 mg qday
flaxseed oil
- not taking ASA -> reports that it gives him IBS
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for CAD: RCA DES for 7 days.
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
CAD: RCA DES.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed
for indigestion.
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
- Acute Myocardial Infarction secondary to instent thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for chest pain and were found
to have a heart attack. You underwent a cardiac catheeterization
that revealed a clot and a stent was placed. It is extremely
important you take your medications as prescribed as this will
help prevent another heart attack.
.
A NUMBER OF MEDICATIONS HAVE BEEN STARTED THAT ARE EXTREMELY
IMPORTANT YOUR TAKE FOR YOUR HEART:
1) Aspirin 325mg Daily (as directed)
2) Plavix (Clopidogrel) 150mg Daily for a week then 75mg Daily
3) Atorvastatin 80mg Daily
4) Metoprolol XL 75mg Daily
5) Lisinopril 5mg Daily
.
We have also prescribed:
1) Ranitidine 150mg Twice Daily for indigestion
2) Calcium Carbonate Three times daily for indigestion as needed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1159**],
following discharge from [**Hospital1 **] 4. His phone number of
[**Telephone/Fax (1) 20587**].
|
[
"996.72",
"414.01",
"564.1",
"410.41",
"272.4",
"412",
"311",
"305.1",
"278.00",
"V62.84",
"E878.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"88.56",
"00.66",
"37.21",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
10441, 10456
|
7239, 9144
|
313, 388
|
10579, 10579
|
4124, 5680
|
11549, 11774
|
3044, 3208
|
9279, 10418
|
10477, 10558
|
9170, 9256
|
5697, 7216
|
10729, 11526
|
3223, 3223
|
2468, 2592
|
3844, 4105
|
263, 275
|
416, 2358
|
3237, 3830
|
10594, 10705
|
2623, 2703
|
2380, 2448
|
2719, 3028
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,456
| 173,920
|
50879
|
Discharge summary
|
report
|
Admission Date: [**2121-6-12**] Discharge Date: [**2121-7-9**]
Date of Birth: [**2066-12-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Elevated Creatinine on Labs
Major Surgical or Invasive Procedure:
IR guided paracentesis
History of Present Illness:
This is a 54 yo woman with HTN, DM and HCV cirrhosis admitted
for HRS, on liver and renal [**First Name3 (LF) **] list who is being
transfered to MICU for development of AMS and identification of
embolic strokes on head MRI. The history was obtained from chart
and previous providers. Neurology, [**First Name3 (LF) **] and renal are
following.
She was admitted three weeks ago whith worsening abdominal
ascites and found to have hepatorenal syndrome. She had a
dialysis line placed at the begining of [**Month (only) **] and initiated
dialysis. She She also underwent two paracentesis on [**6-14**] (21
WBCs, 94 RBCs, 15 polys, 36 lymphs; culture negative) and [**6-27**] (
4lts therapeutic only). She has been on cipro ppx but changed to
cefpodoxime for long qt recently. Two days ago she was noted to
be unsteady and complained of dizziness, suffered a reporeted
mechanical fall and underwent an inital head CT which was
negative. Subsequently she was noted to have slurred speach,
right eye droop and AMS and Neurology was consulted. Repeat head
CT was negative, but a subsequent MRI was notable for new
embolic appearing stroke. Also of note this morning, after
having been NPO overnight, she was noted to have a blood
pressure in the 80s, but this corrected to her baseline of 90s
with 1 LT NS and albumin. In addition she was also noted to have
asterixis and was started on lactulose. She has been afebrile
and her white count has been wnl.
She has a history of varices on EGD [**3-28**] but no history of bleed.
Currently on nedolol. She has not had encephalopathy before, on
report.
.
Vitals prior to transfer were 97 90/46 63 20 100RA.
.
Review of sytems:
(+) Per HPI
(-) Pt c not communicate.
Past Medical History:
HCV cirrhosis (contracted while working as lab tech),
complicated by portal HTN and ascites, on [**Month/Day (4) **] list,
frequent paracentesis, no history of SBP
DM
CKD Cr 1.7 to 2
HTN
2+ MR
[**First Name (Titles) 105777**] [**Last Name (Titles) 32050**] hernia repair [**5-11**] by Dr. [**Last Name (STitle) **]
Social History:
Works as staff accountant at Sound life financial. Lives in
[**Hospital1 **] with husband. [**Name (NI) **] children. Nonsmoker. No etoh. No ivdu
Family History:
No history of liver disease. Father with CVA in 50s. Mother with
DM and CHF Sister with DM.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC: RRR, normal S1/S2, [**12-27**] blowing systolic murmur
appreciated best at apex, no carotid bruits appreciated,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2121-6-11**] 09:00AM BLOOD WBC-4.1 RBC-2.31* Hgb-7.2* Hct-22.9*
MCV-99* MCH-31.2 MCHC-31.5 RDW-18.8* Plt Ct-59*
[**2121-6-12**] 07:45PM BLOOD WBC-4.6 RBC-2.41* Hgb-7.4* Hct-24.1*
MCV-100* MCH-30.8 MCHC-30.8* RDW-18.8* Plt Ct-70*
[**2121-7-8**] 05:00AM BLOOD WBC-7.9 RBC-2.49* Hgb-7.9* Hct-25.8*
MCV-104* MCH-31.6 MCHC-30.5* RDW-21.9* Plt Ct-29*
[**2121-7-9**] 07:00AM BLOOD WBC-8.3 RBC-2.42* Hgb-8.0* Hct-25.0*
MCV-103* MCH-33.2* MCHC-32.2 RDW-20.9* Plt Ct-38*
[**2121-6-12**] 07:45PM BLOOD PT-19.2* PTT-39.5* INR(PT)-1.8*
[**2121-6-13**] 10:25AM BLOOD PT-21.1* INR(PT)-2.0*
[**2121-7-8**] 05:00AM BLOOD PT-20.4* PTT-56.1* INR(PT)-1.9*
[**2121-7-9**] 07:40AM BLOOD PT-20.4* PTT-50.5* INR(PT)-1.9*
[**2121-7-9**] 07:00AM BLOOD Glucose-207* UreaN-29* Creat-5.1*# Na-134
K-3.7 Cl-94* HCO3-32 AnGap-12
[**2121-7-8**] 05:00AM BLOOD Glucose-226* UreaN-20 Creat-4.0*# Na-136
K-3.6 Cl-94* HCO3-30 AnGap-16
[**2121-6-11**] 09:00AM BLOOD UreaN-44* Creat-3.1* Na-137 K-5.1 Cl-110*
HCO3-20* AnGap-12
[**2121-6-12**] 07:45PM BLOOD Glucose-110* UreaN-48* Creat-3.7* Na-134
K-5.8* Cl-110* HCO3-18* AnGap-12
[**2121-6-16**] 05:10AM BLOOD Glucose-102 UreaN-61* Creat-7.0* Na-139
K-5.0 Cl-104 HCO3-18* AnGap-22*
[**2121-6-11**] 09:00AM BLOOD ALT-30 AST-73* AlkPhos-156* TotBili-3.6*
[**2121-6-15**] 06:55AM BLOOD ALT-21 AST-52* AlkPhos-79 TotBili-8.2*
[**2121-7-7**] 07:25AM BLOOD ALT-14 AST-55* AlkPhos-159* TotBili-5.8*
[**2121-7-9**] 07:00AM BLOOD ALT-11 AST-45* AlkPhos-154* TotBili-6.3*
[**2121-7-2**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2121-7-2**] 06:33PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2121-7-9**] 07:00AM BLOOD Calcium-10.1 Phos-3.7 Mg-2.3
[**2121-7-8**] 05:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.2
[**2121-7-7**] 07:25AM BLOOD Albumin-3.6 Calcium-10.4* Phos-4.1 Mg-2.4
[**2121-6-11**] 09:00AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.8 Mg-2.2
[**2121-6-12**] 07:45PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.4
[**2121-6-13**] 07:10AM BLOOD Albumin-4.4 Calcium-9.5 Phos-4.3 Mg-2.3
[**2121-6-26**] 02:45PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2121-6-26**] 12:24PM BLOOD C3-32* C4-6*
[**2121-6-17**] 10:50AM BLOOD HIV Ab-NEGATIVE
[**2121-6-26**] 02:45PM BLOOD HCV Ab-POSITIVE*
[**2121-6-12**] 09:44PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2121-6-14**] 05:24AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2121-6-12**] 09:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
[**2121-6-14**] 05:24AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2121-6-12**] 09:44PM URINE RBC-0-2 WBC-[**4-30**]* Bacteri-OCC Yeast-OCC
Epi-[**4-30**]
[**2121-6-14**] 05:24AM URINE RBC-[**1-23**]* WBC-21-50* Bacteri-MOD Yeast-MOD
Epi-21-50
[**2121-6-14**] 05:24AM URINE Hours-RANDOM Creat-175 Na-26 TotProt-730
Prot/Cr-4.2*
[**2121-6-12**] 09:44PM URINE Hours-RANDOM Creat-242 Na-25 Cl-15
[**2121-6-13**] 12:31PM ASCITES WBC-33* RBC-9400* Polys-15* Lymphs-36*
Monos-0 Mesothe-1* Macroph-48*
[**2121-6-13**] 12:31PM ASCITES TotPro-2.0 Glucose-148 LD(LDH)-68
Albumin-1.3
All Blood Cultures were (-)
Paracentesis Culture (-)
C. Diff testing x2 (-) [**6-13**], [**7-3**]
[**2121-6-26**] 2:45 pm IMMUNOLOGY
**FINAL REPORT [**2121-6-27**]**
HCV VIRAL LOAD (Final [**2121-6-27**]):
472,000 IU/mL.
[**2121-7-2**] 2:12 pm MRSA SCREEN
**FINAL REPORT [**2121-7-5**]**
MRSA SCREEN (Final [**2121-7-5**]): No MRSA isolated.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report RENAL U.S. Study Date of [**2121-6-13**] 3:18 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-13**] 3:18 PM
RENAL U.S. Clip # [**Clip Number (Radiology) 105779**]
Reason: INCREASED CREATINE, RENAL FAILURE WORKUP
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with ESLD and acute on chronic renal
failure
REASON FOR THIS EXAMINATION:
Renal failure worup
Final Report
EXAM: Renal ultrasound obtained [**2121-6-13**].
HISTORY: A 54-year-old woman with end-stage liver disease and
acute on
chronic renal failure.
TECHNIQUE: Multiple static grayscale images through the abdomen
were obtained
and submitted for evaluation.
Findings: Note is made of a significant amount of ascites. The
liver is
shrunken and coarse in echotexture with nodularity, consistent
with the known
history of cirrhosis and end-stage liver disease.
The right kidney measures 9.6 cm in size. A 2.3 x 2.1 x 2.3 cm
anechoic
structure along the upper pole of the right kidney demonstrates
posterior
enhancement and is most consistent with a simple cyst. There is
no evidence
of hydronephrosis or renal calculi within the right kidney.
The left kidney measures 9.6 cm in size. There is no
hydronephrosis, calculi
or definite renal masses identified.
The bladder is distended with urine and is unremarkable in
appearance.
IMPRESSION:
1. Unremarkable ultrasound examination of the kidneys with a
simple cyst in
the upper pole of the right kidney.
2. Ascites.
3. Shrunken, nodular and coarsened echotexture of the kidney,
most consistent
with cirrhosis/end-stage liver disease.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 105780**] [**Name (STitle) 105781**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2121-6-13**] 4:59 PM
Imaging Lab
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report PORTABLE ABDOMEN Study Date of [**2121-6-15**] 8:09 AM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-15**] 8:09 AM
PORTABLE ABDOMEN Clip # [**Clip Number (Radiology) 105782**]
Reason: abdominal pain
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with ESLD and new ARF with new abdominal
pain
REASON FOR THIS EXAMINATION:
abdominal pain
Final Report
ABDOMEN FILM ON [**6-15**]
`Abdominal pain.
REFERENCE EXAM: [**2120-5-11**]
Gas-filled loops of small bowel are seen displaced medially
within the abdomen
consistent with the patient's known ascites. There is no dilated
loops of
small bowel to suggest obstruction. There is a single supine
film, is not
sufficient to assess for free air.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SUN [**2121-6-15**] 2:07 PM
Imaging Lab
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2121-6-15**]
11:00 AM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-15**] 11:00 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 105783**]
Reason: Eval for appendicitis
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with Hep C cirrhosis, recent diagnostic
para to RLQ (no SBP),
now with acute RLQ pain/rebound
REASON FOR THIS EXAMINATION:
Eval for appendicitis
CONTRAINDICATIONS FOR IV CONTRAST:
worsening renal failure;worsening renal failure
Provisional Findings Impression: MKjd SUN [**2121-6-15**] 5:56 PM
PFI: Appendix is normal in appearance. Findings consistent with
cirrhosis
and portal hypertension. Findings also suggest congestive heart
failure.
Gallbladder sludge.
Final Report
EXAM: CT abdomen and pelvis without contrast obtained [**2121-6-15**].
HISTORY: 54-year-old woman with hepatitis C cirrhosis status
post right lower
quadrant paracentesis, now presenting with acute right lower
quadrant pain.
TECHNIQUE: Unenhanced transaxial images from the lung bases
through the
pelvis were obtained with routine protocol.
FINDINGS:
There is a small right pleural effusion. There is diffuse
ground-glass
appearance noted at the lung bases. Also seen is cardiomegaly.
There is
distention of the IVC and diffuse body wall edema. The
constellation of these
findings may be related to fluid overload/congestive heart
failure.
The liver is shrunken and nodular in contour, a morphology
consistent with
cirrhosis. There is a significant amount of ascites and free
pelvic fluid.
The spleen is markedly enlarged. These findings are likely
related to portal
hypertension.
Hyperdense material within the dependent portion of the
gallbladder is most
consistent with sludge. The pancreas and adrenal glands are
unremarkable in
appearance. Low attenuating lesion within the right kidney with
thin
peripheral calcifications is noted, likely representing a renal
cyst.
Otherwise, the kidneys are unremarkable in appearance.
There is diffuse thickening of the wall of the right colon,
which is commonly
identified in patients with liver disease. No evidence of bowel
obstruction.
The appendix is visualized, filled with contrast and
unremarkable in
appearance.
There is diastasis of the rectus abdominis muscle.
Abdominal aorta has a normal course and caliber with scattered
calcified
atherosclerotic plaque.
A few nonenlarged porta hepatis and gastrohepatic lymph nodes
are likely
reactive in etiology. No pathologically-enlarged mesenteric,
retroperitoneal
or intraperitoneal lymphadenopathy is identified.
There is free fluid within the pelvis, with fluid extending into
the inguinal
canals bilaterally.
Osseous structures are grossly unremarkable in appearance.
IMPRESSION:
1. The appendix is normal in appearance.
2. Cirrhosis with findings consistent with portal hypertension,
including
large volume ascites..
3. Cardiomegaly, right pleural effusion. Hazy ground-glass
appearance to the
lungs, distended IVC and body wall edema, all suggesting
congestive heart
failure.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2121-7-1**]
2:09 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-7-1**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 105784**]
Reason: Please eval for acute ischemic stroke or hemorrhage
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with HCV, ESL, ESRD on HD awaiting
liver/kidney [**Hospital **].
Acute MS change after fall, please eval for acute ischemic
stroke or hemorrhage
REASON FOR THIS EXAMINATION:
Please eval for acute ischemic stroke or hemorrhage
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: A 54-year-old woman with cirrhosis, awaiting liver
and kidney
[**Hospital **], who has an acute mental status change status post
fall.
COMPARISON: Non-contrast head CTs performed earlier on the same
day are
available for correlation.
TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR,
[**Hospital **] echo,
and diffusion-weighted images of the head were obtained.
FINDINGS: There are numerous small foci of slow diffusion
involving the
cortex and white matter of the cerebral hemispheres, the
lentiform nuclei, the
right cerebellar peduncle, and the cerebellum bilaterally. These
are
consistent with acute infarctions. Since multiple bilateral
vascular
territories are involved, the etiology is likely embolic.
Multiple small T2
hyperintensities are also seen in the supratentorial white
matter, without
associated diffusion abnormalities, likely related to chronic
small vessel
ischemic disease. The ventricles and sulci are normal in size
and
configuration, without evidence of cerebral edema or cerebral
atrophy. A
portion of the flow void of the cavernous right internal carotid
artery is
poorly visualized, most likely due to volume averaging.
A mucous retention cyst is again seen in the left maxillary
sinus.
IMPRESSION: Numerous small acute infarctions throughout the
supratentorial
and infratentorial brain, in multiple vascular territories,
suggestive of
central embolic etiology.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105785**]TTE
(Complete) Done [**2121-7-2**] at 11:14:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (LF) 1383**], [**First Name3 (LF) 1382**]
[**Hospital1 18**]-Division of Gastroenterol
[**Last Name (NamePattern1) 77317**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-12-15**]
Age (years): 54 F Hgt (in): 61
BP (mm Hg): 90/46 Wgt (lb): 165
HR (bpm): 62 BSA (m2): 1.74 m2
Indication: Cerebrovascular event/TIA. Source of embolism.
ICD-9 Codes: 435.9, 424.0, 424.2
Test Information
Date/Time: [**2121-7-2**] at 11:14 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: Saline Tech Quality: Adequate
Tape #: 2009W0-0:00 Machine: Other
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness:
1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
3.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension:
2.7 cm
Left Ventricle - Fractional Shortening:
0.31 >= 0.29
Left Ventricle - Ejection Fraction:
>= 60% >= 55%
Left Ventricle - Stroke Volume:
73 ml/beat
Left Ventricle - Cardiac Output:
4.50 L/min
Left Ventricle - Cardiac Index:
2.59 >= 2.0 L/min/M2
Aorta - Sinus Level: 2.0 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity:
*2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak [**Last Name (NamePattern1) 21888**]:
18 mm Hg < 20 mm Hg
Aortic Valve - Mean [**Last Name (NamePattern1) 21888**]:
10 mm Hg
Aortic Valve - LVOT VTI:
32
Aortic Valve - LVOT diam:
1.7 cm
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.38
Mitral Valve - E Wave deceleration time: *286 ms 140-250 ms
[**First Name (Titles) **] [**Last Name (Titles) 21888**] (+ RA = PASP):
20 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2121-3-11**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV. PFO is present. Right-to-left shunt across the interatrial
septum at rest. Increased IVC diameter (>2.1cm) with <35%
decrease during respiration (estimated RA pressure (10-20mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT [**Year (4 digits) **].
RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given the severity of TR]. Abnormal diastolic septal
motion/position consistent with RV volume overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest.
Echocardiographic results were reviewed by telephone with the
houseofficer caring for the patient. Bilateral pleural
effusions. Ascites.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. A patent foramen ovale is present wsith
right-to-left shunt of agitated saline across the interatrial
septum at rest. The estimated right atrial pressure is
10-20mmHg. 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). The right
ventricular cavity is moderately dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased [**Month/Day (2) **] consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**11-22**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2121-3-11**], the severity of tricuspid regurgitation is increased
and the right ventricular cavity is now dilated. Minimal aortic
stenosis is also now suggested.
Is there a history to suggest pulmonary embolism as an
explanation for RVE/TR and cerebral infarcts?
IMPRESSION:
CLINICAL IMPLICATIONS:
The patient has mild aortic stenosis. Based on [**2117**] ACC/AHA
Valvular Heart Disease Guidelines, a follow-up echocardiogram is
suggested in 3 years.
Based on [**2118**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Compared with the prior study (images reviewed) of [**2121-3-11**]
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2121-7-2**] 14:24
?????? [**2114**] CareGroup IS. All rights reserved.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CAROTID SERIES COMPLETE PORT Study Date of
[**2121-7-2**] 2:51 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-7-2**] 2:51 PM
CAROTID SERIES COMPLETE PORT; [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) P
Clip # [**Clip Number (Radiology) 105786**]
Reason: Please eval for stenosis and thrombus
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with HCV cirrhosis and acute on chronic
renal insufficiency,
now w/ multiple embolic strokes on MRI.
REASON FOR THIS EXAMINATION:
Please eval for stenosis and thrombus
Provisional Findings Impression: [**First Name9 (NamePattern2) 79381**] [**Doctor First Name **] [**2121-7-3**] 11:20 AM
PFI:
No evidence of deep venous thrombosis in the upper extremities.
No evidence of internal carotid artery stenosis on the right
side. Less than
40% stenosis of the left internal carotid artery.
Final Report
HISTORY: 54-year-old woman with cirrhosis and PE. Upper
extremity DVT is
suspected.
TECHNIQUE: Evaluation of the deep veins in the bilateral upper
extremities
was performed with B-mode, color and spectral Doppler
ultrasound.
FINDINGS: Normal compressibility and flow was seen in the
bilateral internal
jugular, subclavian, axillary, and brachial veins. Also normal
augmentation
and phasicity was noticed.
COMPARISON: None available.
IMPRESSION: No evidence of deep venous thrombosis in the upper
extremities.
HISTORY: 54-year-old lady with multiple embolic strokes. Duplex
scan of the
carotid arteries is requested.
TECHNIQUE: Evaluation of the bilateral extracranial carotid
arteries was
performed with B-mode, color and spectral Doppler ultrasound.
FINDINGS: A minimal amount of plaque was seen in the left
internal carotid
artery, with B-mode ultrasound.
On the right side, peak systolic velocities were 58 cm/sec for
the internal
carotid artery, 70 cm/sec for the common carotid artery and 66
cm/sec for the
external carotid artery.
The right ICA/CCA ratio was 0.82.
On the left side, peak systolic velocities were 87 cm/sec for
the ICA, 71
cm/sec for the CCA and 100 cm/sec for the ECA. The left ICA/CCA
ratio was
1.2.
Both vertebral arteries presented antegrade flow.
COMPARISON: None available.
IMPRESSION:
1. No evidence of internal carotid artery stenosis on the right.
2. Less than 40% stenosis of the left internal carotid artery.
DR. [**First Name (STitle) **] [**Name (STitle) **]
Approved: [**Doctor First Name **] [**2121-7-3**] 3:32 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105787**]Portable TEE (Congenital) Done [**2121-7-3**] at 3:50:39 PM
FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **], Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], E/KS-B23
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-12-15**]
Age (years): 54 F Hgt (in): 65
BP (mm Hg): 108/53 Wgt (lb): 160
HR (bpm): 54 BSA (m2): 1.80 m2
Indication: Cerebellar embolic strokes. Evaluate for cardiac
source of embolus.
ICD-9 Codes: 423.9, 424.0, 745.5
Test Information
Date/Time: [**2121-7-3**] at 15:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TEE (Congenital) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W004-2:44 Machine: Vivid i-4
Sedation: Versed: 1 mg
Fentanyl: 37.5 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Dynamic interatrial
septum. PFO is present. Right-to-left shunt across the
interatrial septum at rest.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: No atheroma in aortic arch. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve. No AR.
MITRAL VALVE: No mass or vegetation on mitral valve. Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips of papillary muscles. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic 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. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
for the patient was notified of the echocardiographic results by
e-mail. Echocardiographic results were reviewed with the
houseofficer caring for the patient.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. The right atrium is
dilated. A patent foramen ovale is present. A right-to-left
shunt across the interatrial septum is seen at rest. Overall
left ventricular systolic function is normal (LVEF>55%). with
normal free wall contractility. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**11-22**]+)
mitral regurgitation is seen. There is a small pericardial
effusion.
IMPRESSION: No intracardiac thrombus or valvular vegetations
seen. Mild to moderate mitral regurgitation. Patent foramen
ovale with right to left shunt at rest.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2121-7-3**] 16:49
?????? [**2114**] CareGroup IS. All rights reserved.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2121-7-2**] 4:39 PM
[**Last Name (LF) **],[**First Name3 (LF) **] F. MED MICU-7 [**2121-7-2**] 4:39 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 105788**]
Reason: please eval for PE and also please time contrast for
vessel
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with cirrhosis and HRS/HD now with new
embolic cva as well as
PFO and right heart strain on echo.
REASON FOR THIS EXAMINATION:
please eval for PE and also please time contrast for vessel
evaluation.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SBNa WED [**2121-7-2**] 9:52 PM
Pulmonary vasculature engorgement. No definite PE. ? filliing
defect in RUL
thought to be a in pulm vein (402b, 32). Bilateral atelectasis.
Contrast
refluxing into IVC likely c/w right heart failure. Large amount
of ascites.
Cirrhotic appearing liver. Catheter tip in RA extending into
IVC.
Wet Read Audit # 1 SBNa WED [**2121-7-2**] 7:33 PM
Pulmonary vasculature engorgement. No definite PE. Bilateral
atelectasis.
Contrast refluxing into IVC likely c/w right heart failure.
Large amount of
ascites. Cirrhotic appearing liver.
Wet Read Audit # 2 SBNa WED [**2121-7-2**] 9:50 PM
Pulmonary vasculature engorgement. No definite PE. ? filliing
defect
in RUL thought to be a in pulm vein (402b, 32). Bilateral
atelectasis.
Contrast refluxing into IVC likely c/w right heart failure.
Large amount of
ascites. Cirrhotic appearing liver.
Final Report
PROCEDURE: CTA chest with and without contrast and
reconstructions.
REASON FOR EXAM: 54-year-old woman with cirrhosis and
hemodialysis. New
embolic CVA, as well as PFO and right heart strain on echo.
TECHNIQUE: MDCT axial images of the chest were obtained at full
expiration
using a low-dose technique without contrast followed by a full
full-dose
technique at full inspiration after a rapid bolus of 100 mL
Optiray contrast
with multiplanar reformats.
No previous CT pulmonary angiogram was available for comparison.
FINDINGS: There is a tiny subsegmental filling defect in the
left lower lobe
(3:46), consistent with a small pulmonary embolism.
No aortic dissection or aneurysm.
The heart is markedly enlarged and there is enlargement of the
pulmonary
artery which is associated with tortuosity of the subsegmental
pulmonary
arteries and distal tapering. There is also evidence of right
heart strain
with bowing of the intraventricular septum into the left
ventricle and
enlargement of the right atrium and right ventricle. A
hemodialysis catheter
passes through the right side of the heart with its tip in the
distal IVC. No
pericardial effusion.
Left upper and lower lobe atelectasis is noted, the lungs are
otherwise clear.
Airways are widely patent to the subsegmental levels.
In the limited views of the upper abdomen, the liver has a
nodular outline
consistent with cirrhosis and there is extensive intra-abdominal
ascites.
Review of the bones does not reveal any destructive or sclerotic
bone lesions.
IMPRESSION:
1. Small left lower lobe subsegmental pulmonary embolism.
2. Pulmonary arterial hypertension with right heart strain
manifested by
enlargement of the right atrium and ventricle with bowing of the
intraventricular septum into the left ventricle. Contrast is
also seen to
reflux into the IVC and azygos.
3. Cirrhosis with diffuse intra-abdominal ascites.
Dr [**Last Name (STitle) **] [**Name (STitle) **] contact[**Name (NI) **]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2121-7-4**] 10:33 AM
Imaging Lab
Brief Hospital Course:
# Hepatorenal Syndrome: Patient was admitted because of an
elevated creatinine on laboratory testing. Her Cr was 5.1 on
admission and it peaked at 6.0 on [**6-13**]. She was treated with
increasing doses of midodrine and octreotide for HRS but her
kidney function never recovered. She was subsequently started on
hemodialysis. A tunneled right subclavian catheter was placed
on [**6-23**] which has been used for this purpose since. Her schedule
is MWF, she has had no issues w/ hypotension during her
dialysis.
.
# HCV Cirrhosis: Pt has a history of HCV requiering intermittent
U/S guieded paracentesis for abdominal discomfort because of
increasing ascites. She was high on the [**Month/Day (4) **] list after
developing HRS with a MELD score ranging in the low to mid 30s.
After being on dialysis for 2 weeks she was evaluated by the
renal [**Month/Day (4) **] list by [**Month/Day (4) **] nephrology and she was
approved for a kidney as well. She was started on rifaxamin and
lactulose after an episode of AMS that was thought to be due to
her CVA with a component of hepatic encephalopathy. She is
currently deactivated from the liver/kidney [**Month/Day (4) **] list
awaiting recovery from ischemic stroke.
.
# CVA: After being started on HD patient was stable having no
issues, just awaiting [**Month/Day (4) **]. As she was high on the list it
was decided that she should stay in the hospital until matching
liver/kidney were obtained so she could undergo surgery. On [**7-1**]
she suffered a fall while going to the bathroom in the middle of
the night. She being assisted by a nurse [**First Name (Titles) 1023**] [**Last Name (Titles) 105789**] the
fall and reported that she hit her head. A head CT was obtained
which was (-) for bleed. On the morning of [**7-2**] she was found
to be unresponsive and to have some neurological deficits. An
MRI brain was obtained which was again (-) for bleed but she was
found to have had multiple ischemic infarts distributed evenly
accross the brain suggesting an embolic shower from unknown
source. She underwent TTE, TEE, carotid dopplers, LE dopplers
and CTA. Despite this work up no source for the emboli was
found, but she was found to have a PFO which could have
permitted venous emboli to cross from RA to LA potentially
causing the strokes. Per cardiology attending [**Location (un) 1131**] the TEE,
there was no apparent thrombus on the HD line tip by TEE.
Cardiology was consulted for eval for closure of the PFO but
they thought that this would not be appropriate as pt w/
multiple medical problems and she would need long term
anticoagulation post-procedure which is contraindicated at the
time. She was also not given a IVC filter since no source of
thrombus was found and it would develop clot on the filter
without anticoagulation. Pt has since improved, is undergoing
in patient PT and passed speech and swallow testing so is taking
PO.
.
# AMS/Hypotension: On morning of [**7-3**] she was found to be
unresponsive and hypotensive. This was thought to be due to her
recent CVA w/ possible component of hepatic encephalopathy and
dehydration as pt was NPO at the time. She was transfered to the
MICU where her hypotension responded to IVF hydration. She was
started on lacutlose and rifaxamin and her mental status
improved. She returned to the floor after ~2 days in the MICU.
She had no more episodes of AMS and her BP has remained stable
at her baseline.
.
# PE: Pt was found to have a small subsegmental LLL PE while
being worked up for embolic source of her CVA. Her respiratory
status was never afected by the PE. She was not started on
anticoagulation as she is at risk for bleeding because of her
ESLD and there is difficulty determine therapeutic levels since
she already has an elevated PTT from her ESLD.
.
# Ascites: Pt requiered 2 therapeutic paracentesis during this
admission. Her last one was done on the day of discharge,
[**2121-7-9**], and she received albumin post-procedure. She has a
history of SBP in the past and is on Cefpodoxime prophylaxis for
this (changed from ciprofloxacin as this caused long QT on pt).
.
# Epistaxis: Pt had an episode of epistaxis after HD on [**7-5**]. It
was at first unresponsive to pressure. ENT was consulted who
suggested Afrin spray and application of more pressure which
stopped the bleeding. Patient had no more episodes of epistaxis.
.
# Diabetes mellitus: Pt has a prior history of DM that had been
well controlled w/ diet modifications as an outpatient. Her
blood glucose has been increasingly hard to control on ISS.
Glargine 10 units was started on [**7-6**], it has been given in the
mornings and received on the morning of discharge. She should
switched to night time dosing. Please titrate her glargine and
humalog sliding scale accordingly.
.
# Coccygeal wound:
Care for as such:
Wound care:
Site: coccyx/sacral
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Commercial cleanser
Change dressing: Other
Comment: please apply mepilex border, q3days prn
.
# Code: FULL
Medications on Admission:
Cholecalciferol 800 Daily
Calcium Carbonate 500 mg TID
Fluticasone Nasal
Clotrimazole 10 mg QID
Pantoprazole 40 mg Q24H
Nadolol 20 mg DAILY
Ferrous Sulfate 325 mg TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Hepatitis C Virus related cirrhosis (contracted while working as
lab tech)
portal hypertension
ascites
hepatorenal syndrome
embolic stroke
pulmonary embolus
patent foramen ovale
DM
Secondary:
h/o SBP, s/p thx abx and ppx cipro
hypertension
mitral regurgitation
[**Hospital1 105777**] [**Hospital1 32050**] hernia repair [**5-11**] by Dr. [**Last Name (STitle) **]
Discharge Condition:
improved, stable
Discharge Instructions:
You were seen at [**Hospital1 18**] for liver failure and kidney failure.
Your kidneys never recovered so you had to be started on
hemodialysis. You were initially listed for liver and kidney
[**Hospital1 **]. It was decided that it would be better for you to
stay in the hospital while you waited for a potential
[**Hospital1 **]. While in the hospital suffered from embolic strokes
related to a congenital hole in your heart. Because we did not
find a source for the clots, and because of your liver disease,
we did not think you were a good candidate for anticoagulation
or filter to prevent other clots. You also had a small amount
of the clot go to your lungs without significant impairment of
your lung function. As a result of your stroke you are curretnly
not on the [**Hospital1 **] list. You are being discharged to undergo
rehab to assess how much function you can regain after your
stroke and after this will be re-evaluated for re-enlisting on
the [**Hospital1 **] list.
Please return to the ED or call your PCP if you experience:
- worsening confusion
- fever greater than 100.4 degrees F
- bloody stool or black tarry stool
- weakness/numbness/tingling anywhere in your body
- difficulty speaking
- visual changes
- facial drooping
- chest pain
- shortness of breath
Followup Instructions:
please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3329**]),
within two weeks of discharge from your rehab.
You have an appointment scheduled with Dr. [**Last Name (STitle) 497**] in the
[**Last Name (STitle) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-8-6**] 8:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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"789.59",
"572.4",
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"86.07",
"88.72",
"38.95"
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icd9pcs
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[
[]
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37836, 37915
|
32584, 37409
|
316, 341
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38333, 38352
|
3239, 7223
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39685, 40177
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2593, 2687
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29153, 29272
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37936, 38312
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38376, 39662
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2702, 3220
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21071, 22252
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249, 278
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29304, 32561
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2035, 2075
|
37422, 37616
|
369, 2017
|
2097, 2413
|
2429, 2577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,477
| 194,112
|
29263+57631
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-2-20**] Discharge Date: [**2103-2-24**]
Date of Birth: [**2033-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion and exertional angina
Major Surgical or Invasive Procedure:
[**2103-2-20**]
Aortic valve replacement, [**Street Address(2) 6158**]. [**Hospital 923**] Medical Biocor
supra tissue valve.
Coronary artery bypass grafting x3 left internal mammary
artery graft, left anterior descending, reverse
saphenous vein graft to the marginal branch of the
posterior descending artery.
History of Present Illness:
69 yo male with known aortic stenosis followed by echocardiogram
which most recently revealed severe aortic stenosis and
development of mild left ventricular hypertrophy. He underwent
cardiac catherization that revealed coronary artery disease.
Past Medical History:
PUD
h/o H.pylori (Rx ~8yrs ago)
aortic stenosis
coronary artery disease
diabetes mellitus
hyperlipidemia
hypertension
splenomegaly/hepatomegaly (due to mono/EBV) s/p liver biopsy
Social History:
Married with 3 children, works as shipper of [**Hospital3 635**] chips.
Denies h/o toxin exposures.
2 pack a day as a teen, no recent cigarettes but occassional
cigar
2 scotch and waters or glass of wine each evening
Family History:
Brother with CABG x 4 at age 64
Mother deceased 70 coronary artery disease
Father stroke deceased 73
Physical Exam:
67" 195#
HR 73 RR 14 right 167/87 left 160/80
WDWN male in NAD
skin warm, dry, no c/c/e
NCAT, PERRL, anicteric sclera, OP benign, teeth in good repair
neck supple, full ROM, no JVD
CTAB
RRR S1 S2 3/6 SEM
soft, NT, ND, +BS
warm, well-perfused, trace bilat.edema
mild dliatation of left GSV below knee
alert and oriented, x3, gait steady, nonfocal
fem bilat. 2+, DP/PT 1+ bilat.
radials 2+ bilat.
carotids with transmitted murmur vs. bruit
Pertinent Results:
[**2103-2-24**] 07:20AM BLOOD WBC-13.2* RBC-3.43* Hgb-10.5* Hct-29.7*
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.8 Plt Ct-317#
[**2103-2-23**] 06:20AM BLOOD WBC-16.3* RBC-3.35* Hgb-9.8* Hct-28.7*
MCV-86 MCH-29.4 MCHC-34.2 RDW-14.0 Plt Ct-192
[**2103-2-22**] 05:55AM BLOOD WBC-22.5*# RBC-3.84* Hgb-11.2* Hct-33.4*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.0 Plt Ct-209
[**2103-2-24**] 09:15AM BLOOD Neuts-85.0* Lymphs-9.1* Monos-4.1 Eos-1.5
Baso-0.3
[**2103-2-24**] 07:20AM BLOOD Plt Ct-317#
[**2103-2-20**] 02:13PM BLOOD PT-15.6* PTT-33.2 INR(PT)-1.4*
[**2103-2-20**] 12:35PM BLOOD PT-15.3* PTT-30.9 INR(PT)-1.3*
[**2103-2-24**] 07:20AM BLOOD Glucose-124* UreaN-31* Creat-1.0 Na-136
K-3.9 Cl-97 HCO3-29 AnGap-14
[**2103-2-20**] 02:13PM BLOOD UreaN-18 Creat-0.7 Cl-113* HCO3-25
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 70347**],[**Known firstname **] [**2033-2-1**] 70 Male [**Numeric Identifier 70348**] [**Numeric Identifier 70349**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. GAGE/dif
SPECIMEN SUBMITTED: Aortic Valve Leaflets.
Procedure date Tissue received Report Date Diagnosed
by
[**2103-2-20**] [**2103-2-20**] [**2103-2-23**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/mb????????????
Previous biopsies: [**-6/4912**] EGD (1).
[**-6/4911**] Consult slides referred to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**].
DIAGNOSIS:
Aortic valve leaflets:
Valvular tissue with degenerative changes and calcification.
Clinical: Coronary artery disease.
Gross:
The unfixed specimen is received is one container labeled with
the patient's name, "[**Known lastname **], [**Known firstname **]", the medical record number
and "aortic valve leaflets." It consists of three aortic valve
leaflets. The largest one measures 2.3 x 1.2 x 0.2 cm. The
smallest one measures 1.6 x 0.9 x 0.3 cm. Each of the valve
leaflets is involved by multiple areas of atherosclerosis and
calcification. There are additionally remaining tan fragments of
soft tissue measuring 2 x 1.2 x 0.3 cm in aggregate. The
specimen is entirely submitted in A-B following decalcification.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 6811**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 70350**] (Complete)
Done [**2103-2-20**] at 12:26:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2033-2-1**]
Age (years): 70 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Valvular heart
disease.
ICD-9 Codes: 440.0, V42.2, 424.1, 396.9, 424.0
Test Information
Date/Time: [**2103-2-20**] at 12:26 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW0-5: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 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: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 0.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *48 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary
veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS:
1) Preserved biventricular systolic function
2) Bioprosthesis is visualized in aortic position
3) Well seated and mechanically stable with good leaflet
excursion
4) No AI
5) Gradient could not be obtained because of poor echo windows
in the deep transgastric position.
6) Intact aorta and no other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2103-2-20**] 12:38
[**Known lastname 6811**],[**Known firstname **] [**Medical Record Number 70351**] M 70 [**2033-2-1**]
Cardiology Report ECG Study Date of [**2103-2-20**] 2:24:40 PM
Sinus rhythm. Left bundle-branch block. Left axis deviation.
Diffuse
secondary repolarization abnormalities. Compared to the previous
tracing
of [**2103-1-30**] complete left bundle-branch block is now present.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 134 142 460/481 41 -38 121
Radiology Report CHEST (PA & LAT) Study Date of [**2103-2-24**] 10:24
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2103-2-24**] 10:24 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 70352**]
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p AVR/CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
Final Report
PA AND LATERAL CHEST ON [**2103-2-24**] AT 10:33
INDICATION: Recent chest surgery, check for effusions.
COMPARISON: [**2103-2-22**].
FINDINGS: The heart is enlarged and there is a right posterior
effusion. The
left costophrenic sulcus is better delineated on this current
study. Some
airspace opacity is seen, likely representing compressive
atelectasis at the
right lung base. Subsegmental atelectasis at the left base is
demonstrated.
There is linear atelectasis at the left upper lung field - that
finding is
unchanged. Pulmonary vascular markings are within normal limits
and
unchanged.
The current study shows increased discrepancy in the height of
the right
hemidiaphragm as compared to the left. If the patient had a deep
inspiration,
possibility of impaired right hemidiaphragmatic motion could be
considered.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2103-2-24**] 6:30 PM
Brief Hospital Course:
Admitted and underwent coronary artery bypass surgery and aortic
valve replacement. See operative report for further details.
Received cefazolin for perioperative antibiotics. He was
transferred to the intensive care until for hemodynamic
monitoring. In the first twenty four hours he was weaned from
sedation, awoke neurologically intact and was extubated without
complications. On post operative day one he was started on
betablockers and diuretics, and transfered to the floor.
Physical therapy worked with him on strength and mobility. He
had short episodes of atrial fibrillation that was treated with
beta blockers and amiodarone. Postoperative day two he had
elevated WBC, no fevers, urine was sent for culture. He
continued to do well with no fevers, chills, urine culture
negative, WBC decreased on post operative day three. On
postoperative day four he was noted for phlebitis right forarm
near AC, with erythema, tender and edema. Blood cultures were
obtained, WBC down to 13 from 22, no fevers. Right arm was
elevated, warm packs applied, area marked. By the afternoon the
erythema decreased slightly, no fevers, and started on Keflex so
he was discharged home with services with plan for follow up
wound check on wednesday. Clearly instructed to call for
fevers, chills, or increasing redness on arm.
Sternal incision no drainage, no erythema, sternum stable
Left EVH no erythema no drainage
Edema +1 upper extremeties, +2 lower extremeties
Weight at discharge 94 preop 86
Medications on Admission:
ASA 81 mg daily
lisinopril 2.5 mg daily
tricor 145 mg daily
MVI
fish oil 1200 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: for right arm phlebitis .
Disp:*40 Capsule(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for if ultram not effective .
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day for 5 days then decrease
to 400 mg once a day for 7 days then decrease to 200mg daily
until follow up with cardiologist .
Disp:*64 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary artery disease s/p CABG
Post operative atrial fibrillation
Type 2 Diabetes mellitus
hyperlipidemia
hypertension
splenomegaly/hepatomegaly (due to mono/EBV) s/p liver biopsy
Cataracts
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**]
Warm packs to right arm phlebitis 4 times a day no longer than
30 minutes, monitor redness - call if increasing, if fevers, or
chills [**Telephone/Fax (1) 170**]
Take complete course of antibiotic and follow up wednesday for
wound check with NP at 11am
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) 6160**] in 1 week [**Telephone/Fax (1) 33129**]
Dr. [**Last Name (STitle) 34547**] in [**2-20**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Wound check appointment [**Hospital Ward Name 121**] 6 with NP Wednesday [**2-28**] at 11am
[**Telephone/Fax (1) 3071**]
Completed by:[**2103-2-25**] Name: [**Known lastname 711**],[**Known firstname **] Unit No: [**Numeric Identifier 11921**]
Admission Date: [**2103-2-20**] Discharge Date: [**2103-2-24**]
Date of Birth: [**2033-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 741**]
Addendum:
Spoke with Mr [**Known lastname **] [**2103-2-25**] at 1300, redness in right arm
continues to decrease and is not as swollen. Denies fevers,
chills. Continues to apply warm packs to arm, elevate
extremity, and taking antibiotic.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1082**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2103-2-25**]
|
[
"424.1",
"786.09",
"401.9",
"451.84",
"E878.2",
"414.01",
"426.3",
"427.31",
"272.4",
"250.00",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
16019, 16201
|
10629, 12128
|
315, 644
|
14256, 14263
|
1954, 7391
|
15027, 15996
|
1373, 1476
|
12265, 13915
|
9532, 9561
|
14018, 14235
|
12154, 12242
|
14287, 15004
|
7440, 9492
|
1491, 1935
|
234, 277
|
9593, 10606
|
672, 919
|
941, 1122
|
1138, 1357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,992
| 193,409
|
24508
|
Discharge summary
|
report
|
Admission Date: [**2144-8-21**] Discharge Date: [**2144-8-25**]
Date of Birth: [**2091-7-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Hematemesis, fever, nausea, vomiting
Major Surgical or Invasive Procedure:
1. Upper endoscopy
2. Packed red blood cell transfusion
History of Present Illness:
53 year old male with history of cholangiocarcinoma on FLOX
chemotherapy presented on day of arrival to oncology clinic with
a few days of nausea, vomiting, diarrhea, lethargy and fever. In
clinic he was found to be dehydrated, vomiting dark red emesis
(consistent with possible old blood), and febrile (low grade).
His labs showed a potassium of 2.5, he was started on potassium
IV and sent to the ED for further evaluation.
.
The patient reports that he began to vomit reddish material 2
days prior to presentation and had 5-6 episodes of hematemesis
the day prior to admission. He reports black watery stool over
the past few days prior to admission as well. Previously his
stool was brown. At his last visit to oncology, he reported poor
appetite with early satiety. He also has mid abdominal pain
worse with eating and nausea for which he takes compazine. ROS
is otherwise notable for subjective fevers for 2 days. He denies
any recent travel or sick contacts.
Of note, the patient reports being admitted to an OSH 2 weeks
ago
with hematemesis; he was also seen at OSH yesterday for similar
symptoms. He reports undergoing EGD which showed question of
metastatic gastric lesions that were bleeding. He is unsure how
these lesions were treated.
.
In the ED: Patient underwent 2 L gastric lavage and was still
not clearing clots. His HCT remained stable at 37. He received
intravenous fluids with potassium. He was then admitted to the
MICU for an emergent upper endoscopy, which demonstrated erosive
esophagitis, gastritis, and compression by tumor, with
ulceration around the stent in his biliary duct without evidence
of bleeding. As a result, patient was started on a proton pump
inhibitor and sulcralfate.
Past Medical History:
1. Atrial fibrillation/flutter.
2. Status post tonsillectomy.
3. Status post cholecystectomy.
4. Status post cyst removal on his throat
5. Status post eye surgery.
6. Carpal tunnel syndrome.
7. Status post port-a-cath placement [**2144-8-14**].
.
Oncologic History:
Metastatic Cholangiocarcinoma:
- initially presented with painless jaundice in [**4-4**]. Diagnosed
via ERCP with cholangiocarcinoma -Klatskin-type tumor
- [**5-5**], external and internal left and right transhepatic
catheter drains
- [**6-/2142**] - exploratory laparotomy - extensive tumor involvement
of the right anterior branch of the hepatic duct as well as
positive lymph nodes in the posterior duodenum. It was
determined based upon this that his cancer was unresectable.
- [**12-7**] gemcitabine and cisplatin
- [**2-4**] disease progression on staging CT
- [**3-7**] started on capecitabine monotherapy
- [**3-7**] biochemical evidence of disease progression, changed to
Taxotere 75 mg/m3 for three weeks. He received a total of four
cycles of Taxotere
- [**Date range (1) 61949**] received 1st cycle of FLOX chemotherapy
Social History:
Lives with friends
Former heavy drinker
Quite smoking in late 90s (previously 1ppd)
Family History:
Non contributory.
Physical Exam:
T:99.4 BP:123/63 P:95 RR:18 O2 sats:97% on RA
Gen: Well appearing in NAD
Neck: Supple
CV: +s1+s2 RRR No M/R/G
Resp: CTA B/L No RRW
Abd: Benign. No rebound. no guarding. Surgical scar.
Neuro: Alert and answering all questions appropriately
Pertinent Results:
EKG: NSR @ 90s. No ST changes. Normal intervals and axis.
.
Upper endoscopy [**2144-8-21**]:
Impression: Esophagitis
Abnormal mucosa in the stomach
Metal stent was seen in the biliary duct, with no evidence of
bleeding from the duct, however there was ulceration on the
mucosal fold across from the stent but no visable vessel or
active bleeding.
[**2144-8-21**] 08:55PM POTASSIUM-3.4
[**2144-8-21**] 08:55PM HCT-31.8*
[**2144-8-21**] 01:55PM GLUCOSE-120* UREA N-19 CREAT-1.1 SODIUM-139
POTASSIUM-2.8* CHLORIDE-96 TOTAL CO2-37* ANION GAP-9
[**2144-8-21**] 01:55PM ALT(SGPT)-14 CK(CPK)-152 ALK PHOS-57
AMYLASE-35 TOT BILI-0.7
[**2144-8-21**] 01:55PM LIPASE-51
[**2144-8-21**] 01:55PM cTropnT-<0.01
[**2144-8-21**] 01:55PM CK-MB-3
[**2144-8-21**] 01:35PM GLUCOSE-115* UREA N-19 CREAT-1.1 SODIUM-138
POTASSIUM-2.9* CHLORIDE-95* TOTAL CO2-31 ANION GAP-15
[**2144-8-21**] 01:35PM GLUCOSE-115* UREA N-19 CREAT-1.1 SODIUM-138
POTASSIUM-2.9* CHLORIDE-95* TOTAL CO2-31 ANION GAP-15
[**2144-8-21**] 01:35PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-61
AMYLASE-37 TOT BILI-0.7
[**2144-8-21**] 01:35PM LIPASE-54
[**2144-8-21**] 01:35PM WBC-7.5 RBC-4.72 HGB-12.6* HCT-37.6* MCV-80*
MCH-26.7* MCHC-33.5 RDW-19.9*
[**2144-8-21**] 01:35PM NEUTS-78.0* LYMPHS-13.6* MONOS-7.3 EOS-1.1
BASOS-0.1
[**2144-8-21**] 01:35PM PLT COUNT-251
[**2144-8-21**] 01:35PM PT-14.9* PTT-21.2* INR(PT)-1.3*
[**2144-8-21**] 10:39AM WBC-7.8# RBC-4.78 HGB-13.1* HCT-37.6* MCV-79*
MCH-27.4 MCHC-34.9 RDW-19.5*
[**2144-8-21**] 10:39AM NEUTS-80.2* LYMPHS-12.5* MONOS-6.7 EOS-0.3
BASOS-0.2
[**2144-8-21**] 10:39AM PLT COUNT-254
[**2144-8-21**] 10:39AM GRAN CT-6270
Brief Hospital Course:
# Hematemesis:
The patient's hematemesis was thought to be secondary to the
gastritis, esophagitis, and ulceration seen on upper endoscopy.
It was also possible that there was a componenet of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]
[**Last Name (NamePattern1) **] tear secondary to delayed nausea and vomiting from
chemotherapy.
- Gastroenterology was consulted and completed the upper
endoscopy. Based on those findings, the patient was started on
pantoprazole [**Hospital1 **] as well as sucralfate. He was initially kept
NPO, and then slowly advanced his diet without difficulty or
recurrence of his hematemesis.
- Initally patient had melena and guaiac positive stools,
thought to be secondary to his upper gastrointestinal source.
These cleared as treatment for his esophagitis and gastritis was
initiated, and no further work-up was completed, as his bowel
movements returned to baseline and were guaiac negative.
- Patient was transfused one unit of packed red blood cells
prior to discharge to improve his anemia. His hematocrit
remained relatively stable during his admission, however drifted
down slightly.
- Patient was counseled to avoid aspirin, NSAIDs, alcohol, or
other anticoagulation.
.
# Metastatic Cholangiocarcinoma:
- Patient was currently on FLOX (5-FU, folinic acid, and
oxaliplatin) - received Cycle 1, day #15 on [**2144-8-14**].
- Patient was kept on zofran as needed for nausea.
- Follow appointment was in place for patient to return to
oncology clinic later during week of discharge.
.
# Atrial fibrillation/flutter: Patient was not on anticoagulated
for his history of atrial fibrillation, and was initially on
metoprolol for rate control. The metoprolol was discontinued,
however, due to low heart rate while not receiving any
rate-controlling or nodal blocking agents. He was noted to have
episodes where his heart rate was in the 30's to 40's at the
time when he broke into sinus rhythm from atrial fibrillation.
At time of discharge, he remained in sinus rhythm with a rate in
the 50's to 60's.
.
# Fevers: Patient was noted to have a fever prior to admission,
but remained afebrile during his stay in the ICU and on the
floors. Blood and stool cultures were negative, and urine
analysis did not suggest infection. Patient did not have any
recurrence of his fever and was not started on any antibiotics.
.
# FEN: Patient's hypokalemia aggressively treated, and was
thought to be secondary to his gastrointestinal losses. He was
given intravenous fluids to replete his gastrointestinal losses,
along with his poor PO intake.
.
# Prophylaxis: Patient was continued on [**Hospital1 **] dosing of
pantoprazole, as well as pneumoboots for DVT prophylaxis.
.
# Code Status: Patient was full code during this admission.
Medications on Admission:
MS Contin 30mg Q12
MSIR 15mg Q4-5PRN
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
4. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO q4-6hours PRN as
needed for pain.
6. Compazine 10 mg Tablet Sig: One (1) Tablet PO As directed. as
needed: Resume as you were previously taking.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Gastritis
Secondary Diagonses:
- Cholangiocarcinoma
- Atrial fibrillation
- Upper gastrointestinal bleed
Discharge Condition:
Stable.
Functioning independently at baseline, evaluated and felt to be
safe for discharge by physical therapy.
Discharge Instructions:
You were admitted due to vomiting that was concerning for
bleeding from your gastorintestinal tract. You were monitored
closely and underwent an upper endoscopy that demonstrated
inflammation, which was likely causing the bleeding. You were
started on medications to help with the pain and inflammation,
and you should continue to take those unless directed otherwise.
You also received one unit of packed red blood cells to help
with your anemia.
.
Please call your primary care physician, [**Name10 (NameIs) **] oncologist, or go
to the emergency room if you experience any vomiting, bleeding,
fevers, chills, abdominal pain, chest pain, shortness of breath,
or other concerning symptoms.
.
Please take all medications as prescribed. Please follow up with
Dr. [**Last Name (STitle) **] at your scheduled appointment on Friday [**2144-8-28**] at
10:30 am.
.
You should avoid taking aspiring and other non-steroidal
anti-inflammatories (eg Advil), and drinking alcohol.
.
Please discuss re-starting your medication metoprolol (used for
blood pressure control and to lower heart rate for atrial
fibrillation) with Dr. [**Doctor Last Name 61950**] was stopped during this stay due
to low heart rate.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] as previously scheduled on
Friday, [**2144-8-28**], at 10:30 am, you may reach his office at ([**Telephone/Fax (1) 11624**].
You also have the following upcoming appointments:
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-8-28**] 10:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2144-8-28**]
10:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
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icd9cm
|
[
[
[]
]
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[
"99.04",
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icd9pcs
|
[
[
[]
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5333, 8108
|
309, 367
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9069, 9183
|
3655, 5310
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8196, 8870
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8920, 8920
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9207, 10406
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3395, 3636
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395, 2112
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8939, 9048
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2134, 3243
|
3259, 3345
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,154
| 145,999
|
39452
|
Discharge summary
|
report
|
Admission Date: [**2189-8-18**] Discharge Date: [**2189-8-23**]
Date of Birth: [**2104-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion and fatigue
Major Surgical or Invasive Procedure:
[**2189-8-18**]: Aortic Valve Replacement with [**Street Address(2) 17009**]. [**Male First Name (un) 923**] Epic Ultra
Porcine, Coronary Artery Bypass Graft Surgery x 3 with LIMA-->
Left Anterior Descending, Reverse Saphenous Vein Graft -->
Ramus, Posterior Descending Artery
History of Present Illness:
This is a 84 year old gentleman with known aortic stenosis who
has been followed by serial echocardiograms. Over the past
several months, he had noted some fatigue and increasing
shortness of breath. He has also developed some peripheral
edema. An echocardiogram was performed which showed
significnatly
worsened aortic stenosis with early left ventricular
dysfunction. A cardiac catheterization was performed which
revealed left main and two vessel disease. Given the progression
of his symptoms and severity of his disease, he was referred for
surgical management.
[**2189-6-24**] Cardiac Catheterization @ NEBH: Left Main 70-80%, LAD
50%, RCA 99%. LVEF 52%. No MR. [**Name13 (STitle) 650**] AS, [**Location (un) 109**] 0.76cm2 (Peak/Mean
38/33mmHg), Trace->1+ AI. Slightly dilated ascending aorta. PA
39/14
[**2189-6-8**] Cardiac Echocardiogram: LVEF 50%, Severe AS, [**Location (un) 109**] 0.7cm2,
(Peak/Mean 75/53mmHg). Trace/mild MR [**First Name (Titles) 151**] [**Last Name (Titles) **]. Trace TR.
Past Medical History:
Aortic stenosis and Coronary Artery Disease
Diabetes mellitus type II
Hyperlipidemia
Hypertension
Infrarenal Abd Aortic Aneurysm, 3.4cm
History of GI Bleed secondary Gastric Ulcer, 3-5 years ago
History of Pancreatitis
Prostate Cancer, s/p XRT
Spinal stenosis s/p Epidurals
Lumbar Disc Disease
Hard of Hearing
Endoscopy, s/p Cauterization of Gastric Ulcer
Right total hip replacement [**2184**]
Achilles Tendon Repair
Social History:
Race: Caucasian
Last Dental Exam: several months ago
Lives with: Wife
[**Name (NI) 1139**]: 20 [**Name2 (NI) **], quit 30 years ago
ETOH: Wine daily, no history of abuse
Family History:
No premature coronary disease
Physical Exam:
Pulse: 60 Resp: 16 O2 sat: 97% BP 156/60
General: Elderly male in no acute distress
Skin: Dry [x] intact [x] - multiple areas of bruising noted
HEENT: NCAT [x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] JVD - none
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM noted radiating to
carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] ventral hernia noted as well
Extremities: Warm [x], well-perfused [x] with chronic venous
statsis changes bilaterally, slightly more erythema noted than
before
Edema 1+ bilaterally
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 (with soft bruit) Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs
Pertinent Results:
[**2189-6-8**] Cardiac Echocardiogram: LVEF 50%, Severe AS, [**Location (un) 109**] 0.7cm2,
(Peak/Mean 75/53mmHg). Trace/mild MR [**First Name (Titles) 151**] [**Last Name (Titles) **]. Trace TR.
[**2189-8-21**] 03:44AM BLOOD WBC-11.3* RBC-3.69* Hgb-11.4* Hct-32.2*
MCV-87 MCH-30.9 MCHC-35.4* RDW-15.3 Plt Ct-140*
[**2189-8-21**] 03:44AM BLOOD Glucose-78 UreaN-21* Creat-1.0 Na-134
K-4.0 Cl-99 HCO3-24 AnGap-15
[**2189-8-21**] 03:44AM BLOOD Calcium-8.5 Phos-3.3 Mg-3.0*
Brief Hospital Course:
The patient was admitted to the hospital after a 10 day course
of Ciprofloxacin for urinary tract infection and brought to the
operating room on [**2189-8-18**] where he underwent an Aortic Valve
Replacement and Coronary Artery Bypass Graft x 3. See operative
note for full details. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated. The patient was neurologically
intact and hemodynamically stable on no inotropic or vasopressor
support. He did have some post operative confusion and was
given Ativan and Haldol which caused somnolence. All narcotics
were discontinued and the patient was oriented and mentally
clear by post operative day 2. On post operative day 2 he
developed atrial fibrillation and ventricular bigeminy. He had
a 15 beat run of ventricular tachycardia. He was started on
Amiodarone and subsequently this was stopped secondary to
bradycardia. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. He was started
on Levaquin for questionable aspiration per Dr [**Last Name (STitle) **] with
copious secretions and white blood count increased to 13. He
remained afebrile and white blood count had decreased at the
time of discharge. Sputum culture came back negative and
antibiotics were stopped. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. He did have a
small residual left apical pneumothorax on post chest tube pull
CXR. The patient was evaluated by the physical therapy service
for assistance with strength and mobility. By the time of
discharge on POD#5 the patient was ambulating, the wound was
healing and pain was controlled with tylenol. The patient was
discharged to [**Hospital **] Rehab in [**Doctor Last Name 1263**] in good condition with
appropriate follow up instructions.
Stop [**8-21**]
Medications on Admission:
Lisinopril 5mg daily
HCTZ 25 mg daily
Lasix 20mg daily
Cardizem CD 180mg daily
Glipizide 10mg twice daily
Aspirin 81mg daily
Simvastatin 20mg daily
Fexofenadine 60mg prn
Ciprofloxacin - 10 day course, day 2 of 10
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Lower [**Doctor Last Name 4048**]
Discharge Diagnosis:
Coronary Artery Disease, Aortic Stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, echymotic, mildly pink, no drainage.
Edema: +2 LE edema bilaterally- left greater than right.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**9-17**] at 1pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr [**Last Name (STitle) 7389**] on [**10-2**] at 3:15pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 87173**] in [**3-16**] weeks [**Telephone/Fax (1) 87174**]
**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:[**2189-8-23**]
|
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"401.9",
"V12.71",
"427.31",
"427.1",
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"293.9"
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icd9cm
|
[
[
[]
]
] |
[
"35.21",
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icd9pcs
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[
[
[]
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7205, 7282
|
3666, 5689
|
310, 589
|
7367, 7644
|
3171, 3643
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,556
| 134,182
|
35677
|
Discharge summary
|
report
|
Admission Date: [**2164-2-4**] Discharge Date: [**2164-2-16**]
Date of Birth: [**2110-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lamictal
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status, hypoxia
Major Surgical or Invasive Procedure:
intubation/extubation, central line placement, arterial line
placement, paracentesis
History of Present Illness:
Pt is a 53 F hx of Hep C, B-thalessemia presents from OSH with
altered mental status, evidence of fall, and hypoxia. Patient is
intubated, sedated, and history is obtained from OSH records.
.
Patient was reportedly brought in to OSH ED after falling and
altered mental status X 2 days, bizarre speech (per husband) and
evidence of fall with bruises. At OSH, c-spine clinically
cleared, head CT neg, and she was found to have 2 rib fractures
as well as very large R infiltrates on CXR. She received
levaquin X 1. Tox screen at OSH revealed high tricyclic level of
670. She was guaiac positive and given 1U PRBCs and transferred
to [**Hospital1 **].
.
In [**Hospital1 **] ED, initial vs were: T104, HR 136, BP 118/67, R 30, 96%
NRB
She was noted to be tachypneic to 40's and saturations in 80's
on NRB, and was intubated for hypoxia and increased work of
breathing. A RIJ was placed. She received Vanc/Zosyn. Propofol
for sedation. BP dropped transiently to 88 on propofol.
.
On the floor, she is intubated and sedated.
.
Review of sytems: unable to be elicited
Past Medical History:
Hep C cirrhosis
Splenomegaly
hx vicodin abuse
Depression
Anxiety
B thalessemia
GERD
Fibromyalgia
Social History:
Drugs: unknown, hx of vicodin abuse
Tobacco: unknown
Alcohol: unknown
Other: married, lives with husband
Family History:
NC
Physical Exam:
Tmax: 38 ??????C (100.4 ??????F)
Tcurrent: 37.7 ??????C (99.9 ??????F)
HR: 117 (116 - 120) bpm
BP: 92/50(59) {92/50(59) - 103/61(70)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 92% Ventilator mode: CMV/ASSIST
Vt (Set): 500 (500 - 500) mL
RR (Set): 15
PEEP: 8 cmH2O
FiO2: 100%
PIP: 27 cmH2O
Plateau: 25 cmH2O
SpO2: 92%
ABG: 7.38/35/86.[**Numeric Identifier 71132**]//-3
Ve: 14.1 L/min
PaO2 / FiO2: 87
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL, scleral icterus
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL
Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),
(Murmur: No(t) Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: No(t) Clear : ,
Rhonchorous: ant and laterally)
Abdominal: Soft, Non-tender, Bowel sounds present, +
hepatomegaly
Extremities: Right: Trace, Left: Trace
Skin: Cool, Jaundice
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Not assessed, No(t) Oriented (to): , Movement: Not
assessed, Sedated, Tone: Normal
Pertinent Results:
[**2164-2-4**] 02:00AM PT-21.8* PTT-39.1* INR(PT)-2.1*
[**2164-2-4**] 02:00AM PLT SMR-LOW PLT COUNT-81*
[**2164-2-4**] 02:00AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL TARGET-2+ SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL BITE-OCCASIONAL
[**2164-2-4**] 02:00AM NEUTS-71* BANDS-15* LYMPHS-9* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2164-2-4**] 02:00AM WBC-8.2 RBC-3.84* HGB-9.3* HCT-27.6* MCV-72*
MCH-24.2* MCHC-33.8 RDW-20.0*
[**2164-2-4**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-7.1
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2164-2-4**] 02:00AM cTropnT-<0.01
[**2164-2-4**] 02:00AM CK-MB-NotDone
[**2164-2-4**] 02:00AM CK(CPK)-52
[**2164-2-4**] 02:16AM LACTATE-3.6* NA+-140 K+-5.0 CL--107 TCO2-23
[**2164-2-5**] 02:13AM BLOOD WBC-13.3*# RBC-3.59* Hgb-8.6* Hct-26.9*
MCV-75* MCH-23.9* MCHC-31.8 RDW-19.3* Plt Ct-69*
[**2164-2-13**] 05:17AM BLOOD Neuts-56 Bands-11* Lymphs-25 Monos-5
Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2164-2-4**] 02:14PM BLOOD FDP-10-40*
[**2164-2-4**] 02:14PM BLOOD Fibrino-571*
[**2164-2-13**] 03:39PM BLOOD Glucose-117* UreaN-40* Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-34* AnGap-7*
[**2164-2-13**] 05:17AM BLOOD ALT-14 AST-60* AlkPhos-100 TotBili-2.7*
[**2164-2-4**] 05:39AM BLOOD Ammonia-80*
[**2164-2-15**] 06:00AM BLOOD Type-ART Temp-37.6 Rates-21/ Tidal V-320
PEEP-22 FiO2-50 pO2-76* pCO2-47* pH-7.45 calTCO2-34* Base XS-7
-ASSIST/CON Intubat-INTUBATED
[**2-4**] Echo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The right atrial pressure is
indeterminate. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
[**2-11**] RUQ U/S:
There is mild ascites, with the largest pocket in the left
lower
quadrant, 5.7 cm deep to the skin. This spot was marked for
paracentesis.
Limited views of the liver redemonstrate shrunken nodular
heterogeneous liver,
consistent with known cirrhosis.
IMPRESSION:
1. Mild ascites with the largest pocket in the left lower
quadrant marked for
paracentesis.
2. Findings consistent with known liver cirrhosis.
Brief Hospital Course:
Patient was a 53 y/o F hx Hep C, rib fractures who presented
with severe PNA and ARDS and was terminally extubated on [**2-16**].
# Hypoxic respiratory failure: s/p intubation. Her fever,
bandemia, CXR are indicative of pneumonia. Suspect bacterial >
viral. It is unclear if she had any aspiration events. Low
clinical suspicion for PE. Notably she is quite hypoxic with P/F
ratio on admission is 87. CXR is asymmetric but still likely had
ARDS. Initial A-a gradient is 19 (expected 16). Pt still
requiring vent support and having episodes of hypoxia with
movement, likely due to derecruitment. Esophageal balloon
placed [**2-7**] for four days. Culture data of limited value given
that cultures obtained after antibiotics administered. Patient
was on Vanc/[**Last Name (un) **]/Cipro until made [**Last Name (un) 3225**] on [**2-13**]. Patient required
significant respiratory support with PEEP greater than 20 and
FIO2 greater than 50. On [**2-15**], noted resp alkalosis and
decreased RR. Patient [**Name (NI) 3225**] since [**2-13**]. Patient was terminally
extubated on [**2-16**].
# Sepsis / Hypotension: She was transiently hypotensive
following intubation and sedation. Given degree of pneumonia,
sepsis if certainly possible. Was requiring levofed for labile
BPs as low as 70s up to 190s until [**2-10**] when pressors were
weaned off. Stable BPs since then. Patient [**Name (NI) 3225**] since [**2-13**].
Patient was terminally extubated on [**2-16**].
# Sedation: patient weaned off paralytics on [**2-9**], slowly
weaning fentanyl and versed. Patient was methadone to reduce
narcotic requirements. Patient was placed on morphine drip on
[**2-16**] before terminal extubation.
# Rib fractures: Likely contributed to impaired respiratory
mechanics. No evidence of flail chest.
# Altered mental status: Hx obtained from some OSH records. Per
husband, she had bizarre speech prior to admission X 2 days. DDx
includes hepatic encephalopathy, medications as she is taking a
lot of psych meds, meningitis is also possible although she has
more likely causes for fever and altered mental status. Mental
status will be difficult to follow given current sedation and
paralytics. Will continue to assess as pt weaned from sedation.
Paracentesis unsuccessful [**2-5**]. Concern for opiate induced
hyperalgesia. Evidence of cirrhosis, portal hypertension and
ascites on RUQ U/S. Patient [**Name (NI) 3225**] since [**2-13**].
# Constipation ?????? had BM over weekend with docusate and PO
lactulose after paralytics removed. Lactulose enemas were given
for possibility of hepatic encephalopathy. Bowel regimen d/c
[**2-13**].
# Hep C: RUQ U/S shows cirrhosis, portal HTN and ascites. Hep C
VL 209,000
# Anemia: She has guaiac positive brown stools at OSH, unclear
what baseline HCT is. She does have hx of B- thalessemia. No
evidence of large bleed. Unknown if has hx varices. Patient [**Name (NI) 3225**]
since [**2-13**].
# Thrombocytopenia: Suspect from chronic liver disease.
# Code: [**Month/Year (2) 3225**] Meeting with Mr. [**Known lastname **], patient's husband and her
daughter, to discuss goals of care. Patient has been
increasingly distressed recently over declining condition.
Multiple conversations in the past expressing her desire not to
have life prolonging therapy in the event of irrecoverable
disease. Her pulmonary function is gradually worsening although
cultures remain negative. She is massively volume overloaded
with chest wall restriction. Family is confident that the
patient would decline further care and would want comfort to be
the primary priority. We will stop meds not directed at her
comfort. No CPR or escalation of care. Withdrawal of mechanical
ventilation done Thursday [**2-16**]. Was on
fentanyl/versed/methadone/morphine gtt.
# Communication: Patient Husband: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 81170**]
Medications on Admission:
flexeril 20 mg QHS
paxil 40 mg daily
lyrica
iron
folate
seroquel 400 mg QHS
imipramine 75 mg daily
tramadol TID
Hydroxyzine 50 mg [**Hospital1 **]
Baclofen 10 mg Q8H
meloxicam (Mobic) 15 mg
Discharge Medications:
none, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
pneumonia with sepsis and ARDS
rib fractures
Secondary:
HCV chirrosis with ascities
Discharge Condition:
expired
Discharge Instructions:
Patient was transferred from OSH for altered mental status and
hypoxia. Patient was intubated for severe pneumonia. Patient
developed severe ARDS. Patient was started on broad spectrum
antibiotics. Cultures did not identify pathologic organism. On
hospital day 10, family meeting was done and code status was
changed to [**Hospital1 3225**] given no improvement on antibiotics and continued
requirement for ventilatory support. Patient was terminally
extubated on [**2-16**].
Followup Instructions:
none, expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2164-2-16**]
|
[
"486",
"054.9",
"282.49",
"995.92",
"287.5",
"518.81",
"E888.9",
"807.02",
"038.9",
"070.54",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.24",
"96.72",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9862, 9871
|
5687, 7496
|
305, 391
|
10009, 10019
|
2996, 5664
|
10543, 10724
|
1760, 1764
|
9824, 9839
|
9892, 9988
|
9609, 9801
|
10043, 10520
|
1779, 2977
|
235, 267
|
1466, 1490
|
419, 1448
|
7511, 9583
|
1512, 1618
|
1634, 1744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,247
| 111,766
|
24928
|
Discharge summary
|
report
|
Admission Date: [**2100-11-18**] Discharge Date: [**2100-11-30**]
Date of Birth: [**2026-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2100-11-22**] - Off pump CABG X 2
History of Present Illness:
Mr. [**Known lastname 4318**] is a 73-year-old male with worsening anginal
symptoms who underwent cardiac catheterization that showed
severe left anterior descending
and circumflex ostial disease. He was noted to have calcium in
his ascending aorta by cath. A CT scan confirmed a porcelain
ascending aorta. He also has baseline chronic renal
insufficiency. Due to the severity of his disease, he was
transferred to the [**Hospital1 18**] for surgical revascularization. He is
presenting for high-risk coronary artery surgery.
Past Medical History:
HTN
Hypercholesterolemia
Renal insufficiency
PVD
AAA
GERD
Chronic Renal Insufficiency
S/P left carotid endarterectomy
Social History:
Lives with wife in [**Name (NI) 62675**], [**Name (NI) **]
Family History:
Cousin w/ CABG at age 50.
Physical Exam:
GEN: WDWN in NAD. A+Ox3
NECK: Left CEA scar well healed, no JVD
HEART: RRR, no murmur
LUNGS: Clear
ABD: Obese, benign
EXT: No varicosities, no edema. 2+ Pulses distally.
NEURO: Normal gait, strength 5/5. Nonfocal.
Pertinent Results:
[**2100-11-18**] 09:50PM PLT COUNT-197
[**2100-11-18**] 09:50PM PT-13.4* PTT-26.5 INR(PT)-1.2
[**2100-11-18**] 09:50PM WBC-9.8 RBC-3.90* HGB-12.5* HCT-34.5* MCV-89
MCH-32.0 MCHC-36.1* RDW-13.4
[**2100-11-18**] 09:50PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2100-11-18**] 09:50PM ALT(SGPT)-26 AST(SGOT)-20 LD(LDH)-163 ALK
PHOS-32* AMYLASE-64 TOT BILI-0.4
[**2100-11-18**] 10:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2100-11-18**] 09:50PM GLUCOSE-118* UREA N-18 CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2100-11-18**] 10:41PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2100-11-30**] 06:58AM BLOOD WBC-10.8 RBC-3.40* Hgb-11.2* Hct-31.6*
MCV-93 MCH-32.8* MCHC-35.3* RDW-14.3 Plt Ct-316
[**2100-11-30**] 06:58AM BLOOD Plt Ct-316
[**2100-11-30**] 06:58AM BLOOD UreaN-18 Creat-1.2 K-4.1
[**2100-11-29**] 06:25AM BLOOD Calcium-8.2* Phos-3.6# Mg-2.2
[**2100-11-19**] Carotid Endarterectomy
1. No evidence of hemodynamically significant stenosis in the
internal carotid arteries bilaterally.
2. Less than 40% stenosis of the distal right common carotid
artery and 40%-59% stenosis of the distal left common carotid
artery.
[**2100-11-19**] CTA
1. Extensive calcific atheromatous disease of the entire aorta.
2. 9 mm probable left adrenal adenoma.
3. Calcified pleural plaque suggests prior asbestos exposure. 2
tiny nodules within the right middle lobe are noted. If there is
no prior history of malignancy, 1-year CT follow-up is
recommended. If there is a prior history of malignancy, this may
be followed in 3 months with CT.
[**2100-11-29**] CT Chest
1. Extensive calcific atheromatous disease of the entire aorta.
2. 9 mm probable left adrenal adenoma.
3. Calcified pleural plaque suggests prior asbestos exposure. 2
tiny nodules within the right middle lobe are noted. If there is
no prior history of malignancy, 1-year CT follow-up is
recommended. If there is a prior history of malignancy, this may
be followed in 3 months with CT.
[**2100-11-25**] CXR
1. Extensive calcific atheromatous disease of the entire aorta.
2. 9 mm probable left adrenal adenoma.
3. Calcified pleural plaque suggests prior asbestos exposure. 2
tiny nodules within the right middle lobe are noted. If there is
no prior history of malignancy, 1-year CT follow-up is
recommended. If there is a prior history of malignancy, this may
be followed in 3 months with CT.
Brief Hospital Course:
Mr. [**Known lastname 4318**] was admitted to the [**Hospital1 18**] on [**2100-11-18**] for surgical
management of his coronary artery disease. He was worked-up in
the usual preoperative manner by the cardiac surgical service
including a carotid duplex ultrasound which showed no evidence
of hemodynamically significant stenosis in the internal carotid
arteries bilaterally. A chest xray showed pleural plaques as
well as a heavily calcified aorta and a CT scan was obtained in
follow-up. This revealed extensive calcific atheromatous disease
of the entire aorta, a 9 mm probable left adrenal adenoma,
calcified pleural plaque suggesting prior asbestos exposure and
2 tiny nodules within the right middle lobe. A 1-year CT
follow-up was recommended. An echocardiogram was performed which
revealed mild mitral regurgitation, a mildly dilated aorta and
no aortic insufficiency. On [**2100-11-22**], Mr. [**Known lastname 4318**] was taken to
the operating room where he underwent off-pump coronary artery
bypass grafting to two vessels. An amiodarone drip was started
intraoperatively for ectopy. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 4318**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Beta blockade and aspirin were resumed. On
postoperative day two, Mr. [**Known lastname 4318**] 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 to assist with his postoperative
strength and mobility. Mr. [**Known lastname 4318**] was noted to cough with thin
liquids and a speech and swallow consult was obtained. No
evidence of aspiration was found and he was allowed to resume a
regular diet. Mr. [**Known lastname 4318**] had some mild sternal drainage
vancomycin was started prophylactically. A CT scan was performed
which showed no evidence of dehiscence or infection. He was
transfused for postoperative anemia. Vancomycin was switched to
levofloxacin. Mr. [**Known lastname 4318**] continued to make steady progress and
was discharged home on postoperative day eight. He will
follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary
care physician as an outpatient.
Medications on Admission:
On transfer:
Toprol 50mg Daily
Folate 1mg daily
Lipitor 10mg daily
Aspirin 81mg daily
Lasix 40mg daily
Zestril 20mg twice daily
Digoxin 0.125mg Daily
Discharge Medications:
1. 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*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
CAD
PVD
HTN
CRI
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or ointments to any incisions
no lifting > 10 # or driving for 1 month
Followup Instructions:
with NP or PA on [**Hospital Ward Name 7717**] within 1 week to evaluate wound
with Dr. [**Last Name (STitle) 62676**] in [**2-25**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2100-12-1**]
|
[
"530.81",
"440.0",
"403.91",
"285.1",
"414.01",
"411.1",
"443.9",
"272.0",
"424.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
7615, 7698
|
3906, 6242
|
289, 328
|
7758, 7765
|
1392, 3883
|
7950, 8166
|
1116, 1143
|
6442, 7592
|
7719, 7737
|
6268, 6419
|
7789, 7927
|
1158, 1373
|
242, 251
|
356, 883
|
905, 1024
|
1040, 1100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,610
| 181,098
|
7366
|
Discharge summary
|
report
|
Admission Date: [**2185-9-15**] Discharge Date: [**2185-9-19**]
Date of Birth: [**2111-3-7**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with a history of diabetes, hypertension, depression
who presented to [**Hospital3 **] Hospital with several episodes
of loss of consciousness. The patient was in her usual state
of health until the day of admission except that she had recently
been suffering from back pain. The afternoon on the day of
admission, she was sitting down and felt generally not well
consisting of lightheadedness, nausea, diaphoresis.
She called her daughter who came and helped her to stand up
to walk over to the couch. Upon standing up, the daughter noted
that the patient's eyes were rolling back and the patient was
becoming unresponsive. The loss of consciousness lasted about 4
minutes accompanied by apparently some lip twitching and bladder
incontinence, but no other movement. The patient woke up, vomited
one time and was confused for a few minutes afterwards, but her
mental status cleared and returned to baseline.
The patient came to the emergency room where she was
hemodynamically stable, but then had another episode of loss
of consciousness. Telemetry showed a sinus rate of 48 with up to
four segment pauses which spontaneously resolved and then
recurred again. The patient's systolic blood pressure was in the
upper 40s during these episodes, but otherwise stayed in the 100s
to 120s. She denied any chest pain, palpitations, shortness of
breath, cough, fever, abdominal pain. She did notice
constipation since the day prior to admission.
Of note, she was started on Paxil the week prior to admission
for depression, but has had no other medication. The patient
stated that she had another episode of loss of consciousness the
week prior to admission, but does not remember any details for
that episode. According to her daughter, she also has had one or
two more episodes since earlier this summer. The daughter
descriptions of the episodes are as given above with minimal lip
twitching and the last time with urinary incontinence, but no
other movement and usually no lasting confusion after the
episode.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes for 26 years.
2. Hypertension.
3. Hypothyroidism.
4. Depression.
5. Iron deficiency anemia.
6. Arthritis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Insulin 40 units q. AM NPH 2 units qpm
2. Paxil.
3. Levothyroxine 100 mcg p.o. q.d.
4. Darvocet p.r.n.
5. Norvasc 5 mg p.o. q.d.
6. Accupril 20 mg b.i.d.
SOCIAL HISTORY: The patient lives alone since the death of
her husband 2.5 years ago. She has nine children. She
denies any alcohol or smoking tobacco.
PHYSICAL EXAMINATION: On admission the patient's temperature
was 97.6 F, pulse 67, blood pressure 150/60 and a respiratory
rate of 18. Oxygen saturation was 98% on room air. On
general exam she was awake in no acute distress. Head, eyes,
ears, nose and throat exam showed pupils to be equal, round
and reactive. Oropharynx is clear. Neck showed no
lymphadenopathy and no jugular venous distention. Chest was
clear to auscultation bilaterally. Heart was regular rate
and rhythm with a II/VI systolic murmur at the right upper
sternal border. No S1, S2. Her abdomen was soft, nontender,
nondistended with active bowel sounds. Extremities showed no
cyanosis, clubbing or edema. Neurologic exam: She was alert
and oriented times three with cranial nerves II through XII
intact. No gross motor or sensory abnormalities. Deep
tendon reflexes were 1+ and symmetric and her toes were
downgoing.
LABORATORY: On admission her CBC had a white blood cell
count of 6.7 with a hematocrit of 38 and platelets of
374,000. Sodium is 122, potassium 4.2, chloride 107,
bicarbonate 27. BUN of 68 and creatinine of 1.1. Glucose
202. Calcium 9.7, phosphate 3.5, magnesium 2.0. ALT 18, AST
76, alkaline phosphatase 72. Her initial CK MB and troponin
were negative.
A head CT Scan showed no abnormalities. Abdominal CT Scan
showed no abnormalities except cholelithiasis without
cholecystitis.
Her EKG showed a normal sinus rhythm with a rate of 70 with a
normal axis and normal intervals without any ST changes.
HOSPITAL COURSE: Given the patient's loss of consciousness and
sodium of 122, the patient was initially admitted to the
Intensive Care Unit for overnight monitoring, but was sent to the
Medicine floor the next day. The etiology of the syncope was
initially considered to be most likely vasovagal given the loss
of consciousness accompanied by drop in blood pressure, drop in
heart rate, lightheadedness and diaphoresis, nausea, vomiting,
however hypoglycemic episodes as well as hyponatremic seizures
were also considered.
Etiology for the hyponatremia was often not initially obvious.
Under consideration was decrease due to cortisol, hypothyroidism,
Paxil which was recently started and possible SIADH given the
finding of a right apical density on her initial chest x-ray.
The hospital course by issues is as follows:
1. CARDIOVASCULAR: The patient's initial blood pressure
were elevated. The Norvasc and Accupril were held. EKG showed
normal sinus rhythm and telemetry revealed no more pauses or
episodes of bradycardia. The patient's initial enzymes were
negative. Given the absence of chest pain and the lack of EKG
changes, a myocardial infarction is considered unlikely and no
further enzymes were checked.
Once on the medical floor the patient's orthostatic signs were
checked. The patient was orthostatic at that point and received
a 500 cc IV bolus of fluid. Shortly thereafter showed mild signs
of orthostasis without symptoms. An echocardiogram was done on
[**9-19**] to rule out cardiac dysfunction. It showed a normal
right atrium, left atrium, right ventricle, left ventricle with
an ejection fraction of greater than 55% and mild thickening of
the mitral valve leading to decreased relaxation of the valve. No
other abnormalities were noted.
The patient's blood pressures remained slightly elevated and she
was restarted on her Accupril three days after admission which
stabilized her blood pressures. She was discharged with
instructions to hold the Norvasc and continue taking the
Accupril.
2. ENDOCRINE: The patient admits that her sugars have been
poorly controlled at home with often low sugars in the morning
and high sugars at lunch. She takes four units of NPH insulin in
the morning and checks her sugars frequently during the day,
about five to six times responding by skipping meals for high
sugars and taking snacks for low sugars, but little use of the
regular insulin.
It is as well possible that the syncope episode was related to
hypoglycemia even though per the daughter her sugar had been high
prior to the last episode of loss of consciousness. The patient
here was reduced to 20 units of insulin NPH in the morning and
giving her regular insulin sliding scale which controlled her
sugars well.
She will follow up the day after discharge with her doctor [**First Name8 (NamePattern2) **]
[**Last Name (Titles) **], Dr. [**Last Name (STitle) **] for further reassignment of her regimen.
Hemoglobin A1c was checked and the level was 8.3. As for the
hypothyroidism, a TSH was checked on admission which was 6.9. The
patient's Levothyroxine was increased from 100 mcg per day to 125
mcg per day. She will have to have her TSH rechecked in four to
six weeks for further adjustment of her dose.
Given the appearance of old compression fractures on initial
chest x-ray, the patient was given a prescription for
Ergocalciferol 400 units q.d. and Calcium Carbonate 500 mg
t.i.d., but should follow up with her primary care physician
prior to starting this medication.
3. HYPONATREMIA: The patient's initial sodium was 122. She
was put on free water restriction and the sodium the next morning
was 132 and has remained in the low 130s since. The patient was
judged to be euvolemic. She was hypothyroid, however it was not
thought that this would be enough to explain the hyponatremia.
Random Cortisol was checked which was 23. The right apical
density in her lung was evaluated with a chest CT Scan which
showed two calcified granulomas in the right apex. The etiology
of the hyponatremia was thus considered to be most likely due to
paroxetine which was discontinued. The patient should not be
taking an SSRI as an outpatient and will refer to Dr. [**Last Name (STitle) **], her
primary care physician for [**Name Initial (PRE) **] different antidepressant medication.
4. DEPRESSION: The patient had been taking p.r.n. Lorazepam
as an outpatient and had recent been started on Paxil. Given the
hyponatremia, the Paxil was discontinued. The patient was put on
a small dose of Lorazepam b.i.d. p.r.n. in-hospital. She will
likely need antidepressant medication, however no new medication
was started during the hospitalization.
5. NEUROLOGY: The daughter's description of the syncopal event
was mostly consistent with vasovagal etiology and not to be due
to seizures.
The patient was discharged on [**9-19**] in stable condition
with instructions to follow up with her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital6 **] as well as her [**Last Name (un) **] physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
CONDITION ON DISCHARGE: Patient was discharged in stable
condition.
DISCHARGE STATUS: Full code.
DISCHARGE MEDICATIONS:
1. Levothyroxine 125 mcg p.o. q.d.
2. Quinapril 20 mg p.o. b.i.d.
3. Insulin 20 units NPH q. AM plus regular insulin sliding
scale.
4. Ibuprofen 400 mg q eight hours p.r.n. back pain.
5. Artificial tears one to two drops o.u. p.r.n.
6. Lorazepam 0.5 to 1 mg p.o. b.i.d. p.r.n.
7. Ergocalciferol 400 units p.o. q.d.
8. Calcium Carbonate 500 mg p.o. b.i.d. to be discussed with
her primary care physician.
DISCHARGE DIAGNOSES:
1. Syncope, likely vasovagal.
2. Hyponatremia, likely due to her Paroxetine.
3. See past medical history.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2185-9-19**] 17:25
T: [**2185-9-22**] 16:24
JOB#: [**Job Number 27136**]
|
[
"250.00",
"780.2",
"401.9",
"458.9",
"276.1",
"564.00",
"427.81",
"300.00",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9984, 10335
|
9550, 9963
|
4294, 9426
|
2784, 3448
|
164, 2222
|
3466, 4276
|
2244, 2605
|
2622, 2761
|
9451, 9527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,226
| 185,457
|
50455
|
Discharge summary
|
report
|
Admission Date: [**2190-4-17**] Discharge Date: [**2190-5-1**]
Date of Birth: [**2140-5-14**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
V Fib arrest
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement
Central line placement
Artic sun cooling blanket
History of Present Illness:
This is a 49 YOM with history of type I DM, HTN, CAD s/p CABG,
and ischemic cardiomyopathy who presents after VFib arrest. Over
the last several weeks has several episodes of dizzy clammy
feelings with normal blood sugars. Has otherwise been healthy
and active. He was at the mall this evening with his wife. [**Name (NI) **]
was feeling fine. He told his wife suddenly that he needed to
sit down. He then quickly passed out, hitting the back of his
head on the ground. Bystanders preformed CPR. When EMS arrived
he was found to be in polymorphic VT. He was shocked at 7pm and
became asystolic. He was given epi/atopine and returned to a
narrow complex rhythm. He was intubated and taken to an OSH. At
the OSH, head CT was reportedly negative. He was started on an
amiodarone dirp and transferred by med flight to [**Hospital1 18**] for
futher care.
.
In our ED, his initial vitals wereHR 103, BP 118/63 satting 100%
on FiO2 100%. He was started on a heparin gtt. He was given
versed for aggitation on the vent and had a CT scan of his c
spine. He also had a 1.5 cm laceration on the back of his head
stapled.
.
Upon arrival to the CCU. Patient was stable. Neuro was consulted
for question of status epilepticus vs myoclonus. A right
subclavian central line and a left A line were placed. He was
started an artic sun cooling blanket at 12am.
Social History:
significant for former tobacco use. There is no history of
alcohol abuse.
Physical Exam:
VS: T 37 C BP 122/61 HR114 RR16 O2100%
VENT: AC 550 RR 12 FiO2 60% PEEP 5 7.35/46/428
Gen: WDWN middle aged male
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Hard c collar in place
CV: PMI located in 5th intercostal space, midclavicular line.
Tachy, RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities. CTAB (anterior), 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.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: No corneal reflex. PERRL. Withdraws with purposeful
movements in all 4 ext in response to noxious stimuli. Exhibits
spontaneous posturing movements.
.
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:
Labs on admission:
[**2190-4-17**] 09:10PM BLOOD WBC-9.8 RBC-5.05 Hgb-11.5* Hct-34.1*
MCV-68* MCH-22.8* MCHC-33.8 RDW-14.8 Plt Ct-158
[**2190-4-17**] 09:10PM BLOOD PT-12.3 PTT-21.7* INR(PT)-1.1
[**2190-4-17**] 11:15PM BLOOD Glucose-350* UreaN-25* Creat-1.3* Na-139
K-4.4 Cl-105 HCO3-15* AnGap-23*
[**2190-4-17**] 09:10PM BLOOD CK(CPK)-269* Amylase-55
[**2190-4-17**] 11:15PM BLOOD ALT-122* AST-147* CK(CPK)-271* AlkPhos-80
TotBili-0.8
[**2190-4-17**] 09:10PM BLOOD CK-MB-5 cTropnT-0.10*
[**2190-4-17**] 11:15PM BLOOD Calcium-8.8 Phos-3.7 Mg-1.7
[**2190-4-17**] 09:15PM BLOOD Glucose-280* Lactate-3.5* Na-139 K-3.8
Cl-103 calHCO3-25
.
EKG demonstrated sinus 94 bpm,nl axis and intervals. LVH. TWI V1
, ST depression in V4-6 with no significant change compared with
prior dated [**6-/2187**]
.
TELEMETRY demonstrated:sinus tach
.
2D-ECHOCARDIOGRAM performed on [**6-/2187**] demonstrated:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild-to-moderate global left ventricular hypokinesis (ejection
fraction 40 percent). 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) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is no pericardial
effusion.
.
CXR: large heart. Right subclavian line terminates at SVC. mild
pulmonary edema. No PTX
.
CT c-spine [**4-17**]: There is no fracture or malalignment within
the cervical spine. The vertebral body and intervertebral disc
space heights are preserved. Mild calcification of the anterior
longitudinal ligament posterior to C2 is degenerative. The
odontoid process approximates well with the anterior arch of C1.
The visualized outline of the thecal sac is unremarkable.
.
Interstitial edema in bilateral lung apices. The visualized
right maxillary sinus is completely opacified, and there is mild
mucosal thickening in the left maxillary sinus. Mastoid air
cells are clear.
.
MRI/MRA brain [**4-19**]:
There is no slow diffusion to indicate an acute infarct. There
is a left parietal subgaleal hematoma present. The brain
parenchymal signal is normal with no evidence of midline shift
or herniation. There is opacification of all of the paranasal
sinuses which could be due to intubation. The normal vascular
flow voids are present.
.
TTE [**4-21**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. Overall left
ventricular systolic function is mildly depressed with
inferolateral hypokinesis/akinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
MR [**Name13 (STitle) 2853**] [**4-24**]:
No signal abnormality is identified within the cervical spinal
cord. Alignment of the vertebral bodies is anatomic. Mild
cervical spondylosis is unchanged.
There remains a small rim of fluid posterior to the anterior
longitudinal ligament between the C2 and C5 levels. The anterior
longitudinal ligament itself appears intact on these images.
Also posterior to the C2 and C3 levels, there is a sliver of
fluid just anterior to the posterior longitudinal ligament; the
ligament itself appears intact. A small amount of fluid is also
seen at the lateral atlantodental joints bilaterally. No soft
tissue abnormalities are appreciated. The visualized cerebellum
and brainstem appear unremarkable.
.
Brief Hospital Course:
Pt is a 49 YOM with known CAD/CM who presents after v fib
arrest.
.
1) CAD/V fib arrest: Patient collapsed in mall and was found to
be in vfib when EMS arrived. He received bystander CPR with
estimated time between collapse and EMS arrival of 15 minutes.
Was shocked and became asystolic and then was given epi/atropine
and returned to narrow complex rhythm. Has h/o CAD s/p 4 vessel
CABG and ischemic cardiomyopathy. EKG done afterwards did not
look ischemic, however may have had acute occlusion of one of
his grafts causing his arrythmia without EKG findings currently.
Had signs of anoxic brain injury on arrival to the CCU including
myoclonus and posturing which are poor prognostic indicators.
Neurology was consulted. He was loaded with IV valproic acid for
sz ppx and placed on versed drip. Given the patient had an
[**Hospital 105124**] hospital arrest and he was within 6 hours of his
arrest the decision was made to treat with therapeutic
hypothermia to reduce cerebral metabolic needs. He was placed on
Vecuronium to reduce shivering during the cooling process. He
was cooled down to 89 degrees for 18 hours per protocol and then
slowly rewarmed. Given the possibility of an ischemic event he
was placed on IV heparin and continued on ASA. He had been
started on amiodarone prior to arrival which was stopped due to
prolonged QT interval. He was continued on BB which was
uptitrated.
.
2) Resp: Patient was intubated in the field for airway
protection. Has no history of lung disease. Was found to have
an aspiration PNA which was treated as below. During the
hospitalization he did not tolerate his ETT, specifically, when
attempting to wean him off of sedation he would cough violently
and become very agitated. Given his poor neurologic status and
likely need for prolonged intubation Interventional Pulmonology
was consulted regarding trach placement. A trach was placed on
[**4-26**]. He continued to have a strong cough despite anesthetics
and cough suppressants. He was changed to PS ventilation and
tolerated this well and was then weaned to trach mask. With
improvement in his PNA he was able to be weaned to NC and his
trach was capped.
.
3) DM: Normally on inuslin pump at home. Sugars initially
elevated to 400 with gap acidosis. Likely DKA in setting of
arrest and no insulin pump. Bolused with 1L NS and placed on
insulin gtt. His anion gap resolved and he was maintained on the
insulin gtt for tight glucose control. [**Last Name (un) **] was consulted for
assistance in transition to SC insulin. Once TFs were
stabilized he was switched to Glargine and RISS. His
long-acting insulin was uptitrated to 50U to be given at
lunchtime daily.
.
4) Renal insufficency - On admission the patient's Cr was
slightly elevated to 1.3. Etiology was likely poor perfusion in
setting of cardiac arrest. His Cr returned to baseline and
remained stable.
.
5) Fever: Patient developed high fevers on HD#2 up to 102.
Initially felt to be either central fevers vs. infection,
however he then developed bandemia suggestive of acute
infection. He was pan-cultured. CXR was consistant with either
aspiration pneumonitis vs. PNA so he was started on ceftriaxone
and flagyl. Sputum culture grew out pan-sensitive Klebsiella so
his flagyl was discontinued. He had recurrent fevers a week
into treatment and was recultured. CXR showed worsening of his
PNA and given the concern for hospital acquired pathogens and
VAP his antibiotics were broadened to vanc/zosyn. Repeat sputum
culure grew out MSSA and the vanco was discontinued. All urine
and blood cultures were NGTD. Zosyn, which was started on
[**2190-4-27**], needs to be continued for a total of two weeks.
.
6) FEN: NPO initially given patient was paralyzed. TFs were
initiated and PEG was placed [**4-26**] for permanant feeding.
.
7) PPX: heparin gtt transiently, then heparin sc, PPI
.
8) Access: R subclavian, left A line
.
9) Code: DNR/I
Medications on Admission:
niacin 500 [**Hospital1 **]
toprolxl 50
diovan 80
plavix 75
crestor 5
insulin pump
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Acetaminophen 160 mg/5 mL Solution Sig: Ten (10) mL PO Q6H
(every 6 hours) as needed.
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for High residuals.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
10. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
13. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
14. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
15. Insulin Regular Human 100 unit/mL Cartridge Sig: AS DIR
Injection AS DIR.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
17. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for seizure activity.
18. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours): Day 1 = [**2190-4-27**]. To be
continued for a total of 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Ventricular fibrillation with cardiac arrest.
Anoxic brain injury.
Discharge Condition:
Awake, does not follow commands, frequent myoclonic jerks.
Discharge Instructions:
You are being discharged after treatment for ventricular
fibrillation with cardiac arrest. Please note the changes in
your medications. You will need to continue antibiotics until
the course is completed.
Followup Instructions:
Follow-up with your cardiologist when your neurological rehab is
completed.
|
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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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12651, 12723
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298, 383
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12834, 12895
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2813, 2818
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,204
| 191,724
|
30230
|
Discharge summary
|
report
|
Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-28**]
Date of Birth: [**2108-3-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Corgard / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
s/p fall vs ?syncope
Major Surgical or Invasive Procedure:
[**2187-8-10**] Cardiac cath
[**2187-8-23**]
1. Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna Ease
valve.
2. Coronary artery bypass grafting x3, with left internal
mammary artery to the left anterior descending coronary artery,
reversed saphenous vein single graft from the aorta to the
second obtuse marginal coronary artery, and reversed saphenous
vein single graft from the aorta to the distal right coronary
artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
79 year old female who was transferred from [**Hospital 1474**] Hospital
for definitive treatment of her AFib. She was admitted to
[**Hospital 1474**] Hospital on [**8-5**] after a fall (? syncope vs.
mechanical, patient not a good historian). She was ruled out for
an MI but she was found to be in AFib with RVR. She endorses
lower extremity edema. Reportedly her AFib has been very hard to
control because she becomes hypotensive with higher doses of
rate controlling medications. She was in rapid atrial
fibrillation with HR 100-110 at rest and 150 with movement. TTE
showed EF 30-35% with AS (valve area 1.33 cm2). She is unsure if
she carries a diagnosis of CHF though she is on lasix as an
outpatient. Also, she reports that she had an infection in both
of her legs for which she was on Keflex for an unknown period of
time. She was found to have three vessel coronary artery disease
and aortic stenosis upon cardiac catheteriation today and is now
being referred to cardiac surgery for an aortic valve
replacement and revascularization.
Past Medical History:
Atrial Fibrillation
Acute on Chronic Systolic Congestive Heart Failure
Type II Diabetes Mellitus
Hyperthyroidism
Depression
RCC s/p radiation to R kidney in [**2183**] (last scan in [**11-3**] with
stable disease)
Right Abdomen abscess s/p colectomy in '[**81**] with colostomy
reversal in [**2182**]
7 mm pancreatic head cyst - ? IPMN
OSA (does not use CPAP)
s/p tonsillectomy
s/p adenoidectomy
Social History:
Retired employee of the billing department in a corporate shoe
office. Quit smoking at age 50, no alcohol.
Family History:
# No history of early CAD/MI
# Father died of prostate cancer at 89
# Mother died of stroke at age 84
Physical Exam:
Pulse:94 Resp:16 O2 sat:97/RA
B/P Left:107/71
Height:5'1" Weight:189 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: dop Left: dop
PT [**Name (NI) 167**]: dop Left: dop
Pertinent Results:
[**2187-8-10**] Cath: 1. Selective coronary angiography of this right
dominant system demonstrated three vessel coronary artery
disease. The LMCA had a 25% lesion at the origin. The distal
LMCA was calcified with plaquing of uncertain severity leading
into ostial LAD and LCx lesions. The LAD was heavily calcified
with a mild ostial plaque. There was a mild stenosis of the
origin of the large D1 with a proximal D1 lesion of 40% and a
mid D1 lesion of 40% as well after the bifurcation. The mid-LAD
had a 40% lesion while the distal LAD had an 80% stenosis. The
LCx was also heavily calcified with an ostial stenosis of 75%.
There was a small OM1, tiny OM2, and a tortuous OM3 with a
proximal 40% stenosis. The LPL1 and LPL2 were of modest caliber.
The RCA was moderately calcified. A 60% ostial stenosis remained
after giving IC TNG (making vasospasm unlikely) that involved
the origin of the large conus and AM/RV branch. Prominent atrial
branches were noted. The RPDA had a 75% proximal stenosis. 2.
Resting hemodynamics revealed preserved systemic arterial
pressure (with a central aortic pressure of 118/66, mean 88
mmHg) with marked mixed venous hypoxemia and marked elevation of
PCW (28 mmHg) consistent with profoundly reduced cardiac output
(CI 1.4 L/min/m2, suggestive of cardiogenic shock) using a
measured VO2 (253 mL/min). Low cardiac output, low gradient
severe aortic stenosis also found ([**Location (un) 109**] 0.6-0.7 cm2 with mean
gradient 20-23 mmHg). Dobutamine was not given in the setting of
atrial fibrillation with ventricular rate of ~100 bpm and recent
history of rapid ventricular rate. 3. Left ventriculography was
not performed. The aortic knob, aortic
valve, and aortic sinuses were calcified. 4. Given low normal
systemic arterial pressures of 100-110 mm Hg, adenosine was not
administered for pressure wire evaluation of the LMCA into the
LAD. 5. Of note, the ABG oxygen saturation was much lower than
the oxygen saturation measured on the same specimen in the
cardiac catheterization laboratory using the AVOX machine (82%
vs. 93% and 91%). Analysis of a subsequent specimen showed a
good match between the AVOX and ABG oxygen saturations,
suggesting loss of O2 from an inadequately sealed specimen sent
down for the initial ABG.
[**2187-8-12**] Chest CT: 1. Asymmetric enlargement of the thyroid gland
with an enlarged right thyroid lobe. Possible nodules present.
Thyroid ultrasound is recommended. 2. Enlarged mediastinal lymph
nodes with a 26 mm right upper paratracheal lymph node (suggest
consideration of bronchoscopic biopsy if biopsy of this node is
desired). 3. 2 mm pulmonary nodule within the left upper lobe
(4:59). If there are no risk factors for lung carcinoma, further
followup is not required. If the patient is high risk for lung
carcinoma, followup CT at 1 year is recommended. If there is a
known malignancy then suggest follow up CT in 3 months. 4. Small
bilateral pleural effusions. 5. Diffuse cardiac enlargement. 6.
Mild-to-moderate aortic calcification. 7. Stable enlargement of
the left adrenal gland since [**2183-8-25**].
[**2187-8-13**] Carotid U/S: 1. No evidence of significant carotid
artery stenosis bilaterally. 2. Calcified atherosclerotic
plaques bilaterally, left more than right.
[**2187-8-17**] Head CT: No evidence of acute intracranial
abnormalities.
[**2187-8-8**] 05:45AM BLOOD WBC-9.0 RBC-4.81 Hgb-12.2 Hct-37.5
MCV-78* MCH-25.4* MCHC-32.5 RDW-16.5* Plt Ct-183
[**2187-8-22**] 08:40AM BLOOD WBC-10.4 RBC-4.55 Hgb-11.4* Hct-35.6*
MCV-78* MCH-24.9* MCHC-31.9 RDW-17.1* Plt Ct-201
[**2187-8-28**] 05:37AM BLOOD WBC-9.1 RBC-3.46* Hgb-9.1* Hct-28.9*
MCV-83 MCH-26.4* MCHC-31.6 RDW-16.8* Plt Ct-160
[**2187-8-8**] 05:45AM BLOOD PT-17.6* PTT-40.1* INR(PT)-1.6*
[**2187-8-26**] 05:58AM BLOOD PT-12.6 INR(PT)-1.1
[**2187-8-8**] 05:45AM BLOOD Glucose-129* UreaN-29* Creat-1.1 Na-136
K-4.1 Cl-97 HCO3-26 AnGap-17
[**2187-8-20**] 05:50AM BLOOD Glucose-94 UreaN-21* Creat-0.8 Na-135
K-4.5 Cl-100 HCO3-28 AnGap-12
[**2187-8-28**] 05:37AM BLOOD Glucose-73 UreaN-26* Creat-0.7 Na-134
K-3.8 Cl-92* HCO3-32 AnGap-14
[**2187-8-8**] 05:45AM BLOOD ALT-25 AST-29 AlkPhos-42 TotBili-0.8
[**2187-8-18**] 07:31AM BLOOD ALT-106* AST-40 AlkPhos-56 TotBili-0.9
Brief Hospital Course:
MEDICAL COURSE:
79 y/o female admitted on [**8-5**] to [**Hospital1 1474**] following a fall
found to be in A fib with RVR and low normal pressures, admitted
to [**Hospital1 18**] for definitive care of AFib, found to have
significantly decreased EF, 3-vessel CAD and severe AS.
Diagnoses:
# Systolic Congestive Heart Failure: Apparently just diagnosed
at the outside hospital that she was transferred from. BNP of
2,134. EF on repeat Echo here significantly decreased EF at
20-25%. She was also clinically in CHF with peripheral edema,
crackles on lung exam, overloaded CXR and DOE. During her stay
she was gently diuresed but diuresis was difficult at times
because occasionally her pressures drop and/or her Cr would bump
up a bit. For this reason she was gently but steadily diuresed
with spironolactone and IV Lasix. On the days prior to planned
surgery she was almost euvolemic (peripheral edema better, still
with some bibasilar rales). At that time she was down about 6
Kilos since admission.
# Aortic Stenosis: Pt had known AS but Cardiac cath showed that
this has continued to worsen. Valve gradient of 35 mm Hg.
Valve area estimated 0.6 cm2 on cath. AS is severe. Will
likely need AVR if she can tolerate the procedure. NTG was held
during her stay as she was very preload dependent. Cardiac
surgery saw and evaluated the patient and decided that aortic
valve replacement was the best option for her at this time.
# Coronary Artery Disease: Ruled out for MI at outside hospital.
Patient has strong risk factor history. Cath showed 3 vessel
disease most appropriate for CABG. For this reason they decided
to plan CABG at the same time as AVR.
# Afib: Pt was admitted in atrial fibrillation. Report from the
OSH was that his was new and she may need to be cardioverted.
Upon further chart biopsy we found out she has been in atrial
fibrillation for a long time and that cardioversion was not the
best option at this time. Initially her beta blockade was
titrated up for rate control. Because there was concern that
her beta blockade may be contributing to decreased cardiac
output her beta blockade was titrated down and digoxin was
started. She has been adequately rate controlled on Metoprolol
and Digoxin since that time. As far as her anticoagulation she
was admitted on Dabigatran and this medication was continued
throughout her admission.
# Transamnitis: Exact etiology unknown but likely caused by
hepatic congestion [**12-27**] poor forward flow. LFT's were trended
during this admission and trended back down nicely. She did not
have any RUQ tenderness or signs of systemic infection during
her stay. Given the rise in her LFT's her methimazole and
Statin were held for a period of time but restarted when her
LFT's had come back down.
# Cough: Pt complained of cough on admission. Etiology unclear.
[**Name2 (NI) 116**] have been related to her CHF. No white count. Afebrile.
Cxr w/o failure or PNA. This symptom resolved after several
days.
# Hypotension: SBP to the 90's per report on admission. Pt was
not hypotensive at all during this admission.
# Fall: Initial presenting complain to OSH. Unclear etiology
but sounds Mechanical vs. syncope. Unclear story. Sounds like
she may have been on a lot of sedative medications. Syncopal
etiology concerning for AS. Sedative medications minimized
during her stay.
# Type II Diabetes Mellitus: Home medications were held during
this admission and her glucose was adequately controlled with
sliding scale insulin.
# Hyperthyroidism. Patient has history of hyperthyroidism with
a goiter. TSH within normal limits. Thyroid function tests
were rechecked later in admission because we were holding her
methimazole for a few days. These tests showed...
# Depression: Patient did not complain of symptoms during her
stay. She was maintained on her home citalopram.
# RCC s/p radiation in '[**83**]: Not addressed during this admission.
# 7 mm pancreatic head cyst: Not addressed during this
admission.
# Hip Pain: No fractures per report. Pt was given acetaminophen
as needed for pain.
# Right Foot Cellulitis: Reportedly diagnosed as an outpatient.
Treated with Keflex for unknown duration at OSH. Patient does
not appear to have cellulitis at this time. No antibiotics
given during this stay.
SURGICAL COURSE:
On [**2187-8-23**] Mrs. [**Known lastname 21991**] was brought to the operating room where
she underwent an aortic valve replacement and coronary artery
bypass graft x 3. Please see operative note 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 did require pressor/inotrope support initially and these
medications were weaned off on post-op day one. On
post-operative day one she was started on beta-blockers and
diuretics and diuresed towards her pre-op weight. Post-op she
remained in atrial fibrillation (history of) and later in
post-op course (day 4) was started back on Dabigatran. Later on
this day she was transferred to the step-down unit for further
care. Chest tubes and epicardial pacing wires were removed per
protocol. During her post-op course she worked with physical
therapy for strength and mobility. She continued to make steady
progress without complications and on post-op day five she was
discharged to rehab facility with the appropriate medications
and follow-up appointments.
Medications on Admission:
Oxazepam 15 mg TID
Miralax
Dabigatran 150 mg [**Hospital1 **]
Methimazole 5 mg [**Hospital1 **]
Tylenol 325 mg q 6 hours
Calcium+D 600-200 MR [**First Name (Titles) **]
[**Last Name (Titles) **] 50 mg, 1-2 tablets qhs
Fenofibrate 134 Mg qam
Pravastatin 40 mg daily
Celexa 20 mg tablet daily
Stool softener 100 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Metoprolol Succinate 25 mg [**Hospital1 **]
Metformin 1000 mg
Lasix 40 mg tablets - 2qam, 1 qpm
Potassium Chloride crystals 20 meq daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. methimazole 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day).
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
14. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
15. oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic valve
replacement and coronary artery bypass graft
Atrial Fibrillation
Acute on Chronic Systolic Congestive Heart Failure
Type II Diabetes Mellitus
Hyperthyroidism
Depression
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage
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
Surgeon: Dr. [**Last Name (STitle) 914**] [**2187-10-2**] at 3PM
Cardiologist: Dr. [**Last Name (STitle) 1911**] [**2187-10-4**] at 1PM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 6700**] [**Telephone/Fax (1) 6699**] in [**2-27**] 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:[**2187-8-28**]
|
[
"V58.67",
"244.9",
"793.11",
"719.45",
"311",
"458.29",
"424.1",
"V10.52",
"272.4",
"428.23",
"416.8",
"414.01",
"786.2",
"V58.61",
"327.23",
"V15.82",
"V70.7",
"241.0",
"401.9",
"250.00",
"428.0",
"E888.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"38.93",
"88.56",
"39.61",
"35.21",
"36.15",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
15041, 15144
|
7420, 12915
|
341, 838
|
15416, 15635
|
3175, 6452
|
16558, 17080
|
2471, 2574
|
13457, 15018
|
15165, 15395
|
12941, 13434
|
15659, 16535
|
2589, 3156
|
281, 303
|
866, 1911
|
6461, 7397
|
1933, 2330
|
2346, 2455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,260
| 102,599
|
30154
|
Discharge summary
|
report
|
Admission Date: [**2131-3-6**] Discharge Date: [**2131-3-12**]
Date of Birth: [**2063-3-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
intubation, upper endoscopy
History of Present Illness:
This is an 68 yo M w/ h/o MI, CHF w/ EF 20%, afib, CVA from
possible embolic event, colon CA s/p resection, h/o GIB,
laryngeal cancer undergoing XRT and chemotherapy with a G-tube,
and PVD s/p bilateral CIA and EIA stents on [**2-27**], who presents
with melana over 24 hours and Hct drop from 29 to 19 over 1 day.
He was transferred from the [**Hospital **] [**Hospital **] Hospital and Rehab Center.
Per Rehab records, had loose tarry stools 6 times since
yesterday, with one large black and bloody stool this AM.
.
Patient is moderately poor historian. Reports melanic stools
since yesterday. Denies nausea/vomiting/ hematemesis/coffee
ground emesis, LH, CP, dyspnea, abdominal pain, headache. Per
daughter, he had bloody or black stools in [**2130-10-4**] after
XRT for laryngeal cancer. Per his PCP, [**Name10 (NameIs) **] was discontinued
at this time; however it was restarted in [**Month (only) 956**] when he was
diagnosed with a CVA.
.
On arrival in the ED Mr. [**Known lastname 19755**] was tachycardic and
hypotensive at 87/64; two large bore IVs were placed, and
transfusion was initiated. Mr. [**Known lastname 19755**] was admitted to the
MICU.
Past Medical History:
-s/p prior hospitalization for respiratory failure, renal
failure and altered mental status, secondary to Klebsiella
pneumoniae pneumonia (tx with Zosyn, Levofloxacin--sent out on
Amikacin, Levofloxacin)
-C. difficle colitis
-Laryngeal cancer-recurrent, undergoing chemo/radiation
s/p G tube after XRT
-Indwelling Foley
-Colon Cancer s/p resection in 8 years
-Renal Insufficiency
-Cardiomyopathy
-Multiple sclerosis X 40 y
-CVA-frontal, [**2131-1-4**] (in the setting of discontinuing
[**Year (4 digits) **] for GIB in [**Month (only) **])
-CAD, s/p MI
-CHF ([**10-9**] last EF 20-25%, 1.4-1.5 thrombus L apex, not
mobile), s/p defibrillator
-History of GIB - [**Hospital6 **], per daughter unclear
cause
peripheral neuropathy
-afib (on [**Hospital6 **])
-history of GIB - ~[**10-9**] [**Month/Year (2) **] initially discontinued, but
restarted after likely CVA
Social History:
From rehab facility.
Previous to rehab, lives with his son and daughter in law.
Smoked 2+ ppd X 50 years, quit recently. Occ EtOH, stopped
several years ago. Denies IVDU.
Family History:
NC
Physical Exam:
NAD, lying flat in bed
HEENT: anicteric, PERRL 2-->1, EOMI, OP w/ dry MM, no JVD
CV: 90's, regular, no murmurs appreciated, but distant HS
Resp: CTAB, no wheezes, no crackles
Abd: thin, G-tube in place w/ small amt of firmness adjacent to
tube, soft
Ext: 1+ LE edema, L DP barely palpable but [**Month/Year (2) 17394**], L PT
palpable and [**Month/Year (2) 17394**]
Pertinent Results:
[**2131-3-9**] 04:17AM BLOOD WBC-8.7 RBC-4.10* Hgb-13.0* Hct-36.1*
MCV-88 MCH-31.7 MCHC-36.1* RDW-16.1* Plt Ct-139*
[**2131-3-6**] 09:57PM BLOOD Hct-20.5*
[**2131-3-6**] 03:00PM BLOOD WBC-11.0 RBC-1.90*# Hgb-6.3*# Hct-19.5*#
MCV-103* MCH-33.2* MCHC-32.3 RDW-16.4* Plt Ct-242
[**2131-3-9**] 04:17AM BLOOD Plt Ct-139*
[**2131-3-8**] 02:24AM BLOOD PT-12.2 PTT-27.6 INR(PT)-1.0
[**2131-3-6**] 03:00PM BLOOD PT-15.3* PTT-26.6 INR(PT)-1.4*
[**2131-3-9**] 04:17AM BLOOD Glucose-96 UreaN-22* Creat-0.8 Na-144
K-3.5 Cl-111* HCO3-26 AnGap-11
[**2131-3-6**] 03:00PM BLOOD ALT-20 AST-22 LD(LDH)-225 AlkPhos-64
Amylase-88 TotBili-0.2
EGD: A single non-bleeding localized erosion was seen in the
second part of the duodenum adjacent to the G tube balloon. A
single acute cratered 8mm ulcer was found in the apex of the
duodenum with an adherent clot suggesting recent bleeding. A
total of 4 cc Epinephrine 1/[**Numeric Identifier 961**] injections were applied to the
base and on the clot of the ulcer for hemostasis with success.
[**Hospital1 **]-CAP Electrocautery was also applied for hemostasis
successfully. In addition, a single Hemoclip was also applied
for hemostasis successfully.
Brief Hospital Course:
A/P: 68 yo M w/ MMP including CAD, s/p MI w/ EF 20%, PVD s/p
stents on [**2-27**], colon CA, who presents w/ melena and 10 pt Hct
drop over 24 hours, while on [**Month/Year (2) **], [**Month/Year (2) **], plavix. lovenox. Pt
required 8U PRBC, 4U FFP and one bag of platelets. Give
persistant GI bleeding and falling hematocrit, Mr. [**Known lastname 19755**] [**Last Name (Titles) 8783**]t an urgent EGD. Given his history of laryngeal cancer
s/p XRT, he was electively intubated prior to the EGD. The EGD
revealed erosion at the site of the insertion of the G tube at
the second portion of the duodenum (the G tube had advanced into
the duodenum) and another erosion with a blood clot. Both
ulcers were injected with epinephrine. A clip was applied at
the base of the ulcer with clot.
.
After the EGD, Mr. [**Known lastname 71861**] hematocrit remained stable at 36
and he was extubated successfully on HD #2.
.
Per discussion with the patient's primary care physician,
[**Name10 (NameIs) **] will not be restarted. Aspirin and clopidogrel may be
reinstituted, probably ~7 days from discharge, in concert with
recommendations from Mr. [**Known lastname 71861**] primary care physician and
[**Known lastname 1106**] surgeon.
.
Surgery was consulted regarding the G-tube. They repositioned
and re-secured the G-tube. A G tube study was obtained that
demonstrated appropriate filling of the stomach and tube feeds
were restarted. After confirming with the rehabilitation center
Mr. [**Known lastname 19755**] was previously cared for at, he was restarted on
a heart healthy, diet.
.
Mr. [**Known lastname 71861**] creatinine was initially elevated above his
baseline in the setting of hypovolemia, but returned to baseline
after appropriate resuscitation with blood products.
.
Patient had 2 episodes of 14 and 18 beat VT on [**2131-3-10**]. Vital
signs were otherwise stable. We replaced his electrolytes to
keep his potassium > 4.0 and his magnesium >2.0. He will follow
up with Dr. [**Last Name (STitle) 2077**] on [**2131-3-15**].
Medications on Admission:
[**Date Range **] 81 mg PO daily
[**Date Range 197**] 7.5 mg PO daily
Plavix 75 PO daily
Lasix 20 mg IV after PRBCs
Lipitor 10 mg PO daily
Lovenox 55 mg SC q12H
MVI
Docusate
Senna
Bisacodyl
Percocet 5/325mg PO prn
miconazole nitrate 2% Q8H to rash
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
-Erosion in the second part of the duodenum
-Ulcer in the apex of the duodenum (injection, thermal therapy)
-Bleeding likely caused by the duodenal ulcer, which was likely
due to trauma from the G tube balloon.
Discharge Condition:
stable, hematcrit stable at 35-36 for over 36 hours
Discharge Instructions:
Please take all medications as prescribed. Please do not take
your Plavix, [**Location (un) **], or aspirin unless instructed by your
primary care doctor. These can contribute to gastrointestinal
bleeding. You have had a gastrointestinal bleed which has
stopped. You should take protonix (a new medication which helps
prevent recurrent gastrointestinal bleeding) twice daily.
.
You should return to the emergency department if you resume
bleeding again (black tarry stools, or grossly bloody stools),
if you feel lightheaded/like you might pass out, if you have
chest pain or shortness of breath, or for any other symptoms
that concern you.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**First Name (STitle) 2077**], [**Telephone/Fax (1) 14967**]. You have been scheduled for an appointment
on Thursday, [**3-15**] at 4:45 PM.
.
You have a follow-up with the [**Month (only) 1106**] surgeon on [**3-29**] as
follows, with the following scheduled studies:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] LMOB (NHB) Date/Time:[**2131-3-29**]
10:15
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] LMOB (NHB) Date/Time:[**2131-3-29**]
10:45
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2131-3-29**] 11:15
Completed by:[**2131-3-12**]
|
[
"276.7",
"584.9",
"414.01",
"536.49",
"285.1",
"532.40",
"V45.02",
"427.1",
"276.0",
"161.9",
"412",
"287.5",
"275.2",
"276.8",
"440.20",
"V10.05",
"427.31",
"428.0",
"340",
"V12.59",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"99.05",
"45.13",
"96.71",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6834, 6906
|
4244, 6287
|
321, 351
|
7161, 7215
|
3043, 4221
|
7908, 8748
|
2638, 2642
|
6585, 6811
|
6927, 7140
|
6313, 6562
|
7239, 7885
|
2657, 3024
|
273, 283
|
379, 1546
|
1568, 2433
|
2449, 2622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,323
| 154,743
|
28582
|
Discharge summary
|
report
|
Admission Date: [**2102-1-26**] Discharge Date: [**2102-2-8**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Dysphagia, chronic aspiration, aspiration pneumonia/pneumonitis.
Major Surgical or Invasive Procedure:
Intubation [**2102-1-31**]
Tracheostomy tube
PEG tube
History of Present Illness:
[**Age over 90 **] y/o Russian- speaking female with end-stage Alzheimer's
Disease, likely recent CVA in setting of hip fracture [**12/2101**]
with left sided weakness, ? stage IV gallbladder cancer, type II
DM, AS who was admitted from rehab with dysphagia and agitation.
GI is being asked to consult regarding PEG tube placement.
.
In brief, patient was recently hospitalized at [**Hospital1 18**] with hip fx
complicated by acute onset left upper extremity weakness which
was thought to be secondary to an acute CVA. In the interim, she
has had worsening coordination with swallowing, with residual
food noted in the oropharynx. She was also noted to have a
worsening cough, raising the concern for aspiration.
.
She had reportedly been tolerating a diet of thin liquids and
pureed solids at rehab per her care worker, but due to the above
concerns, she was evaluated by speech and swallow at rehab with
subsequent recommendations to keep the patient NPO. During
current hospitalization, she has been re-evaluated by
videofluoroscopic swallowing evaluation which demonstrated
moderate to severe oropharyngeal dysphagia. Although speech and
swallow have cleared her for a modified PO diet, she is at risk
of deterioration in swallowing function and malnutrition. After
extensive conversation, the family and daughter, who is the HCP,
wish to proceed with medical decisions to maximize longevity of
life given religious beliefs.
Past Medical History:
1. End stage Alzheimers
2. Breast cancer s/p bilateral mastectomy
3. ? CVA in setting of hip fracture [**12-30**] with new onset left
sided weakness - CT shows chronic ischemic vascular changes, can
not exclude subacute infarct
4. superior and inferior ramus fracture, treated conservatively
[**12-30**]
5. ? stage IV Gallbladder cancer (pt beleives cancer went away
without any treatment?) - [**2098**] RUQ U/S showed cholelithiases but
no other abnormalities
6. Hypertension
7. Diabetes
8. Aortic stenosis
9. Diverticuloisis
10. Basal Cell carcinoma
11. Recurrent UTIs
12. Nephrolithiases s/p surgical removal
Social History:
Pt currently resides at Newbridge on the [**Doctor Last Name **] following
hospitalization for hip fracture/CVA. Previously lived in an
apartment with 24 hr home health care. Prior to that lived with
daughter. Is widowed with 2 daughters. Orthodox [**Hospital1 **]. Never
used etoh, remote use of tobacco, quit age 40.
Family History:
The patient has two brothers who are deceased. Neither of them
had cancer. According to the patient's daughter, there is no
other family history of breast cancer or ovarian cancer. The
patient is of Ashkenazi [**Hospital1 **] descent.
Physical Exam:
Admission Physical Exam
Vitals: 97.5 160/78 102 22 99RA
General: Alert, oriented x 1, moving arms and legs, picking at
IV and sheets
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
Lungs: Mild basilar crackles, but mostly transmitted upper
airway noises
CV: Regular rate and rhythm, harsh systolic murmur at left USB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, dry legs, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: does not move her left arm or left leg. Moving right side
spontaneously.
Pertinent Results:
Admission Labs:
[**2102-1-26**] 04:40PM PLT COUNT-359#
[**2102-1-26**] 04:40PM NEUTS-83.5* LYMPHS-10.6* MONOS-4.9 EOS-0.8
BASOS-0.3
[**2102-1-26**] 04:40PM WBC-9.8 RBC-3.17* HGB-9.5* HCT-29.1* MCV-92
MCH-30.0 MCHC-32.6 RDW-15.0
[**2102-1-26**] 04:40PM CK-MB-3 cTropnT-0.06*
[**2102-1-26**] 04:40PM ALT(SGPT)-24 AST(SGOT)-72* ALK PHOS-204* TOT
BILI-0.2
[**2102-1-26**] 04:40PM estGFR-Using this
[**2102-1-26**] 04:40PM GLUCOSE-102* UREA N-26* CREAT-0.7 SODIUM-139
POTASSIUM-6.9* CHLORIDE-107 TOTAL CO2-24 ANION GAP-15
[**2102-1-26**] 04:55PM LACTATE-2.2* K+-4.3
[**2102-1-26**] 05:00PM URINE HYALINE-0-2
[**2102-1-26**] 05:00PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2102-1-26**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2102-1-26**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2102-1-26**] 05:00PM URINE GR HOLD-HOLD
[**2102-1-26**] 05:00PM URINE HOURS-RANDOM
.
Notable Labs:
[**2102-1-26**] 04:40PM BLOOD CK-MB-3 cTropnT-0.06*
[**2102-1-27**] 06:44AM BLOOD CK-MB-3 cTropnT-0.06*
[**2102-1-31**] 05:55AM BLOOD CK-MB-7 cTropnT-0.08* proBNP-6091*
[**2102-1-31**] 03:00PM BLOOD CK-MB-8 cTropnT-0.08*
EKG [**2102-1-26**]:
Sinus rhythm. Probable left ventricular hypertrophy. Compared to
the previous tracing of [**2102-1-3**] no change
CXR [**2102-1-27**]:
There is no acute intracranial hemorrhage, mass effect, or
extra-axial collection. The ventricles and sulci are prominent
consistent with global atrophy and unchanged compared with
prior. [**Doctor Last Name **]-white differentiation is intact; however, there is
diffuse periventricular white matter hypodensity, consistent
with chronic small vessel ischemia, and there are numerous
bilateral lacunar infarcts as noted previously. There are
vascular calcifications, the soft tissues are otherwise
unremarkable. The mastoid air cells are clear, as are the
visualized paranasal sinuses.
1. No acute intracranial process.
CT HEAD [**2102-1-26**]:
1. No acute intracranial process.
2. Chronic changes of small vessel ischemia and global cortical
atrophy
RUQ US [**2102-1-27**]:
Small gallstone with no signs of cholecystitis. No biliary
dilatation and no ascites is seen in the right upper quadrant
CXR [**2102-1-31**]:
Overall severity of the pre-described predominantly interstitial
pulmonary edema is not substantially changed. However, in the
interval, a left lower lobe atelectasis and small left pleural
effusion have newly occurred. Unchanged moderate cardiomegaly.
No pneumothorax, no pneumonia.
TTE [**2102-2-1**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 55-60 %). There is a mild resting left
ventricular outflow tract obstruction. The remaining left
ventricular segments contract normally. The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. The pulmonic valve
leaflets are thickened. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
IMPRESSION: Mild aortic stenosis. Mild regional left ventricular
systolic dysfunction with preserved ejection fraction. Mild
right ventricular free wall hypokinesis. Moderate mitral
regurgitation. Small circumferential pericardial effusion.
Chest Radiograph [**2101-2-8**]: IMPRESSION: Progression of chronic
suggestion to now pulmonary edema in this [**Age over 90 **]-year-old female
patient. Covering house officers [**Doctor Last Name 1057**] and covering [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] were informed.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **]yoF with end-stage dementia, recent hip
fracture and questionable CVA, HTN, DMII who was admitted with
agitation and difficulty swallowing concerning for aspiration.
1. AGITATION/AMS: While there was initial concern that she had
altered mental status, conversations with her 24 hour care
worker and daughter revealed that she was near her baseline of
oriented x 1. Intermittent agitation was controlled with PO
seroquel. The source of her agitation was not clear. CXR
revealed a questionable RML infiltrate, which was treated as an
aspiration pneumonia given low grade temps in the ED. Her
troponin was elevated to 0.06, though it was stable when trended
without any signs of ischemia on EKG. Her agitation was felt to
be related to her end-stage alzheimer's disease, versus pain
associated with her recent hip fracture, which was treated with
IV morphine intermittently.
While in the ICU and extubated, geriatrics was consulted for
help with her agitation as her QT was found to be prolonged on
admission to the ICU while being given several medications
including haldol for control of her agitation. It was
recommended to give standing seroquel (with prn doses for
agitation), ativan prn for agitation, and pain control with
standing tylenol and morphine concentrate soln prn.
2. ASPIRATION RISK: She presented with poor swallowing and PO
intake. Due to aspiration risk, a CXR was obtained which showed
an equivocal RML infiltrate. She was treated with unasyn for
suspected aspiration pneumonia and was made NPO. She failed a
bedside swallow evaluation. The video swallow showed aspiration
with nectars, but she managed honey-thick liquids and pureed
solids. Due to decreased PO intake on this diet, her family
strongly urged the medical staff to place a PEG tube for added
nutrition. It was explained on numerous occasions that such a
measure would not prolong her life, and would not prevent
aspiration. They remained certain of their decision and plans
were made to pursue placement. After transfer to the ICU an
ethics consult was placed and a family meeting with the ethics
team took place. It was felt that prolonging her life would be
consistent with her wishes and a G-J tube was placed without
complication on [**2-1**].
3. HYPERCARBIC RESPIRATORY FAILURE: She developed respiratory
distress on HD5, with RR into the 30s, desaturation, and
difficulty managing secretions. She could not maintain her sats
on NRB (88-90%), and an ABG showed respiratory failure with
pH7.16 and pC02 of 60. She was subsequently transferred to the
ICU where she was intubated. She was treated with a 10 day
course of unasyn for aspiration PNA. She was extubated on [**2-2**],
but very quickly started reaccumulating her secretions and
became agitated with worsening respiratory function in the
setting of a.fib with RVR so she was reintubated. Discussion
with the family regarding trach resulted in trach placement on
[**2-5**] (it was explained to the family that this would not prevent
aspiration, but would only allow for easier suctioning and would
prevent an ETT from having to be replaced in the future). She
was quickly weaned to a trach mask but continued to have
intermittent episodes of respiratory distress requiring
placement back on the ventilator, suctioning, and occasionally
diuresis with 40mg IV lasix.
CXR on the day of discharge showed LLL opacity in the setting of
aspriation the day prior to discharge. She was afebrile with a
normal WBC so this was thought to be due to aspiration
pneumonitis and not a clinical PNA.
4. ATRIAL FIBRLLATION WITH RVR: The patient has no history of
a.fib, but went into a.fib with RVR during suctioning when in
respiratory distress. She did not respond to IV metoprolol so
diltiazem was tried with improvement in her HR and she was
transiently treated with a dilt gtt and then switched to an
amiodarone gtt. On amio she converted to sinus rhythm. Plan is
to continue the amiodarone load - currently she is receiving
400mg PO TID for planned 7 day course (ends [**2102-2-13**]) with
transition to 400mg PO BID afterwards. Further management per
her primary care physician.
5. EKG CHANGES: The patient had EKG changes concerning in the
setting of respiratory distress for an acute cardiac event vs
strain. Her troponins were mildly elevated which was more
consistent with strain. BNP was elevated and a TTE was checked
which showed mild aortic stenosis, mild regional left
ventricular systolic dysfunction with preserved ejection
fraction, mild right ventricular free wall hypokinesis, and
moderate mitral regurgitation. She was intermittently diuresed
with some improvement in her respiratory status.
6. POSITIVE BLOOD CULTURE: a single blood culture from the day
of admission grew gram positive cocci on HD2. She was
empirically started on vancomycin. Surveillance culutres were
repeatedly negative over the following 4 days. The culture grew
staph epidermidis, which was felt to be a contaminant. Vanco
was subsequently stopped on HD4.
ACCESS: PICC in place. Pulled back 2.5 cm the day of discharge
as it was shown to be in the right atrium on CXR. This was not
reimaged prior to leaving.
Communication: HCP and daughter, [**Name (NI) **] [**Telephone/Fax (1) 69198**]
Code: Full code
Medications on Admission:
omeprazole 20 mg Q day
Metformin 500 mg PO BID
Bethanechol 25 mg po BID
Simvastatin 10 mg Q day
lovenox 30 mg SQ [**Hospital1 **]
Lorazepam 0.5 mg PO TID
seroquel 25 mg Qam 50 mg Q pm
zoloft 12.5 mg Q day
Lidocaine patch daily
Tylenol 650 mg Q 6hr PRN pain
Oxycodone 5 mg PO Q 6 hr PRN pain
Senna 8.6 mg [**Hospital1 **] PRN constipatin
zofran 4 mg PO Q8 PRN nausea
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
[**1-22**] Adhesive Patch, Medicateds Topical DAILY (Daily).
2. metformin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day.
3. bethanechol chloride 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
4. simvastatin 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
5. lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation: Hold for sedation, RR<12.
6. quetiapine 25 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at
bedtime).
7. quetiapine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO qAM.
8. Zoloft 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
9. senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO once a day.
10. acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3
times a day).
11. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
12. lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H (every
12 hours) as needed for anxiety.
13. lorazepam 2 mg/mL Syringe [**Month/Day (2) **]: One (1) Injection Q4H (every
4 hours) as needed for anxiety/nausea.
14. lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at
bedtime).
15. morphine 5 mg/mL Solution [**Month/Day (2) **]: 4mg Injection Q3H (every 3
hours) as needed for pain.
16. morphine 10 mg/5 mL Solution [**Month/Day (2) **]: 3-4mg PO Q3H (every 3
hours) as needed for pain.
17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
19. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
20. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times
a day) for 7 days: Take for seven more days. Then continue on
amiodarone 200mg daily.
21. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous
DAILY (Daily).
23. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Aspiration pneumonitis, end-stage Alzheimer's Disease
Secondary: Likely CVA with left hip fracture, hypertension, type
2 diabetes mellitus, aortic stenosis
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for increased cough,
difficulty swallowing and worsening confusion. You developed a
prolonged hospital course due to recurrent issues with your
breathing. Due to concerns for several episodes of pneumonia, a
PEG tube and a tracheostomy tube were placed. You were
rehydrated and treated with antibiotics (Unasyn/Augmentin) which
improved your confusion. You were evaluated by Speech and
Swallow who recommended a specific diet for you, to protect you
from choking.
.
It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
- start albuterol 6 puffs INH q6h
- start lansoprazole 30mg PO daily
- start amiodarone as directed
- start lorazepam as directed
- start morphine as directed
- start seroquel as directed
- your zoloft dose has been increased
Followup Instructions:
Please contact your primary care physician for an appointment
within 1 week after discharge from the hospital.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9347**]
Completed by:[**2102-2-8**]
|
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"438.82",
"401.9",
"331.0",
"281.9",
"562.10",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
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"96.04",
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icd9pcs
|
[
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|
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210, 276
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397, 1828
|
3693, 7929
|
16544, 16640
|
1850, 2463
|
2479, 2799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,612
| 102,069
|
34541
|
Discharge summary
|
report
|
Admission Date: [**2172-5-12**] Discharge Date: [**2172-5-23**]
Date of Birth: [**2108-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Gastric carcinoma involving the gastroesophageal junction.
Major Surgical or Invasive Procedure:
[**2172-5-12**]: 1. Esophagogastroduodenoscopy. Left thoracoabdominal
incision. Total gastrectomy. Distal esophagectomy.
Roux-en-Y esophagojejunostomy. Placement of jejunostomy tube.
History of Present Illness:
Mr. [**Known lastname **] is a 64-year-old gentleman with a known diagnosis of
proximal gastric squamous cell carcinoma who has undergone 5
months of chemotherapy. He is admitted for a left
thoracoabdominal incision, total gastrectomy,
distal esophagectomy and placement of jejunostomy tube.
Past Medical History:
Gastric cancer
GERD
Anemia
Pseudogout
Social History:
Smoked 2 PPD until 8 years ago; smokes half a cigar almost
daily. Formerly drank 6-pack of beer nightly, now significantly
reduced and only occasional wine. Occassional marijuana use. He
is married and retired. Has had a variety of occupations
including biology teacher, real estate manager, taxi driver, and
chef.
Family History:
Mother had a heart attack at 58 and died of an MI at age 63.
Father died with gangrene and an unknown gastrointestinal
problem.
Physical Exam:
VS: T: 98.6 HR: 74 SR BP: 154/86 Sats: 95% RA
General: No apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopath
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on Left otherwise clear
GI: benign
Extr: warm no edema
Incsion: Left thoracotomy clean dry intact, mid abdominal
incision open, clean, pink granulated tissues
Neuro: non-focal
Pertinent Results:
[**2172-5-21**] WBC-14.1* RBC-2.35* Hgb-8.5* Hct-24.7* Plt Ct-316
[**2172-5-20**] WBC-17.4* RBC-2.51* Hgb-9.5* Hct-27.2* Plt Ct-312
[**2172-5-19**] WBC-13.2* RBC-2.51* Hgb-9.8* Hct-27.2* Plt Ct-241
[**2172-5-18**] WBC-11.2* RBC-2.32* Hgb-8.6* Hct-24.9* Plt Ct-172
[**2172-5-17**] WBC-9.4 RBC-2.41* Hgb-9.0* Hct-25.6* Plt Ct-134*
[**2172-5-16**] WBC-10.5 RBC-1.89* Hgb-7.6* Hct-21.2* Plt Ct-137*
[**2172-5-13**] WBC-6.1 RBC-2.21* Hgb-8.8* Hct-25.4* Plt Ct-114*
[**2172-5-12**] WBC-5.0 RBC-2.60* Hgb-10.6* Hct-29.9* Plt Ct-125*
[**2172-5-19**] Glucose-90 UreaN-26* Creat-1.1 Na-138 K-4.1 Cl-103
HCO3-25 AnGap-14
[**2172-5-16**] 07:45AM BLOOD Glucose-96 UreaN-21* Creat-1.2 Na-134
K-4.0 Cl-103 HCO3-24 AnGap-11
[**2172-5-15**] 09:45AM BLOOD Glucose-117* UreaN-20 Creat-1.1 Na-134
K-3.9 Cl-103 HCO3-23 AnGap-12
[**2172-5-19**] 06:50AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
[**2172-5-18**] Source: Abdominal Wound.
GRAM STAIN (Final [**2172-5-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2172-5-20**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
CXR:
[**2172-5-19**]:As compared to the previous radiograph, the left-sided
chest tube has been removed. There is a moderate left-sided
pleural effusion, but no pneumothorax is seen. The right lung is
unchanged.
[**2172-5-16**]: A drain is noted to the right of the trachea. Cardiac
and mediastinal contours are unremarkable. There has been
interval improvement in the extent of bibasilar atelectasis. No
pneumothorax is noted. Bony structures are unremarkable. Small
amount of residual subcutaneous emphysema is noted along the
right chest wall.
Esophagus [**2172-5-19**] IMPRESSION: No evidence of leak.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2172-5-12**] for
Esophagogastroduodenoscopy. Left thoracoabdominal incision.
Total gastrectomy. Distal esophagectomy. Roux-en-Y
esophagojejunostomy. Placement of jejunostomy tube. He was
transferred to the SICU intubated with a Bupivacaine/Dilaudid
Epidural with good pain control. The NGT to intermittent
suction, 2 chest tubes to suction. Overnight he episodes of
hypotension which responded to fluid boluses. On [**5-13**] he was
extubated, pulmonary toilet, the chest tube was removed. Trophic
tube feeds were started. He transferred to the floor. On
[**2172-5-15**] he was seen by physical therapy and nutrition. He was
started on pain medication via J-tube with good control. On
[**2172-5-16**] the epidural was removed. He was transfused 2 Units
PRBC for a HCT of 21 to a HCT 24. He developed cellulitis of the
abdominal wound. 0n [**5-17**] the foley was removed he voided. On
[**5-18**] the abdominal incision was open and packed with wet-dry.
He was started on Ancef. Wound cultures with no growth. On
[**5-19**] an esophagus study revealed no leak. The NGT was removed
and he started clear liquid diet. The [**Doctor Last Name **] drain was removed.
On [**5-20**] the white count was elevated, the wound was enlarged.
His bowel function returned, the tube feeds Replete with fiber
were advanced to Goal of 85/hr. He continued to ambulate, given
tube feed instructions and was discharged to home with VNA on
[**2172-5-22**]. He will follow-up as an outpatient.
Medications on Admission:
aspirin 325 daily, plavix 75 daily, lipitor 80 daily,
lansoprazole 30 mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Five (5) PO BID (2
times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Date Range **]: 5-10 MLs
PO Q3-4H () as needed for pain.
Disp:*400 ML(s)* Refills:*0*
3. Aspirin 325 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily):
crush.
4. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day): crush meds.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Lipitor 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush
med.
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Augmentin 400-57 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Five (5) ML PO Q8H (every 8 hours) for 6 days.
Disp:*90 ML* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gastric cancer s/p chemo treatment
Myocardial Infarction [**10-20**] s/p 3 BMS LAD
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough, or sputum production
-Chest pain
-J-tube site develops drainage
Should your feeding tube sutures become loose or break, please
tape tube securely and call the office [**Telephone/Fax (1) 170**].
If your feeding tube falls out, save the tube, call the office
immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a
timely manner because the tract will close within a few hours.
Completed by:[**2172-5-25**]
|
[
"V45.82",
"V87.41",
"682.2",
"412",
"530.81",
"338.12",
"998.59",
"285.9",
"151.0",
"458.29",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"40.3",
"96.6",
"43.99",
"38.91",
"46.39"
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icd9pcs
|
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[
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47,045
| 126,474
|
7697+55867
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-10-22**] Discharge Date: [**2126-11-7**]
Date of Birth: [**2050-2-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old gentleman with a history of 3 vessel
CAD s/p CABGx3 and multiple stents, CHF, HTN, Hyperlipidemia,
CRF who presented to the [**Hospital1 18**] with chest pain overnight and
worsening SOB.
In general, Mr. [**Known lastname **] [**Last Name (NamePattern1) 27983**] he was in his normal state of health
two days prior to admission; the day prior to admission he felt
fatigued, but didn't develop CP or SOB until lying in bed the
night prior to admission. At this time, he had difficulty lying
flat. He describes the chest discomfort as pressure and a
squeezing sensation in his neck; it was the same as CP that he
has had in the past. He took 3 nitros without resolution of
symptoms. This morning, he continued to have CP and started
having N/V- according to his wife this is not characteristic for
his usual CP.
Mr. [**Known lastname 27984**] wife explains that his functional capacity had been
decreasing over the past year in the setting of multiple CHF
exacerbations. However, he had been doing well since he was last
hospitalized in [**6-20**] for gouty arthritis and aspiration PNA. At
baseline, he can walk around the house and down his driveway but
not around the block. He can climb a flight of stairs slowly. He
does not get chest pain or shortness of breath with either
activity. He describes occasionally getting chest pain at home,
the last time two months ago, that always resolves with
sublingual nitro. He sleeps with 1-2 pillows and this has not
increased lately. He weighs himself daily and is usually around
164-166 lbs; he has not noticed this increasing lately and
weight on Saturday was 167 lbs. He denies any recent swelling in
his legs. He takes his BP daily; this morning it was 142/56; it
usually runs in the 120s systolic. He did develop a dry cough
this am, but did not have a cough prior. No fever, no recent
illness.
Admission to [**Hospital1 18**] in [**6-20**] for fever and joint pain that was
attributed to gouty arthritis. Patient was diuresed during that
admission and his Creatinine bumped and so he was discharged on
half home dose of Lasix; in [**9-20**] this was increased to 160 [**Hospital1 **]
by Dr. [**Last Name (STitle) **] who thought he was fluid overloaded in clinic;
lisinopril was decreased at this time to 20 mg po daily.
In the ED, vitals were VS 99.0 84 120/57 36 96% BiPAP. EKG
showed intraventricular conduction delay with ST elevations but
no intervention per cards fellow. He was given 325 aspirin, 3
nitro total, now on nitro gtt. Received levaquin/flagyl for RLL
PNA. On transfer to the CCU, patient was CP free on
non-rebreather.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
[**7-/2109**]: CABG with SVG-OM2CAD
[**3-11**]: CABG with LIMA-LAD and SVG-?diagonal
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**9-/2109**] PTCA
[**7-/2114**] PTCA of RCA
[**3-13**] BMS to SVG-OM2
[**10-13**] 3 DES to SVG-OM2
[**9-14**]: DES to LMCA and RCA
[**9-15**]: Repeat DES to LMCA into LCx
[**11-16**]: POBA of LAD and LCx
[**2-19**]: PTCA of in-stent restenosis of his left main into the
proximal circumflex stent.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Carotid stenosis 60-69% right ICA stenosis, 70-79% left ICA
stenosis in [**7-/2125**]
DMII- last HgA1C 7.7
Gout
PVD
Depression and Anxiety
Social History:
Retired. Machine operator in [**Last Name (un) 27903**] stethoscope factory.
Married with three children. Stopped smoking 30 years ago.
Smoked 2-3 packs per day. No EtOH. No drugs. He typically is
able to walk short distances in his house. He just recently
started going for daily walks.
Family History:
B: Died of MI at 42, B: had multiple MIs; F, M: died. Whole
mothers side diabetes mellitus
Physical Exam:
Admission Exam:
Vital signs: T 97.3, HR 76, BP 129/61, RR 20, Sat % 99 on RA
.
Gen: Well appearing, somewhat drowsy man in NAD.
.
Extrem: No erythema, warmth or prominent effusion in any joint.
Can not fully extend at elbows bilaterally; extend to
approximately 170 degrees. Prominent tophi on R elbow. Full
strength in extension but decreased strength in flexion at elbow
bilaterally. Some pain to manipulation of elbow joints, R>L.
Full ROM of shoulders above head but can not reach arms to touch
face anteriorly. Weakness to pressure when holding arms at 90
degrees. Thick fingers with multiple small nodules on L DIPs
that appear to be tophi. Weak grip and also unable to fully
extend fingers. No other finger deformities. Full ROM in knees
and ankles without pain upon manipulation. Full strenth in lower
extremities. No pain with pressure to muscles in calves, thighs
or arms.
.
Skin: No rashes. Dark discoloration on anterior lower legs
bilaterally consistent with venous changes.
Discharge Exam:
Tmax: 98 T current: 98
HR: 59-84
RR: 18-20
BP: 102-116/45-60
O2 sat: 95% RA
24 hour:
I=890 O=880
STool x2, dar, OB neg
Weight: 152 (152.8)
.
Exam: Alert
HEENT - oropharyx clear.
CV - S1, S2 with 2-3/6 systolic murmur at the LUSB.
Lungs - Clear to auscultation
Ab - Soft, non-tender, BS +
Ext - No edema, feet warm, radial/pedal pulses 2+
Pertinent Results:
[**11-4**] Echo:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate to
severe global left ventricular hypokinesis (LVEF = 25 %). No
masses or thrombi are seen in the left ventricle. Right
ventricular cavity size is normal with borderline normal free
wall motion. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-12**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-12**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with marked
global hypokinesis. Mild-moderate mitral regurgitation.
Mild-moderate aortic regurgitation.
Compared with the prior study (images reviewed) of [**2126-3-12**], the
severity of aortic regurgitation is increased (may be related to
much higher systemic blood pressure). The estimated pulmonary
artery systolic pressure is now lower. Bieventricular sizes and
systolic function are similar.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2123**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**10-27**] CXR:
IMPRESSION: AP chest compared to 5:56 p.m.:
Right internal jugular line has been partially withdrawn and now
ends at or
just below the anticipated location of the superior cavoatrial
junction.
Multifocal pneumonia and mild-to-moderate pulmonary edema are
unchanged.
Moderate cardiomegaly, small bilateral pleural effusions are
stable. ET tube
in standard placement and nasogastric tube passes below the
diaphragm and out
of view. No pneumothorax.
[**11-3**] CXR:
FINDINGS: As compared to the previous radiograph, the
right-sided central
venous access line has been removed. The lung volumes continue
to be low,
with an unchanged aspect of the bilateral, predominantly basal
parenchymal
opacities, likely to reflect a combination of pneumonia and
pulmonary edema.
Unchanged moderate cardiomegaly. Status post bypass surgery. No
evidence of
pleural effusions.
Video Swallow study:
IMPRESSION: Aspiration with thin liquids and penetration with
nectar
consistency.
Brief Hospital Course:
76 year old gentleman with a history of 3 vessel CAD s/p CABGx3
and multiple stents, CHF, HTN, Hyperlipidemia, CRF who presented
to the [**Hospital1 18**] with chest pain and worsening SOB. Respiratory
failure thought to be secondary to septic shock from PNA with
additional element of CHF; patient had recurrent fevers and He
was intubated and Swan was placed showing increased wedge and
decreased SVR, confirming septic shock as well as CHF component.
# Pneumonia/Septic Shock: Pt found to have multifocal pna on CXR
and sepsis. Initially intubated and swanned which showed cardiac
pressures consistant with septic shock. Pt was treated with a
course of Ceftriaxone, Azithromycin and Flagyl for pneumonia and
transitioned to Vanc/Zosyn to end of course. He was sucessfully
extubated and transitioned to the step down unit. CXR on
[**2126-11-5**] showed no change in pneumonia but pt was weaned off O2
and has had no significant cough or SOB.
# Acute on Chronic Diastolic CHF: Known diastolic and systolic
CHF with EF 35% on ECHO [**11-4**]. Lasix dose increased to [**Hospital1 **]. Pt
currently appeared euvolemic by day of discharge. Given history
of multiple CHF exacerbations, spironolactone was started at low
dose. Continues on Lisinopril and Metoprolol XL at lower doses
than on admission. At rehab, recc checking daily weights and
keep on Low Na diet. On discharge his weight was 68.8 kg or 151
pounds
# Leukocytosis and Fever: WBC peaked at 18 and decreased to 11.7
by discharge. Leukocytosis was attributed to his pna and sepsis.
Despite improvement of the pneumonia, WBC continued to be
elevated and pt had recurrent fevers. Multiple cultures of urine
and blood sent, all negative. C-diff, lengionella antigen also
negative. Recurrent low grade fevers were attributed to gout
flair with elevated UA and arthralgias and warm joints. Rheum
saw pt and decision was made to give pt colchicine every other
day as well as prednisone 10mg. Pt has been afebrile for the 4
days prior to discharge. He will follow up with Rheum
outpatient.
.
# Delerium: Likely [**2-12**] hospitalization, acute illness and
disrupted sleep schedule. Cleared somewhat before discharge
although pt continues to have mild confusion. Initially agitated
at night after extubation, now restless at night only.
Clonazepam was not continued during hospital stay because of
somnolance and confusion. Citolapram was restarted. Infectious
w/u negative as above. Pt's delerium improved during
hospitalization although he continued to have episodes of
sun-downing the days prior to dsicharge.
.
#Hyperglycemia: Humalog sliding scale.
.
# Acute on Chronic Kidney Disease: Baseline Cr 1.5-1.7,
creatinine as high as 3.0, decreased to 1.8 by day of discharge.
.
# CAD: Extensive CAD history. History of acute onset CP in the
setting of pulmonary edema concerning for MI on admission. Ruled
out for MI. No cardiac cathatheterization done. Continued on
aspirin, clopidogrel, siimvastatin and metoprolol.
.
# Gout: Arthalgias and a few warm joints and low grade recurrent
fevers. Rheumatology consult felt pain and stiffness was was
multifactorial including arthritis, torn rotator cuff and gout.
Inceased uric acid level was suggestive of gout. High Sed rate
(100s) thought [**2-12**] infections and hospitalization. Home dose of
Allopurinol was continued and colchiciine, prednisone and
tylenol added to treat pain. Pt will see his outpatient
rheumatologist in f/u next week. He will continue his prednisone
10mg daily and colchicine for now.
.
# Anxiety: citolapram restarted. Held benzos for
delerium/sedation.
Medications on Admission:
Cardiac:
Furosemide 160 mg PO daily
Lisinopril 20 mg daily
Toprol XL 100 mg [**Hospital1 **]
Nifedipine 90 mg daily
Isosorbide Mononitrate 60 mg daily
Atorvastatin 40 mg daily
Plavix 75 mg daily
ASA 325 mg daily
Nitroglycerin 0.4 mg SC as needed
.
Gout:
Allopurinol 100 mg daily
.
Vacscular Dementia:
Pentoxifylline 400 mg TID
.
Depression:
Citalopram 10 mg daily
Clonazepam 0.5 mg [**Hospital1 **]
.
Diabetes:
NPH insulin 40 U in am; 50 U pm
Regular 3 U am; 4 U pm
.
Other:
Docusate 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Ketoconazole 2% cream as needed
Fluocinonide 0.05% cream as needed
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Constipation.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 doses as needed for
chest pain.
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Hold SBP < 100.
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
17. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
18. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
19. Outpatient Lab Work
Please check Chem-7 on Sunday [**11-10**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
Sepsis secondary to pneumonia
Chronic Systolic Congestive Heart Failure
Delerium
Hypernatremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. We
determined that you had a serious infection on top of congestive
heart failure. Because of these two complicated problems, you
had to be intubated in the ICU for treatment. You were treated
with antibiotics and pills to remove the fluid from your lungs
and body.
.
We made the following changes to your medications:
1. Start colchicine every other day to treat your gout
2. start Tylenol every 8 hours to treat your joint pain.
3. start prednisone for joint pain, you will taper this off
slowly
4. decrease Toprol to 25 mg daily
5. decrease Lisinopril to 2.5 mg daily
6. STOP taking Imdur, clonazepam and Nifedipine
7. Start taking Trazadone to help you sleep
8. Decrease Penoxifylline to twice daily because of your kidney
function
9.Start taking Heparin injections to prevent blood clots.
10. Increase furosemide to 160 mg twice daily
11. Decrease insulin to 40 units at night
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs in 1 day or 5 puonds in 3 days.
Followup Instructions:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2126-11-13**] at 12:00 PM
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: [**Hospital3 249**]
When: FRIDAY [**2127-2-7**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2126-12-2**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 4839**]
Admission Date: [**2126-10-22**] Discharge Date: [**2126-11-7**]
Date of Birth: [**2050-2-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 4871**]
Addendum:
see updated discharge medication list and page one information
below
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Constipation.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 doses as needed for
chest pain.
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Hold SBP < 100.
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: please give for 10 mg for 3 days, then decrease to
7.5 mg until he sees Dr. [**Last Name (STitle) 4872**] next week. .
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
17. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
18. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
19. Outpatient Lab Work
Please check Chem-7 on Sunday [**2036-11-9**]. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a
day: start after Prednisone 10 mg dosing is finished.
21. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
(40) units Subcutaneous once a day: Before Breakfast. Give 30
units before dinner in addition.
22. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous three times a day: before meals.
see attached scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 15**]
Discharge Diagnosis:
Sepsis secondary to pneumonia
Chronic Systolic Congestive Heart Failure
Delerium
Hypernatremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. We
determined that you had a serious infection on top of congestive
heart failure. Because of these two complicated problems, you
had to be intubated in the ICU for treatment. You were treated
with antibiotics and pills to remove the fluid from your lungs
and body.
.
We made the following changes to your medications:
1. Start colchicine every other day to treat your gout
2. start Tylenol every 8 hours to treat your joint pain.
3. start prednisone for joint pain, you will taper this off
slowly
4. decrease Toprol to 25 mg daily
5. decrease Lisinopril to 2.5 mg daily
6. STOP taking Imdur, clonazepam and Nifedipine
7. Start taking Trazadone to help you sleep
8. Decrease Penoxifylline to twice daily because of your kidney
function
9.Start taking Heparin injections to prevent blood clots.
10. Increase furosemide to 160 mg twice daily
11. Decrease insulin to 30 units at night
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1594**] if weight goes
up more than 3 lbs in 1 day or 5 puonds in 3 days.
Followup Instructions:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2126-11-13**] at 12:00 PM
With: [**First Name8 (NamePattern2) 4873**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 4874**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) 3895**]) [**Location (un) 4875**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 762**]
When: FRIDAY [**2127-2-7**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2147**] [**Last Name (NamePattern4) 4876**], M.D. [**Telephone/Fax (1) 23**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1577**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2126-12-2**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4877**], MD [**Telephone/Fax (1) 337**]
Building: [**Hospital6 189**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 4878**] MD [**MD Number(1) 4879**]
Completed by:[**2126-11-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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18978, 19040
|
8139, 11731
|
287, 294
|
19179, 19179
|
5476, 6712
|
20458, 21594
|
4005, 4097
|
16869, 18955
|
19061, 19158
|
11757, 12364
|
19357, 19706
|
4112, 5101
|
3063, 3512
|
5117, 5457
|
6735, 8116
|
19735, 20435
|
231, 249
|
322, 2959
|
19194, 19333
|
3543, 3683
|
2981, 3043
|
3699, 3989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,119
| 114,398
|
35491
|
Discharge summary
|
report
|
Admission Date: [**2113-4-5**] Discharge Date: [**2113-4-11**]
Date of Birth: [**2034-4-4**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin / Vancomycin / Bactrim Ds
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
FEVER;HYPOTENSION
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 80843**] is a 79 year old female with past medical history of
perforated duodenal ulcer, complicated recovery with several
infections, presents from rehabilitation with fevers, vomiting,
and leukocytosis.
.
Ms. [**Known lastname 80843**] experienced a perforation of her duodenum in
[**12/2112**], which required urgent surgery at an outside hospital.
Her course since that time has been complicated by a number of
infections of fluid collections and indwelling lines, with
several admissions here at [**Hospital1 18**] for sepsis-like physiology. She
has been followed closely by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] in the department of
infectious disease, and has continued on linezolid and
fluconazole since her discharge on [**2113-3-24**]. During her last
stay, studies of her duodenum revealed normal passage of
contrast without obstruction or leakage, but she continues to be
limited in her ability to take PO's. She has been followed
closely by Dr. [**Last Name (STitle) 1924**] in surgery as well.
.
She was brought to the emergency room today from rehabilitation
after she experienced fevers, abdominal pain, nausea, as well as
worsening renal function and leukocytosis and diarrhea. She also
reports that she has noted a diffuse red rash over her whole
body that started one or two days prior to admission. She had
been started on Bactrim [**2113-4-4**] for fevers and increasing WBC
(noted to be 18.3 as compared to 12.1 on [**3-29**]). She had had a CT
of her abdomen and pelvis completed as an outpatient on [**4-4**]
that demonstrated a slight increase in right upper abdominal
fluid collection as compared to [**3-19**], as well as persistent
inflammatory stranding adjacent to the duodenum and stable
narrowing of her superior mesenteric vein.
.
Her initial vital signs revealed a temperature of 98.3, blood
pressure of 70/54 right arm and 97/73 in left arm, heart rate of
94, respiratory rate of 18, 97% on 2 liters nasal cannula.
.
She recieved 5 liters of intravenous fluids. ID was contact[**Name (NI) **] in
the emergency room, and recommended linezolid and zosyn which
she received. She also received 50 mg of benadryl for a diffuse
red rash.
She was noted to be guaiac negative. Surgery was consulted and
evaluated the patient in the ED.
Past Medical History:
Duodenal perforation
Intra-abdominal abscess
Staph coag negative sepsis
Iron deficiency anemia
Depression
Diarrhea
Hypertension
Hypercholesterolemia
GERD
Recurrent low back pain s/p disc operation ~ 20 years ago
Social History:
Does not smoke cigarettes. Does drink alcohol. Lives
independently.
Does not smoke cigarettes. Does drink alcohol. Lives
independently.
Family History:
Noncontributory.
Physical Exam:
At discharge: A&Ox3. Appropriate, Listens and responds to
questions appropriately, pleasant
V.S 98.5, 86, 142/72, 18, 99 Ra
Gen: no acute distress
CV: RRR, S1, S2. No murmurs ascultated
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, nontender. G tube also in place, c/d/i
EXT: 2+ pitting edema. 2+ DP pulses BL
Pertinent Results:
[**2113-4-11**] 04:45AM BLOOD WBC-11.4* RBC-2.84* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.7 MCHC-32.6 RDW-17.5* Plt Ct-401
[**2113-4-5**] 02:00PM BLOOD WBC-15.7*# RBC-3.18* Hgb-9.7* Hct-28.3*
MCV-89 MCH-30.6 MCHC-34.4 RDW-17.6* Plt Ct-502*
[**2113-4-7**] 04:52AM BLOOD Neuts-55.5 Lymphs-18.4 Monos-4.6
Eos-21.1* Baso-0.3
[**2113-4-11**] 04:45AM BLOOD Plt Ct-401
[**2113-4-11**] 04:45AM BLOOD Glucose-126* UreaN-7 Creat-0.7 Na-146*
K-4.2 Cl-112* HCO3-25 AnGap-13
[**2113-4-5**] 02:00PM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.1
[**2113-4-11**] 04:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
.
BCX negative x 2.
.
UCX negative.
.
STUDIES
[**4-5**] CT Abd/Pelvis: Limited evaluation without contrast. No free
air. No apparent change in size of upper abdominal fluid
collection with adjacent inflammatory change since [**4-4**]. No new
collection.
Micro:
[**2113-3-18**] Blood VRE
[**2113-2-8**] Fluid MRSA, [**Female First Name (un) 564**]
Brief Hospital Course:
The patient was brought to the emergency room from
rehabilitation after she experienced fevers, abdominal pain,
nausea, as well as worsening renal function and leukocytosis and
diarrhea. She also reports that she has noted a diffuse red rash
over her whole body that started one or two days prior to
admission. She had been started on Bactrim [**2113-4-4**] for fevers
and increasing WBC (noted to be 18.3 as compared to 12.1 on
[**3-29**]). She had had a CT of her abdomen and pelvis completed as
an outpatient on [**4-4**] that demonstrated a slight increase in
right upper abdominal fluid collection as compared to [**3-19**], as
well as persistent inflammatory stranding adjacent to the
duodenum and stable narrowing of her superior mesenteric vein.
.
Her initial vital signs revealed a temperature of 98.3, blood
pressure of 70/54 right arm and 97/73 in left arm, heart rate of
94, respiratory rate of 18, 97% on 2 liters nasal cannula.
.
She recieved 5 liters of intravenous fluids. ID was contact[**Name (NI) **] in
the emergency room, and recommended linezolid and zosyn which
she received. She also received 50 mg of benadryl for a diffuse
red rash.
She was noted to be guaiac negative. Surgery was consulted and
evaluated the patient in the ED.
.
Upon arrival to the [**Hospital Unit Name 153**], she is no distress and has no
complaints. Her BP is 110/70, with heart rate in the 70's.
.
IMAGING:
[**2113-4-5**]
CT Abdomen and Pelvis without contrast
Limited evaluation without contrast. No free air. No apparent
change in size of upper abdominal fluid collection with adjacent
inflammatory change since yesterday. No new collection.
.
[**2113-4-5**]
Chest x-ray
The lungs are of low volume. There is stable appearance to the
scattered tiny calcific densities, which may be related to a
prior granulomatous infection.
There is subtle added density at the left costophrenic angle
suggestive of infective change. Cardiomediastinal silhouette is
stable. Right lung is clear.
.
CONCLUSION:
Subtle added density at the left lung base, may represent
infective change. Please ensure followup to clearance.
.
#) Fevers, leukocytosis: Sources of potential infection include
abdominal fluid collection, pneumonia (given appearance of CXR,
though no cough or sputum reported), or urinary source given
urine analysis. Most likely is abdominal in setting of abdominal
discomfort and emesis, however after discussion with surgery
team, this has been an ongoing unexplained problem for her
(inability to take good PO's), and the fluid collection is not
significantly changed from prior scans.
Also possible is drug reaction in setting of rash and elevated
eosinophils, though leukocytosis and hypotension are more
consistent with infection as etiology. She has no RUQ tenderness
to suggest cholecysitis, with benign LFT's. No significant
findings on CT, but c. difficile infection is possibility given
diarrhea and leukocytosis.
Relatively recent echocardiogram from [**2113-3-22**] was without
vegetations, and she has no stigma of endocarditis, but this is
also a possible source of recurrent infections.
- Per ID team who was contact[**Name (NI) **] in [**Name (NI) **], [**First Name3 (LF) **] continue linezolid,
zosyn, and fluconazole. The referral sheet indicated that she
completed fluconazole on [**4-2**] and Zyrox 600 mg on [**2113-4-2**] as
well.
.
#) Hypotension: Suspect secondary to sepsis in setting of
fevers, leukocytosis. Other possible (and likely) contributing
etiology is volume depletion in setting of poor PO intake while
at rehabilitation and concurrent administration of usual blood
pressure medications. Given diffuse red rash after initiation of
Bactrim and history of similiar rash with ciprofloxacin,
allergic reaction (not anaphylactoid) is another possibility.
Her hypotension has responded well to IVF while in the ED. BP on
prior admission was systolic of 110's.
- IVF boluses for goal MAP >55, will need to consider placement
of central line should she continue to require boluses beyond
those given in ED, also would then be able to measure CVP
.
#) Acute renal failure: Baseline creatinine is 0.9-1.1. Suspect
pre-renal etiology in setting of concurrently elevated BUN,
fevers, and emesis contributing to significant insensible
losses. Component of ATN is also possible given hypotension and
continued administration of anti-hypertensives. Urine output has
picked up to over 50cc/hour with IVF resuscitation.
- Hydration, follow up trend
- Urine electrolytes, urine sediment
- Should his renal function not improve, will consider renal
ultrasound or additional work-up
.
#) Rash: Patient noted diffuse erythema yesterday, at which time
she was also started on Bactrim for increasing leukocytosis. She
has a history of a similar rash which was ultimately felt to
likely be secondary to mediations (ciprofloxacin) in the setting
of eosinophila. She again today has a marked eosinophila, and
given temporal association to new medication, this is highest on
the differential. No mucosal involvement noted, no pruritis or
new peeling or blistering.
- Patient received benadryl 50 mg once in the [**Last Name (LF) **], [**First Name3 (LF) **] continue
to treat should she be symptomatic, though this would make
mental status more difficult to assess.
.
#) Eosinophila: As noted above in discussion of rash.
- Will follow trend, also check stool O&P - negative
.
#) Anemia: Patient's HCT today on admission is 28, which is up
from her baseline prior to discharge (25-27), likely
representing some degree of hemoconcentration. No history of
bleeding. Guaiac negative in ED. Has history of iron deficiency.
- Monitor trend, guaiac stools.
.
#) Duodenal performation: Patient has had difficulty with PO's
since her surgery and complicated recovery. During last stay she
had studies demonstrating patent duodenum without obstruction,
but she may need further intervention to improve ability to take
PO's and assist with chronic nausea and vomiting.
.
#) Mental status: Unknown baseline at this time, though she is
on remeron as outpatient. She is currently oriented, though has
poor recall of recent events. Per surgery team, this is close to
her baseline.
- Continue to monitor, obtain further information from family in
AM.
- Resume remeron once taking PO's.
.
#)ID was consulted and they recommended Daptomycin 450 mg IV
Q24H fir a total of 4 weeks. laboratory monitoring required:
-weekly CBC/diff, BUN/Cr, LFT, CK
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
.
#) Psych agrees pt depressed, but do not recommend SSRI while on
Linezolid, nor Remeron, and to check TSH (3.9)
.
The patient was transfered to [**Hospital Ward Name **] 5. She was placed on
telemetry secondary to prior sepsis. She was made NPO and tube
feeds were administered via GJ tube at a goal rate of 40, which
she tolerated well. A PICC line was placed for long term ABX per
ID. The patient has a history of chronic loose stools, she was
started on imodium 2 mg [**Hospital1 **] PRN with good effect.
.
Physical therapy also worked with patient and [**Hospital 80844**] rehab.
Please see physical therapy note.
.
The patient will follow up with ID on [**2113-4-14**] and Dr. [**Last Name (STitle) 1924**] in 2
weeks.
Medications on Admission:
Vancomycin 750mg IV daily, Flucanazole 200mg daily, Lisinopril
10mg twice daily, Metoprolol 12.5 mg twice daily, Remeron 15mg
nightly, Prevacid 30mg twice daily, Tylenol, Senna, Maalox,
Lactulose PRN, Prochlorperazine 10mg q6h PRN nausea, dulcolax PR
PRN, Benadryl cream, Dorzolamide-timolol 2-0.5% drps twice daily
both eyes,
Florastor II cabs twice daily, MVI, combivent, insulin
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Dorzolamide-Timolol 2-0.5 % Drops [**Last Name (STitle) **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritus.
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Daptomycin 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: last dose
[**2113-5-5**].
7. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
8. Sodium Chloride 0.9 % 0.9 % Syringe [**Month/Day/Year **]: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
9. Prevacid 30 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. Florastor 250 mg Capsule [**Month/Day/Year **]: Two (2) Capsule PO twice a
day.
11. Insulin
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**1-13**] amp D50 [**1-13**] amp D50 [**1-13**] amp D50 [**1-13**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units
12. Prochlorperazine Maleate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
every six (6) hours as needed for nausea.
13. Loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times
a day) as needed for loose stool.
14. Mirtazapine 15 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QHS PRN.
Discharge Disposition:
Extended Care
Facility:
life care center of [**Location (un) **]
Discharge Diagnosis:
Primary:
FEVER
HYPOTENSION
leukocytosis
Acute renal failure
Anemia
Duodenal performation
.
Secondary:
Duodenal perforation and repair [**12/2112**]
- Intra-abdominal abscess
- Staph coagase negative sepsis
- Iron deficiency anemia
- Depression
- Diarrhea
- Hypertension
- Hypercholesterolemia
- GERD
- Recurrent low back pain s/p disc operation ~ 20 years ago
Discharge Condition:
Stable.
Tolerating tube feeds at goal rate. Please cycle and encourage
PO intake during day.
Pain well controlled.
Discharge Instructions:
Rehab:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
GJ Tube:
-Please continue to assess GJ tube site for s/s of infection
-Please change dressing QD and PRN
-Please cycle tube feeds: Peptamen 1.5 Full strength;
Goal rate: 40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q8h
.
Please check weekly labs CBC/Diff/BUN/Cr/AST/ALT/CK and fax to
Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 432**].
.
Please continue with Daptomycin 450 mg IV Q24H until [**5-5**].
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] office, [**Telephone/Fax (1) 7508**], to make a
follow up appointment in 2 weeks.
.
Scheduled Appointments :
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2113-4-14**] 10:30
Completed by:[**2113-4-11**]
|
[
"724.2",
"041.12",
"693.0",
"995.92",
"038.9",
"532.90",
"E931.9",
"311",
"401.9",
"280.9",
"272.0",
"567.22",
"530.81",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14133, 14200
|
4387, 10363
|
315, 322
|
14605, 14722
|
3434, 4364
|
16295, 16621
|
3076, 3094
|
12090, 14110
|
14221, 14584
|
11683, 12067
|
14746, 16272
|
3109, 3109
|
3123, 3415
|
258, 277
|
350, 2669
|
10378, 11656
|
2691, 2905
|
2921, 3060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,856
| 195,249
|
48060+48061+48062
|
Discharge summary
|
report+report+report
|
Admission Date: [**2122-7-19**] Discharge Date: [**2122-7-28**]
Date of Birth: [**2076-1-19**] Sex: F
Service: CCU
THIS REPORT REPRESENTS THE EVENTS FROM [**2122-7-19**] THROUGH
[**2122-7-26**].
CHIEF COMPLAINT: Congestive heart failure.
HISTORY OF PRESENT ILLNESS: This is a 46 year old female
with a history of postpartum dilated cardiomyopathy with an
ejection fraction of about 15% who was recently admitted for
congestive heart failure exacerbation. She presented
initially to the [**Hospital Unit Name 196**] team on [**2122-7-19**], after Visiting
Nurses Association noted that her cuff blood pressure was
70/50. The patient was totally asymptomatic at the time
without any chest pain or shortness of breath.
On admission, the patient was noted to have a creatinine
elevation from 2.0 to 5.1 with a potassium of 5.5. The
patient was also noted to have decreased urine output. There
was some question of whether or not she took her Zestril as
prescribed. The patient was noted to have a FENA of 0.9%
even with diuretics on board. The primary team felt that the
patient was dry, possibly over-diuresed, and gave her 500 cc.
of normal saline; also, her Bumex was held for one to two
doses.
An echocardiogram was obtained and showed an unchanged
ejection fraction with global left ventricular hypokinesis
and akinesis. Her CKs remained flat.
The patient went for a right heart catheterization on
[**2122-7-21**]. This showed a right atrial pressure of 26, PA
pressure of 72/46, and a pulmonary capillary wedge pressure
of 39. The patient was given 2 mg of intravenous Bumex in
the Catheterization Laboratory with about 300 cc. of diuresis
in result. The patient was transferred to Coronary Care Unit
on Dobutamine.
Currently, the patient states that she is less short of
breath, but is still very short of breath while in the supine
position. The patient had acute respiratory distress while
in the Catheterization Laboratory when placed in the supine
position. For this reason, the Swan was not left in.
The patient denies any chest pain, nausea, vomiting, fevers
or chills. The patient states that she does have some
burning with urination.
PAST MEDICAL HISTORY:
1. Postpartum dilated cardiomyopathy with an ejection
fraction of 15%.
2. Cardiac catheterization from [**2115**] shows normal
coronaries.
3. Noninsulin dependent diabetes mellitus.
4. Chronic renal failure with baseline creatinine of 2.0.
5. Hypercholesterolemia.
6. Asthma.
7. Gout.
8. History of hepatitis B and C.
9. Status post cholecystectomy.
10. Stress test from [**2121-2-4**] showed mild to moderate
reversible inferior wall defect.
MEDICATIONS AS OUTPATIENT:
1. Bumex 2 mg p.o. twice a day.
2. Digoxin 0.125 mg p.o. q. day.
3. Avandia 4 mg p.o. q. day.
4. Zestril 2.5 mg p.o. q. day.
5. Aspirin.
6. Lopresor XL 25 mg p.o. q. day.
7. Lipitor 20 mg p.o. q. day.
8. Albuterol.
9. Serax 15 mg p.o. twice a day.
ALLERGIES: Lasix, penicillin, codeine, Lidocaine.
SOCIAL HISTORY: The patient lives with her children. She
has a past history of cocaine use times ten years, currently
clean. The patient has a 14 year tobacco use history. The
patient denies any alcohol use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 96.2 F.; pulse 107; blood
pressure 96/42; respiratory rate 23; O2 saturation 98% on two
liters. In general, the patient is moderately short of
breath. HEENT: Mucous membranes were moist. Pupils are
equal, round, and reactive to light and accommodation. Lungs
clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm, no murmurs. soft S1 and S2. Abdomen is
obese, normoactive bowel sounds, soft, nondistended.
Slightly tender in right lower quadrant, no rebound or
guarding. Extremities with no cyanosis, clubbing or edema.
Neurological: Alert and oriented times three.
LABORATORY: EKG with sinus tachycardia, left bundle branch
block which is old, no changes.
White blood cell count 4.9, hematocrit 28.5, platelets 183,
calcium 9.3, magnesium 2.3, phosphorus 6.0. INR 1.0. Sodium
133, potassium 5.0, chloride 91, bicarbonate 26, BUN 73,
creatinine 5.0. Glucose 111. CK 224, MB 2, troponin less
than 0.3.
Urinalysis with leukocyte esterase moderate, white blood
cells 41, squamous epithelial cells 5. Urinalysis with
sodium 30, urine creatinine 120, urine urea at 215.
Echocardiogram from [**2122-7-20**], ejection fraction less than
15%, severe left ventricular systolic depression with
akinetic anterior septum, hypokinesis/akinesis of anterior
wall, inferior wall and apex. Right ventricle is normal.
Three plus mitral regurgitation, two plus tricuspid
regurgitation.
HOSPITAL COURSE: The patient is a 46 year old female with a
history of post partum cardiomyopathy with ejection fraction
of about 15% and diabetes mellitus, who presents after
Visiting Nurses Association noticed systolic blood pressure
of 70. She was noted to a have acute on chronic renal
failure with a bump in her creatinine from 2.0 to 5.1 in just
several days. The patient was initially felt to be prerenal
but noted to have pulmonary capillary wedge pressure of 39.
1. PUMP: With the patient's ejection fraction of 15%, and
the elevated capillary wedge pressure, she was felt to be in
cardiogenic shock with her decreased blood pressure. The
patient's situation was not helped by the fact that about two
doses of her Bumex were held because she was initially felt
to have been over-diuresed.
The patient was placed on 2 mg intravenously of Bumex twice a
day. She seemed to be responding well to this dose of Bumex
given her urine output. The patient was also kept on
Dobutamine as an ianotropic given her severely depressed left
ventricular function in the setting of cardiogenic shock.
The patient's Dobutamine was titrated to 12 micrograms per
kilogram per minute. Overall, the patient was making good
urine. Unfortunately, she was taking too much in the form of
liquids as intake. Once the patient's intake was stemmed,
she started becoming net negative. Her goal was to keep her
two liters net negative per day. To further meet these
goals, the patient was started on Natrecor, initially at
0.01, and then titrated to 0.2 micrograms per kilogram per
minute.
The patient was Swan-ed for hypotension on [**2122-7-25**].
Surprisingly, her cardiac index was higher than expected at
3.28 on 12 of Dobutamine and 3 of Neo-Synephrine. However,
her SVR was only 480, consistent with a septic like picture.
Given that the patient was already well hydrated for her
treatment of sepsis, the team still felt that diuresis was
the goal for this patient and to maintain at least one to two
liters negative per day.
Of note, the patient is not a candidate for heart transplant.
She has generally been noncompliant and given her social
history including past cocaine use, she has been deemed to be
not a candidate. In the future, she may be possibly a
candidate for biventricular pacing should the need arise.
2. CORONARY ARTERY DISEASE: The patient was continued on
aspirin and Lipitor. Beta blockers were held secondary to
hypotension. It is unclear if the patient even has active
cardiac disease. She does have diabetes mellitus which is a
cardiac coronary artery disease equivalent. The patient's
CKs remained flat as already noted. There was no ischemic
event to explain the patient's worsened cardiogenic shock.
3. HYPOTENSION: The patient's hypotension was initially
thought to be secondary to cardiogenic shock. There was no
initial cardiac index calculated when she was first given a
Swan in the Catheterization Laboratory on [**2122-7-20**]. The
patient was kept on Dobutamine and Neo-Synephrine. It was
felt that optimally the Dobutamine was more important in
maintaining the blood pressure as it would increase the
patient's cardiac output, whereas the patient was likely
already clamped down from her cardiogenic shock and the
addition of too much alpha activity would be deleterious.
Overall, the patient kept her mean arterial pressure between
60 and 70.
On [**2122-7-23**], the patient was noted to be more hypotensive,
with mean arterial pressures between 50 and 55. The
Neo-Synephrine had to be titrated up to a maximum of 5,
however, this led to a decrease in urine output. Of note,
the patient was very pruritic that day, complaining that she
had eaten some tuna fish and now she was itching all over.
The patient was given Benadryl and Zantac for treatment of
any possible systemic allergic reaction.
The patient also spiked a temperature up to 101.0 F. The
patient was pan cultured. Because of her hypotension and
fever, she was stared on empiric Vancomycin, Levofloxacin and
Flagyl. The patient also received a dose of intravenous
Dexamethasone both to cover any adrenal insufficiency and for
any possible allergic systemic reaction.
The patient's hypotension eventually resolved. She had also
become quite tachycardic up to a rate of 130, in normal sinus
rhythm. This, too, resolved, especially after getting
Tylenol.
After about 24 hours, the patient started growing Gram
positive cocci from her blood cultures drawn peripherally and
from her left sided arterial line. As already noted, she had
a Swan placed on [**2122-7-25**]. This was consistent with a
septic like picture superimposed on a cardiogenic picture.
Because the patient's cardiac index was higher than expected,
her Dobutamine was able to be weaned slightly to 5 micrograms
per kilogram per minute. Her Neo-Synephrine was also
titrated down as tolerated.
4. RENAL: The patient presented with acute on chronic renal
failure. The patient's chronic renal failure is likely
secondary to a combination of diabetes mellitus and her
depressed left ventricular function. The patient's current
acute on chronic renal failure is likely secondary to
cardiogenic shock. The patient was found to be prerenal by
her FENA secondary to poor perfusion. The patient did
receive a renal ultrasound which showed right and left kidney
sizes of 9 centimeters. There was no hydronephrosis or
stones identified.
The Renal consultation team was consulted. Initially it was
unclear whether or not the patient would diurese
appropriately. The patient never came close to requiring any
emergent dialysis for ultra-filtration. Once she started
diuresing with the Bumex and the Natrecor, her creatinine
came down. By [**2122-7-26**], her creatinine was close to
baseline at 2.3. The patient was placed on Renagel and Tums.
5. INFECTIOUS DISEASE: As already noted, the patient became
febrile up to 101.4 F., on [**2122-7-23**]. The patient grew four
out of four bottles of Gram positive cocci in pairs and
clusters, which was identified as Staphylococcus aureus. The
patient's right sided IJ line was discontinued. This was
noted to have some pus at the end. In addition, the
patient's left arterial line was taken out as blood cultures
drawn from that line also grew Staphylococcus aureus.
A new right sided arterial line was replaced on [**2122-7-26**].
The patient was kept on Vancomycin, renally dosed. We are
checking trough levels every day. Levofloxacin and Flagyl
were discontinued.
6. The patient was noted to be anemic with a hematocrit of
28, but stable. The patient's iron studies are consistent
with iron deficiency anemia, although the patient likely also
has a low epo state given her chronic renal failure. The
patient was started on iron. The patient would likely
benefit from an epo level as an outpatient.
7. RIGHT LOWER QUADRANT PAIN: This appears to be chronic;
the patient states that she has had this since [**2122-2-4**]. The patient has had negative CT scans, the last from
[**2122-2-4**]. The patient's pain was controlled with
standing Tylenol and p.r.n. Oxycodone. The patient's pain
overall improved. The patient was taken off the standing
Tylenol in order to track her fever curves.
This concludes my interim STAT dictation on this patient for
the events from [**2122-7-19**] until [**2122-7-26**].
The remainder of the [**Hospital 228**] hospital course will be
dictated at a future time.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2122-7-26**] 18:23
T: [**2122-7-26**] 21:44
JOB#: [**Job Number 101343**]
Admission Date: [**2122-7-19**] Discharge Date: [**2122-8-2**]
Date of Birth: [**2076-1-19**] Sex: F
Service:
ADDENDUM: This is an addendum to discharge summary #[**Numeric Identifier 101344**].
On [**2122-7-27**], the patient remained hemodynamically stable
with improved diuresis. Dobutamine was weaned slightly. The
Neo was decreased to 2. The patient's creatinine was stable
at 2.3. The cultures returned from the patient's previous
clinically infected lines growing out methicillin-sensitive
Staphylococcus aureus and the patient was started on
vancomycin 1 gram q.d.
On [**2122-7-28**], the Neo and dobutamine were discontinued.
The patient did experience some decreased oxygen saturation
with respiratory alkalosis on 40% face mask. The original
ABG from the morning of [**2122-7-28**] showed a gas of 7.51, 40,
50, 88% and a second gas 05:00 hours at 7.56/32/64 on 90%.
The patient also noted that her right lower extremity
appeared to be larger than her left lower extremity. Her
right lower extremity was measured at 27 cm at 5 cm proximal
to the malleolar diameter. The left lower extremity was
measured at 24 cm at 5 cm proximal to the malleolar diameter.
Because of the concern for deep venous thrombosis despite
being on heparin, 7,500 units b.i.d., the patient had lower
extremity Doppler studies which were negative for DVT. Of
note, on [**2122-7-28**], the patient also had a rectal temperature
at 18:00 hours of 101. A chest x-ray, urine, and blood
cultures were obtained. It was felt that oxacillin would be a
preferential treatment for MSSA over vancomycin, but the patient
stated she had a penicillin allergy. Therefore, an allergy
consult was obtained. At this time, it was felt that
the patient was hypoxic secondary to her congestive heart
failure and aggressive diuresis was planned.
In the p.m. on [**2122-7-28**], a penicillin skin test was performed
and was negative with greater than 90% certainty that she has
no current penicillin allergy.
On [**2122-7-29**], a Physical Therapy evaluation demonstrated that
the patient was unable to support herself without the
assistance of others. After being negative 1.5 liters
overnight with CVP of 15 and a PA pressure of 49/29 with an
SVR of 460, the patient's lung examination and oxygenation
were much improved. She was breathing 97% on 4 liters nasal
cannula. A repeat ABG showed a gas of 7.47/42/102/97.
During the afternoon of [**2122-7-29**], the patient complained of
foot and arm pain bilaterally, stating, "I have gout". The
patient was started on colchicine 0.6 mg q. eight hours
p.r.n. The results of the chest x-ray from the previous day
showed no infiltrates, mild CHF. The urine was negative for
UTI.
Later on [**2122-7-29**], the patient was started on oxacillin 1
gram q. six hours IV. The vancomycin was discontinued.
During the evening of [**2122-7-30**], the patient was further
diuresed with being negative 2 liters in the morning of
[**2122-7-30**].
On [**2122-7-30**], the patient's Swan and A line were discontinued
and the patient was transferred to the floor. The patient
was quite distressed on [**2122-7-30**] as a result of learning of a
recent death of her nephew by shooting. On [**2122-7-30**], the
patient's Natrecor was discontinued.
On [**2122-7-31**], early in the morning of [**2122-7-31**], the patient's
systolic blood pressure dropped to 68; however, after
repeating the blood pressure approximately five minutes
later, it increased to 90 mmHg. After discussion with the
CHF Service, the patient was started on Captopril at 6.25 mg
t.i.d. p.o. and her Zaroxolyn was discontinued. The patient
did much better in terms of mobility and was able to transfer
to a chair for four hour periods times two.
By the evening of [**2122-7-31**], the patient's ins were equal to
her outs and her creatinine remained stable at 2.4.
On [**2122-8-1**], the patient was started on carvedilol 3.25 mg
b.i.d. p.o. Based on clinical examination, electrolytes, as
well as ins and outs, it was felt that the patient was back
to her baseline fluid status. Her weight was 126.4 kilograms
which was her original dry weight before CHF exacerbation.
It was decided on [**2122-8-1**] to discontinue IV Bumex and start
her on Bumex 2 mg p.o. q.d. due to a mild bump in creatinine
to 2.8 from 2.4. Her Captopril dose was decreased to 3.125
t.i.d. and as a result of a phosphorus of 6, the patient was
started on Sevelamer phosphate binder.
On [**2122-8-2**], at this point, the patient's medications for CHF
included carvedilol 3.125 mg per day, Captopril 3.125 mg
t.i.d., Bumex 2 mg daily, digoxin 0.125 mg q.o.d. On
[**2122-8-2**], the prior night, the patient had learned that her
nephew had been stabbed and killed. This was the second
murder in her family in one week and she was obviously quite
distressed, stating "I want to cry". After counseling and a
visit from the social worker, the patient was able to go
about her usual activities with euthymia with decreased
affect.
Of note, the patient's systolic blood pressure did drop to 74
after one dose of carvedilol on [**2122-8-2**], however, it quickly
returned to 90/59 after five minutes.
Laboratories on [**2122-8-2**] revealed a sodium of 129-125,
potassium 3.6, chloride 80, bicarbonate 31, BUN 86,
creatinine 3.1 from 2.8, glucose 214, hematocrit 28.4 from
31.5. Due to the increase in creatinine and decrease in
hematocrit, the patient's hematocrit was followed q. eight
hours and the Captopril was discontinued. The Bumex p.o.
dose was discontinued as well. The patient also had a brief
episode of chest pressure/pain that persisted for five to ten
minutes and was relieved by one Oxycodone. The pain radiated
to her back. An EKG was obtained which showed her baseline
left bundle branch block pattern with discordant T waves.
The patient remained asymptomatic.
At this point, it was thought that the CHF medications had
been optimized and the patient was awaiting placement at a
rehabilitation center.
This discharge summary addendum includes the dates [**2122-7-27**]
to [**2122-8-2**]. Another discharge addendum will follow.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2122-8-2**] 02:54
T: [**2122-8-2**] 15:07
JOB#: [**Job Number 101345**]
Admission Date: [**2122-7-19**] Discharge Date: [**2122-8-5**]
Date of Birth: [**2076-1-19**] Sex: F
Service:
ADDENDUM: This discharge summary will cover the dates from
[**2122-8-3**] to [**2122-8-5**].
[**2122-8-3**]: The patient had no overnight events and was felt
to be at her stable baseline weight of 126 kg. Her vital
signs remained stable. Of note, her creatinine did jump to
3.3 from 3.1. The patient's hematocrit was also noted to be
28.4. This was the first time in one week that the patient's
hematocrit had dropped below 30. At this time it was decided
that the patient would receive one unit of packed red blood
cells over four hours. The patient received this unit and on
[**2122-8-4**] was doing quite well and remained hemodynamically
stable with a stable lung examination and weight.
[**2122-8-4**]: The patient received her final dose of oxacillin
for methicillin-sensitive Staphylococcus aureus line sepsis.
Her hematocrit had responded nicely to one unit to an
hematocrit of 29.8 from 28.7. However it was decided that an
additional unit would not only improve her oxygenation status
but would also serve to draw the extracellular fluid into the
intravascular space and therefore improve the likelihood of
diuresis. The patient was also started on Epogen 40,000
units subcutaneous q. week. Her Epogen dose was given on
Tuesdays and the hope was that this would improve her
hematocrit as well.
[**2122-8-5**]: On the day of discharge the patient denied
paroxysmal nocturnal dyspnea, orthopnea, palpitations, chest
pain, shortness of breath or lightheadedness. She had
tolerated her second unit of packed red blood cells quite
well. Her complete blood count on the date of discharge was
white count 10.1, hematocrit 32.0, platelet count 375. Of
note, in the patient's chemistries her creatinine had risen
from 3.4 to 3.6.
Other laboratory studies of note, on the day of discharge the
patient's blood and urine cultures were still pending. These
should be followed up upon by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital 191**] clinic on
[**2122-8-12**].
Upon physical examination it was found that the patient did
have some mild crackles at the bases of the lungs and
therefore required additional diuresis. After discussing the
case with the congestive heart failure service it was decided
that she would be started on Bumex 2 mg p.o. q.d. and that
she would have daily creatinine checks and weight checks. At
the time of discharge the patient was in no apparent distress
in stable condition, hemodynamically stable.
The patient was instructed to limit her fluid intake to one
liter of fluid per day and to limit her intake of salt to 2
grams of sodium per day. She was going to be discharged to
be rehabilitated at the [**Hospital3 672**] Hospital and the
staff at JMH is advised to check the patient's daily weights
and b.i.d. creatinine, and call these in to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
She can be contact[**Name (NI) **] through the page operator at [**Hospital1 346**] at 1-[**Telephone/Fax (1) 101346**]. It was strongly
advised that upon discharge from the rehabilitation hospital
that the patient be under the care of a psychiatrist as well
as maintain close contact with her primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital Ward Name 23**] Center [**Company 191**]. She does have an
appointment on [**2122-8-12**] at 1:30 PM. The phone number for Dr.[**Name (NI) 101347**] office is [**Telephone/Fax (1) 250**]. The patient is advised to see
Dr. [**First Name (STitle) **] within one week of discharge.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Atorvastatin 20 mg tablets, one tablet p.o. q.d.
3. Calcium carbonate 500 mg, one p.o. q.d.
4. Albuterol aerosol 1-2 puffs q. 6 hours p.r.n.
5. Ferrous sulfate 325 mg, one p.o. b.i.d.
6. Digoxin 125 mcg, one tablet p.o. q.o.d.
7. Heparin 7,500 units subcutaneously twice a day for DVT
prophylaxis.
8. Bisacodyl 10 mg suppository q.h.s.
9. Sodium chloride 0.65% nasal spray q.i.d. p.r.n.
10. Pantoprazole 40 mg p.o. q.d.
11. Sevelamer 800 mg p.o. t.i.d.
12. Glucotrol XL 5 mg tablet p.o. q.d.
13. Epogen 40,000 units subcutaneously once per week on
Tuesdays.
14. Bisacodyl 5 mg tablet, two tablets p.o. q.d.
15. Carvedilol 3.125 mg tablet, p.o. b.i.d. Please hold
carvedilol for systolic blood pressure less than 80.
16. Bumex 2 mg, one p.o. q.d.
17. Lorazepam 1 mg IV q. 6 hours p.r.n. anxiety.
18. Promethazine 12.5 mg IV q. 6 hours p.r.n. nausea and/or
vomiting.
19. Ondansetron 8 mg IV q. 8 hours p.r.n. nausea and/or
vomiting.
20. Insulin sliding scale as per the standard of the [**Hospital3 **] Hospital.
NOTE: The patient is aware of her diagnosis as is her
family. It is ESSENTIAL to please check daily weights and
b.i.d. creatinine and call in the results once per day to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 69**]. Dr. [**Last Name (STitle) **]
may be contact[**Name (NI) **] at [**Telephone/Fax (1) 101346**]. The patient is to be on a
strict 2 gram sodium or less diet, renal/diabetic diet. She
is to be fluid restricted to one liter of fluid per day.
Upon discharge from JMH the patient is to be evaluated for
home services and physical therapy, social work, psychiatry
and teaching regarding her diagnosis are strongly
recommended. Please also note that when taking the patient's
blood pressure, her blood pressure in the coronary care unit
was correlated to be 10 points below the arterial pressure.
that is, if the patient's blood pressure by the cuff is 80,
the actual pressure by the arterial line is 90. Please feel
free to contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with any questions
regarding the patient's transition of care.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2122-8-5**] 13:25
T: [**2122-8-5**] 13:53
JOB#: [**Job Number 32766**]
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74,674
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12814
|
Discharge summary
|
report
|
Admission Date: [**2176-10-5**] Discharge Date: [**2176-10-11**]
Date of Birth: [**2098-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain, wide complex tachycardia
Major Surgical or Invasive Procedure:
Internal Cardiac Defibrillator placement
cardiac catheterization
History of Present Illness:
78 y/o gentleman with chronic AF, known CAD--NSTEMI in [**8-28**] (3 x
13 mm Cypher to RPLV and 2.25 x 18 mm Cypher to LCx/OM; also
found to have 3-% LMCA, 70% mLAD with an 80% D1 and 90% D2),
repeat PCI in [**10-29**] with BMS to mid-LAD for 70% stenotic lesion,
possible ISR in [**2174**] with DES to LAD ([**Hospital1 3278**]), AS with most
recent estimate of [**Location (un) 109**] of 1.07 cm2, presents from [**Hospital1 **] ED where he was found to have an irregular wide-complex
tachycardia associated with chest pain.
.
The patient has a history of chronic stable angina, class II
Canadian Classification, able to walk about 1 mile or 1 flight
of stairs before angina and SOB. Was in USOH when at 8PM
tonight noted anginal equivalent only increased in intensity
(SSCP radiating to L arm). Took 3 SL NTG without relief. Taken
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where found to have Wide-complex tachycardia.
Given Morphine IV, metoprolol IV 5mg x 2, Amiodarone 150mg IV x
1, and started on a diltiazem bolus 20 mg and 5mg/hr gtt.
Rhythm appeared to convert to sinus when he was loaded on
stretcher for EMS and symptoms resolved. Since then has had no
further episodes of AF and no further CP or SOB. Of note, he
stopped Plavix 6 months ago at the advice of his cardiologist.
.
In [**Hospital1 18**] ED his vitals were T 98.6 HR 61 BP 97/40 RR 25 87%
RA-> 100 % in NRB. Patient recieved 600 mg plavix x 1. His BP
occasionally dropes to SBP of 80s which improved to 110s with
500cc of NS.
.
On arrival to CCU, patient was asymptomatic.
.
ROS was negative for fever, chills, abdominal pain, recent
BRBPR, melena, dysuria, hematuri. Cough recently which patient
attributes to allergies. On cardiac review of symptoms, in
addition to above, patient notes stable 2 pillow orthopnea, no
PND or claudication.
Occasional RLE edema. All other review systems were negative.
.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-> CAD: NSTEMI [**2172**] PCI- DES of the r-PLV and LCx/OM, [**10-29**] PCI-
BMS
to LAD; [**2174**]- PCI ([**Hospital1 3278**]) [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] for possible ISR
-> Aortic Stenosis ([**Location (un) 109**] 1.07, mean Grad 21 mmHg), EF 50% on ETT
[**2172**]
-> Atrial Fibrillation
3. OTHER PAST MEDICAL HISTORY:
[**2172**]- CVA with residual speech difficulties
Anemia
GIB
Anxiety
Appendectomy
Right Inguinal hernia
Social History:
Married with 1 adult son. [**Name (NI) **] is retired. Prior to retiring he
was a construction worker. Quit smoking 30 years ago. Prior to
quitting he smoked <1ppd for approximately 20-25 years. Denies
drinking alcoholic beverages or recreational drug use.
Family History:
Father died of a myocardial infarction in his early 70's. His
sister underwent a CABG and died from a CVA at the age of 78.
His brother died of a myocardial infarction at the age of 39.
Physical Exam:
Gen: Pleasant, in NAD, able to follow commands
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP 12 cm. Normal carotid upstroke without
bruits.
CV: Soft S1S2, Irregluarlary irregular. II/VI systolic murmur
best at USB. Early diastolic murmur.
LUNGS: Bibasilar crackles.
ABD: Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by
palpation. Abdominal bruit is present.
EXT: 1+ edema BL. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Grossly intact, no focal deficits.
Discharge exam:
97.3 111/61 72 96% RA
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP 12 cm. Normal carotid upstroke without
bruits.
CV: Soft S1S2, Irregluarlary irregular. II/VI systolic murmur
best at USB. Early diastolic murmur.
LUNGS: CTA.
ABD: Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by
palpation. Abdominal bruit is present.
EXT: 1+ edema BL. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Grossly intact, no focal deficits.
Pertinent Results:
LABS ON ADMISSION:
[**2176-10-5**] 12:00AM WBC-13.5*# RBC-4.01* HGB-12.2* HCT-37.7*
MCV-94# MCH-30.5 MCHC-32.5 RDW-14.0
[**2176-10-5**] 12:00AM NEUTS-88.4* LYMPHS-8.0* MONOS-2.5 EOS-0.6
BASOS-0.5
[**2176-10-5**] 12:00AM PLT COUNT-127*
[**2176-10-5**] 12:00AM PT-27.5* PTT-32.9 INR(PT)-2.7*
[**2176-10-5**] 12:00AM CK-MB-8
[**2176-10-5**] 12:00AM cTropnT-0.05*
[**2176-10-5**] 12:00AM CK(CPK)-118
[**2176-10-5**] 12:00AM GLUCOSE-122* UREA N-29* CREAT-1.3* SODIUM-137
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2176-10-5**] 04:49AM %HbA1c-5.6
[**2176-10-5**] 04:49AM CK-MB-30* MB INDX-9.6* cTropnT-0.59*
[**2176-10-5**] 04:49AM CK(CPK)-313*
[**2176-10-5**] 01:02PM CK-MB-34* MB INDX-11.1* cTropnT-0.71*
[**2176-10-5**] 01:02PM CK(CPK)-306*
.
ECHO [**2176-10-5**]: The left atrium is dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 30-40 %) secondary to
akinesis of the basal septum and hypokinesis of the rest of the
left ventricle. There is considerable beat-tobeat variability of
the left ventricular ejection fraction due to an irregular
rhythm. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild to moderate ([**1-26**]+) mitral
regurgitation is seen.
.
CARDIAC CATHETERIZATION [**2176-10-7**]:
1. Coronary angiography in this right dominant system revealed
diffuse calcified coronary artery disease. The LMCA had mild
disease. The LAD had widely patent stents, and total occlusion
of a moderate sized diagonal seen on prior catheterization from
[**2173-11-11**]. The distal 70% stenosis of the LAD was unchanged
versus prior. The LCX had a widely patent stent, and mild
luminal irregularities. The RCA was a large vessel, with
moderate calcification and serial 40-50% stenoses. There was a
large RPL that had a 60% stenosis in the mid-vessel, which was
unchanged compared with prior.
2. Resting hemodynamics revealed moderate-to-severe aortic
stenosis with mean gradient of 18 mmHg and estimated aortic
valve area of 1.0 cm2. There were elevated left and right-sided
filling pressures with mean RA pressure of 15, mean PCWP of 35
mmHg, and LVEDP of 29 mmHg. Cardiac output was mildly depressed
at 4.0 L/min.
.
ABDOMINAL ULTRASOUND [**2176-10-7**]:
1. Atherosclerotic aorta with AAA measuring 4.1 cm at the widest
diameter. Slight interval increase from the ultrasound of
[**2173-10-24**].
2. No hydronephrosis. Bilateral renal cysts.
3. No evidence of renal artery stenosis.
.
LABS ON DISCHARGE:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
7.9 3.88* 11.8* 35.4* 91 30.5 33.4 14.2 150
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
106* 20 0.9 134 4.0 101 26 11
.
PT PTT INR(PT)
14.4* 28.6 1.2*
Brief Hospital Course:
78 year old gentleman with coronary artery disease with PCI in
[**2174**], hypertension, moderate aortic stenosis, atrial
fibrillation, presented with rest angina in the setting of rapid
heart rate with wide complex tachycardia.
.
# CORONARIES: Presenting chest pain was concerning for unstable
angina. Known CAD as above. Cardiac enzymes were cycled with
peak trop at 0.92, MB 34, CK 313. Diagnostic left heart cath
showed patent coronaries with prior stents in place, no evidence
of renal artery stenosis. Pt received heparin drip during
hospitalization, as coumadin was held in anticipation of
procedures. Aspirin and plavix were started and continued at
discharge. HbA1c and lipid panel as above, all normal. Statin
was continued in house and at discharge, along with ACE
inhibitor, beta blockade, aspirin and plavix.
.
# RHYTHM: Episodes of wide complex tachycardia concerning for
ventricular tachycardia, orginating from left ventricular or
right ventricular outflow tract. Electrophysiology
study/intervention deferred in setting of highly calcific aorta
and moderate aortic stenosis. Initial rate control with
metoprolol. Sotalol was then started, monitored for QT
prolongation. Patient then remained in persistent atrial
fibrillation. Sotalol was continued, along with heparin gtt.
Patient had ICD placed on [**2176-10-10**], tolerated procedure well.
Metoprolol started after ICD was place. Warfarin was started
one day prior to discharge. INR had been therapeutic for at
least one month prior to admission. INR 1.2 on discharge, will
recheck INR in three days.
.
# PUMP: Known moderate/severe aortic stenosis in our system and
currently on exam. Cath in [**2173**] with aortic valve area of 1.07
with gradient of 21 mmHg. Transthoracic echo as above. Imdur
was added to lisinopril, metoprolol, sotalol on discharge.
.
# Abdominal aortic aneurysm: Abdominal ultrasound showed AAA
measuring 4.1 cm at the widest diameter, slight interval
increase from the ultrasound of [**2173-10-24**].
.
# ARF: Creatinine 1.3 on admission. Last Creatinine in our
system is 0.9 in [**2173**].
Renal function improved over course of stay, 0.9 on discharge.
.
CODE: FULL
.
COMM: With patient and Wife, [**Name (NI) 39471**], [**Telephone/Fax (1) 39472**]
Medications on Admission:
Aspirin 325mg daily
Metoprolol tartrate 75 mg [**Hospital1 **]
Simvastatin 80 mg qdaily
Warfarin 2mg for 2 days, then 1 mg next day, then repeat
Isosorbide dinitrate 10 mg tid
Lisinopril 5 mg qdaily
Nitroglycerin 0.4 SL prn
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: one
half tablet every third day.
8. Metoprolol Succinate Oral
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
10. Outpatient Lab Work
Please check INR on Monday [**10-14**] and call results to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 719**].
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*6 vils* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Ventricular Tachycardia
Non ST elevation Myocardial Infarction
Discharge Condition:
stable.
Discharge Instructions:
You had a dangerous heart rhythm called ventricular tachycardia
and was started on sotolol, a medicine to prevent this rhythm.
In addition, an internal defibrillator (ICD) was placed that
will shock you out of this rhythm. You cannot get the ICD
dressing wet for one week. No showers of baths. You may wash
your hair in a sink. You are scheduled in the device clinic in 1
week, they will check the function of the ICD and take off the
dressing. No lifting more than 5 pounds with your left arm for 6
weeks, no lifting your left arm over your head for 6 weeks. You
will be on antibiotics to prevent an infection at the ICD site
for 3 days. You also had a cardiac catheterization that showed
extensive blockages in your coronary artery. Your medicines were
adjusted to help your heart function.
Medication changes:
1. Sotolol: to prevent ventricular tachycardia
2. Restart your coumadin at 2 mg, you will need to check your
INR on Monday [**10-14**].
3. Decrease your aspirin to 81mg, continue taking plavix.
.
Please call Dr. [**Last Name (STitle) **] if your ICD fires, if you have any
redness, swelling, tenderness or bleeding at the ICD site, if
you have any chest pain, fevers, chills or trouble breathing.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet: information was given to you about
this at discharge.
.
Followup Instructions:
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: He will see
you during the device clinic appt.
Device Clinic: [**Hospital Ward Name 23**] [**Location (un) 436**], [**Hospital1 18**], [**Hospital Ward Name 516**], [**Location (un) **] [**Location (un) 86**]: Date/Time: [**2176-10-18**] 3:00pm
.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Last Name (NamePattern1) 39473**], [**Location (un) 86**] Date/time: [**11-6**] at 1:30pm.
.
|
[
"441.4",
"410.71",
"427.31",
"428.0",
"413.9",
"428.23",
"427.1",
"272.4",
"584.9",
"300.00",
"424.1",
"440.0",
"401.9",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
11400, 11457
|
7788, 10061
|
352, 419
|
11564, 11574
|
4520, 4525
|
13021, 13659
|
3227, 3415
|
10335, 11377
|
11478, 11543
|
10087, 10312
|
11598, 12391
|
3430, 3975
|
2478, 2799
|
3991, 4501
|
12411, 12998
|
276, 314
|
7569, 7765
|
447, 2368
|
4539, 7550
|
2830, 2935
|
2390, 2458
|
2951, 3211
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,274
| 176,245
|
43288
|
Discharge summary
|
report
|
Admission Date: [**2190-5-23**] Discharge Date: [**2190-5-26**]
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F, h/o recent admission for PNA/sepsis/UTI, h/o
COPD/asthma,CHF,AF,DM presents from [**Hospital 100**] Rehab with report of
hypoxia to the 70's and a R lung 'white out' on CXR. In
ambulance bay on arrival had wide complex tachycardia. Pt noted
to be having recent diarrhea and ? c.diff, is on Abx. Pt is
[**Name (NI) 595**] speaking with baseline alzheimer's dementia. Per the
daughter the patient has had chronic abdominal pain since her
PEG procedure from the last admission. At baseline she is
communicative, but since the last admission, the daughter
describes increased confusion and difficulty communicating.
.
Of note, the patient was recently hospitalized from [**3-15**] to [**4-5**]
with sepsis, PNA (MRSA and klebsiella), UTI, course c/b afib
with RVR. Trach, PEG, PICC were performed during that admission.
.
ED Course: Pt was found to be in SVT vs. VT and loaded with amio
and put on an amio gtt. She was then in AF. Cardiology was
consulted. A CXR was done that shows worsened pulmonary edema
since her last admission, though a focal consolidation could not
be ruled out, so she was covered with levo/vanco for ?PNA. She
was also given xopenex and atrovent nebs for wheezing. Labs were
significant for tnt of 0.04 (all <0.01 in past), Cr of 1.3
(baseline 1.0), WBC 10.9 (baseline range 5-10), lactate 1.4, and
a pos UA. other labs as below. vitals on transfer 99, 100 AF,
137/56, 20, 97%RA
Past Medical History:
HTN
hypercholesterolemia
diastolic CHF EF 60%
COPD/asthma
paroxysmal afib
sick sinus syndrome s/p pacemaker
Diabetes Mellitus (when she was in former rehab hospital)
DVT
?CAD
Nephrolithiasis
cataracts
CRI w/ baseline Cr 1.3 on [**10-16**] (per H&P from [**8-2**] Heb Reb
baseline 2)
dementia
CVA [**92**] yrs ago, periods of confusion since then
poor balance with frequent falls (coumadin stopped)
urinary incontinence
s/p left mastectomy for breast ca
anemia (unknown baseline)
Past Surgical History:
Left radical mastectomy
appendectomy.
Social History:
Non-smoker, no EtOH. Former nurse. Lives at [**Hospital 100**] Rehab.
Family History:
Noncontributory
Physical Exam:
PE: T98.8,P88,BP149/78,RR26,O2Sat 99% V,
AC: fiO2 0.5, PEEP 10, RR 20, Tv 425
GEN: non-communicative, alert but looking uncomfortable in bed
NEURO: CN II-XII intact, PERRL, MAE, alert
HEENT: NCAT, OP clear, TM clear,
NECK: supple, no LA, normal thyroid
RESP: on vent, diffuse rhonchi b/l R>L, mild crackles at bases
CV: RRR, no M/R/G
ABD: NL BS, mild distended with general TTP, nonfocal, not
peritoneal
GU:NL
EXT: no edema
SKIN: no rash
Pertinent Results:
[**2190-5-23**] 09:20PM TYPE-ART PO2-343* PCO2-56* PH-7.36 TOTAL
CO2-33* BASE XS-4
[**2190-5-23**] 08:39PM LACTATE-1.4
[**2190-5-23**] 08:35PM GLUCOSE-138* UREA N-44* CREAT-1.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-12
[**2190-5-23**] 08:35PM estGFR-Using this
[**2190-5-23**] 08:35PM CK(CPK)-24*
[**2190-5-23**] 08:35PM cTropnT-0.04*
[**2190-5-23**] 08:35PM CK-MB-NotDone
[**2190-5-23**] 08:35PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.4
[**2190-5-23**] 08:35PM WBC-10.7 RBC-3.88*# HGB-11.5*# HCT-35.5*#
MCV-91 MCH-29.5 MCHC-32.3 RDW-15.2
[**2190-5-23**] 08:35PM NEUTS-57.3 BANDS-0 LYMPHS-33.9 MONOS-3.7
EOS-4.7* BASOS-0.5
[**2190-5-23**] 08:35PM PLT SMR-LOW PLT COUNT-97*#
[**2190-5-23**] 08:35PM PT-20.6* PTT-31.5 INR(PT)-1.9*
[**2190-5-23**] 08:35PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
[**2190-5-23**] 08:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2190-5-23**] 08:35PM URINE RBC-[**7-6**]* WBC->50 BACTERIA-MANY
YEAST-RARE EPI-0-2
.
[**2190-5-23**] URINE URINE CULTURE-PRELIMINARY {GRAM NEGATIVE
ROD(S)} INPATIENT
[**2190-5-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2190-5-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
CXR:
4/27IMPRESSION: Limited study, with:
1. Pulmonary edema, worse since [**2190-4-1**].
2. Tracheostomy and gastrostomy tubes, dual-chamber pacemaker
and right subclavian PICC, as before.
.
Cardiology Report ECG Study Date of [**2190-5-23**] 9:02:46 PM
Atrial fibrillation with an average ventricular rate of 101
beats per minute.
Left bundle-branch block. Low QRS voltage in the limb leads.
Non-specific
ST-T wave changes. Compared to the previous tracing ventricular
tachycardia is
no longer present.
TRACING #3
.
abd xray [**5-24**] :IMPRESSION: No bowel dilatation to suggest toxic
megacolon. No evidence of obstruction.
.
cxr [**5-25**] FINDINGS: In comparison with the study of [**5-23**], the
various devices remain in place. Diffuse haziness of both
hemithoraces with preservation of pulmonary markings is
consistent with substantial pleural effusions. Ill-defined
vessels are consistent with the clinical impression of pulmonary
edema. The possibility of a focal pneumonia is impossible to
exclude, especially in the absence of a lateral view.
Brief Hospital Course:
A/P: 89 yo [**Date Range 595**] speaking woman with multiple medical problems
including COPD/CHF/AF and recent admit PNA/sepsis and is s/p
trach/peg at last admission. Also, in wide complex tachycardia
on arrival, she was loaded with amio and then amio gtt,reverted
to afib afterwards.
.
# Hypoxia: Pt has a h/o COPD and asthma and was noted to be
wheezing on exam. XR was revealing for pulm edema, which seemed
to be corroborated on physical exam, but also may have shown a
consolidation c/w pna. On the vent, patient is now sating well
and had good O2 sats while in the ED. WBC not elevated with no L
shift and afebrile on this. DDx: PNA, CHF, COPD, PE. Likely
hypoxia is secondary to heart failure.
Abx for HAP, including coverage MRSA/Klebsiella pna :Levo/Vanc.
Pt received doses in ED. Pt was not specifically treated for
PnA during the hospital stay as she was no displaying signs of
pna. Hypoxia thought secondary to vol overload. Sats improved
after diuresis. Pt was placed on standing nebs prn. Pt was not
given any steroids as they were not deemed necessary. PT was
given lasix with prn IV boluses for diuresis. Pt will be going
to rehab where her vent settings can be further titrated/weaned
prn.
.
#ID-Pt has h.o C.diff from [**Hospital 100**] Rehab, continued on her PO
vanco. UTI was being treated with Vanco (h/o MRSA UTI in the
past) and cipro. Holding off for treating for a PNA at this
point. Pt reportedly had one positive blood culture at [**Hospital 100**]
Rehab for enterococcus, which may be a contaminant but would
likely be covered by the vancomycin she is receiving for her
UTI. Also, the line tip cultured at the time and was negative.
PT is on vanco for ?+bcx and h/o MRSA UTI.
.
# COPD/Asthma: She was continued on her home dose inhalers.
.
# Elevated CE: all previous CE were <0.01 and her admission
Troponin was 0.3, which is mildly elevated. Pt seemed to be
having more abd pain, but being a woman/diabetic atypical
presentations common, so she had three sets of cardiac
biomarkers to rule out MI. Pt ruled out for MI. EKG showed signs
of atrial fib. Pt was continued on her ASA, BB, statin.
.
# CHF: intact systolic EF, h/o diastolic dysfunction but not
assessed due to poor study on most previous echo. Has evidence
of worsening failure on CXR.
diuresis with goal net neg 1L on the day of admission, O2 sats
improved after receiving extra IV lasix (40mg) and diuresing.
.
# Tachycardia: Pt was in a wide complex tachycardia on arrival
to the ED which was felt to be SVT vs. VT. Pt was stable,
maintaning BP and mentating. HR while [**Doctor First Name **] the MICU was irreg in
AF after initiation of amiodarone. Insighting events may include
hypoxia, infection, pain
Cardiology was consulted and recommended d/c amio gtt, starting
diltiazem 30mg po daily and uptitrating PRN. Would suggest dilt
gtt instead of amio as needed for rate control. She did not
require diltiazem gtt, and her beta blocker was increased from
25mg po tid to 37.5mg po tid
.
# AF: Has been paroxysmal and is anticoagulated with warfarin.
After tachycardia broke, still in AF.
- con't anticoagulation with goal INR [**2-28**]
- qd INR checks
.
# SSS s/p pacemaker: pt is intermittantly paced, on EKG but it
is inconsistant and ? pacer functionality. Pt has maintained
BP's throughout in the rapid tacycardia and now in AF
.
# HTN: pt's BP appropriate, will continue on outpatient BB,
lasix
.
# Hyperlipidemia: con't statin
.
# thrombocytopenia: stable
-cont to trend
.
# Abdominal pain/distention: As per the daughter and notes,
patient has experienced chronic abdominal pain ever since the
trach and peg, and has required chronic pain control. She is
mildly distended, but does not have an elevated WBC/F and
lactate normal. Pt has required zofran prn at the nursing home
for this issue on chronic basis. DDx: C.diff colitis,
gatroenteritis, gastrtitis, SBO, chronic abd pain
KUB: "No bowel dilatation to suggest toxic megacolon. No
evidence of obstruction."
LFTs, alk phos, amylase/lipase-were wnl
serial abdominal exams were unchanged
continue pt's chronic pain regimen w/ liquid oxycodone
.
# C.diff colitis: [**Name6 (MD) **] the MD note, pt was dx w/ c.diff colitis
and has been on PO vancomycin. There is no documentation of a +
c.diff.
- c.diff toxin
- con't PO vancomycin
.
# DM: con't SSI and baseline lantus. will do 1/2 dose lantus
while NPO
.
# CRI: past note states baseline at 1.3, but previous labs show
baseline 0.9-1.1.
.
# UTI: Pt had UTI on prior admission as well, and cleared, now
with + UA and Cx pending.
- Cipro/Vanco to cover urine as she has had MRSA urine tract
infections-14 day course
.
# FEN: NPO, replete prn
# PPx: sch, warfarin, PPI, bowel
# ACCESS: midline
# CODE: DNR (confirm w/ daughter)
# COMM: Pt's daughter [**Name (NI) 23**], is HCP. (h)[**Telephone/Fax (1) 93241**],
(w)[**0-0-**], (c)[**Telephone/Fax (1) 93242**]
Medications on Admission:
Aspirin 81 mg qd
Metoprolol 25 mg TID
Simvastatin 20 mg qd
Warfarin 5.5 mg qd
lasix 20mg qd
Albuterol/Ipratropium 2 puffs q6h
Mucomyst neb 200mg/2ml [**Hospital1 **]
Insulin lantus 10U qhs
Insulin Regular QID SSI
Omeprazole 20 mg qd
Oxycodone 15mg q8h
Vancomycin 1g qd (started [**5-20**])
Vancomycin 250 mg qid PO (started [**5-19**])
Chlorhexidine Gluconate
Fe [**Hospital1 **], KCL 20mg qd
Simethicone 80 mg q8h
Trazodone 75mg qhs
artificial tears
miconazole cream tid
prn
bisacodyl, lactulose, senna
viscus lidocaine in mouth
ativan 0.5mg q6h prn
Zofran 4mg q8h prn
oxycodone 10mg
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
Intravenous Q48H (every 48 hours): to complete 14 day course.
1st day [**5-24**].
2. Pantoprazole 40 mg IV Q24H
3. Cipro I.V. 400 mg/40 mL Solution [**Month/Year (2) **]: One (1) Intravenous
once a day for 14 days: to complete 14 day course for UTI tx.
1st day [**5-24**].
4. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
9. Vancomycin 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
10. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
12. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
14. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q 8H (Every 8
Hours).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-27**]
Drops Ophthalmic PRN (as needed).
16. Miconazole Nitrate 2 % Cream [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
17. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4H (every 4
hours) as needed for breakthrough pain.
18. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
19. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation QID (4 times a day).
20. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
21. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3
times a day).
22. insulin sliding scale
see attached sheet
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
hypoxia secondary to CHF/volume overload
acute on chronic diastolic congestive heart failure
urinary tract infection
COPD
------------------
hypertension
hypercholesterolemia
Discharge Condition:
vitals stable.
Discharge Instructions:
You were admitted after you were found to have a low oxygen
saturation, in addition you had chest x ray findings that were
concerning for volume overload. While in the ambulance you had
an abnormal rhythm that was likely your underlying heart rhythm.
You were given a medication for this and your heart rate and
rhythm are now back to your usual. You were found to have a
urinary tract infection for which you are being treated with
vancomycin and ciprofloxacin. Your low oxygen was felt to be
due to fluid in your lungs. Your oxygenation status improved.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
You should follow up with your physician as determined by the
rehab physicians.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2190-6-15**]
|
[
"428.33",
"493.20",
"428.0",
"427.31",
"403.90",
"272.0",
"518.83",
"V45.01",
"585.9",
"V44.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12983, 13049
|
5275, 10149
|
255, 262
|
13268, 13285
|
2865, 5252
|
14012, 14249
|
2373, 2390
|
10786, 12960
|
13070, 13247
|
10175, 10763
|
13309, 13989
|
2228, 2268
|
2406, 2846
|
208, 217
|
290, 1703
|
1725, 2205
|
2284, 2357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 157,119
|
22417
|
Discharge summary
|
report
|
Admission Date: [**2132-5-26**] Discharge Date: [**2132-5-30**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine / Tramadol
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Nausea, vomitting, diarrhea, and hyperglycemia.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27 year-old female with type I DM (diagnosed at age 16) who
presented to ED with 1 day of N/V/D and hyperglycemia. Pt noted
that she started having vomiting 1 day prior to admission,
associated with nausea. Overnight, she had 2-3 episodes of
loose stool - no blood. She denies fevers, chills, abdominal
pain, cough, SOB. Of note, patient has had multiple admissions
similar to this in the past.
She currently manages her diabetes with carbohydrate correcting
and 24 mg glargine. States she took her glargine yesterday
evening as prescribed.
Has chronic back pain relating to an accident in the past. She
is also extremely tearful, states that she recently came to
terms with childhood sexual abuse by her uncle, which occurred
at age 11. Only brought this up within the past week with her
mother.
In the ED, initial vs were: 98.9 125 114/66 20 100% Found to
have glucose of 519 and anion gap of 20. Patient was given 2L
NS with 40 meq K. Insulin gtt initiated. Dilaudid 0.5mg for
pain.
On the floor, pt recieved 2L NS, 80 meq K, zofran for nausea.
Insulin gtt at 5units/hr, increased to 8units/hr. 4g Ca
Gluconate, 2g Mg
Past Medical History:
- Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her
first pregnancy.
- Severe anxiety/panic attacks
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Grade I esophageal varices seen on scope in [**2132-1-1**],
negative liver ultrasound, normal LFTs, hep panel negative
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-3**] - lower back pain since then.
- S/P MVA [**2130**], ex-lap
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
- H pylori, s/p 2-week triple therapy on [**2132-1-24**]
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment with her son. She is currently unemployed and
received disability. Her mother and sisters live nearby. She had
to drop out of school for becoming a medical assistant due to
her multiple hospitalizations. She does not smoke and reports
rare alcohol use on holidays. She denies drug use.
Family History:
Grandmother with type 1 diabetes, no history of CAD,
hypertension, celiac disease, IBD.
Physical Exam:
Admission PE:
Vitals: T: BP: 131/81 P: 118 R: 16 O2: 100%
General: Alert, oriented, no acute distress
[**Location (un) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardia, 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 , no CVA tenderness.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2132-5-26**] 07:30PM BLOOD WBC-17.6*# RBC-3.97*# Hgb-11.4*#
Hct-35.0*# MCV-88 MCH-28.7 MCHC-32.5 RDW-13.1 Plt Ct-236
[**2132-5-27**] 03:00AM BLOOD PT-12.4 PTT-20.9* INR(PT)-1.0
[**2132-5-27**] 03:00AM BLOOD Plt Ct-212
[**2132-5-26**] 06:02PM BLOOD Glucose-349* UreaN-34* Creat-1.6* Na-145
K-4.6 Cl-106 HCO3-13* AnGap-31*
[**2132-5-26**] 06:02PM BLOOD Calcium-9.8 Phos-3.7 Mg-2.8*
Discharge labs:
[**2132-5-29**] 05:03AM BLOOD WBC-6.8 RBC-3.27* Hgb-9.2* Hct-28.7*
MCV-88 MCH-28.0 MCHC-32.0 RDW-13.1 Plt Ct-147*
[**2132-5-29**] 05:03AM BLOOD Glucose-43* UreaN-8 Creat-0.8 Na-137
K-3.8 Cl-105 HCO3-27 AnGap-9
[**2132-5-29**] 05:03AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 Iron-126
[**2132-5-29**] 05:03AM BLOOD calTIBC-342 VitB12-556 Folate-6.7
Ferritn-92 TRF-263
Imaging:
[**5-26**] CXR: No acute cardiopulmonary process
Brief Hospital Course:
27 year-old woman with type 1 diabetes mellitus, admitted to the
ICU with DKA. There were no signs of any localizing infections.
Trigger may be related to emotional stressors. Patient
recently disclosed to her family regarding childhood sexual
abuse by her aunt's boyfriend. DKA was managed with aggressive
fluid repletion and insulin infusion. Once adequately improved,
she moved to the medicine floor where her insulin regimen was
slightly adjusted because of hypoglycemia.
PROBLEM LIST:
# DKA: Unclear trigger, possibly emotional stressor. Resolved
with insulin and IV fluid administration.
# DM, type I, uncontrolled with complications (gastroparesis):
- Lantus reduced from 24 to 20 units QHS
- Sliding scale humalog with meals
- Continued [**Last Name (un) **] follow-up
# Nausea, vomiting: While the patient does have diabetic
gastroparesis, she also has increased nausea/vomiting relating
to emotional trauma from her childhood abuse (as reported by
social work)
# Anxiety / sexual abuse: Patient was sexually abused as a
child, and, for the first time, disclosed this to her mother
just one week prior to admission. Psychiatry was consulted in
the emergency room and recommended to consider in-home services
such as a psychiatric VNA at discharge. Social work has been
very involved during this hospitalization in working with the
patient. The patient's mood and affect are actually much
brighter than in prior admissions.
# Chronic back pain: Dilaudid and oxycodone used initially
during admission. These were discontinued as to not exacerbate
diabetic gastroparesis. Tramadol used sparingly. Gabapentin
has been effective in the past, but the patient discontinued use
of this because of nausea. It is possible that the increased
nausea from Gabapentin may have been from developing DKA or
worsening gastroparesis. She was amenable to restarting
Gabapentin at a lower dose and titrating back up as tolerated.
# HTN: Continue Lisinopril
# Bacteruria-- >100K staph in urine, d/w lab, this is not
saprophyticus, just regular coag negative staph. Given absence
of [**Last Name (un) **], and minimal pyuria, no need for antibiotics at this
time.
TRANSITIONAL ISSUES:
- Close follow-up with [**Hospital3 **] and clinical
pharmacist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) regarding management of diabetes and
chronic back pain
- Close follow-up [**Last Name (un) **] providers regarding diabetes management
- Close follow-up with social work and considering other mental
health services for continued support with regard to her recent
disclosure of childhood sexual abuse.
Medications on Admission:
lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
ondansetron 4 mg Tablet
insulin glargine 100 unit/mL Solution Sig: Twenty Four (24)
units Subcutaneous at bedtime.
Humalog 100 unit/mL Solution Sig: 1-15 units Subcutaneous
three times a day: pls adjust per home sliding scale.
Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
3. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: 1-10 units Subcutaneous
with meals: as directed by your sliding scale.
5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): may increase slowly up to 2 Capsules twice daily
if tolerated.
Disp:*100 Capsule(s)* Refills:*2*
7. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: per sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
- Diabetic ketoacidosis
- Chronic back pain
- Diabetic gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented with nausea, vomiting, diarrhea, and high blood
sugar and were admitted to the ICU for management of diabetic
ketoacidosis. Your condition was stabilized intravenous insulin
and fluids. On the medicine floor, adjustments were made to
your insulin regimen to try to get your blood sugars into the
more normal range. Please contact the 24 hour [**Last Name (un) 387**] line if
your blood sugars are too high or too low.
For your chronic back pain, it would be in your best interest to
avoid/minimize opiod pain medications (like Oxycodone, Dilaudid,
and even Tramadol). These medications can exacerbate your
diabetic gastroparesis. Gabapentin was restarted in the
hospital which has provided you some symptom relief in the past.
This medication can be slowly increased as you can tolerate.
Please continue to seek support through your family, primary
care clinic, and social work as you continue to deal with trauma
from past physical abuse.
MEDICATION CHANGES:
- Lantus insulin reduced to 17 units at night (previously 24
units)
- Gabapentin restarted at 100 mg twice daily. If tolerated, may
increase up to 200 mg twice daily as tolerated. Please work with
your primary care provider if you have any questions regarding
this medication.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2132-6-6**] at 11:50 AM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: REHABILITATION SERVICES
When: FRIDAY [**2132-6-20**] at 11:10 AM
With: [**Name (NI) 29835**] [**Name (NI) 29836**], PT [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: [**Hospital Ward Name **] [**2132-7-15**] at 12:00 PM
With: [**Name6 (MD) 1089**] [**Name8 (MD) 1090**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage;
Also, [**Last Name (un) **] appt as already scheduled (3 weeks from now)
|
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icd9cm
|
[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,777
| 178,636
|
38405
|
Discharge summary
|
report
|
Admission Date: [**2173-2-18**] Discharge Date: [**2173-3-2**]
Date of Birth: [**2105-11-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation [**2173-2-18**]
Lumbar puncture [**2173-2-20**]
History of Present Illness:
67F with end stage multiple sclerosis c/b torticollis who
presents to ED from long-term care facility with AMS. Patient
with chronic indwelling foley, and she finished a course of
cipro on [**2-14**] for a UTI. She became increasing altered in the
days prior to admission and became unresponsive in the ED. She
was admitted to the ICU with BP of 86/40 and was intubated for
airway protection. She was fluid responsive, and never on
pressors. Initially she put on Vanc/Cefepime/Cipro for sepsis of
unknown source. Urine cx grew Vanc-sensitive enterococcus, and
abx were narrowed to Vanc alone. Due to persistent altered
state, EEG was ordered which showed concern for non-convulsive
status epilepticus. She was by neuro and started on Keppra with
resolution of seizure activity. LP, although difficult, was
negative for high OP, meningitis, and HSV. She remained
intubated until [**2-25**]. Prior to extubation, tan secretions were
noted and she was placed on VAP protocol with Vanco, Tobra
(given no cipro for seizures), Zosyn. MiniBAL and sputum cx are
pending.
.
Currently, patient denies difficulty breathing or cough. She is
hungry, asking for doritos, and denies abdominal pain or nausea.
She has no headache.
Past Medical History:
- Multiple sclerosis diagnosed at age 30, wheel chair bound
since [**2166**]
- Torticollis
- Scoliosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] rod placement
- Constipation
- Chronic pain
- Allergic rhinitis
- Depression
- Peripheral vascular disease
- Urinary incontinence
- Neurogenic bladder with chronic Foley catheter
- HTN
- Osteoporosis
- Obstructive hydrocephalus
- Insomnia
Social History:
Has been living in a nursing facility for about the past 2
years. Is divorced and has one son who is her only support
outside the facility. No tobacco, alcohol, or drug use per son.
Family History:
Parents lived till mid 80s w/o major medical ailments. Father
died of heart attack. Grandmother developed dementia at last
year of her life.
Physical Exam:
FEX ON MICU ADMISSION
Vitals: T: 101, BP: 130s-170s/40s-90s, P: 120s-130s, R: 15 O2:
100% on AC with TV=400, PEEP=5, FiOs=50%
General: Intubated/sedated, responds to painful stimuli
HEENT: Sclera anicteric, dry MM, ET tube in place, PERRL
Neck: muscle contractures with rightward head deviation from
torticollis
CV: Tachcardic, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: Bilateral upper extremities appear mottled and cool to the
touch with good pulses. Lower extremities are warm, well
perfused, 2+ pulses, no clubbing or edema
Neuro: intubated/sedated, responds to painful stimuli, opens
eyes spontaneously, marked muscular contractures, rightward head
deviation from torticollis
FEX ON DISCHARGE
VS - 98.8 98.3 159/77 96 20 97%RA
General: Awake, alert, oriented and appropriate
HEENT: Sclera anicteric, MMM
Neck: Muscle contractures with rightward head deviation from
torticollis
CV: RRR, no murmurs, rubs, gallops
Lungs: Appears comfortable on RA. Limited posterior
ausculatation clear.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: No CCE, no joint swelling or pain, RLE with anterior
bruising, no increased swelling or pain.
Neuro: awake, alert, and oriented. Good attention and follows
commands. Marked muscular contractures, rightward head deviation
from torticollis. Strength unchanged
Pertinent Results:
PERTINENT MICROBIOLOGY:
[**2173-2-25**] 12:04 pm Mini-BAL
**FINAL REPORT [**2173-2-27**]**
GRAM STAIN (Final [**2173-2-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2173-2-27**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Time Taken Not Noted Log-In Date/Time: [**2173-2-18**] 11:54 am
BLOOD CULTURE
**FINAL REPORT [**2173-2-22**]**
Blood Culture, Routine (Final [**2173-2-21**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
ENTEROCOCCUS FAECALIS.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 2.0 MCG/ML SENSITIVE Sensitivity testing
performed by
Etest. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2173-2-19**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 0503 ON
[**2-18**] - [**Numeric Identifier 85530**].
GRAM POSITIVE COCCI.
PAIRS AND SHORT CHAIN.
Aerobic Bottle Gram Stain (Final [**2173-2-19**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by DR. [**Last Name (STitle) **] [**2173-2-19**] 12:18PM.
Time Taken Not Noted Log-In Date/Time: [**2173-2-18**] 11:11 am
URINE
**FINAL REPORT [**2173-2-20**]**
URINE CULTURE (Final [**2173-2-20**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
.
PERTINENT STUDIES:
[**2173-2-27**] Radiology CHEST PORT. LINE PLACEM
Rotated positioning. Previously seen left IJ catheter has been
removed. Left subclavian PICC line is present. The tip may be
partially obscured by the spinal hardware. However, I suspect it
is unchanged in position and likely lies at the SVC/RA junction.
No pneumothorax is detected. Again seen is obscuration of the
left diaphragm and increased retrocardiac density. There is more
pronounced patchy opacity at the right base. Suspect mild
pulmonary vascular plethora.
[**2173-2-26**] Radiology CHEST (PORTABLE AP)
Interval extubation. Stable bilateral pleural effusions, large
on the left and small on the right. Possible minimal pulmonary
edema.
[**2173-2-21**] Neurophysiology EEG
This is an abnormal continuous ICU monitoring study because
of frequent bifrontal and parasagittal generalized periodic
epileptiform discharges. Although some of the bifrontal
discharges have triphasic features but, given their evolution,
these are most likely related to earlier epileptiform activity.
These findings are indicative of focal cortical irritability and
potential epileptogenicity predominantly in the bifrontal
regions. In addition, the background is diffusely slow and
disorganized indicative of moderate to severe encephalopathy.
Compared to the prior day's recording, there is improvement with
fewer blunted discharges and longer periods of disorganized
theta activity without bifrontal discharges.
[**2173-2-20**] Radiology MR HEAD W & W/O CONTRAS
1. Unchanged ventriculomegaly with associated cerebellar
atrophic
changes, with no evidence of transependymal migration of CSF.
Scattered foci of high signal intensity are identified in the
subcortical and periventricular white matter, likely consistent
with chronic microvascular ischemic changes.
2. Chronic hydrocephalus, possibly communicating, is a
consideration, there is no evidence of leptomeningeal
enhancement to suggest arachnoiditis, the possibility of a
Dandy-Walker variant is also a consideration.
3. Unchanged opacity of the ethmoidal air cells and sphenoid
sinus suggesting an ongoing inflammatory process.
[**2173-2-20**] Cardiovascular ECHO
Poor image quality. 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. The RV is not well seen but
overall normal free wall contractility is probably normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild to moderate ([**12-28**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
[**2173-2-20**] Neurophysiology EEG
This is an abnormal continuous ICU monitoring study because of
frequent generalized periodic epileptiform discharges (GPEDs) at
times as frequent as one to two per second. These do not
evolvefurther into non-convulsive status epilepticus. However,
these findings are indicative of severe cortical irritability
and potential epileptogenicity in a generalized distribution.
The backgroundtowards the later portion of the recording is
diffusely slow and disorganized indicative of moderate to severe
encephalopathy.
[**2173-2-19**] Radiology BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in either lower extremity.
The study and the report were reviewed by the staff radiologist
.
[**2173-2-18**] Radiology CT HEAD W/O CONTRAST
1. No evidence for intracranial hemorrhage or other definite
acute process.
2. Moderate enlargement of all ventricles, more striking than
background cerebral atrophic changes, although cerebellar
atrophy is substantial. There is no hypodensity about the
ventricles to suggest transependymal edema. Correlation with
clinical history is recommended and comparison to prior head CT,
if available, may be helpful to assess for chronicity. Major
differential considerations include chronic hydrocephalus,
probably communicating, associated with a prior inflammatory
process such as arachnoiditis or perhaps in association with a
congenital lesion such as Dandy-Walker variant.
3. Opacification of the left sphenoid sinus with bony thickening
suggesting longer chronicity and hyperdense material suggestive
of fungal colonization.
Blood:
[**2173-2-18**] 12:54PM BLOOD WBC-20.3* RBC-4.26 Hgb-13.0 Hct-38.2
MCV-90 MCH-30.4 MCHC-33.9 RDW-12.6 Plt Ct-242
[**2173-2-20**] 01:15PM BLOOD WBC-15.5* RBC-3.44* Hgb-10.1* Hct-29.0*
MCV-84 MCH-29.5 MCHC-35.0 RDW-13.1 Plt Ct-210
[**2173-2-23**] 03:09AM BLOOD WBC-15.3* RBC-3.38* Hgb-9.8* Hct-28.3*
MCV-84 MCH-29.0 MCHC-34.6 RDW-13.1 Plt Ct-272
[**2173-2-26**] 02:15AM BLOOD WBC-17.6* RBC-3.55* Hgb-10.3* Hct-30.6*
MCV-86 MCH-29.0 MCHC-33.7 RDW-13.1 Plt Ct-457*
[**2173-2-28**] 05:20AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-26.5*
MCV-82 MCH-29.1 MCHC-35.5* RDW-13.5 Plt Ct-456*
[**2173-3-2**] 05:16AM BLOOD WBC-13.9* RBC-3.29* Hgb-9.9* Hct-27.5*
MCV-84 MCH-30.1 MCHC-36.1* RDW-14.0 Plt Ct-485*
[**2173-2-20**] 01:15PM BLOOD PT-13.3* PTT-31.9 INR(PT)-1.2*
[**2173-2-22**] 04:31AM BLOOD PT-12.1 PTT-37.4* INR(PT)-1.1
[**2173-2-18**] 12:54PM BLOOD Glucose-149* UreaN-30* Creat-0.8 Na-145
K-3.7 Cl-112* HCO3-18* AnGap-19
[**2173-2-21**] 03:41AM BLOOD Glucose-125* UreaN-10 Creat-0.2* Na-142
K-3.2* Cl-106 HCO3-29 AnGap-10
[**2173-2-23**] 03:09AM BLOOD Glucose-131* UreaN-9 Creat-0.3* Na-144
K-3.7 Cl-101 HCO3-35* AnGap-12
[**2173-2-25**] 03:40AM BLOOD Glucose-135* UreaN-15 Creat-0.4 Na-137
K-4.2 Cl-100 HCO3-24 AnGap-17
[**2173-2-28**] 05:20AM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-141
K-2.9* Cl-104 HCO3-27 AnGap-13
[**2173-3-2**] 05:16AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2173-2-18**] 12:54PM BLOOD ALT-18 AST-30 LD(LDH)-367* CK(CPK)-171
AlkPhos-92 Amylase-111* TotBili-0.4
[**2173-2-20**] 01:15PM BLOOD ALT-18 AST-29 LD(LDH)-360* AlkPhos-94
Amylase-57 TotBili-0.5
[**2173-2-18**] 12:54PM BLOOD Lipase-26
[**2173-2-18**] 12:54PM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-0.06*
[**2173-2-19**] 03:57PM BLOOD Calcium-9.1 Phos-1.2* Mg-1.8
[**2173-2-23**] 03:09AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
[**2173-2-27**] 05:39AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7
[**2173-3-2**] 05:16AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
[**2173-2-21**] 03:41AM BLOOD Cortsol-8.3
[**2173-2-19**] 03:57PM BLOOD TSH-0.84
[**2173-2-20**] 09:09PM BLOOD Vanco-8.0*
[**2173-2-25**] 03:40AM BLOOD Vanco-32.0*
[**2173-2-26**] 02:15AM BLOOD Tobra-1.8*
[**2173-2-27**] 08:53PM BLOOD Vanco-14.5
[**2173-2-18**] 10:49AM BLOOD Type-ART pO2-160* pCO2-53* pH-7.31*
calTCO2-28 Base XS-0
[**2173-2-19**] 09:06AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.34*
calTCO2-23 Base XS--3
[**2173-2-24**] 02:25PM BLOOD Type-ART PEEP-5 pO2-141* pCO2-40 pH-7.48*
calTCO2-31* Base XS-6 Intubat-INTUBATED
[**2173-2-18**] 11:08AM BLOOD Lactate-4.4*
[**2173-2-18**] 12:51PM BLOOD Lactate-1.8
[**2173-2-19**] 09:06AM BLOOD Glucose-148* Lactate-2.5* Na-143 K-4.4
Cl-115*
[**2173-2-20**] 01:24PM BLOOD Lactate-0.7
[**2173-2-24**] 02:25PM BLOOD Lactate-1.8
URINE:
[**2173-2-18**] 04:14PM URINE Color-AMBER Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2173-2-18**] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2173-2-18**] 04:14PM URINE RBC-121* WBC-62* Bacteri-MANY Yeast-NONE
Epi-1
[**2173-2-18**] 04:14PM URINE CastHy-8*
[**2173-2-25**] 10:07AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2173-2-25**] 10:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
CSF:
[**2173-2-20**] 03:46PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-1
Lymphs-70 Monos-29
[**2173-2-20**] 03:46PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-85
[**2173-2-20**] 03:46PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-NEGATIVE
[**2173-2-20**] 2:09 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2173-2-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2173-2-23**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
67 year old female with PMH of multiple sclerosis and
torticollis presenting from a long term care facility for
further evaluation of altered mental status and being
transferred to the ICU for likely urosepsis after intubation for
airway protection.
ACTIVE PROBLEMS
# Urosepsis: The patient has a known neurogenic bladder from her
underlying multiple sclerosis with a chronic indwelling Foley.
On admission, she was noted to be in septic shock with positive
UA, BP of 86/40 and altered mental status. Due to her
unresponsive state, she was intubated and placed on a vent in
the ED. Her septic shock was initally treated broadly with
vanco/cefepime/cipro; as further cultures came back, she was
discovered to have a Vancomycin sensitive enterococcus growing
from blood and urine. She did not require any pressors during
her hospitalization. The day prior to her discharge from the ICU
she was noted to have increased tan secretions, increasing WBC
count, and low grade fever concerning for VAP. She was initated
on VAP protocol with Tobramycin and Zosyn in addition to her
Vancomycin for VSE. However, she was rapidly extubated and
transferred to the floor with improving clinical status. All
BAL/sputum Cx returned negative for growth and decision was made
to discontinue VAP coverage. Pt was switched to ampicillin
alone to complete a 14 day course for VSE urosepsis, last dose
[**3-4**] PM, then PICC line may be pulled.
# Respiratory Failure/VAP: She was intubated until 1 day prior
to her discharge from the ICU for concerns regarding her mental
status, as well as secretions. She was also a very difficult
intubation due to her torticollus. Given concern for VAP on [**2-25**]
in setting of with new tan secretions and leukocytosis, she was
started on tobramycin and zosyn in addition to vanco on [**2-25**]. She
was also started on hyoscyamine for secretions. Following
discharge from the ICU, patient's respiratory status was greatly
improved and she was satting well on room air. Given clinical
improvement and negative BAL cultures, VAP coverage antibiotics
were discontinued. Pt was monitored clinically on Ampicillin
alone for an additional 48hrs and remained afebrile with no new
respiratory symptoms, maintaining sats on RA.
# Altered Mental Status/Seizures: Patient noted on EEG
suggestive of non-convulsive status. Unclear how long patient
has been having seizures. An LP was performed, which was
predominately negative. Patient was started on acyclovir,
empirically. MRI showed chronic hydrocephalus and
ventriculomegaly with periventricular white matter changes.
Acyclovir was discontinued once CSF was negative for HSV.
Patient became much more alert and interactive following
extubation. She was maintained on Keppra and Risperdal was
stopped. On transfer to the floor, patient was alert and
oriented x3. She was discharged at her baseline mental status.
# Goals of care: Patient a DNR/DNI, confirmed in discussion with
patient once extubated and lucid; son and HCP [**Name (NI) **] expressed
interest in the patient being made do not hospitalize with
palliative care. As of now, patient may be rehospitalized, but
the facility should contact [**Name (NI) **] prior to transferring her to
hospital. [**Doctor First Name **] was advised to follow up with facility if the
patient decides those are her wishes.
#. Sinus Tachycardia. Patient had sinus tachycardia into the
120s while in the ICU. Patient was placed on lower dose
Metoprolol 37.5 mg TID while in the ICU. Prior to discharge,
metoprolol was increased to her home dose of 150mg daily and HR
remained in the 80s.
# CT read of fungal sinusitis: Per ENT, CT was suggestive of a
chronic process and not invasive fungal disease. ENT recommended
an outpatient follow-up for possible resection if symptomatic.
Currently, fungal ball is not symptomatic.
CHRONIC PROBLEMS
# Hydrocephalus: Chronic, no changes during hospitalization.
#. Multiple Sclerosis. The patient has severe multiple
sclerosis with resultant muscle contractures; she has been
wheelchair bound since [**2166**], and has a neurogenic bladder
requiring chronic Foley. We continued her on some of her home
medications, but not all given concerns for her mental status.
Her baclofen was decreased to 5mg tid, and her bethanechol was
discontinued.
#. Chronic pain. Seemingly related to contractures from
underlying multiple sclerosis. Patient denied pain during her
stay. We continued her on a lidoderm patch prn but have been
holding her home ibuprofen, MS Contin, tramadol, gabapentin and
voltaren gel. She was doing well on this minimized regimen and
may not need this additional medications going forward.
#. HTN. Held home lisinopril while in ICU in setting of
urosepsis. After transfer to the floor, her home dose of
lisinopril was restarted. Metoprolol was also started at a lower
dose (37.5 mg TID) until uptitration to her home dosing of
150mg Toprol daily prior to discharge.
#. Osteoporosis. Held home alendronate. Continued Calcium
supplementation.
#. Constipation. Continued home docusate, senna, miralax.
#. Depression: Had been holding home medications given
intubation and altered mental status. Discontinued risperdol and
Tramadol given they can lower seizure threshold. We also held
her abilify and trazadone. We continued her citalopram.
MEDICATION CHANGES
Start Keppra 750mg po bid
Start ampicillin 2 IV q4 to complete 2 weeks
Decrease baclofen to 5mg tid
Stop bethanechol
Stop morphine
Stop Tramadol
Stop gabapentin
Stop Risperdal
Stop trazodone
Stop voltaren
TRANSITIONAL ISSUES
-Made a number of adjustments to her psychiatric and pain
medications. Would monitor closely
-Will need to complete 14 days of ampicillin to treat urosepsis
-Patient with apparent fungal ball in sinus on CT. Currently
asymptomatic. Would continue to monitor.
-Please talk to HCP and son [**Name (NI) **] before any major changes to
patient's goals of care
***If patient becomes febrile, develops productive cough or
worsening respiratory status, low threshold to initiate
Vancomycin and Pip/Tazo for 7 day course for HCAP treatment.***
Medications on Admission:
- Alendronate 70mg weekly on Monday
- ASA 81mg daily
- Baclofen 10mg TID
- Bethanechol 50mg QID
- Calcium carbonate 500mg TID
- Cranberry 475mg daily
- Docusate 200mg [**Hospital1 **]
- Fish Oil daily
- Fleet enema rectally every day PRN constipation
- Loratadine 10mg daily
- Fiber daily
- Metoprolol succinate 150mg daily
- Multivitamin daily
- Miralax 17 grams twice daily
- Selenium 200mcg
- Senna 4 tabs twice daily every other day
- Vitamin B complex daily
- Vitamin C 500mg daily
- Vitamin D 1000 units daily
- Ibuprofen 600mg TID
- Lidoderm 5% patch topically to sternum (12 hrs on/12 hrs off)
- Tylenol 1000mg three times daily
- Morphine ER 30mg [**Hospital1 **]
- Tramadol 75mg every 6 hours prn pain
- Abilify 2.5mg at bedtime
- Citalopram 40mg daily
- Gabapentin 100mg every morning
- Gabapentin 300mg at 2PM and 8PM
- Risperdal 0.5mg [**Hospital1 **] prn agitation
- Trazodone 100mg at bedtime
- Voltaren 1% gel to chest every 4 hours PRN pain
- Lisinopril 10mg daily
- Flaxseed oil 1000mg daily
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
on Monday.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
4. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO three times a day.
5. cranberry 475 mg Capsule Sig: One (1) Capsule PO once a day.
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Fish Oil Oral
8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
10. Fiber Supplement Powder Oral
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Miralax 17 gram/dose Powder Sig: One (1) pack PO twice a day
as needed for constipation.
14. selenium 200 mcg Capsule Sig: One (1) Capsule PO once a day.
15. senna 8.6 mg Capsule Sig: Four (4) Capsule PO every other
day.
16. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
17. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
21. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three
times a day.
22. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
23. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
25. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Intravenous every four (4) hours for 3 days: Last dose 3/8 PM.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for living
Discharge Diagnosis:
Sepsis from a urinary source
Status epilepticus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you had a severe
urinary tract infection which led to persistent seizures. You
were treated in the intensive care unit, and you were intubated
for several days. You were started on IV antibiotics to treat
your infection and started on levetiracetam (Keppra) to control
the seizures. Once these were controlled, you were transferred
to the floor, and we watched you for a few days while we
adjusted your medications. At this time, it is safe for you to
return home. You should follow up with your neurologist as
scheduled below.
Please note the following changes to your medications:
Start Keppra 750mg po bid
Start ampicillin 2 IV q4 to complete 2 weeks
Decrease baclofen to 5mg tid
Stop bethanechol
Stop morphine
Stop Tramadol
Stop gabapentin
Stop Risperdal
Stop trazodone
Stop voltaren
Followup Instructions:
Location: [**Hospital3 3765**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Bldg
Address: 131 ORNAC [**Apartment Address(1) 85531**], [**Location (un) 1514**], MA
Phone: [**Telephone/Fax (1) 85532**]
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], Neurology
Appt: [**3-9**] at 11am
|
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icd9cm
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[
[
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,656
| 157,923
|
8592
|
Discharge summary
|
report
|
Admission Date: [**2167-12-17**] Discharge Date: [**2167-12-23**]
Date of Birth: [**2111-7-17**] Sex: M
Service: MEDICINE
Allergies:
Quinine
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Hyperglycemia, Back Pain, Leg Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 yo M with T2DM, ESRD s/p renal transplant who presented to
clinic today with left leg weakness and back pain. He notes that
the symptoms have increased with exercise over the past month
and has had two falls over the past week; he denies shooting
pain or paresthesias. He has had chronic back pain, s/p L4-L5
laminectomy in [**2165**].
.
As he was being evaluated in clinic, he was noted to be markedly
lethargic. A fingerstick was obtained which was greater than
assay and he was subsequently sent to the ED for further
evaluation. He notes that he woke up this morning feeling
hypoglycemic, and had honey and nuts cereal along with a glass
of [**Location (un) 2452**] juice.
.
In the emergency department, initial vitals were 98.3, 95,
128/78, 18, 100% RA. His glucose was found to be 1300 per report
initially and patient was started on insulin drip and IVF. UA
was notable for ketones without evidence of infection. Blood
cultures were drawn.
.
Patient arrives on floor in good condition, with glucose of 263
on repeat draw.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, chest pain, shortness of
breath, nausea, vomiting, abomindl pain, diarrhea;
Past Medical History:
- Type 2 DM
- ESRD [**1-5**] DM, s/p cadaveric renal Tx 10/[**2162**]. Participating in
research study.
- h/o C.diff '[**61**] (per pt report)
- HTN
- hypercholesterolemia
- GERD
- Obesity
- h/o chronic low-grade temps (99.5), recently resolved
- h/o right charcot foot
- s/p CCY
Social History:
- Patient works as a music teacher at a local school. He lives
at home with his wife and his mother.
- Patient denies smoking, alcohol use and other drug abuse.
Family History:
N/A
Physical Exam:
Tc: 99.7 Tm 100.6 BP:99/62(90-129/57-84) HR:90(89-102) RR:20 02
sat:99% on RA
GENERAL: Pleasant, male in NAD appears older than stated age
HEENT: Normocephalic, atraumatic. No conjunctival pallor. B/L
sclera injected. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops. JVP=7cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Pain with palpation of L hip and with rotation of
hip. Pain with passive flexion and extension of knee.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 4-/5 strength throughout except LLE [**2-5**].
1+ reflexes, equal BL. Normal coordination. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on Admission:
[**2167-12-17**] 11:16PM BLOOD WBC-3.1* RBC-5.54 Hgb-15.5 Hct-45.5
MCV-82 MCH-28.1 MCHC-34.2 RDW-14.8 Plt Ct-177
[**2167-12-17**] 04:00PM BLOOD Neuts-62 Bands-0 Lymphs-17* Monos-19*
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2167-12-17**] 06:45PM BLOOD Glucose-542* UreaN-37* Creat-1.6* Na-134
K-4.5 Cl-94* HCO3-25 AnGap-20
[**2167-12-17**] 06:45PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.0
[**2167-12-18**] 03:16AM BLOOD tacroFK-4.6*
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-12-23**] 10:00AM 8.7 5.14 13.7* 44.4 86 26.7* 30.9* 14.5
173
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2167-12-23**] 10:00AM 76.7* 13.9* 6.9 1.6 0.9
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2167-12-21**] 07:05AM NORMAL1 NORMAL NORMAL NORMAL NORMAL
NORMAL
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-12-23**] 10:00AM 275*1 15 1.2 134 4.3 98 29 11
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2167-12-19**] 07:40AM 12 16 30*1 89
ADDED ON @ 1045AM
OTHER ENZYMES & BILIRUBINS Lipase
[**2167-12-19**] 07:40AM 18
ADDED ON @ 1045AM
CPK ISOENZYMES CK-MB cTropnT
[**2167-12-19**] 07:40AM NotDone1 0.012
ADDED ON @ 1045AM
NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY Calcium Phos Mg
[**2167-12-23**] 10:00AM 8.3* 2.1* 2.0
PITUITARY TSH
[**2167-12-19**] 07:40AM 1.5
ADDED ON @ 1045AM
ANTIBIOTICS Vanco
[**2167-12-21**] 07:05AM 21.3*
TROUGH
TOXICOLOGY, SERUM AND OTHER DRUGS tacroFK
[**2167-12-23**] 10:00AM 12.91
Micro: EBV VL pending upon discharge
[**2167-12-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING
INPATIENT
[**2167-12-19**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-FINAL INPATIENT
[**2167-12-19**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT
[**2167-12-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2167-12-19**] URINE URINE CULTURE-FINAL INPATIENT
[**2167-12-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2167-12-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2167-12-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2167-12-17**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
Studies:
[**12-17**] CXR: Heart size normal. No pleural abnormality or evidence
of
central adenopathy.
1/14 L spine: Status post L4 through L5 posterior fusion without
fracture or change in alignment. Unchanged minimal lucency
surrounding the right L4 pedicle screw.
.
1/14Knee: No fracture or dislocation. Probable suprapatellar
joint
effusion. Vascular calcifications.
.
[**12-19**] CXR: No evidence of acute cardiopulmonary process.
.
CT Abd/pelvis:
1. Right renal transplant with no peri-transplant fluid
collection or mass to
suggest post-transplant lymphoma.
2. No mesenteric or retroperitoneal lymphadenopathy is
demonstrated.
3. Diffuse body wall fat stranding suggestive of mild fluid
overload.
.
MRI spine:
1. The patient is status post posterior fixation, consistent
with L4 and L5 laminectomies and interval placement of
transpedicular screws as described in detail above. There is no
evidence of mass, mass effect, or fluid collection to suggest
abscess or osteomyelitis, persistent diffuse low-signal
intensity throughout the lumbar spine, similar to the prior
examination.
2. Multilevel disc degenerative changes throughout the lumbar
spine as
described in detail above. More significant at the level of
L3/L4, L4/L5
levels. Causing moderate-to-severe spinal canal stenosis.
.
[**12-19**] Pelvic XR: The patient is after lumbar spine surgery. There
is no evidence of pelvic fracture. There are degenerative
changes that did not significantly change since the prior study.
Multiple phleboliths and calcifications of the vessels are
projecting over the pelvis.
No evidence of fracture is present in each of the femurs.
Note is made that if clinical concern is significant, further
evaluation with cross-sectional imaging might be considered.
Brief Hospital Course:
Mr. [**Known lastname 1968**] is a 56 yo M with DM 2 and ESRD s/p transplant [**2162**]
admitted to ICU for HONK vs. DKA who developed febrile
neutropenia while on the floor.
MICU course:
While in the ICU, the patient was started on an insulin drip and
D5 1/2NS then converted to 70/30 [**Hospital1 **] with a humalog sliding
scale per the recommendations of [**Last Name (un) **] (where he is regularly
seen). His sugars corrected to the 300s the night prior to
transfer, and then the 160s-180s the night of transfer. [**Last Name (un) **] &
Transplant nephrology were consulted and are following. The DKA
was thought to be secondary to non-compliance, but given his
recent history of GI complaint, the true reason is unclear. The
patient also complained of LE weakness, but walked successfully
with Physical Therapy.
.
# Fevers: Patient with febrile neutropenia(drops counts on
immunosuppression), received 1 dose of neupogen and 4 days of
vanc/ceftaz. Patient defervesed but no source was idenitified.
CMV VL neg and EBV VL pending upon discharge. Blood, urine
cultures with no growth. CXRs clear. CT abd/pelvis wnl and MRI
Lspine without abscess.
.
# Leukopenia/cytosis: Neutropenic, in setting of
immunosupression with progaf and cellcept for kidney tranplant.
Improved with neupogen x1.
.
# Diabetes Mellitus s/p DKA vs HONK: [**Last Name (un) **] assisted in the
management of his difficult to control sugars s/p HONK. The
underlying cause of this is still unclear but I presume most
likely [**1-5**] nonadherence to insulin and possible infection. Ruled
out forischemia. Insulin 70/30 [**Hospital1 **] uptitrated by Joslian. Con
Humalog sliding scale.
.
# Left leg weakness, chronic back pain. Likely chronic pain but
given multiple falls concerning for acute exacerbation. Is
status post L4-L5 decompression and fusion [**8-10**] and has had
similar symptoms as an oupt. Does have left lower ext weakness.
MRI without acute pathology. Neuro consulting believe
radiculopathy [**1-5**] lumbar stenosis. No acute fx on pelvix xrays.
Continue home dose tramadol prn. PT consult assessed and cleared
for [**Last Name (un) **] PT. Neuro recommended outpatient follow up for possible
EMG. Ortho follow up warranted as well for complaints of left
leg giving out.
.
# Acute on CKD: Improved with hydration. Likely pre-renal. S/p
kidney transplant. Cr at 1.3 baseline for recent years.
Transplant nephrology following. Continued Myfortic &
Tacrolimus, daily tacro levels which were within normal limits.
AceI held. Resumed patient's lasix.
.
# Hyponatremia: Upon admission, thought [**1-5**] pseudohyponatremia.
Improved after patient's glucose control improved.
.
# Transietn Thrombocytopenia: Improve as patient stabilized.
Coags wnl.
.
# Weightloss: 75 lb overlast year he attributes to life
stressor, GI [**Name8 (MD) 3782**] MD [**First Name (Titles) **] [**Last Name (Titles) **] for gastroparesis, neuropathy
and possible depression. Cont nortryptiline 10mg qhs.
.
# Sleep Apnea: Patient has CPAP at home he refused to use. In
house, 4L oxygen use at night. Outpatient sleep follow up.
.
# HTN. BP have been borderline. Patient says lisinipril stopped
as outpatient because of this. Resumed lasix after BP improved.
.
# GERD: Continued home [**Hospital1 **] protonix
.
# General Care: FEN: IVF in ICU, replete electrolytes, diabetic
diet, Prophylaxis: Subcutaneous heparin, bowel reg, pain
control, home PPI, Access: PIV, Communication: Patient,
patient's brother [**Telephone/Fax (1) 30137**], Code: Full confirmed,
Disposition: home with services.
Medications on Admission:
- Enalapril 2.5 mg daily.
- Furosemide 20 mg daily.
- Lantus 50 units every evening.
- Humalog sliding scale.
- Myfortic 180 mg b.i.d.
- Protonix 40 mg b.i.d.
- Prograf 4 mg b.i.d.
- Tramadol 50 mg as needed.
- Aspirin 81 mg daily.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
3. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO bid ().
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: 36 Units
qam and 26 units qpm units Subcutaneous twice a day.
Disp:*qs units* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: as directed per sliding
scale units Subcutaneous four times a day.
Disp:*qs for 30 days units* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary:
Hyperosmolar Nonketotic Acidosis
Febrile Neutropenia
Lumbosacral radiculopathy
Diabetes
.
Secondary:
status post kidney transplant(ESRD)
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 ICU because of your diabetes being out
of control which we believe was because you were not taking
enough insulin. That stabilized but because of your
immunosuppressants you counts dropped too low and you had a
fever which required broad spectrum antibiotics. [**Last Name (un) **] was
following you in the hospial and adjusted your insulin regimen.
You were also seen by the neurology team because of your hip and
back pain. You had an MRI of you back which showed the
degeneration in your spine which was old.
.
Please keep all your follow up appointments.
.
Please take all medications as prescribed.
Medication changes:
1)We also started you on NPH insulin and stopped the lantus.
2)We also started you on Vitamin D.
3)All other medications remain unchanged.
.
If you develop any warning symptoms listed below or any other
symptoms that are concerning to you, please call your primary
care doctor or go to your local emergency room.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]
Specialty: Orthopedics
Date/ Time: Monday, [**1-25**] at 12:40pm
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 551**], [**Location (un) 86**] MA
Phone number: ([**Telephone/Fax (1) 2007**]
.
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**]
Specialty: Endocrinology/[**Last Name (un) **]
Date/ Time: Tuesday, [**12-29**] at 11:30am
Location: One [**Last Name (un) **] Place, [**Location (un) 86**] MA
Phone number: ([**Telephone/Fax (1) 4847**]
.
Appointment #3
MD: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2168-1-1**] 1:45pm
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 895**]
Central Suite, [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 250**]
Special instructions for patient: Dr [**Last Name (STitle) 21883**] is your new physician
in [**Name9 (PRE) 191**] and Dr [**Last Name (STitle) 21883**] works closely with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]
both will be involved in your care. For insurance purposes
please indicate Dr. [**Last Name (STitle) **] as your Primary Care Physician.
.
Appointment #4
MD: Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**]
Specialty: Neurology
Date/ Time: [**2168-1-19**] 3:00pm
Location: [**Location (un) 830**], [**Hospital Ward Name 23**] Building [**Location (un) 858**],
[**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 1694**]
.
Appointment #5
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Sleep Disorders
Date/ Time: Wednesday, [**12-30**] at 9:00am
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 858**], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 6856**]
Special instructions for patient: Please arrive at 8:50am for
check in.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2167-12-23**]
|
[
"530.81",
"357.2",
"250.42",
"276.7",
"536.3",
"585.9",
"250.62",
"278.00",
"276.1",
"780.61",
"996.81",
"287.5",
"584.9",
"250.22",
"311",
"338.29",
"403.90",
"288.00",
"272.0",
"V15.81",
"250.12"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12173, 12232
|
7274, 10836
|
305, 311
|
12422, 12422
|
2993, 2998
|
13588, 15871
|
2015, 2020
|
11118, 12150
|
12253, 12401
|
10862, 11095
|
12599, 13231
|
2035, 2974
|
1392, 1518
|
13251, 13565
|
231, 267
|
3457, 7251
|
339, 1373
|
3012, 3438
|
12436, 12575
|
1540, 1821
|
1837, 1999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,211
| 197,875
|
34988
|
Discharge summary
|
report
|
Admission Date: [**2191-11-11**] Discharge Date: [**2191-11-24**]
Date of Birth: [**2108-8-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2191-11-18**] - CABGx3(Left internal mammary artery->Left anterior
descending artery, Vein graft->Obtuse marginal artery, Vein
graft->Posterior descending artery)
[**2191-11-14**] - Cardiac Cathetriztaion
History of Present Illness:
83F with history of hypertension admitted to OSH for 2 weeks of
chest pain radiating to back, neck and arm who is not
transferred to [**Hospital1 **] for further evaluation and possible cardiac
catheterization. Pt states that the pain began about 2 week ago.
It has been intermittent with paroxyms lasting 5-10 minutes. Pt
states that the onset is gradual and that the pain increases
over the 5-10 minutes to a maximum of [**11-4**]. She had taken ASA
at home with some relief of her symptoms and NTG at the OSH
which relieved her symptoms. The pain seems to be getting worse
over the last 2 weeks. At times it takes her breath away. She
does state that the pain is the same as reflux symptoms that she
has had in the past, though this pattern and presenation s clear
more persistent and severe. The patient notes that her chest and
abdomen turn red when she is having the pain and that her blood
pressure shoots up to the 190s from a baseline in the 150-160s.
She denies palpitations but does note dyspnea on exertion which
has been progressive since her stroke six years ago, likely due
to a significant decrease in her activity level. EKGs at OSH
unchanged from baseline but does have significant LVH with ST
changed. Trop at OSH equivocal at .04. Pt started on a heaprin
gtt prior to transfer.
On review of systems, s/he denies has a prior history of stroke.
She denies recent fevers, chills or rigors. All of the other
review of systems were negative except for depression and
occational swelling of her right lower extremity.
On arrival to the floor, vitals 98.1 196/86 75 18 99%RA. Pt was
having 8/10 chest pain. EKG was inchanged from baseline and pain
responded to 2 NTG's.
Past Medical History:
Stroke 6 years ago with residual right-sided hemiparesis
Hypertension
Macular Degeneration
Chronic Renal Failure Baseline Cr: 1.6
Social History:
-Tobacco history: Smoked on Saturday nights for 50 years
-ETOH: 1 glass of white wine with dinner nightly
-Illicit drugs: No
Family History:
Brother multiple stents. Sister valve replacement
Physical Exam:
Admission Exam:
VS: T= 98.1 BP= 158/65 HR= 75 RR= 18 O2 sat= 95% RA
GENERAL: Well-appearing, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murumur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+
Pertinent Results:
C. Cath [**2191-11-14**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with mild-moderate LMCA
CAD.
2. Moderate pulmonary arterial hypertension.
3. Moderate-severe LV diastolic heart failure.
4. Severe aortic stenosis ([**Location (un) 109**]>0.7 given known AI)
5. Likely significant mitral regurgitation given prominent
(almost
giant) PCW V waves
CT Chest
IMPRESSIONS:
1. Vascular calcifications involve a portion of the ascending
aorta as
detailed above, its major branches, and the coronary arteries.
2. Aortic valve and mitral annular calcifications.
3. Small right and minimal left pleural effusion, without
evidence of
pulmonary edema.
4. Subpleural right middle lobe nodules measure up to 5 mm. In a
patient
without strong risk factors for intrathoracic malignancy,
follow-up CT would
be recommended in 12 months; if there are strong risk factors,
initial follow-
up in [**7-7**] months time would be recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
guidelines.
5. Calcified lung nodules consistent with prior granulomatous
disease.
6. Small-to-moderate hiatal hernia, with probable redundant
mucosa.
7. Colonic diverticulosis.
8. Left renal calculus.
Carotid U/S
IMPRESSION:
1. No signal significant ICA stenosis on either side.
2. Antegrade flow in both vertebral arteries.
ECHO [**2191-11-12**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. There are focal calcifications
in the aortic arch. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2191-11-24**] 05:25AM BLOOD WBC-10.2 RBC-3.35* Hgb-10.6* Hct-30.0*
MCV-90 MCH-31.5 MCHC-35.2* RDW-14.4 Plt Ct-305#
[**2191-11-24**] 05:25AM BLOOD Glucose-104 UreaN-49* Creat-1.4* Na-144
K-3.6 Cl-106 HCO3-25 AnGap-17
Brief Hospital Course:
Mrs. [**Known lastname 62993**] was admitted to the [**Hospital1 18**] on [**2191-11-11**] for further
management of her chest pain. Aspirin, beta blockade, a statin
and heparin were continued. She underwent a cardiac
catheterization which revealed severe three vessel coronary
artery disease and severe aortic stenosis. Given the severity of
her disease, the cardiac surgical service was consulted for
surgical management. Mrs. [**Known lastname 62993**] was worked-up in the usual
preoperative manner including a carotid duplex ultrasound which
showed no significant stenosis of the bilateral internal carotid
arteries. A dental consult was obtained for oral clearance for
surgery. After obtaining a panorex of her teeth, no evidence of
oral infection was noted which would contraindicate valve
surgery. She was transfused with packed red blood cells for
preop anemia. She developed ST changes and hypotension and was
transferred to the cardiac intensive care unit for monitoring.
On [**2191-11-18**], Mrs. [**Known lastname 62993**] was taken to the operating room where
she underwent coronary artery bypass grafting to three vessels
and an aortic valve replacement using a 21mm [**Company **] mosaic
ultra porcine valve. Please see operative note for details.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, she awoke
neurologically intact and was extubated. She was slowly weaned
off her pressors and iontropes. Aspirn, a statin and
betablockade were rsuemd. On postoperative day two, she was
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. The patient was discharged
in good condition to rehab on POD 6.
Medications on Admission:
Home Medications:
Aggrenox 20/100 [**Hospital1 **]
Citalopram 20mg daily
Lipitor 10mg daily
Diovan 320 mg daily
Metoprolol 100 mg daily
HCTZ 25mg daily
Discharge Medications:
1. Furosemide 10 mg/mL Solution Sig: Two (2) Injection TID (3
times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
AS/CAD s/p CABGx2/AVR
CVA
HTN
Depression
Macular degeneration
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.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**2-27**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 8579**] (cardiology) in 2 weeks ([**Apartment Address(1) 80022**] [**Location (un) **], [**Numeric Identifier 80023**] Phone:
[**Telephone/Fax (1) 23882**])
Please call all providers for appointments.
Completed by:[**2191-11-24**]
|
[
"585.9",
"424.1",
"414.01",
"403.90",
"410.71",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"36.12",
"35.21",
"36.15",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8904, 8970
|
5852, 7700
|
334, 544
|
9076, 9083
|
3328, 3353
|
9860, 10335
|
2570, 2622
|
7903, 8881
|
8991, 9055
|
7726, 7726
|
3370, 5829
|
9107, 9837
|
2637, 3309
|
7744, 7880
|
284, 296
|
572, 2259
|
2281, 2412
|
2428, 2554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,064
| 185,284
|
22213
|
Discharge summary
|
report
|
Admission Date: [**2144-10-22**] Discharge Date: [**2144-10-28**]
Date of Birth: [**2083-5-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
syncope, altered mental status, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 61yo male with ESRD on peritoneal dialysis, atrial
fibrillation on coumadin, CAD (s/p CABG in '[**33**] and PTCA in '[**41**])
and DMII, who was brought by ambulance from rehab for an episode
of unresponsiveness. The patient was apparently found at
[**Hospital3 **] unresponsive in chair during lunch. At the
time, the SBP was 60s (baseline 80/50s), HR 70s, Glucose 135,
ABG: 7.4/44/195. SBP increased to the 90s when placed supine
and after receiving 500cc bolus NS. The patient awoke and was
without complaints; he denied chest pain, palpitations,
shortness of breath, and did not recall what happened. Pt was
subsequently brought to [**Hospital1 18**] for ?syncope and ?sepsis, although
the latter was thought to be unlikely as he had been receiving
broad spectrum antibiotics(vancomycin and meropenem) for heel
ulcers that grew MRSA and klebsiella. In the [**Hospital1 18**] ED, the
patient was found to be tremulous with BP 80/50 and given 4L NS
without change in BP. At this point, the patient was started on
dopamine at which point he went into rapid afib. Dopamine was
subsequently discontinued and the patient was started on
levophed with an increase in BP to 111/52. The patient also had
a positive UA with purulent urine (pyuria); he was thus started
on fluconazole. CXR and head CT were negative for acute
changes. The patient remained afebrile without changes in WBC.
At this point, the patient was sent to the Intensive Care Unit
for further evaluation of the patient's hypotension.
Past Medical History:
1. CAD: 4 vessel CABG [**2133**], PTCA/stent [**2141**] and [**2143**] (SVG->OM;
SVG->RCA; LIMA-> LAD patent)
2. Ischemic cardiomyopathy with CHF 40%
3. Atrial fibrillation: on coumadin
4. Type 2 DM with neuropathy, nephropathy, and retinopathy
5. HTN
6. ESRD on Peritoneal Dialysis since [**2141**]
7. Anemia of chronic disease
8. Peptic ulcer disease
9. PVD
10. Hyperlipidemia
11. Left heel ulcer
.
PSH:
1. 4 vessel CABG [**2133**]
2. Right SFA-peroneal vein graft @ OSH
3. Left SFA-BKpop vein graft @ OSH
4. Left TMA
5. Right 1st toe amputation
6. Multiple debridement
Social History:
Pt is divorced. Quit smoking cigarettes in [**2125**] after 90 pack
year history. Occasional alcohol use. Retired vice president of
insurance company. Lives at [**Hospital3 **] center.
Family History:
Brother has DM.
Physical Exam:
Physical Exam:
VS: 98 94/46 (baseline 80/40) 80 20 99%RA FS-148
GEN: pleasant, NAD, comfortable appearing male appearing his
stated age, multiple bruises throughout
HEENT: PERLLA, EOMI, sclera anicteric, no conjuctival injection,
mucous membranes slightly dry, no lymphadenopathy, no thryroid
nodules or masses, no supraclavicular lymph nodes, no posterior
lymphadenopathy, neck supple, full ROM, neg JVD
[**Last Name (un) **]: CTA b/l but decreased breath sounds
COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops
ABD: positive bowel sounds, nontender but slightly distended,no
guarding, no rebound or masses
BACK: neg CVA tenderness
EXT: no cyanosis, clubbing, edema. multiple toe amputations
bilaterally. Also has several stage II decubitis on lower
extremity with one 3cmx4cm decub on lateral aspect of left leg
that is still open. Two others on heel bilateraly appear to be
healing stage II ulcers.
NEURO: Alert and oriented x3. No focal deficits. CNII-XII are
intact, and patient with 5/5 strength throughout, normal
sensation throughout. No pronator drift.
Pertinent Results:
[**2144-10-22**] 04:12PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2144-10-22**] 04:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2144-10-22**] 04:12PM URINE RBC-[**2-7**]* WBC->50 BACTERIA-FEW YEAST-FEW
EPI-0-2
.
ECG [**2144-10-22**]: atrial flutter at 94. Q in II, III, F, V1, poor R
wave progression. unchanged from previous
CXR [**2144-10-22**]: no infiltrate, no pulm enlargement, mild CM, L
PICC in place, R subclavian line in R atrium
CT head [**2144-10-22**]: atrophy, chronic R subinsular white matter
lacunae, calcification of carotids, no acute bleeds.
[**2144-10-25**] 05:35AM BLOOD WBC-7.6 RBC-2.71* Hgb-8.5* Hct-25.3*
MCV-93 MCH-31.3 MCHC-33.5 RDW-16.5* Plt Ct-176
[**2144-10-24**] 04:48AM BLOOD Neuts-81.0* Lymphs-12.5* Monos-3.9
Eos-2.1 Baso-0.5
[**2144-10-25**] 02:50PM BLOOD PT-26.3* PTT-57.6* INR(PT)-4.4
[**2144-10-25**] 05:35AM BLOOD Glucose-150* UreaN-37* Creat-4.1* Na-133
K-3.6 Cl-100 HCO3-27 AnGap-10
[**2144-10-23**] 04:25AM BLOOD CK-MB-5 cTropnT-0.41*
[**2144-10-22**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2144-10-22**] 02:20PM BLOOD cTropnT-0.42*
[**2144-10-25**] 05:35AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
[**2144-10-23**] 03:58AM BLOOD Cortsol-35.2*
XRAY of HEELS
The anterior aspect of the calcaneus is not included on the
lateral view. Increased density along the extreme posterior
periphery of the calcaneus is unchanged compared with [**2144-6-17**]
and is thought to represent normal variation in the calcaneus.
There is a small erosion in the posterior calcaneus, near the
site of Achilles tendon insertion, likely relates to the
retrocalcaneal bursa. Otherwise, no bone destruction, abnormal
sclerosis, or periosteal new bone formation is detected. There
is diffuse [**Month/Day/Year 1106**] calcification. No radiopaque foreign body is
detected.
No radiographic findings to confirm the presence of
osteomyelitis.
BLOOD CULTURES: NO GROWTH.
URINE CULTURE: YEAST
SWAB CULTURE: XANTHOMONAS (Bactrim sensitive), MRSA
Brief Hospital Course:
1) SYNCOPE: The patient received a thorough workup for syncope,
including evaluation for cardiogenic, neurogenic, and infectious
etiologies. With respect to the cardiac workup, the patient was
placed on telemetry to evaluate for possible dysrhythimias, the
result of which was negative. Troponin was found to be slightly
elevated compared to baseline, but this was attributed to ESRD.
ECHO was performed which revealed normal left ventricular cavity
size with moderate global hypokinesis consistent with a diffuse
process. There was mild mitral regurgitation and EF was found
to be 30-35%. EKG was consistent with a possible old inferior
infarct and nonspecific ST-T wave changes. With respect to a
neurogenic etiology, the patient's presentation was found to be
consistent with cerebral hypoperfusion in the context of
multiple [**Month/Day/Year 1106**] metabolic derangements such as hypotension.
Head CT revealed no acute intracranial process and the patient
was already anticoagulated on coumadin with an INR of 1.9 for
his chronic atrial fibrillation. With respect to infectious
etiologies, the patient was found to have multiple sources, such
as the peritoneal dialysis catheter, PICC line, purulent U/A,
and multiple ulcers, that could be contributing to a septic
hypotension and consequent syncope. The PICC line was removed
but found to have no growth on culture. The patient was
continued on vancomycin for MRSA cultured from the wound and
meropenem for klebsiella cultured from the wound as well (but
not documented at this hospital). Bactrim was started to cover
for stenotrophomas (from wound culture in past). Ultimately,
the patient was found to have a negative workup with respect to
all three interdisciplinary evaluations. Further assessment of
the patient's previous hospital records revealed the patient's
baseline blood pressure is 80/40. As such, it is possible the
patient's syncopal episode was secondary to hypovolemia in the
context of an already brittle blood pressure. Without evidence
of infection, that is without a white count/fever/positive blood
culture, all antibiotics were discontinued except fluconazole
which was used to treat the patient's UTI with yeast found in
culture. Blood pressure remained stable at discharge to the
baseline value of 80/40 +/- 10 systolic.
2) MENTAL STATUS CHANGES: On admission, the patient was found to
be confused and disoriented. As stated above, the neurological
service evaluated the patient and found this presentation
consistent with cerebral hypoperfusion in the context of
multiple [**Month/Day/Year 1106**] metabolic derangements including hypotension
and UTI. With resolution of the patient's hypotension and
antibiotic treatment for the patient's MRSA, klebsiella, and
yeast infections, the patient's mental status returned to
baseline.
3. ESRD on peritoneal dialysis: The renal service was
consulted and peritoneal dialysis continued. The patient's
outpatient regimen was altered slightly to include: 4 cycles,
Dextrose 2.5%, 2.5 liters, dwell time 4 hours with alternating
Dextrose solutions between 2.5% and 1.5%.
4. DMII: The patient's outpatient lantus dose was initially
held in light of the patient's decreased PO intake and
substituted with a regular insulin sliding scale. After the
patient was transferred to the floor from the intensive care
unit, however, the patient's outpatient dose will need to be
restarted. At discharge, however, the patient was able to
tolerate his outpatient lantus dose of 4 units.
5. CAD: The patient was noted to have a baseline troponin of
0.2 and renal failure. The patient denied chest pain, which
would not necessarily be surprising in a diabetic. However,
troponins did not increased and the patient did not demonstrate
other cardiac symptoms. He was continued on ASA and statin in
the intensive care unit, but metoprolol was held initially
secondary to hypotension. At discharge, the patient was able to
tolerate a dose of 12.5 mg metoprol twice daily.
6. ATRIAL FIBRILLATION: The patient experienced an episode of
RVR on dopamine which resolved with discontinuation of that
drug. Coumadin should be restarted when INR is less than 2.5 at
a dose of 1 mg each night.
7. PAIN: Pain was adequately addressed with dilaudid iv as
needed.
8. Code: DNR/DNI as per discussion with patient.
9. Communications:
A). [**Name (NI) **] [**Name (NI) 27328**] (son, [**Name (NI) 382**], [**Name (NI) 24402**], OR: [**Telephone/Fax (1) 57960**]
B). Dr. [**Last Name (STitle) 57961**] [**Name (STitle) **] @ [**Hospital3 **] tel: [**Telephone/Fax (1) 57962**] / cell:
[**Telephone/Fax (1) 57963**]
Medications on Admission:
1. Aspirin 81mg once daily
2. Lopressor 37.5mg [**Hospital1 **]
3. Fentanyl Patch 75mcg q72hours (inc from 50mcg q72hours on
[**2144-10-15**])
4. Lexapro 20mg once daily
5. Ambien 10mg PO QHS PRN
6. Ativan 0.5mg PO Q8hours PRN
7. Calcitriol 0.25mg once daily
8. Calcium Carbonate 500mg TID
9. Epogen 10000units sub Q three times/week (Mon, Wed, Fri)
10. Zocor 10mg once daily
11. Coumadin 1.5mg QHS (last INR 1.9 on [**2144-10-21**])
12. Protonix 40mg once daily
13. Dilaudid 2mg 1-2 tabs q3-4 hours PRN
14. Lantus 4units QAM
15. RISS
16. Vancomycin 1gm Q22hours until [**2144-10-27**]
17. Meropenem 500mg IV BID until [**2144-10-27**]
18. Colace
19. Senna
20. Dulcolax
21. Niferex
22. MVI
23. Vit B12
24. Folate
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily).
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
PRN () as needed for agitation.
15. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
19. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q6H (every 6 hours) as needed for pain.
20. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
22. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO at
bedtime: Please restart when INR < 2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
* hypotension complicated by syncope
* bilateral heel ulcers with osteomyelitis
* s/p multiple toe amputations with MRSA positive wound cultures
* ESRD on peritoneal dialysis
* Diabetes
* atrial fibrillation
* CAD
Discharge Condition:
good
Discharge Instructions:
1. Please take all of your medications.
2. Please seek medical attention should you experience any of
the following: shortness of breath, chest pain, palpitations,
sudden weakness, lightheadedness, dizziness, loss of
consciousness, fainting, nausea, vomiting, fever, chills
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**]
Date/Time:[**2144-12-24**] 8:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2144-12-24**] 9:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"425.4",
"996.62",
"995.91",
"041.10",
"285.29",
"414.00",
"357.2",
"403.91",
"E879.8",
"250.50",
"250.40",
"707.14",
"583.81",
"038.9",
"428.0",
"458.9",
"V45.81",
"427.31",
"362.01",
"041.3",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.49",
"38.93",
"99.04",
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
13349, 13419
|
5948, 10594
|
359, 365
|
13677, 13683
|
3868, 5925
|
14005, 14580
|
2744, 2761
|
11382, 13326
|
13440, 13656
|
10620, 11359
|
13707, 13982
|
2791, 3849
|
276, 321
|
393, 1913
|
1935, 2526
|
2542, 2728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,093
| 165,393
|
30026
|
Discharge summary
|
report
|
Admission Date: [**2141-1-25**] Discharge Date: [**2141-1-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
s/p fall, hypotension, critical AS
Major Surgical or Invasive Procedure:
R IJ, aterial line placement, intubation
History of Present Illness:
87yo M with hx of severe AS (last mean gradient 50 mmhg, area
0.6 cm2 in [**6-29**]), HTN, PVD is transferred from [**Hospital3 **]
after having found supine on the floor. His neighbor called EMS
who found him down on the floor. Pt states he tripped and fell.
At [**Hospital1 **], Afebrile, SBP 70s, head CT was negative, received 4L
NS and neosynephrine gtt started. Also, ECG had ECG had ST
elevation in V2 ST depression in V5, V6, LVH with trop 39, and
only heparin gtt was started and transferred to [**Hospital1 18**] further
managment for NSTEMI and hypotension. Called the [**Hospital3 4107**]
to confirmed that he only received heparin gtt and no ASA or
statin.
.
ED Course Here at [**Hospital1 18**]: VS afebrile, 88, 75/40, RR22, 94% on
oxygen not documented. Received 3 more L NS and continued on
neosynephrine. Pt had melenatic stools with guaiac positive
stools. NG lavage was not performed. Pt received 2 units of
blood in the ED.
.
Pt denies any chest pain, shortness of breath, lightheadedness,
palpitations prior to the fall. Currently, pt has no complaints
other than R shoulder pain with blood cuff inflation. He does
states that he's been feeling weak and not ambulatory. Denies
hematochezia/melena.
.
ALLERGIES: NKDA
Past Medical History:
PAST MEDICAL HISTORY:
PVD
HTN
LVH
critical AS
s/p hernia repair in '[**30**]
.
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension
AS as above
.
Cardiac History: None
.
Percutaneous coronary intervention: None
.
Pacemaker/ICD: None
.
Other Past History: As above
Social History:
Per EMS report, pt looked grossly dehydrated when first
evaluated the patient when found on the floor. Pt was alert and
[**Location (un) 71641**] to communicate with EMS although unable to communicate.
The house was unkept, unsanitary, and in desrepari. His sole
caretaker is 50yo mentally disabled sone. [**Name2 (NI) 71642**] neighbor
expressed concern for Mr. [**Last Name (Titles) 71643**] condition on scene at his
residence and called the hospital for his son's inability to
take care at home alone.
.
Social history is significant for the absence of current tobacco
use. + past tobacco use 50 years ago, smoked for 20 years 1 ppd.
There is no history of alcohol abuse. There is no family history
of premature coronary artery disease or sudden death.
.
On review of symptoms, 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.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 76/38 mm Hg at 30 degree angle. Pulse was 92
beats/min and regular, respiratory rate was 20 breaths/min.
Weight 138 lbs.
Generally the patient was well developed, malnourished and well
groomed. The patient was oriented to person, [**Hospital3 4107**] and
[**1-4**].
.
There was no xanthalesma and conjunctiva were pale and dry oral
mucosa. The neck was supple with JVP not visible. The carotid
waveform was flat. There was no thyromegaly. The were no chest
wall deformities, scoliosis or kyphosis. The respirations were
not labored and there were no use of accessory muscles. The
lungs were coarse with expiratory rhonchi diffusely.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. Heart was difficult to
auscultate due to rhonchi but normal S1 and somewhat diminished
S2 with II/VI systolic ejection murmur.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities were cool. There were no
abdominal, femoral or carotid bruits. Inspection and/or
palpation of skin and subcutaneous tissue showed very dry skin.
.
Pulses:
Right: Carotid 1+ Femoral barely palpable Popliteal DP not
palpable PT not palpable
Left: Carotid 1+ Femoral barely palpable Popliteal not palpable
DP dopplerable PT not palpable
Pertinent Results:
[**2141-1-25**] 12:34PM BLOOD WBC-19.1* RBC-3.45* Hgb-11.0* Hct-34.9*
MCV-101* MCH-31.8 MCHC-31.5 RDW-15.7* Plt Ct-335
[**2141-1-26**] 01:11AM BLOOD WBC-19.9* RBC-4.19* Hgb-13.3* Hct-40.0
MCV-96 MCH-31.8 MCHC-33.2 RDW-16.1* Plt Ct-269
[**2141-1-25**] 12:34PM BLOOD Neuts-93.0* Bands-0 Lymphs-4.6* Monos-2.2
Eos-0 Baso-0.2
[**2141-1-26**] 01:11AM BLOOD Plt Ct-269
[**2141-1-26**] 01:11AM BLOOD PT-18.5* PTT-46.7* INR(PT)-1.7*
[**2141-1-25**] 08:50AM BLOOD Glucose-159* UreaN-87* Creat-2.4* Na-139
K-5.0 Cl-105 HCO3-17* AnGap-22*
[**2141-1-26**] 01:11AM BLOOD Glucose-57* UreaN-81* Creat-2.5* Na-138
K-5.7* Cl-110* HCO3-11* AnGap-23*
[**2141-1-25**] 08:50AM BLOOD CK(CPK)-1498*
[**2141-1-25**] 12:34PM BLOOD ALT-175* AST-567* LD(LDH)-1585*
CK(CPK)-2063* AlkPhos-154* TotBili-0.7
[**2141-1-25**] 04:57PM BLOOD CK(CPK)-2588*
[**2141-1-26**] 01:11AM BLOOD CK(CPK)-2411*
[**2141-1-25**] 08:50AM BLOOD CK-MB-166* MB Indx-11.1*
[**2141-1-25**] 08:50AM BLOOD cTropnT-5.39*
[**2141-1-25**] 12:34PM BLOOD CK-MB-280* MB Indx-13.6* cTropnT-5.77*
[**2141-1-25**] 04:57PM BLOOD CK-MB-380* MB Indx-14.7* cTropnT-6.92*
[**2141-1-26**] 01:11AM BLOOD CK-MB-344* MB Indx-14.3* cTropnT-9.57*
[**2141-1-25**] 08:50AM BLOOD Calcium-8.0* Phos-5.8* Mg-2.2
[**2141-1-26**] 01:11AM BLOOD Calcium-7.8* Phos-7.7*# Mg-2.6
[**2141-1-25**] 12:34PM BLOOD VitB12-1313* Folate-12.7
[**2141-1-25**] 12:34PM BLOOD Cortsol-53.9*
[**2141-1-25**] 02:52PM BLOOD Type-ART pO2-99 pCO2-29* pH-7.24*
calTCO2-13* Base XS--13 Intubat-NOT INTUBA
[**2141-1-25**] 07:10PM BLOOD Type-ART pO2-81* pCO2-31* pH-7.32*
calTCO2-17* Base XS--8
[**2141-1-25**] 11:36PM BLOOD Type-ART pO2-88 pCO2-51* pH-7.06*
calTCO2-15* Base XS--16
[**2141-1-26**] 12:20AM BLOOD Type-ART Rates-/20 Tidal V-500 PEEP-5
FiO2-100 pO2-300* pCO2-34* pH-7.13* calTCO2-12* Base XS--17
AADO2-381 REQ O2-67 -ASSIST/CON Intubat-INTUBATED
[**2141-1-26**] 02:02AM BLOOD Type-ART FiO2-50 pO2-133* pCO2-25*
pH-7.16* calTCO2-9* Base XS--18 Intubat-INTUBATED
[**2141-1-25**] 11:36PM BLOOD Lactate-5.7* Na-139 K-5.5* Cl-114*
[**2141-1-25**] 09:07AM BLOOD Lactate-7.7* K-5.2
.
[**1-25**] CXR
Perihilar interstitial abnormality with upper lobe predominance
suggests pulmonary edema with patient in Trendelenburg position.
Heart is normal size. Smaller bilateral pleural effusions may be
present. There is either a calcification projecting over the
descending thoracic aorta or an intraaortic balloon pump. A
followup study has been ordered but is not available as yet and
should clarify this finding.
Brief Hospital Course:
Patient is a 87yo M with severe AS, [**Hospital **] transferred from OSH s/p
mechanical fall, found to have NSTEMI in the setting of UGIB.
He was agressively volume recussitated [**12-30**] hypovolemic shock and
neosynephrine was used for hypotension. Pt did have postive NG
lavage with coffee ground ememsis. His NSTEMI appeared to be
due to UGIB with hypotension resulting in demand ischemia.
Because of this, anticoagulants were not given.
.
We had great difficulty placing an arterial line and then
placing a central line. Within 12 hours of admission, he became
acutely short of breath and after confirming his wishes, he was
intubated. Over the next several hours he became progressively
more hypotensive, requiring 3 pressors. CPR was not indicated
at that point [**12-30**] poor prognosis and he passed away within 24
hours of admission.
.
Autopsy was requested by the family based on patient wishes.
Medications on Admission:
CURRENT MEDICATIONS: At home
Quinapril 20mg qday
Klor Cor 10meq qday
Atenolol 50mg qday
HCTZ 25mg qday
.
Meds on transfer:
neosynephrine
IVF
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"263.9",
"401.9",
"276.51",
"785.59",
"424.1",
"410.71",
"584.9",
"443.9",
"578.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8399, 8408
|
7265, 8180
|
297, 339
|
8459, 8468
|
4734, 7242
|
8520, 8526
|
3229, 3312
|
8371, 8376
|
8429, 8438
|
8206, 8206
|
8492, 8497
|
3327, 4715
|
223, 259
|
8227, 8311
|
367, 1607
|
1651, 1908
|
1924, 3213
|
8329, 8348
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,425
| 150,548
|
46475
|
Discharge summary
|
report
|
Admission Date: [**2167-3-10**] Discharge Date: [**2167-3-19**]
Service: MEDICINE
Allergies:
Codeine / Aspirin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
-Right femur repair
History of Present Illness:
Please see initial H&P for more information.
.
Briefly, Ms. [**Known lastname 74916**] is a [**Age over 90 **] year-old woman with a history of
cervical spondylosis, lumbosacral radiculopathy and spinal
stenosis and old RBBB who presented 8 days prior to CCU transfer
after a fall at home with hip fracture. In the ED she was
hypotensive and had a left femoral cordis placed. She went
urgently to the OR on day of admission ([**3-10**]) for an ORIF. Her
post op course was complicated by a presumed hospital acquired
pneumonia (fevers, question of abnormal CXR, leukocytosis and
hypoxia) being treated with vancomycin and levaquin. She was
also hyponatremic after her surgery. She developed a fistula and
pseudoaneurysm at the site of her cordis, was evaluated by
vascular surgery and had a thromin injection on [**3-13**]. She had
b/l LE u/s to evaluate for ? DVT/PE in setting of fevers,
hypoxia, was negative on [**3-18**]. On [**3-16**] at approximately 5pm pt was
noted to go into a slow atrial flutter with rates 30-50s. For
the first 24-36 hours she was hemodynamically stable with a
normal BP. EP was consulted who recommended holding her nodal
agents, BB held. Today her blood pressures dropped to 80-100s
with an associated decrease in urine output for which she
triggered, increased 02 requirement to 4L and crackles on exam.
She was also noted to go into acute renal failure with an
increase in her creatinine from 0.9-1.4. She was given ~750cc
IVF with no improvement. She was transferred to the CCU for
further management of her hemodynamically unstable bradycardia.
.
On arrival to CCU, pt persistently bradycardic with HR 30-50s.
BP stabilized to low 100s. Was alert and oriented. Complained of
dizziness and difficulty breathing. Otherwise denied pain or
other complaints.
Past Medical History:
# Polymyalgia rheumatica
# Hypertension
# Breast cancer with chest wall recurrence s/pleft mastectomy
# GERD
# Occipital neuralgia
# Cervical spondylosis and spinal stenosis
# R. knee osteoarthritis- gets R.knee intraarticular injections
# S/P left parotid gland excision
# hx of RBBB
# Right cervical myofascial pain syndrome.
# Hemorrhoids
Social History:
Not a smoker. She lives alone, walks with a walker, and has VNA
several times a week. She does not drink alcohol. No drug use.
Relatives in area: nephew, niece, who "have heart problems" and
are not caregivers.
Family History:
Her mother had coronary artery disease and diabetes. Her father
had throat cancer. Her brother had coronary artery disease
Physical Exam:
VS: 98.1 52 115/58 (Aflutter) 18 96% 6L NC/NRB
GENERAL: Elderly woman. NAD. Responding to questions/commands,
arousable.
HEENT: NCAT. Sclera anicteric. slight crusting around eyes.
NECK: Supple, JVP 8cm.
CARDIAC: Bradycaria. Nl S1, S2.
LUNGS: Hard irregular nodule L chest wall anteriorly. s/p L
mastectomy. Rhonchorous. Crackles R>L with right sided
expiratory wheeze.
ABDOMEN: Soft, non-tender, minimal distention. +BS
EXTREMITIES: Pitting edema to knees bilaterally. S/p cordis L
groin with hematoma tracking down posterior aspect to mid-tibia.
s/p ORIF on right, dsg in place c/d/i. Pitting edema LUE. (s/p
axillary LN dissection)
Pertinent Results:
LABS ON ADMISSION:
[**2167-3-9**] 08:20PM WBC-6.6 RBC-2.65* HGB-7.3*# HCT-21.0*#
MCV-79*# MCH-27.7 MCHC-35.0 RDW-16.5*
[**2167-3-9**] 08:20PM NEUTS-73.7* LYMPHS-20.9 MONOS-4.7 EOS-0.5
BASOS-0.2
[**2167-3-9**] 08:20PM PLT COUNT-299
[**2167-3-9**] 08:20PM PT-13.1 PTT-33.9 INR(PT)-1.1
[**2167-3-9**] 08:20PM CK-MB-6
[**2167-3-9**] 08:20PM CK(CPK)-193*
[**2167-3-10**] 02:50AM CK(CPK)-195*
[**2167-3-9**] 08:20PM GLUCOSE-120* UREA N-19 CREAT-1.1 SODIUM-122*
POTASSIUM-4.4 CHLORIDE-86* TOTAL CO2-27 ANION GAP-13
[**2167-3-10**] 05:56AM TSH-3.7
[**2167-3-10**] 05:56AM CK-MB-6 cTropnT-0.07*
[**2167-3-10**] 05:56AM CK(CPK)-184*
[**2167-3-10**] 09:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2167-3-10**] 09:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2167-3-10**] 09:46PM URINE OSMOLAL-434
[**2167-3-10**] 09:46PM URINE HOURS-RANDOM CREAT-90 SODIUM-LESS THAN
.
[**3-12**] Urine cx x 2: negative
[**3-3**] Blood cx x 3: negative
[**3-18**] Urine cx x 1: pending
[**3-18**] Bloox cx x 1: pending
.
IMAGING
[**2167-3-9**] HEAD CT
CONCLUSION: Chronic sinus mucosal disease. There is no acute
hemorrhage or
mass effect. Stable appearance to the atrophy and chronic brain
ischemia.
.
[**2167-3-19**] CXR
IMPRESSION: Overall, minimally changed study with slight
interval decrease in
pulmonary vascular congestion.
.
[**2167-3-19**] ECHO
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Aortic sclerosis without stenosis. Mild mitral regurgitation.
Moderate pulmonary hypertension.
.
[**2167-3-18**] LENIS BILATERAL: negative
.
[**2167-3-17**] EKG
Possible atrial flutter with variable ventricular rate but
cannot exclude
motion artifact. Right bundle-branch block. Left axis deviation.
Left
anterior fascicular block. Possible anterior myocardial
infarction.
Compared to the previous tracing of [**2167-3-11**] cardiac rhythm now
may be
atrial flutter, although motion artifact cannot be excluded with
certainty.
Rate PR QRS QT/QTc P QRS T
54 108 144 448/437 81 -44 94
.
Brief Hospital Course:
[**Age over 90 **] f presents with femur fracture after a mechanical fall.
.
# Bradycardia: Patient had acute onset bradycardic overnight on
[**2167-3-17**]. Appeared to be in atrial flutter with poor conduction.
Nodal agents were discontinued EP Cardiology was consulted.
Ablation was discussed as an option but given patient's
concurrent pneumonia and other comorbities the decision was made
to wait on such a procedure until it would tolerated more
easily. Patient was continued on lovenox for VTE prophyllaxis.
Initially bradycardia was thought to be asymptomatic. However,
she began to develop complications of her bradycardia including
somnolence, shortness of breath, low urine output, and ARF
within 48 hours of onset. At this point she was transferred to
the ICU for further management of her poor cardiac output.
Unsuccessful attempt was made to pharmacologically control
rhythm. Pt was desatting on NC, switched to NRB. Became
increasingly delirious. Heart rhythm progressed to complete
heart block, rate in 30s. Per family mtg with niece, pt made
CMO. Pt gradually expired.
.
#. R Femur fracture. Seen by ortho/trauma in ED, went to OR on
[**2167-3-10**] where her femur was surgically repaired. Patient's pain
was adequately controlled after surgery. Patient was continued
on calcium and vitamin D. Patient was started on lovenox [**Hospital1 **]
after it was determined that femoral
pseudoaneurysm/fistula/hematoma was stable. Physical therapy was
started.
.
#. AMS: Patient experienced several episodes of confusion and
somnolence after her surgery which may be attributable to pain
medications. Infection may also be a significant contributor.
Pain medications were titrated and patient was started on
empiric treatment for hospital acquired pneumonia. Patient
became bradycardic on [**2167-3-17**] and her somnolence subsequently
increased.
.
# Hospital Acquired Pneumonia: Patient reports recent pneumonia.
She developed increased oxygen requirements and increased sputum
production during her admission. She was started on empiric
treatment for HAP with vancomycin and levoquin. Patient was
given symptomatic relief with nebulizer treatments and chest PT.
.
#. Anemia. Microcytic. Hct down from 30 in [**2166-8-19**] to 20 on
admission. Guaiac positive stools. Colonoscopy in [**2165**] showed 3
sessile 3cm non-bleeding polyps in the cecum and a single
sessile 1 cm non-bleeding polyp of benign appearance was found
in the transverse colon. No large hematoma seen on CT.
Ultrasound of femoral vessels after surgery showed
pseudoaneurysm which was injected with thrombin. Follow up
imaging showed resolution of pseudoaneurysm, fistula, and
hematoma during admission. Patient received 2 units pRBC during
her admission.
.
# Acute Renal Failure: Patient developed elevated creatinine
and low urine output 24 hours after acute onset bradycardia.
Presumed etiology was poor forward flow to the kidneys. Patient
was given several small IVF boluses without response. She
became hypotensive and somnolent and was transferred to the ICU.
Medications on Admission:
1. Metoprolol 25mg PO bid
2. Valsartan 160 mg PO daily
3. Amlodipine 5 mg Po daily
4. Rosuvastatin 20 mg PO daily
5. Levothyroxine 25 mcg daily (could not verify)
6. Clonazepam 1 mg PO qhs PRN (could not verify)
7. Lorazepam 0.5 mg PO bid PRN (could not verify)
8. Prednisone 5 mg qod (stated she takes this daily
9. Anastrozole 1 mg PO daily (could not verify)
10. Docusate 100mg PO bid
11. Acetaminophen 325 mg PO q4hr PRN
12. Ferrous Sulfate 325mg daily
13. Pramoxine-Mineral Oil-Zinc 1-12.5 %Ointment Sig: One (1)
14. Appl Rectal [**Hospital1 **] (2 times a day) as needed.
15. Esomeprazole Magnesium 40mg PO daily
16. Meclizine 12.5 mg PO daily
17. Albuterol 90 mcg q4-6hr PRN
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
-Right femur fracture
-Hyponatremia
-Left thigh pseudoaneurysm
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2167-6-8**]
|
[
"447.0",
"584.9",
"401.9",
"530.81",
"E879.8",
"442.3",
"280.9",
"458.9",
"276.1",
"428.0",
"427.89",
"780.09",
"427.32",
"428.33",
"725",
"721.0",
"820.21",
"426.10",
"112.1",
"486",
"E885.9",
"997.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
9506, 9515
|
5677, 8744
|
237, 259
|
9622, 9631
|
3488, 3493
|
9684, 9718
|
2692, 2817
|
9477, 9483
|
9536, 9601
|
8770, 9454
|
9655, 9661
|
2832, 3469
|
186, 199
|
287, 2080
|
3508, 5654
|
2102, 2446
|
2462, 2676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,371
| 167,239
|
42422+42423
|
Discharge summary
|
report+report
|
Admission Date: [**2103-11-30**] Discharge Date: [**2103-12-1**]
Date of Birth: [**2053-11-27**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / prednisone
Attending:[**First Name3 (LF) 2248**]
Chief Complaint:
dizziness/ SOB / chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 year old woman with hypothyroidism, and history of Hodgkin's
lymphoma, who presented with fatigue and SOB. Symptoms started
3 weeks ago. She saw her PCP where ECG showed 3rd degree heart
block. No recent febrile illness or tick exposure. No CP, or
chest pressure. She has a headache, but no photo or phonophobia.
Mild lightheadedness, but no syncope. Remote history of
hodgkins lymphoma, but chemotherapy regimen was unclear. Of
note, she had exertional shortness of breath over the summer
which resolved.
.
Of note, the patient was bitten by a dog recently and has
erythema of her right hand. The dog is known to the family. The
patient has pain and swelling but denies any other symptoms.
.
In the ED, initial vitals were 98.5 38 176/58 16 100%. Bedside
echo showed AV dissociation, but no pericardial effusion. Labs
were normal. CXR showed no findings on wetread. Most recent set
of vitals not provided by the ED.
Past Medical History:
1. CARDIAC RISK FACTORS: none previously identified, no prior
history of CAD or known coronary disease
2. OTHER PAST MEDICAL HISTORY:
History of Hodgkin's lymphoma - unclear which chemotherapy given
Hypothyroidism - most recent TSH 6
Tendinitis
4. PAST SURGICAL HISTORY:
Splenectomy
Social History:
SOCIAL HISTORY She is divorced and has been living with a
boyfriend for 12 years. She has two kids, 21 years old
and 18 years old. She is currently working 30-35
hours as an assistant working with the disabled kids in the
school system. No ETOH use.
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T= 97.3 BP= 183/83 HR= 86 RR= 21 O2 sat= 96 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple , no JVP appreciable
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Area of incision is taped. Will evaluate in AM. Gauze is dry
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e in LE. Right hand is erythematous and
edematous. Tooth mark present on dorsum. Pain on pressing
.
On discharge:
General: comfortable.
HEENT : NCAT, no oxygen. PERRL, EOMI, anicteric sclerae
CV: RRR, normal s1s2, no MRG
Lungs: CTAB, no rhonchi or wheezes
Abdomen: soft, NTTP, no masses, no rebound tenderness or
guarding
Extremities: warm, well perfused. Hand is less erythematous than
on admission, but still has some erythema and swelling. Left arm
is in sling.
Neuro: CN2-12 intact. Motor [**3-29**] bilaterally in all extremities.
Sensation is intact bilaterally. No focal abnormalities
elicited.
Pertinent Results:
[**2103-12-1**] 09:00PM BLOOD WBC-11.2* RBC-4.98 Hgb-14.5 Hct-43.6
MCV-88 MCH-29.1 MCHC-33.2 RDW-14.0 Plt Ct-289
[**2103-12-1**] 06:49AM BLOOD WBC-9.4 RBC-4.73 Hgb-13.8 Hct-41.9 MCV-89
MCH-29.1 MCHC-32.8 RDW-14.4 Plt Ct-293
[**2103-11-30**] 01:04PM BLOOD WBC-9.0 RBC-4.74 Hgb-14.0 Hct-41.9 MCV-88
MCH-29.6 MCHC-33.5 RDW-14.1 Plt Ct-319
[**2103-12-1**] 09:00PM BLOOD Neuts-68.8 Lymphs-20.2 Monos-5.9 Eos-4.4*
Baso-0.7
[**2103-11-30**] 01:04PM BLOOD Neuts-63.1 Lymphs-26.9 Monos-5.9 Eos-3.2
Baso-0.9
[**2103-12-1**] 09:00PM BLOOD PT-11.3 PTT-29.6 INR(PT)-1.0
[**2103-11-30**] 01:04PM BLOOD PT-10.6 PTT-28.5 INR(PT)-1.0
[**2103-12-1**] 09:02PM BLOOD Creat-0.8
[**2103-12-1**] 09:00PM BLOOD UreaN-25*
[**2103-12-1**] 06:49AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-140
K-4.7 Cl-106 HCO3-27 AnGap-12
[**2103-12-1**] 09:00PM BLOOD Calcium-8.7 Phos-4.1 Mg-1.8
[**2103-12-1**] 06:49AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
[**2103-12-1**] 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild degenerative aortic stenosis. Moderate aortic
regurgitation. Mild mitral regurgitation. Moderate pulmonary
hypertension. Given the appearance of the aortic and mitral
valves, is there a history of chest irradiation?
.
CXR [**2103-11-30**]
IMPRESSION:
1. Blunting of left costophrenic angle which may be due to a
small pleural
effusion.
2. Mild prominence of the right hilum for which further
evaluation with
dedicated PA and lateral views is recommended
.
CXR [**2103-12-1**]
Pacemaker leads terminate in right atrium and right ventricle.
There is no
definitive pneumothorax seen but minimal apical pleural air
cannot be excluded
and repeated radiograph is recommended in case patient is
symptomatic. Left
lower lobe consolidation has progressed since the prior study
and might
reflect developing infection, worsening atelectasis or
aspiration. Left and
right pleural effusions are small, unchanged since the prior
study. Mild
vascular engorgement is seen.
.
Brief Hospital Course:
50 YO female with relatively healthy PMH (Hodgekin's Lymphoma
and hypothyroidism) presented with complete heart block, s/p
pacemaker placement. Patinet currently hypertensive and has
erythema on right hand [**12-27**] dog bite.
.
Heart Block - the patient had a pacemaker placed on the day of
admission. She was observed overnight and tolerated the
pacemaker. On the day after admission, the patient had a chest
xray that showed no pneumothorax, but small amount of air in the
apex could not be ruled out definitively. It was recommended
that the patient get a repeat xray in the next week. The patient
was discharged in stable condition
.
Dog Bite - there was worry that the patient's dog bite would
become infected. Her blood cultures were negative. To be safe,
the patient was sent home on a 2 week course of augmentin to
prevent infection, especially with a new foreign object
(pacemaker) in the patient.
.
Hypertension - the patient did have hypertension to the 180s
while on the floor. However, the patient admitted to anxiety.
She received her home dose of lorazepam 0.5mg that night, and
her hypertension resolved. We encouraged the patient to see her
PCP about the hypertension, and she was started on lisinopril
5mg
Medications on Admission:
Levothyroxine 25 mcg daily
Lorazepam 0.5mg [**Hospital1 **]
Fluoxetine 40mg daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 4 days: Please
take [**11-26**] a day as needed for pain until you see your primary
care physician. [**Name10 (NameIs) 357**] limit these pills and try alternatives,
such as tylenol or ibuprofen.
Disp:*8 Tablet(s)* Refills:*0*
2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks: please make sure to
complete this course of antibiotics.
Disp:*42 Tablet(s)* Refills:*0*
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-complete heart block
Secondary diagnosis
-cellulitis hand - secondary to dog bite
-HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 30485**], you came to us after experiencing dizziness, chest
pain, and shortness of breath over the last few weeks. While
with us, we found that your heart had an abnormal rhythm that
required a pacemaker. You received that pacemaker and did well.
While with us, we also noticed that your right hand was swollen
and tender, and we determined that a dog had bit your hand
recently. Given our concern for infection, especially with your
new pacemaker, we decided to send you home on a longer course of
antibiotics.
- Please start augmentin 500mg three times a day for 14 days.
- Please start lisinopril 5mg daily for high blood pressure
Followup Instructions:
Please call your primary care physician and schedule [**Name Initial (PRE) **] follow up
appointment in the next week. You should speak with her about
your high blood pressure (you will need to have your blood drawn
this week to check your electrolytes now that we have started
you on a new blood pressure medication), the dog bite on your
hand, and your new pacemaker.
If you hand becomes more swollen, tender or painful, please call
your primary care doctor immediately to discuss management.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**]
Completed by:[**2103-12-3**] Admission Date: [**2103-12-1**] Discharge Date: [**2103-12-5**]
Date of Birth: [**2053-11-27**] Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / prednisone
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L arm and L leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 50 year-old R-handed woman with PMHx of
hypothyroidism, distant hx of Hodgkins lymphoma s/p chemotherapy
and radiation, now s/p pacemaker placement on [**2103-11-30**] for 3rd
degree heart block of unknown origin who presents as a code
stroke with new L arm and L leg weakness.
.
Pt reports that yesterday ([**2103-11-30**]) she had her pacemaker placed
without issue, but they told her she should be on bedrest, so
she
didn't get up after her operation. She noticed that her L arm
and shoulder hurt near where the pacemaker was placed. The next
morning ([**2103-12-1**]) she woke up to go to the bathroom and other
than
some L arm soreness felt normal. However, she was then gotten
out of bed at 10am to go to a CXR, and she felt her L leg "give
out", and she felt it was too weak to support her weight. So,
she was sat down by the nurses, told to rest, and when the
transportation team came to get her again at 11am, she was able
to get up and walk to the stretcher without difficulty. She
doesn't know how quickly the weakness went away over that 1 hour
time period. She was then discharged home at around 2pm and had
no difficulty walking to the car, or walking out of the car into
her home. She was watching the football game at around 4:30pm
(although she thinks could have been as early as 3:30pm or as
late as 5pm), when she felt lightheaded and sweaty, and then
noticed she couldn't hold herself up on the cough, and tried to
scoot up. However, she realized at the point she couldn't move
her L leg. She didn't notice any difficulty with her L arm, but
she was "trying to keep it from moving" because of her recent
pacemaker placement on that side. Her family debated if she
should go to the hospital, eventually decided and brought her to
the ED.
.
In the ED a code stroke was called for her L leg weakness, and
she was found to have a R ACA stroke as described below.
.
Of note, pt reports H/A every other day since [**Holiday **],
bilaterally "behind my eyes", and that she would frequently wake
up with them, but they never woke her from sleep.
.
On neuro ROS, the pt reports L leg weakness as above, denies
current headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies numbness, parasthesiae. No bowel
or
bladder incontinence or retention.
.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Hodgkins lymphoma first diagnosed in [**2074**], given radiation and
had remission, but then relapsed in [**2076**] and had repeat
radiation
and chemotherapy. No relapses since then.
- hypothyroidism (most recent TSH 6)
- splenectomy (when diagnosed with Hodkins lymphoma)
- S/p pacemaker placement [**2103-11-30**] for 3rd degree heart block of
unknown origin
Social History:
Divorced, living with her boyfriend (who she calls
husband) for 12 years. She has 2 kids, 21 and 18yo. She works
as an assitant working with disabled kids parttime. She smoked
"a couple of cigarettes per day" for abour 15 years, but quit 20
yrs ago. Denies any current alcohol use, but used to drink
socially, denies illicits.
Family History:
No hx of stroke or MI.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.0 P: 92 R: 16 BP:144/59 SaO2: 98%RA
General: 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
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted, c/d/i dressing of
pacemaker pocket.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
.
Neurologic:
.
NIH Stroke Scale score was 7:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 3
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty, but was slow to respond to some questions.
Attentive, able to name DOW backward without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Able to read
slowly
but without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. Pt unable to hold up L arm
to test for pronator drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 1 5- 4 5- 5 5- 5- 0 0 0 0 0 0 0
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on the R and extensor on the L.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted
on RUE, unable to test on LUE. No dysmetria on FNF in RUE,
unable
to test on LUE.
.
-Gait: Deferred
===============
Physical Exam on Discharge:
Non-focal examination. No pronator drift. Full strength. Steady
gait. Clinically bilateral pleural effusions. Stable oxygen
staurations and respiratory rate.
Pertinent Results:
Laboratory investigations:
Admission labs;
[**2103-11-30**] 01:04PM BLOOD WBC-9.0 RBC-4.74 Hgb-14.0 Hct-41.9 MCV-88
MCH-29.6 MCHC-33.5 RDW-14.1 Plt Ct-319
[**2103-11-30**] 01:04PM BLOOD Neuts-63.1 Lymphs-26.9 Monos-5.9 Eos-3.2
Baso-0.9
[**2103-11-30**] 01:04PM BLOOD PT-10.6 PTT-28.5 INR(PT)-1.0
[**2103-12-1**] 06:49AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-140
K-4.7 Cl-106 HCO3-27 AnGap-12
[**2103-12-1**] 06:49AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
.
Stroke risk factors and pertinent labs:
[**2103-12-2**] 04:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7 Cholest-166
[**2103-12-2**] 04:00AM BLOOD Triglyc-74 HDL-69 CHOL/HD-2.4 LDLcalc-82
[**2103-12-2**] 04:00AM BLOOD %HbA1c-6.0* eAG-126*
[**2103-12-2**] 04:00AM BLOOD TSH-6.9*
[**2103-12-1**] 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-11-30**] 01:04PM BLOOD cTropnT-<0.01
[**2103-12-2**] 04:00AM BLOOD CK-MB-7 cTropnT-0.03*
[**2103-12-2**] 04:00AM BLOOD CK(CPK)-172
[**2103-12-2**] 04:00AM BLOOD Lipase-21
.
Discharge labs:
[**2103-12-5**] 08:40AM BLOOD WBC-6.6 RBC-4.53 Hgb-12.9 Hct-40.2 MCV-89
MCH-28.6 MCHC-32.2 RDW-14.2 Plt Ct-276
[**2103-12-2**] 04:00AM BLOOD PT-10.7 PTT-57.4* INR(PT)-1.0
[**2103-12-5**] 08:40AM BLOOD Glucose-102* UreaN-29* Creat-0.6 Na-137
K-4.4 Cl-102 HCO3-26 AnGap-13
[**2103-12-5**] 08:40AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.7
.
.
Urine:
[**2103-12-1**] 10:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050*
[**2103-12-1**] 10:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2103-12-1**] 10:00PM URINE RBC-9* WBC-1 Bacteri-NONE Yeast-NONE
Epi-2
[**2103-12-4**] 03:22PM URINE Color-Red Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2103-12-4**] 03:22PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2103-12-4**] 03:22PM URINE RBC->182* WBC-17* Bacteri-FEW Yeast-NONE
Epi-0
[**2103-12-4**] 03:22PM URINE CastHy-11*
[**2103-12-4**] 08:35PM URINE Mucous-OCC
[**2103-12-4**] 03:22PM URINE Mucous-FEW
[**2103-12-4**] 08:35PM URINE Color-Red Appear-Hazy Sp [**Last Name (un) **]-1.023
[**2103-12-4**] 08:35PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-5.5 Leuks-SM
[**2103-12-4**] 08:35PM URINE RBC->182* WBC-19* Bacteri-MOD Yeast-FEW
Epi-3
[**2103-12-1**] 11:28PM URINE UCG-NEG
[**2103-12-1**] 11:28PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Microbiology:
[**2103-11-30**] 7:50 pm BLOOD CULTURE
**FINAL REPORT [**2103-12-6**]**
Blood Culture, Routine (Final [**2103-12-6**]): NO GROWTH.
.
[**2103-12-4**] 8:35 pm URINE Site: NOT SPECIFIED OLD S#
2040C.
**FINAL REPORT [**2103-12-5**]**
URINE CULTURE (Final [**2103-12-5**]): NO GROWTH.
.
.
Radiology:
CHEST (PORTABLE AP) Study Date of [**2103-11-30**] 12:48 PM
FINDINGS: Single portable AP view of the chest was obtained.
There is
blunting of the left costophrenic angle which may be due to a
trace effusion.
No focal consolidation is seen. There is no pneumothorax. There
is mild
prominence of the right hilum which could relate to underlying
vasculature,
however, recommend further evaluation with dedicated PA and
lateral views.
The cardiac silhouette is top normal. The mediastinum is
unremarkable.
IMPRESSION:
1. Blunting of left costophrenic angle which may be due to a
small pleural
effusion.
2. Mild prominence of the right hilum for which further
evaluation with
dedicated PA and lateral views is recommended.
.
CHEST (PA & LAT) Study Date of [**2103-12-1**] 11:46 AM
AP and lateral radiographs of the chest were reviewed in
comparison to [**11-30**], [**2103**].
Pacemaker leads terminate in right atrium and right ventricle.
There is no
definitive pneumothorax seen but minimal apical pleural air
cannot be excluded
and repeated radiograph is recommended in case patient is
symptomatic. Left
lower lobe consolidation has progressed since the prior study
and might
reflect developing infection, worsening atelectasis or
aspiration. Left and
right pleural effusions are small, unchanged since the prior
study. Mild
vascular engorgement is seen.
.
CT/CTA BRAIN WITH PERFUSION / CTA NECK Study Date of [**2103-12-1**]
8:59 PM
FINDINGS:
On the unenhanced head CT, there is no evidence for acute
ischemia. There is
no hemorrhage, midline shift or mass effect. Evaluation of the
CTA of the
neck demonstrates mild atheromatous irregularity of the right
common and
proximal ICA but without significant stenosis. There is also a
mild plaque at
the origin of the right vertebral artery which causes mild
stenosis. There is
a plaque at the origin of the left ICA and the left carotid bulb
causing mild
approximately 20-30% stenosis. The left vertebral artery is
markedly
hypoplastic and there appears to be poor flow proximally which
could be
related to high-grade stenosis or hypoplasia. The remaining of
the left
cervical vertebral artery also demonstrates irregularity which
could be
related to atherosclerotic disease or may be technical in
nature. There is
moderate plaquing at the right subclavian artery beyond the
takeoff of the
vertebral artery.
CTA images through the brain demonstrate no evidence for
high-grade stenosis, or vascular occlusion.
No aneurysm is seen within limits of the examination.
There is mild irregularity and narrowing of the ACA branches
which may be
related to atherosclerotic disease. Alternatively, this could be
technical.
There is possibility of an infundibulum at the origin of the
left superior
cerebellar artery.
Bilateral pleural effusions are noted. There are apparent
goiterous changes
in bilateral thyroid lobes which should be correlated with an
ultrasound if
not already performed.
There is a rounded focus of ground-glass density in the right
upper lobe which
could represent pneumonia in the appropriate clinical setting.
There is also
apparent consolidation in the left upper lobe. Clinical
correlation is
advised.
IMPRESSION:
No evidence for vascular occlusion intracranially.
Atherosclerotic disease in the bilateral carotid bifurcations
and proximal
ICAs, left greater than right but which does not appear to be
more than 50%.
Thyroid lesions which could represent goiter but consider
further evaluation
with ultrasound if not already performed.
Biapical lung densities which could represent consolidation or
pneumonia in
the appropriate clinical setting. Bilateral pleural effusions.
.
CHEST (PORTABLE AP) Study Date of [**2103-12-2**] 3:51 AM
Portable AP radiograph of the chest was reviewed in comparison
to [**2103-12-1**].
Pacemaker leads terminate in right atrium and right ventricle,
unchanged.
Cardiomediastinal silhouette is stable. The patient continues to
be in even
progressed pulmonary edema. Right basal opacity most likely
represents part
of the edema, but might reflect an area of atelectasis or
infection. Left
retrocardiac consolidation is unchanged. Small-to-moderate
bilateral pleural
effusions are redemonstrated.
No evidence of pneumothorax is present.
.
CHEST (PORTABLE AP) Study Date of [**2103-12-3**] 9:48 AM
IMPRESSION: AP chest compared to [**11-30**] through 8:
Previous mild pulmonary edema has improved, but small bilateral
pleural
effusions have increased. Left lower lobe opacification could be
a
combination of atelectasis and edema since it has improved since
[**12-1**].
Heart size normal. Atrioventricular pacer defibrillator leads in
standard
placements. No left pneumothorax.
.
CHEST (PA & LAT) Study Date of [**2103-12-4**] 10:42 AM
FINDINGS: There has been a slight improvement in bibasilar lung
aeration as well as mild pulmonary edema. However, moderate
pleural effusions persist bilaterally. Atrioventricular pacer
defibrillator remains in the left hemithorax. There is no
evidence of new consolidation, effusions, or pneumothoraces.
IMPRESSION: Mild improvement in bibasilar lung aeration.
Persistent moderate pleural effusions persist.
.
.
Cardiology:
ECG Study Date of [**2103-11-30**] 10:25:16 AM
Complete heart block with an escape rhythm which has a right
bundle-branch
block pattern and left posterior fascicular block. No previous
tracing is
available to assess whether this is a junctional rhythm with
aberration or a
fascicular rhythm.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
33 0 88 [**Telephone/Fax (2) 91859**] 68
.
Portable TTE (Complete) Done [**2103-11-30**] at 12:50:19 PM FINAL
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild degenerative aortic stenosis. Moderate aortic
regurgitation. Mild mitral regurgitation. Moderate pulmonary
hypertension. Given the appearance of the aortic and mitral
valves, is there a history of chest irradiation?
.
ECG Study Date of [**2103-12-1**] 9:57:40 AM
Dual chamber paced rhythm is present with atrial sensed,
ventricular paced
rhythm. Intra-atrial conduction defect is seen.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 0 130 426/468 0 -65 102
.
ECG Study Date of [**2103-12-1**] 10:56:16 PM
Atrial sensed, ventricular paced rhythm. Intra-atrial conduction
defect.
T wave inversion anterolaterally is new since tracing #2. Acute
ischemic
injury needs to be assessed.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 0 136 442/473 0 -67 117
Brief Hospital Course:
50RHF with PMH of hypothyroidism, distant history of Hodgkin's
lymphoma s/p chemotherapy and radiation, and 3rd degree heart
block of unknown origin s/p pacemaker placement on [**2103-11-30**], who
represented as a code stroke on [**2103-12-1**] with left leg>arm
weakness in keeping with right ACA ischemia. Of note, she had
been started on lisinopril just prior to presentation which was
felt to perhaps be the inciting event. Her exam was initially
notable for left proximal arm weakness and complete left leg
plegia. She was admitted to the ICU and started on pressors with
significant improvement in her weakness suggesting hypoperfusion
as opposed to infarction. CTA (it was not possible to perform
MRI scanning due to the presence of her pacemaker) revealed a
stenotic right ACA and no clear acute infarction. She developed
orthopnoea and dyspnea on exertion and CXR revealed bilateral
pleural effusions and pulmonary edema likely due to her
aggressive IV fluid resuscitation to maintain her BP. She
received a single dose of IV furosemide in the ICU and no
further diuresis given concern for further hypoperfusion. She
was transferred to the floor and remained stable and although
initially symptomatic as a result of her effusions, this
improved and she was mobilising well. Home antihypertensives
were stopped. She remained stable and was discharged home with
services for cardiovascular monitoring on [**2103-12-5**]. She has
neurology and cardiology follow-up.
.
.
# Neurology:
Patient was recently s/p pacemaker placement on [**2103-11-30**] and
represented as a code stroke on [**2103-12-1**] with left leg>left arm
weakness in keeping with right ACA ischemia. Of note, she had
been started on lisinopril just prior to presentation which was
felt to perhaps be the inciting event resulting in perhaps
symptomatic hypoperfusion.
Initial examination revealed left proximal arm weakness and
complete L leg plegia and notably this improved somewhat with
elevation of her BP.
CT head revealed no evidence for acute ischemia, hemorrhage,
midline shift or mass effect. CTA head showed mild irregularity
and narrowing of the ACA branches particularly on the right felt
likely due to atherosclerosis in addition to no other evidence
for high-grade stenosis or vascular occlusion. CT perfusion
revealed decreased perfusion in the right ACA territory. CTA
neck showed atherosclerotic disease in the bilateral carotid
bifurcations and proximal ICAs, left greater than right but
which does not appear to be more than 50% in addition to mild
plaque at
the origin of the right vertebral artery which causes mild
stenosis and the left vertebral artery was noted to be markedly
hypoplastic with poor flow proximally which was felt could be
related to high-grade stenosis or hypoplasia. In addition, there
was incidental note of apparent goiterous changes in bilateral
thyroid lobes.
She was admitted to the ICU given likely hypoperfusion and was
started on pressors with significant improvement in her
weakness. As a result, her lisinopril was stopped. Phenylephrine
drip was weaned off on [**2103-12-2**] and she was maintained on IVF
with a goal SBP 140-150. Her weakness continued to improve
rapidly, and by [**2103-12-3**] she had regained full strength
throughout her left arm and leg.
However she began to complain of shortness of breath when lying
flat, and a CXR showed pulmonary edema and moderate bilateral
pleural effusions. Fluids were stopped and she received 10mg IV
furosemide. On advice of cardiology and out of concern for
dropping her BP and causing hypoperfusion symptoms, she received
no further diuretics. She remained on close BP monitoring with
goal SBP 140-150. She was followed by cardiology and had a
pacemaker interrogation on [**2103-12-2**] which showed normal function
and although she had episodes of paced tachycardia in the 100s
and per cardiology this tachycardia represented pacing from SA
node. She was transferred to the floor on [**2103-12-3**].
Stroke risk factors were addressed. She was monitored on
telemetry and this showed a paced rhythm throughout. Pre-op TTE
on [**2103-11-30**] showed normal systolic function with no evidence of
cardioembolic source and this was not repeated. Lipid panel
revealed total chol 166, LDL 82, TG 74, HDL 69. HbA1c was 6.0%.
She was started on aspirin 325mg daily and atorvastatin 20mg
daily and as above lisinopril was held.
The diagnosis was felt to be likely ACA hypoperfusion given ACA
narrowing on CTA and perfusion deficit on CTP with resolution of
symptoms with higher BPs.
She remained stable on transfer to the floor with a good BP and
non-focal examination throughout the rest of her stay. Although
she was initially symptomatic as a result of her bilateral
pleural effusions with orthopnoea and dyspnoea on exertion, this
improved and repeat CXRs showed better aeration but still
moderate pleural effusions. She was mobilising well and PT
cleared her to go home. We stopped lorazepam on discharge out of
concern for possible hypotension. She remained stable and was
discharged home with services for cardiovascular monitoring on
[**2103-12-5**]. She was advised that if she had any further weakness
on the left side, she should return to the ED and in the interim
should try and lie flat to improve blood pressure. She has
neurology follow-up.
.
# CVS:
Patient was followed by cardiology and maintained on telemetry
monitoring. Her pacemaker was interrogated on [**2103-12-2**] and was
found to be functioning normally. She began to complain of
shortness of breath when lying flat on [**2103-12-3**]. Repeat CXR
showed pulmonary edema and bilateral moderate pleural effusions.
This was felt likely to her aggressive IV fluid resuscitation
during her stay. Fluids were stopped and she received 10mg IV
furosemide in the ICU and no further fluids due to concern for
further hypoperfusion. Echo was not repeated as recent pre-op
echo on [**2103-11-30**] demonstrated normal systolic function. She had
episodes of paced tachycardia in the 100s and per cardiology
this tachycardia represented pacing from SA node. She has
cardiology follow-up.
.
# ID:
She remained afebrile with no leukocytosis and no leukocytosis.
She was continued on Augmentin 500mg Q8H for a planned 14 day
course for R hand cellulitis resulting from a dog bite. UA was
equivocal and UCx revealed no growth. BCs were negative.
.
# PULM:
CXR on [**2103-12-2**] showed pulmonary edema with bilateral pleural
effusions. This had slightly improved on [**2103-12-3**] although still
showed b/l pleural effusions. O2 sats remained stable on RA
throughout her stay. IVF were stopped and her respiratory status
was monitored closely in the ICU. On transfer to the floor she
was initially symptomatic as above with orthopnoea and dyspnoea
on exertion, this improved and repeat CXRs showed better
aeration but still moderate pleural effusions.
.
# ENDO:
TSH was found to be elevated at 6.9. Patient has a history of
hypothyroidism and note incidental finding on CT of apparent
goiterous changes in bilateral thyroid lobes. She was maintained
on fingersticks and insulin sliding scale during her admission.
HbA1c was 6.0%.
.
# FEN:
She was cleared by speech for a regular diet. Electrolytes were
monitored and repleted as needed. IVF were discontinued due to
concern for pulmonary edema.
.
# PPx:
She was maintained on pneumoboots and s/c heparin throughout her
admission.
Medications on Admission:
- metronidazole 500mg [**Hospital1 **] (Rx'd for pelvic/abdominal pain)
- levothyroxine 25mcg QD
- ativan 0.5mg [**Hospital1 **]
- fluoxetine 40mg QD
- lisinopril 5mg QD (just discharged on this as a new med)
- augmentin 500mg TID x14 days (just discharged on this as a new
med for R hand cellulitis from a dog bite)
Discharge Medications:
1. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days: started [**2103-12-1**] for 14
day course to finish [**2103-12-14**].
Disp:*30 Tablet(s)* Refills:*0*
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*5*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1) Right anterior cerebral artery ischemia in the setting of
right ACA stenosis
2) Bilateral moderate pleural effusions secondary to IV fliuds
3) Third degree heart block status post pacemaker
4) Dog bite treated with augmentin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Non-focal examination. No pronator drift. Full
strength. Steady gait. Clinically bilateral pleural effusions.
Discharge Instructions:
Dear Ms. [**Known lastname 30485**],
You were admitted to [**Hospital1 69**] on
[**2103-12-1**] with left arm and leg weakness. You were found to have
decreased blood flow to the right front part of your brain. You
were initially admitted to the Intensive Care Unit for medicines
to increase your blood pressure. Imaging of the blood vessels of
your head revealed a narrowing in the corresponding artery which
supplie this area called the anterior cerebral artery. Your
weakness improved greatly after being started on medications to
increase your blood pressure. For this reason, we believe the
most likely cause of your weakness was relatively low blood
pressure causing inadequate flow to your brain through this
narrowed vessel after starting lisinopril. We have therefore
stopped your lisinopril for this reason. Please do NOT restart
the lisinopril at this time. We started aspirin and a
cholesterol lowering [**Doctor Last Name 360**] called atorvastatin to reduce stroke
risk. If you have any further weakness on this side, you must
come back to the ED and in the interim should try and lie flat
as this improves blood pressure.
.
In order to increae your blood pressure, we used a large volume
of IV fluids and this resulted in fluid collections in the
outside of both lungs. However, on the day of discharge you were
breathing comfortably. The fluid collections should go away on
their own over time.
You developed some bleeding in the urine, likely as a result of
the placement of a catheter. Please contact us if this does not
resolve.
We made the following changes to your medications:
We HELD lorazepam as this can lower blood pressure (we prefer
that you discontinue this)
We STOPPED lisinopril
We STARTED aspirin 325mg daily
We STARTED atorvastatin 20mg daily
Please continue augmentin for your dog bite and possible urinary
infection to finish on [**2103-12-14**]
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:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week.
.
We have organised the following neurology follow-up:
Department: NEUROLOGY
When: WEDNESDAY [**2104-2-6**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & HAUSSEN [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
We have organised the following cardiology appointment:
Department: CARDIOLOGY
When: Wednesday, [**2104-1-9**] at 3:50 PM
With: [**First Name11 (Name Pattern1) 2922**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 72622**]
Address:
[**Hospital1 641**]- [**University/College **]
[**Hospital1 **].
[**University/College **], [**Numeric Identifier **]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"682.4",
"E906.0",
"V10.72",
"437.0",
"434.91",
"428.31",
"428.0",
"V45.01",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
35793, 35842
|
27330, 34751
|
10197, 10203
|
36114, 36114
|
17018, 17496
|
38484, 39366
|
13774, 13913
|
35118, 35770
|
35863, 36093
|
34777, 35095
|
36388, 37960
|
18038, 27307
|
15442, 16812
|
1580, 1594
|
13928, 13942
|
16840, 16999
|
2839, 3328
|
37989, 38461
|
10133, 10159
|
10231, 13023
|
13956, 14853
|
36129, 36364
|
17512, 18022
|
13045, 13410
|
13426, 13758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,634
| 177,043
|
42076
|
Discharge summary
|
report
|
Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-7**]
Date of Birth: [**2123-5-24**] Sex: F
Service: MEDICINE
Allergies:
Hydrocodone / poppyseeds
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F with complex medical history including COPD, CKD Stage 3,
PAF s/p ablation on coumadin, diastolic CHF, aortic stenosis s/p
percutaneous valvuloplasty, hypertension, hyperthyroidism on
Methimazole, presenting with abdominal pain at site of abdominal
hernia.
.
Patient presented to [**Hospital6 3105**] the day prior to
admission with complaints of progressively worsening abdominal
pain over the site of a periumbilical hernia (developed in
[**2191**]). Patient reports that the pain is always present, but
over the last several days, it has become intolerable, [**9-21**] and
constant. Pain is not relieved with tylenol. Pain is not
associated with nausea or vomiting, diarrhea, constipation, or
blood in stool. She has two solid bowel movements daily, and
last bowel movement was day prior to admission. She denies
fever or chills. She denies dysuria, urgency or frequency of
urination.
.
In addition, patient reports worsening exercise tolerance over
the same period of time. She is usually able to walk to the
kitchen without shortness of breath, but now reports dyspnea
when walking "to the table."
.
At [**Hospital6 3105**], patient received Ancef 1000mg IV
to treat abdominal cellulitis. She also received duonebs for
shortness of breath and morphine IV for pain control. A CT
abdomen showed no incarceration of the hernia with incidental
finding of lung consolidation concerning for pneumonia. She was
transferred to [**Hospital1 18**] for surgical evaluation of hernia.
.
In the ED, initial vital signs were: 97.3 85 133/39 18 100% 3L.
Physical exam was notable for aortic stenosis murmur [**4-17**],
bibasilar crackles with soft expiratory wheeze. Her abdominal
exam was significant for tender peri-umbilical and suprapubic
area with an umbilical hernia, a large pannus with peau d'orange
swelling and erythema in the suprapubic area. Her lower
extremity exam was significant for increased warmth and
erythema. Labs were significant for Cr 1.3, Hct 34.1, INR 1.7
(on coumadin), BNP > 1000 and troponin 0.03. General surgery was
consulted who noted no incarceration of hernia and suggested
admission to medicine for pain control. A portable CXR
demonstrated bilateral effusions and could not exlude pneumonia.
An EKG demonstrated SR at 78bpm without evidence of STEMI. She
was given 4mg IV morphine x 1 for pain control, and duonebs x2
for relief of shortness of breath. Vitals on transfer were: 98.1
83 134/50 16 94% 3L.
.
On the floor, initial vital signs were T97.7, BP 159/54, HR 79,
95% on 3L, RR 32. Patient was complaining of ongoing abdominal
pain and shortness of breath.
.
Of note, patient also reports that approximately two weeks ago
she fell off of her couch, landing on the floor. She called 911
and EMS services evaluated her at home, but did not take her to
the ER. She has been able to walk without weakness in her
extremities. She walks with the assistance of a walker at
baseline.
Past Medical History:
Abdominal hernia at site of old feeding tube
COPD- on 3L home oxygen
diastolic CHF (EF 65% documented on [**2196-9-14**] pre-valvuloplasty)
Aortic stenosis- s/p percutaneous aortic valvuloplasty [**9-/2196**] @
[**Hospital1 112**]
Atrial fibrillation- on coumadin
Sick sinus syndrome- permanent pacer
HTN
Hyperlipidemia
CRI (baseline Cr 1.3)
h/o VRE UTI on bactrim prophylaxis.
Anemia
Hyperthyroidism- on methimazole
Pancreatic mass in tail
Social History:
Lives alone in [**Name (NI) 3844**], [**First Name3 (LF) **]-in-law and granddaughter live
next door. VNA assists with medication daily. Husband died 1
year ago. Three children, one daughter died one year ago in
motorcycle accident, one daughter lives in [**Name (NI) 7661**] and one son.
[**Name (NI) 1139**]- quit 20 years ago
Alcohol- rare
Illicits- denies
Family History:
Mother- died in car accident
[**Name (NI) 12238**] emphysema
Sister- coronary artery disease
Physical Exam:
Admission Physical Exam:
Vitals: T:97.7 BP:159/54 P:79 R:32 O2:95% on 3L NC, Weight: 90.6
kgs
General: Elderly female sitting up in bed with pursed lip, rapid
breathing, but in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP difficult to evaluate but does not appear
elevated, no LAD
Lungs: Clear to auscultation bilaterally, course crackles in
bilateral bases extending 1/3 up.
CV: Regular rate and rhythm, normal S1 + S2, grade [**5-18**] harsh
holosystolic murmur throughout precordium but best heard at
RUSB, radiating to carotids
Abdomen: Large pannus with diffuse ecchymosis, large
supraumbilical hernia, tender to palpation but reducible. Peau
d'orange skin changes without erythema or warmth in pannus below
umbilicus, with significant pitting edema and swelling. No
redness or discharge in bilateral inguinal regions below pannus.
Ext: Diffuse ecchymosis on left>right thigh without palpable
hematoma. 2+ lower extremity edema bilaterally extending to
knee. DP/PT pulses not palpable.
Neuro: CN II-XII intact. Strength 5/5 throughout. Full ROM in
b/l hips
.
Discharge Physical Exam:
Vitals - Tm: 98.0, HR: 60-62, BP:(110-139/37-64) RR: 20-24 02
sat: 96-97% 3L NC
Weight: 92.6kgs down from 94.9kgs yesterday
GENERAL: Obese caucasian female in NAD. Oriented x3. Mood,
affect appropriate.
NECK: Supple, no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**4-17**] cresendo/decresendo murmur best
heard at LUSB, which radiates to right carotid.
LUNGS: Diminished but clear throughout
ABDOMEN: There is a large, reducible, umbilical hernia, which is
non-tender, and less swollen and erythematous. The area beneath
the pannus has cleared up, no open sores, mild erythema, no
drainage. The remainder of her abdomen is soft, non-distended.
EXTREMITIES: woody edema halfway up shins bilaterally,trace
edema otherwise, extremities warm, 1+ DP/PT bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
skin tear on left hand (no longer open, healing nicely).
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
Pertinent Results:
Admission Labs:
.
[**2196-11-30**] 02:00AM BLOOD WBC-7.4 RBC-3.52* Hgb-10.6* Hct-34.1*
MCV-97 MCH-30.0 MCHC-31.0 RDW-15.4 Plt Ct-276
[**2196-11-30**] 02:00AM BLOOD Neuts-75.7* Lymphs-16.0* Monos-7.0
Eos-1.1 Baso-0.3
[**2196-11-30**] 02:00AM BLOOD PT-19.3* PTT-24.6 INR(PT)-1.7*
[**2196-11-30**] 02:00AM BLOOD Plt Ct-276
[**2196-11-30**] 02:00AM BLOOD Glucose-88 UreaN-47* Creat-1.3* Na-143
K-4.3 Cl-103 HCO3-31 AnGap-13
[**2196-11-30**] 09:15PM BLOOD Glucose-99 UreaN-45* Creat-1.2* Na-143
K-4.0 Cl-104 HCO3-33* AnGap-10
[**2196-11-30**] 09:15PM BLOOD CK(CPK)-23*
[**2196-11-30**] 02:00AM BLOOD proBNP-3652*
[**2196-11-30**] 02:00AM BLOOD cTropnT-0.03*
[**2196-11-30**] 02:00AM BLOOD Calcium-9.2
[**2196-11-30**] 09:15PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2196-11-30**] 09:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-62* pH-7.36
calTCO2-36* Base XS-6 Comment-GREEN TOP
[**2196-11-30**] 09:59PM BLOOD Lactate-1.5
.
Pertinent Labs:
.
[**2196-11-30**] 02:00AM BLOOD proBNP-3652*
[**2196-11-30**] 02:00AM BLOOD cTropnT-0.03*
[**2196-11-30**] 09:15PM BLOOD CK-MB-3 cTropnT-0.04*
[**2196-12-1**] 07:05PM BLOOD TSH-1.4
[**2196-12-2**] 05:26AM BLOOD Triglyc-126 HDL-55 CHOL/HD-3.4
LDLcalc-106
[**2196-11-30**] 09:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-62* pH-7.36
calTCO2-36* Base XS-6 Comment-GREEN TOP
[**2196-11-30**] 09:59PM BLOOD Lactate-1.5
[**2196-12-6**] 04:50AM URINE RBC-8* WBC-52* Bacteri-MOD Yeast-NONE
Epi-1 TransE-<1
.
Discharge Labs:
.
[**2196-12-7**] 06:35AM BLOOD WBC-4.8 RBC-2.95* Hgb-8.7* Hct-27.2*
MCV-92 MCH-29.6 MCHC-32.0 RDW-15.8* Plt Ct-207
[**2196-12-7**] 06:35AM BLOOD Plt Ct-207
[**2196-12-7**] 06:35AM BLOOD PT-22.8* INR(PT)-2.1*
[**2196-12-7**] 06:35AM BLOOD Glucose-68* UreaN-52* Creat-1.3* Na-141
K-4.4 Cl-104 HCO3-30 AnGap-11
[**2196-12-7**] 06:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.6
.
Micro/Path:
.
MRSA Screen: Negative
.
Imaging/Studies:
.
ECG [**2196-11-30**]:
Normal sinus rhythm. Left ventricular hypertrophy by voltage.
Non-specific
ST-T wave changes that could reflect the ventricular
hypertrophy. No previous tracing available for comparison.
.
TTE [**2196-11-30**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is moderately
dilated with normal free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Mild to moderate
([**2-14**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with hyperdynamic LV systolic
function. Moderate to severe mitral regurgitation. Mild to
moderate aortic regurgitation. Hypertrophied and dilated right
ventricle with normal systolic function, severe tricuspid
regurgitation and severe pulmonary hypertension.
.
CXR Portable [**2196-11-30**]:
FINDINGS: There is moderate pulmonary edema and likely small
pleural
effusions. No pneumothorax is seen. There is moderate
cardiomegaly. The
presence of pericardial effusion is not well evaluated. A
left-sided
dual-lead pacemaker is in standard position.
.
CXR Portable [**2196-12-2**]:
IMPRESSION:
1. Moderate bilateral pulmonary edema, improved.
2. Moderate left pleural effusion and small right pleural
effusion, improved.
3. Bilateral ill-defined nodular opacities may represent vessels
en face, but PA and lateral views should be obtained once the
patient is stabilized.
.
CXR Portable [**2196-12-3**]:
IMPRESSION: AP chest compared to [**11-30**] and 21:
Mild pulmonary edema improved between [**11-30**] and 21 and has
not changed
subsequently. Severe cardiomegaly, moderate left pleural
effusion, and
generalized pulmonary vascular engorgement are stable.
Transvenous right
atrial and right ventricular pacer leads are continuous from the
left axillary pacemaker. No pneumothorax.
.
CXR PA/LAT [**2196-12-6**]:
MPRESSION: Persistent evidence of cardiac enlargement and
pulmonary vascular congestion. Significant improvement cannot be
identified. Variations in vascular pulmonary appearance may in
this case relate to different phases of inspiration.
.
Spirometry [**2196-12-5**]:
SPIROMETRY 2:44 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 0.86 2.30 37
FEV1 0.66 1.58 42
MMF 0.55 1.96 28
FEV1/FVC 76 69 111
LUNG VOLUMES 2:44 PM Pre drug Post drug
.
Actual Pred %Pred Actual %Pred
TLC 2.03 3.93 52
FRC 1.30 2.30 56
RV 1.12 1.63 68
VC 0.91 2.30 40
IC 0.73 1.64 45
ERV 0.18 0.66 27
RV/TLC 55 42 133
He Mix Time 0.00
.
OSH IMAGING:
CT abdomen/pelvis (OSH): Wide fascial defect with no evidence of
small
bowel dilation within hernia or within abdomen. Possible
pneumonia in lower base of lung. No evidence of incarceration.
Brief Hospital Course:
73 yo F with a history of COPD (3L home O2), diastolic CHF,
aortic stenosis s/p recent ballon valvuloplasty, and h/o
periumbilical hernia presenting with progressively worsening
dyspnea and abdominal pain.
.
ACTIVE DIAGNOSES:
.
# Diastolic CHF Exacerbation: On admission, patient reported
progressively worsening shortness of breath limiting her
exercise tolerance significantly. She was previously able to
walk to her kitchen and prior to admission could only walk "to
the table." She denied worsening cough or increased oxygen
requirement, but did note that her abdomen had become more
swollen and her lower extremity edema was significantly worse.
Given patient's history of aortic stenosis s/p valvuloplasty, we
were initially concerned about worsening aortic stenosis causing
progression of symptoms. TTE performed on the day of admission
showed that the valve area was 1.2, consistent with [**Hospital1 24300**] report of the post-valvuloplasty valve area. Patient
had evidence of significant pulmonary hypertension and right
ventricular overload. She was initially diuresed on the floor,
but became increasingly dyspneic and hypoxic, and was
transferred to the CCU for augmented diuresis on lasix drip. A
CXR was consistent with pulmonary edema [**3-16**] volume overload. She
was diuresed on a lasix drip for 24 hours, then transitioned to
home regimen of lasix 80mg PO BID. She had pulmonary function
testing in-house which demonstrated severely decreased lung
volumes, FVC, FEV1 but preserved FEV1/FVC consistent with a
severe restrictive defect and similar to prior PFT's at [**Hospital1 112**] a
year prior. She continued to be diuresed and was ultimately
switched to a maintenance dose of lasix of 40mg PO daily when
she reached her functional baseline of poor exercise tolerance
on 3LNC (her home O2 dose). She was also switched from captopril
to low-dose lisinopril. Follow-up was established with her PCP
and [**Name9 (PRE) 3782**] cardiologist in [**Location (un) 3844**].
.
# Non-incarcerated periumbilical hernia/Abdominal Pain: Patient
was initially seen at [**Hospital6 3105**] with chief
complaint of abdominal pain. She has a known large
periumbilical hernia related to old feeding tube. She had a CT
scan which was negative for incarceration of hernia, and on exam
at [**Hospital1 18**], hernia was large and easily reducible. The surgery
team saw the pt and did not think surgical intervention was
warranted. Exam was significant for pannus edema with peau
d'orange skin changes. Underneath the pannus there was some
erythema, but without obvious signs of infection. She was
evaluated by the wound care nurse, who recommended trial with an
abdominal binder, which refused by the patient. As her diuresis
progressed her pannus edema was significantly reduced and her
abdominal pain improved markedly. She was started on tylenol and
tramadol PRN for pain control.
.
CHRONIC DIAGNOSES:
.
# COPD: Patient was initially continued on her home medications
including albuterol nebulizer treatments prn, singulair and
prednisone 30mg daily. On further review of discharge summary
from [**2196-9-12**] admission at [**Hospital1 112**], it was clear that patient
should have been tapered off of prednisone several months
earlier. Therefore she was decreased to 20mg daily with plan to
continue with a slow taper at a suggested rate of 10mg after 1
week, 5mg after the next, and then cessation of therapy. She was
discharged on her 3LNC home O2 dose as above.
.
# Paroxysmal atrial fibrillation: Stable. Not in afib during
this admission per EKG's and tele. On coumadin 2mg daily with
subtherapeutic INR on admission of 1.7. She was continued on her
coumadin and her INR was 2.2 at the time discharge.
.
# Chronic kidney disease: Likely multifactorial. Baseline Cr
1.3. Patient was at baseline on admission but bumped to 1.7 in
the setting of aggressive diuresis. She was then transitioned to
PO lasix at a maintenance dose of 40mg PO daily and her Cr
returned to baseline.
.
#Hyperthyroidism: Stable. Continued on her home methimazole.
.
#Chronic Normocytic Anemia: Pt with significant anemia with
crits from high 20's to low 30's. Unclear etiology but likely
multifactorial and could be playing a role in her poor exercise
tolerance. Previously on procrit which she stopped taking due to
cost. Workup and management of this issue was deferred to the
outpatient setting.
.
TRANSITIONAL ISSUES:
#Dispo: Patient recommended for placement in rehab but she has
already used up all of her rehab time provided by her insurance
and is at the functional baseline. She was discharged home with
home VNA and home PT.
.
#Steroid Taper: Pt has inadvertently been on prednisone for a
period of months following discharge from [**Hospital1 112**] and was initiated
on a slow taper in-house from 30mg to 20mg. We suggested to
continue this taper to 10mg over the next week, then 5mg the
following week, then cessation of prednisone with monitoring of
her electrolytes and blood pressures to watch for adrenal
insufficiency.
.
#Bactrim PPX: Pt is currently on bactrim PPX in conjunction to
her prednisone. This medications can likely be discontinued
following cessation of her prednisone.
.
#Lasix: Her lasix dose was changed to 40mg PO once daily at the
time of discharge as a maintenance dose. However, it is likely
that her compliance with a low Na diet will decrease at home and
her dosage will likely need to be increased back towards her
80mg PO BID dose level on admission. She will need a Chem 7
during her next PCP [**Name Initial (PRE) 648**].
.
#Pain Control: Pt was started on tramadol PRN for control of
pain related to her pannus edema and reducible abdominal hernia.
She had previously tried oxycodone which had made her very
sleepy but tolerated tramadol quite well.
.
#Anemia: Pt with significant anemia during this hospitalization
who will need continued outpatient workup and management.
.
#Cardiology Follow-up: Pt set up with cardiology follow-up with
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in NH.
Medications on Admission:
- Prednisone 30mg daily
- Ativan 0.5 tid prn
- Iron 325mg [**Hospital1 **]
- Singulair 10mg daily
- MVI
- Celexa 40mg daily
- Albuterol nebulizer q4h prn
- Coumadin 2mg daily
- Miralax 17g daily
- Lasix 80mg [**Hospital1 **]
- Methimazole 5mg po daily
- Bactrim SS 400-80mg daily
- Sotalol 80mg daily
- Captopril 12.5mg daily
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. methimazole 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
8. sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for one week, then decrease to 10mg daily for one week, then
decrease to 5mg daily for one week, then discontinue.
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q 8 hours PRN as
needed for anxiety.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) nebulizer Inhalation four times a day.
14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for abdominal pain.
18. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
19. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
-Diastolic congestive heart failure exacerbation
Secondary:
-COPD on 3L home oxygen
-pulmonary hypertension
-depression
-hypertension
-anemia
-GERD
-Hypothyroidism
-Reducible umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
PHYSICAL EXAM:
Vitals - Tm: 98.0, HR: 60-62, BP:(110-139/37-64) RR: 20-24 02
sat: 96-97% 3L NC
Weight: 92.6kgs down from 94.9kgs yesterday
In/Out (Last 24H): in 1230cc out 1650cc (negative 420cc)
.
Tele: No significant events
.
GENERAL: Obese caucasian female in NAD. Oriented x3. Mood,
affect appropriate.
NECK: Supple, no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**4-17**] cresendo/decresendo murmur best
heard at LUSB, which radiates to right carotid.
LUNGS: Diminished but clear throughout
ABDOMEN: There is a large, reducible, umbilical hernia, which is
non-tender, and less swollen and erythematous. The area beneath
the pannus has cleared up, no open sores, mild erythema, no
drainage. The remainder of her abdomen is soft, non-distended.
EXTREMITIES: woody edema halfway up shins bilaterally,trace
edema otherwise, extremities warm, 1+ DP/PT bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
skin tear on left hand (no longer open, healing nicely).
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
Labs: [**2196-12-7**]: WBC 4.8, Hct 27.2, plt 207, INR 2.1, Na 141, K
4.4, BUN 52, Cr 1.3, gluc 68
*Of note, pt has chronic anemia, had been on Procrit 4000 units
weekly but has not been taking this medication due to cost*
Discharge Instructions:
Dear Ms [**Known lastname **],
.
You were admitted to [**Hospital1 18**] with shortness of breath and
abdominal pain. Your shortness of breath was mostly due to a
congestive heart failure exacerbation, though your pulmonary
hypertension and COPD also played a role. To prevent further CHF
exacerbations, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
goes up more than 3 lbs. Be sure to limit your salt intake in
your diet and restrict your fluids to 1500cc/ day.
Your abdominal pain is due to your abominal hernia. This was
evaluated with a CT scan and by our surgeons, who did not feel
that surgery was required. Your pain did improve significantly
with removal of excess fluid. If you continue to have pain at
home you can take Tramadol 50mg every 8 hours as needed (you
should avoid using the Oxycodone).
You should resume your Coumadin at 2mg daily. You should have
your INR checked on Monday. The goal for your INR is [**3-17**].
Your kidneys are not working 100% but they appear to be at
baseline right now. You should have your electrolytes and kidney
function test repeated on Monday.
The following changes were made to your medications:
** STOP captopril (because you are switching to Lisinopril)
** START lisinopril at 2.5mg dose to treat yor heart failure
** CHANGE prednisone to a tapered dose: 20mg daily for one week,
then decrease to 10mg daily for one week, then decrease to 5mg
daily for one week, then discontinue medication.
** DECREASE your Lasix to 40mg daily, you will need to have your
electrolytes and kidney function tests repeated on Monday
** START Simvstatin 40mg daily (for cholesterol)
** START Tramadol 50mg every 8 hours as needed for abdominal
pain
.
Please follow-up with the appointments listed below:
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital1 **] PHYSICIAN SERVICES OF [**Name9 (PRE) **]
Address: [**Location (un) 53354**], [**Hospital1 **],[**Numeric Identifier 40170**]
Phone: [**Telephone/Fax (1) 53355**]
Appointment: TUESDAY [**12-14**] AT 4:00PM
Name: [**Last Name (LF) 925**], [**First Name3 (LF) **]
Specialty: CARDIOLOGY
Location: NE HEART INSTITUTE AT [**Hospital3 **] CENTER
Address: 1 [**Hospital1 **] DR, [**Location (un) **] [**Numeric Identifier 66328**]
Phone: [**Telephone/Fax (1) 91305**]
**We are working on a follow up appointment with Dr. [**First Name (STitle) **]
within 1 month. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
Completed by:[**2196-12-7**]
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11889, 12097
|
301, 307
|
20279, 20279
|
6384, 6384
|
23588, 24409
|
4122, 4216
|
18324, 19928
|
20055, 20258
|
17974, 18301
|
21805, 23565
|
7846, 11866
|
20445, 21781
|
16308, 17948
|
247, 263
|
335, 3262
|
6400, 7307
|
20294, 20430
|
7323, 7830
|
12115, 16287
|
3284, 3726
|
3742, 4106
|
5348, 6365
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,100
| 140,348
|
20541
|
Discharge summary
|
report
|
Admission Date: [**2182-5-19**] Discharge Date: [**2182-6-29**]
Date of Birth: [**2142-8-19**] Sex: F
Service: SURGERY
Allergies:
Apple / Peach / Pear
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
admitted [**5-19**] for renal failure MELD 39, received liver
transplant
Major Surgical or Invasive Procedure:
Paracentesis
liver transplant
History of Present Illness:
HPI from admission to transplant surgery [**6-12**]:
39 yo woman w cirrhosis [**1-21**] schistosomaisis, MELD 39
awaiting liver transplant admitted [**5-19**] for acute renal failure
and transferred to MICU today for declining mental status and
bradycardia, pre-op for OLTx in the morning.
Her hospital course has been notable for a rising creatinine,
hyperphosphatemia, hypercalcemia, low TSH and total T4 levels,
and blood transfusions as well as infusions of albumin.
Since transfer to the MICU earlier today she has been stable
from
a cardiopulmonary standpoint. From a mental status standpoint,
she continues to be responsive to physical stimuli but not to
voice.
Original HPI from admission [**5-19**]:
39 y/o woman with ESLD s/s shistosomiasis on transplant list who
is presenting from home with inability to urinate. Per reports,
she was seen in clinic friday and was doing reasonably well.
Over the weekend, however, she developed shortness of breath,
worsening pruritis, and inability to urinate. She reports she
did not make urine for 14 hours. She denies fevers, chills,
nausea, or vomitting. She also notes frequent hicups.
.
On arrival to the emergency department, her blood pressure was
90/43, HR 72 Rr 18, sating 100%RA. She had a foley catheter
placed which immedietly drained 500cc of dark urine. She did not
have a bladder pressure transduced in the ED and the medical
floors do not transduce bladder pressures. She did not get IV
fluids in the emrgency department. Urine studies were not sent.
.
She had labs drawn which showed cr 1.2 and she was admitted. Of
note, she was recently admitted from [**Date range (1) 46783**] for acute renal
failure and had her spironolactone and lasix held on discharge.
She has not re-started them. Her creatinine on discharge [**5-11**]
was 0.6 and when checked in clinic [**5-17**] was also 0.6.
Past Medical History:
1)ESLD from schistosomiasis; currently on the transplant list.
She is s/p single treatment with Praziquantel and no evidence of
organisms on ERCP evaluations; she has known about her liver
disease for about 8-10 years. She also had episodes of jaundice
and pruritis 10 to 15 years ago in [**Country 4194**], both times when she
was pregnant. Once in her sixth month of pregnancy and once in
her eight month of pregnancy. She was told that she had
hepatitis C. She has hepatitis C antibody, but negative PCR. She
lost her baby both times. Her jaundice and pruritis resolved
after delivery, both episodes. She is immune to hepatitis A. She
is vaccinated for hepatitis B. No prior history of culture
positive SBP, but has received empiric treatment in the past.
2)Grade [**12-21**] varicies and portal gastropathy without bleeding on
endoscopy in [**12-28**]
3)HCV+ but PCR repeatedly negative
4)s/p CCY 15y ago in [**Country 4194**] for which she received blood txf
5)s/p tubal ligation
6)GERD, previously admitted for associated epigastric pain
7)Strongyloides Ab positive in [**12-28**] - treated w/5 days
Ivermectin
8) SBP on cefpodoxime ppx
.
Social History:
Married, lives with her husband in [**Name (NI) 15739**] [**Name (NI) **]. Originally from
[**Country 4194**]. She works part time as a housekeeper (private homes). No
tobacco, alcohol, or IVDA.
Family History:
Non-contributory
Physical Exam:
On admission
GEN: ill appearing, though not in any acute distress
HEENT: jaundiced, no JVP elevation
CV: RRR s1, s2, II/VI systolic murmur ascultated, did not
radiate to axilla or carotids
RESP: CTA bilaterally
ABD: Her belly is soft. It is not firmly distended. the patient
denies tenderness above her baseline. Guiac posative stools
EXT: no edema
Pertinent Results:
[**2182-5-20**] 05:30AM BLOOD WBC-4.4 RBC-2.25* Hgb-7.3* Hct-20.5*
MCV-91 MCH-32.6* MCHC-35.8* RDW-22.8* Plt Ct-42*
[**2182-5-19**] 12:35PM BLOOD WBC-5.4 RBC-2.51* Hgb-8.2* Hct-22.9*
MCV-92 MCH-32.8* MCHC-35.8* RDW-22.2* Plt Ct-36*
[**2182-5-20**] 05:30AM BLOOD PT-31.4* PTT-72.4* INR(PT)-3.2*
[**2182-5-19**] 12:35PM BLOOD PT-27.8* PTT-65.3* INR(PT)-2.8*
[**2182-5-20**] 06:05PM BLOOD Glucose-134* UreaN-76* Creat-2.5* Na-134
K-4.4 Cl-103 HCO3-16* AnGap-19
[**2182-5-20**] 05:30AM BLOOD Glucose-91 UreaN-79* Creat-1.5* Na-134
K-3.0* Cl-102 HCO3-17* AnGap-18
[**2182-5-19**] 12:35PM BLOOD Glucose-120* UreaN-80* Creat-1.2* Na-132*
K-3.4 Cl-102 HCO3-20* AnGap-13
[**2182-5-20**] 05:30AM BLOOD ALT-81* AST-165* AlkPhos-154*
TotBili-49.2*
[**2182-5-19**] 12:35PM BLOOD ALT-90* AST-189* LD(LDH)-267*
AlkPhos-179* TotBili-54.4*
[**2182-5-20**] 05:30AM BLOOD Albumin-2.9* Calcium-8.8 Phos-6.6*
Mg-3.3*
[**2182-5-19**] 12:35PM BLOOD TotProt-5.3* Albumin-3.4 Globuln-1.9*
Calcium-9.2 Phos-6.4* Mg-3.2*
[**2182-5-19**] 12:35PM BLOOD Osmolal-306
[**2182-5-19**] 12:35PM BLOOD Ammonia-117*
.
[**5-20**] CXR Low lung volumes Bibasal opacif likely atelectasis OGT
below diaphragm COnsider PA / lateral with increased inspiration
GWLms
.
CXR [**6-4**]
Pulmonary and mediastinal vascular congestion have worsened
consistent with a greater volume overload, but there is no
pulmonary edema, and no findings in the lungs to suggest
pneumonia. Mild cardiomegaly is longstanding. Feeding tube
passes into the stomach and out of view. Pleural effusion, if
any, is minimal. No pneumothorax.
.
[**5-19**] Renal U/s 1. Mild fullness in the left kidney, compared to
right kidney, but no hydronephrosis bilaterally. 2. Ascites.
.
CT abdomen/pelvis [**6-4**]
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a nasal duodenal
feeding tube that terminates in the third portion of the
duodenum. The shrunken cirrhotic appearance of the liver with
splenomegaly and extensive splenorenal shunts as well as
retroperitoneal collaterals is similar to before. Two exophytic
masses are again noted in the liver, corresponding to known foci
of hepatocellular carcinoma. Each is similar in size and
density; the lower one in segment VI is relatively [**Name2 (NI) 15410**], but
the appearance is unchanged. There is no evidence that either
one of them has hemorrhaged. Massive low-density ascites is
present without areas of high densities to suggest hemorrhage.
There is moderately more ascites than on the prior CT.
Comparison with
interval ultrasound is difficult to judge for small changes
because of the
differences in modality. Within the limitations of a
non-contrast study, the pancreas, and kidneys are unremarkable.
The right adrenal gland appears normal. The left is difficult to
visualize because of extensive superimposed collateral vessels.
CT OF THE PELVIS WITH IV CONTRAST: The bladder, uterus, sigmoid,
and rectum are unremarkable.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION: Massive low-density ascites with no evidence of
intra-abdominal hemorrhage. Similar appearance of cirrhosis with
two masses known thought to represent hepatocellular carcinoma
and evidence for portal hypertension
Brief Hospital Course:
39 y/o woman with end stage liver disease [**1-21**] schistosomiasis
admitted with urinary retention and acute renal failure.
Urinary Retention and Acute Renal Failure; had 500cc dark urine
drained upon placement of foley on admission. Fena was
consistent pre-renal etiology, but Cr clearly improved with
catheterization. Unclear if this represents retention from
medication effect, obstruction, or abdominal pressure or if
there is a component of relative volume [**Name2 (NI) 54946**] as well.
Suspect volume depletion +/- medication effect on bladder
function. Cr continued to fluctuate widely while in house, and
patient required several doses of albumin. For this reason, she
could not be continued on diureitcs to help reduse her ascites
burden. She was continued on octreotide and midodrine for
presumed HRS. Renal failure was complicated by hypercalcemia and
hyperphosphatemia. An endocrine consult was called to help
illucidate some of these electrolyte abnormalies. Her calcium
was as high as 13.4 with free Ca 1.63 on [**6-11**] at which point
pamidronate 30mg was given over 24 hours. She was also started
on calcitonin 4 units/kg (200 units) [**Hospital1 **]. She was unable to get
large volume fluids given her significant ascites and low
albumin.
Anemia: Last scope [**2182-4-11**] without large varices (has grade I
and II from a scope in [**2181-12-20**]). Reticulocyte of 5.5
consistent with appropriate marrow response. Patient required
several PRBC transfusions while inhouse. Likely a combined
effect of impaired renal function and chronic oozing from portal
gastropathy.
Depression: on citalopram.
Hypothyroidism: TFTs noted low TSH and T4. It was not known if
hypothyroidism could be worsened by liver disease. Endocrine
consult was requested that concluded
Cirrhosis: MELD on admission was 35 and fluctuated whilely with
Cr changes. Patinet was listed for transplant and received
transplant on [**6-12**]. Paracentesis x2 while in house was negative
for SBP. She was continued on cefpodoxime for SBP ppx.
On [**6-12**] patient received liver transplant. After transplant she
was admitted to the SICU and was weaned from vent. She had
waxing and [**Doctor Last Name 688**] mental status which continued to improve. She
received immunosuppression with MMF and FK. By [**6-21**] she was off
cardiac meds, stable on room air and was NPO. She had a
post-pyloric dobhoff placed on [**6-21**] for nutrition. She was
incontinent of loose brown stools and C.diff was sent and all
were negative. [**6-22**] She had some issues with hyperglycemia and
she had elevated K [**6-24**] which was controlled with
insulin/kayexelate and Calcium gluconate. She had a swallow
evaluation on [**6-24**] and was safe for thin liquids and soft solids
and her diet was advanced along with tube feeds and she was
transferred to the floor from the SICU. On [**6-25**] her central line
and foley were removed and she was out of bed with physical
therapy ambulating with a walker. She was started on calorie
counts as per nutrition recommendations. Her JP drain was takean
out on [**6-28**] and she started lasix 20 mg PO BID with good urine
output response. She had no nausea of vomiting and rehab screen
was started. She has been doing well and her pain was improved
on [**2182-6-29**]
Medications on Admission:
Cefpodoxime 100 mg po BID
Citalopram 20 mg PO DAILY
Midodrine 12.5mg po TID
Clotrimazole 10 mg 5 x daily
Rifaximin 400mg po TID
Pantoprazole 40 mg po BID
Lactulose 30ml po TID
Novasource Renal Full strength 35 ml/hr
Discharge Medications:
1. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Insulin Sliding Scale
Insulin sliding scale attached
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain. ML(s)
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**12-21**]
Injection Q6H (every 6 hours) as needed for nausea.
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day for 1 doses: 6PM [**5-31**] and 6AM [**6-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary;
End stage liver disease s/p liver transplant
Hepatorenal Syndrome
Hepatic Encephalopathy
Discharge Condition:
vital signs stable
Discharge Instructions:
You were admitted with urinary retention and acute renal
failure. We believe this was because of worsening liver disease.
We gave you medication to help your kidneys called octreotide
and midodrine which helped your kidneys. Your liver disease was
so severe that you stayed in the hospital while awaiting liver
transplant and received a liver transplant on [**2182-6-13**]
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, nausea, vomiting, diarrhea,
headache, confusion or dizziness, please call your primary care
doctor or go to your local emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2182-7-4**] 1:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2182-7-4**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2182-7-11**] 3:40
|
[
"456.21",
"572.2",
"790.94",
"572.4",
"789.59",
"530.81",
"425.7",
"275.42",
"788.20",
"571.5",
"428.0",
"285.9",
"287.4",
"997.5",
"293.0",
"275.3",
"788.5",
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"E878.0",
"518.0",
"572.3",
"244.9",
"599.0",
"262",
"276.2",
"584.5",
"311",
"120.9",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"96.6",
"89.64",
"96.71",
"38.93",
"99.15",
"54.91",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
12150, 12229
|
7296, 10596
|
352, 384
|
12370, 12390
|
4070, 7273
|
13040, 13457
|
3667, 3686
|
10862, 12127
|
12250, 12349
|
10622, 10839
|
12414, 13017
|
3701, 4051
|
240, 314
|
412, 2270
|
2292, 3438
|
3454, 3651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,529
| 163,940
|
48868
|
Discharge summary
|
report
|
Admission Date: [**2127-4-4**] Discharge Date: [**2127-4-9**]
Date of Birth: [**2053-3-1**] Sex: F
Service: GYN/ONCOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old G5
P414 diagnosed with grade [**1-13**] endometrioid type endometrial
cancer by ultrasound guided dilatation and curettage on
[**2127-3-5**] during an evaluation for post menopausal bleeding.
The patient has been having postmenopausal bleeding since
approximately [**2126-9-10**]. The patient was originally
scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] for evaluation on [**2127-4-2**],
but was admitted to the gyn/oncology service on [**2127-4-1**] for
increased vaginal bleeding. The patient had a decrease in
hematocrit from [**2127-2-28**] to [**2127-4-1**]. The patient's
vaginal bleeding decreased substantially while in house. The
patient did not require blood transfusion and remained
hemodynamically stable. The patient was discharged to home
on hospital day two and scheduled for staging procedure on
[**2127-4-4**]. Anesthesia preoperative.
Patient was admitted. During hospital stay the patient denies
lightheadedness, fainting, abdominal pain or urinary
symptoms.
PAST OBSTETRICAL HISTORY: Full term normal spontaneous
vaginal delivery times five.
GYN HISTORY: No abnormal pap smears or sexually transmitted
diseases. The patient is unsure of last mammogram.
ALLERGIES: Penicillin.
FAMILY HISTORY: No gyn or colon cancer.
PAST MEDICAL HISTORY: Asthma, type 2 diabetes,
hyperlipidemia, obesity, hypertension, degenerative joint
disease, anxiety, gout, glaucoma.
MEDICATIONS:
1. Glucophage 500 mg po b.i.d.
2. Valium 5 mg prn.
3. Procardia XL 30 mg q.d.
4. Flovent.
5. Serevent.
6. Nitro prn.
7. Quinine 200 mg q.h.s.
8. Alphagan OU t.i.d.
9. Betaxolol OU b.i.d.
10. Lasix 60 q.d.
11. Proventil prn.
12. Lipitor 10 mg po q.d.
13. Allopurinol 100 mg po q.d.
14. Xalatan OU t.i.d.
SOCIAL HISTORY: No alcohol or drugs. Chews tobacco. Lives
alone.
PHYSICAL EXAMINATION: The patient was afebrile, vital signs
are stable upon presentation. No acute distress. Obese. No
cervical lymphadenopathy. Cardiovascular regular rate and
rhythm. No murmurs, rubs or gallops. Lungs clear to
auscultation. No rales, wheezes or rhonchi. Abdomen obese,
nontender, nondistended. Positive bowel sounds. Sterile
speculum examination normal external female genitalia.
Normal vaginal mucosa. No cervical masses. Sterile vaginal
examination difficult secondary to habitus. No adnexal
masses. Slightly enlarged uterus. Rectovaginal no palpable
masses. Extremities no clubbing, cyanosis or edema.
ASSESSMENT/PLAN: This is a 74 year-old P4 with endometrial
cancer. Dr. [**First Name (STitle) 1022**] discussed with the patient while she was
admitted the nature of the tumor and recommendations of a
staging procedure with a total abdominal hysterectomy and
bilateral salpingo-oophorectomy. The patient was explained
that the surgery could involve lymph node dissection
depending on intraoperative findings. The patient was told
that the need for postoperative adjuvant therapy, radiation
therapy and chemotherapy both would be determined by the
surgical and pathologic findings. Details and risks of the
surgery were discussed with the patient including bleeding,
infection, potential damage to bowel or urinary system
requiring more surgery. Consent was signed.
HOSPITAL COURSE: For details of surgery done on [**2127-4-4**]
please see operative note. Postoperatively, the patient
required a 12 hour admission to the Intensive Care Unit
secondary to anemia, decreased urine output, decreased mental
status. For her mental status changes the patient had
received pain medications and became increasingly somnolent
and difficult to arouse. The patient was given Narcan in the
Intensive Care Unit and instantaneously became arousable and
alert and oriented times three. From a renal standpoint the
patient's renal output had dropped to approximately 5 cc per
hour on postoperative day zero. Of note, she had been NPO
all day and had 900 cc estimated blood loss. The patient
also had a bowel prep the night before. The patient received
1 unit of packed red blood cells with no significant increase
from her preoperative hematocrit. The patient remained
hemodynamically stable. The patient was transfused an
additional 2 units of packed red blood cells for a total of 3
on postoperative day 0/1. The patient's hematocrit improved.
The patient's urine output improved overnight with hydration
and transfusion. The patient's creatinine stayed within
normal limits. The patient was discharged from the Intensive
Care Unit and transferred to the floor on postoperative day
one.
1. Neurological: The patient was changed to pain
medications on postoperative day two without difficulty. The
patient's pain remained controlled during entirety of
hospital stay. The patient was discharged to home with
Percocet and Motrin.
2. Renal: The patient's hematocrit stayed within normal
limits during hospital stay. The patient had adequate urine
output during hospital stay. The patient's Foley catheter
was discontinued on postoperative day two without difficulty.
3. Gastrointestinal: The patient was advanced to a regular
diet on postoperative day three with passage of flatus. The
patient had several episodes of emesis on postoperative day
three and just was made NPO for 24 hours. On postoperative
day four the patient was tolerating a regular diet without
nausea and vomiting and was discharged to home tolerating a
regular diet.
4. Endocrine/type 2 diabetes: The patient was on finger
sticks q.i.d. being covered with a regular insulin sliding
scale and the patient was tolerating po. The patient is to
start Glucophage upon discharge to home.
5. Pulmonary/asthma: The patient was on asthma medications
during hospital stay without difficulty.
6. Fluids, electrolytes and nutrition: The patient was
transitioned from intravenous fluids to po diet on
postoperative day two without difficulty. The patient's
electrolytes were repleted as needed. The patient was
tolerating a regular diet by postoperative day four without
difficulty. Physical therapy consult was obtained to
evaluate home needs regarding activities of daily living and
ambulation. The patient will require a walker initially at
home. The patient was given a walker upon discharge to home.
DISCHARGE DIAGNOSES:
1. Endometrial cancer status post total abdominal
hysterectomy - bilaterally salpingo-oophorectomy - omental
biopsy.
2. Hypertension.
3. Type 2 diabetes.
4. Hyperlipidemia.
5. Glaucoma.
DISCHARGE STATUS: Good.
DISCHARGE CONDITION: The patient is discharged to home with
VNA for home safety evaluation and the patient is to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] and is to call the office to confirm
appointment. The patient is to resume all home medications
and the patient was given a prescription for Percocet and
Motrin.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 16-314
Dictated By:[**Last Name (NamePattern1) 6763**]
MEDQUIST36
D: [**2127-4-10**] 08:30
T: [**2127-4-15**] 12:30
JOB#: [**Job Number 102642**]
|
[
"182.0",
"218.2",
"250.00",
"493.90",
"518.0",
"997.3",
"276.5",
"401.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"65.61",
"54.23",
"68.4",
"54.25"
] |
icd9pcs
|
[
[
[]
]
] |
6722, 7288
|
1458, 1483
|
6482, 6700
|
3456, 6461
|
2047, 3438
|
167, 1441
|
1506, 1955
|
1972, 2024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,779
| 166,441
|
6913
|
Discharge summary
|
report
|
Admission Date: [**2158-2-12**] Discharge Date: [**2158-2-27**]
Date of Birth: [**2080-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
Redo-Sternotomy, Aortic Valve Replacement w/ [**Street Address(2) 11688**]. [**Male First Name (un) 923**]
Mechanical Valve [**2158-2-16**]
History of Present Illness:
This 77 year-old patient who has had previous bypass grafts in
[**2143**] with vein grafts to diagonal,obtuse marginal and posterior
descending artery and left
internal mammary artery to the left anterior descending artery
presented with increasing symptoms of dyspnea on exertion. He
was investigated and was found to have critical aortic stenosis
with preserved left ventricular function and patent coronary
grafts. His aortic valve was severely calcified with very
significant calcification in the region of the sinotubular
junction. He is also on Coumadin for preoperative atrial
fibrillation. He was electively admitted
for aortic valve replacement.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graftx4
([**2143**])
Aortic Stenosis
Atrial Fibrillation (on Coumadin)
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease s/p Femoral Artery Endarterectomy,
External Iliac to Perineal Bypass
Abdominal Aortic Aneurysm s/p Repair
Social History:
Quit smoking 40 yrs ago after approx. 1 ppd x 25 yrs.
Occ. ETOH
Family History:
[**Name (NI) 2280**], Father [**Name (NI) **] CA
Physical Exam:
VS: 64AF 16 128/61
General: 77 y/o male lying supine in bed in NAD
Skin: Well-healed Sternotomy Incision and Midline Abd Incision
HEENT: NC/AT, PERRL, EOMI, OP Benign
Neck: Supple, FROM, -Carotid Bruits
Lungs: CTAB -w/r/r
Heart: Irreg-Irreg +S1S2, 2/6 SEM
AbD: Soft, Protuberant, NT/ND, +BS
Ext: Warm, with healed open saph incision rle
Pertinent Results:
Chest CT [**2-16**]: 1. Diffuse atherosclerotic calcifications
involving all portions of the thoracic aorta, but with greater
involvement of the descending aorta and arch than the ascending
aorta. 2. Congestive failure with interstitial edema and small
right pleural effusion.
Echo [**2-17**]: No change in LV function LV EF 50-55%. RV with mild
to moderate hypokinesis, improved from intial moderate
hypokinesis immediately post bypass. MR remains high mild to
moderate range, TR remains mild to moderate. Mechanical #23
Aortic valve prosthesis in situ. No AI, No perivalvular leaks.
Peak gradient 10 mm Hg, Mean gradient 5 mm Hg, but views for cw
doppler suboptimal.
[**2158-2-27**] 06:30AM BLOOD WBC-6.7 RBC-2.80* Hgb-9.2* Hct-25.6*
MCV-91 MCH-33.0* MCHC-36.1* RDW-15.4 Plt Ct-285
[**2158-2-27**] 06:30AM BLOOD Plt Ct-285
[**2158-2-27**] 06:30AM BLOOD UreaN-19 Creat-0.9 K-4.0
[**2158-2-12**] 03:38PM BLOOD ALT-18 AST-26 AlkPhos-160* TotBili-1.1
[**2158-2-26**] CXR
PA and lateral chest radiographs demonstrate the patient to be
status post CABG. Sternal wires and surgical staples project
over the left basilar atelectasis that has improved. The lungs
are now clear. No effusion. Trachea is midline.
[**2158-2-23**] EKG
Atrial fibrillation with a mean ventricular response, rate 110.
Right
bundle-branch block. Left axis deviation. Left anterior
fascicular block.
Compared to the previous tracing of [**2158-2-13**] multiple
abnormalities persist
without major change.
[**Last Name (NamePattern4) 4125**]ospital Course:
As mentioned in the HPI, patient was electively admitted
pre-operatively secondary to his h/o Atrial Fibrillation and
being on Coumadin. Coumadin was discontinued and he was started
on Heparin. His INR was followed and awaited it to come down to
under 1.3 prior to surgery. Also prior to surgery he underwent a
chest CT to evaluate his calcified aortic valve/aorta (please
see pertinent results). He received Vit K and was eventually
brought to the operating room on [**2-17**]. He underwent a
Redo-Sternotomy, Aortic Valve Replacement with a Mechanical
Valve. Please see operative note for surgical details. He was
transferred to the CSRU in stable condition on Epi, Levo, and
Neo. Patient remained intubated until post-operative day two
when Propofol was weaned and patient awoke neurologically
intact. Warfarin therapy was resumed. Mechanical ventilation was
then weaned and he was extubated. Chest tubes were removed
post-op day two. Patient also remained on multiple
Inotropes/Pressors through post-operative day three. Patient
continued to have improving hemodynamics and drips were slowly
weaned. Foley catheter and Swan were removed on post-op day
three and he was transferred to the cardiac step-down unit. He
was started on Heparin for a subtherapeutic prothrombin time. He
required several large doses of Warfarin before becoming
therapeutic. Given his history of atrial fibrillation and
mechanical valve, Warfarin was dosed for a goal INR between 2.0
- 3.0. Heparin was eventually discontinued on postoperative day
*****. He underwent a speech and swallow evaluation on
postoperative day four for a questionable episode of aspiration.
He experienced coughing and difficulty breathing. Evaluation
revealed no signs of aspiration but based on his history, there
was concern for laryngospasm of his vocal cords secondary to
regurgitation. He had no diet restrictions and tolerated a
regular diet for the rest of his hospital stay without further
difficulty. Over several days, he clinically improved with
diuresis and continued to make steady progress with physical
therapy. His INR slowly progressed towards a therapeutic range.
Medical therapy was optimized and he was cleared for discharge
on postoperative day ten. At discharge, his BP was 124/80 with
a HR of 84 atrial fibrillation. All surgical wounds were clean,
dry and intact. He will follow-up with Dr. [**Last Name (Prefixes) **], his
cardiologist and his primary care physician as an outpatient.
Dr. [**Last Name (STitle) 26033**] will manage his coumadin dosing for a target INR of
2.5-3.5. His first blood draw PT/INR will be [**2158-2-28**] at 10:30AM.
His INR on discharge was 2.6 and he was discharged with 5mg
tablets.
Medications on Admission:
Atenolol, Norvasc, Warfarin, Lasix, Doxazosin, Lipitor,
Glucophage
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking pain medication to prevent
constipation.
Disp:*30 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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
3. 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*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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:*1*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Coumadin 5 mg Tablet Sig: as Instructed by Dr. [**Last Name (STitle) 26033**]
Tablet PO once a day: Take as instrcuted by Dr. [**Last Name (STitle) 26033**]. Please
note that dose will change based on your PT/INR blood levels.
Goal INR is 2.5-3.5.
Disp:*45 Tablet(s)* Refills:*0*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
14. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
SOUTH [**State **] VNA
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement (Mechanical Valve)
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
([**2143**])
Atrial fibrillation
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease
Discharge Condition:
Good
Discharge Instructions:
1) You can take a shower. Wash incisions with water and gentle
soap. Gently pat dry. Do not take bath. Do not apply lotions,
creams, ointments or powders to incisions until they have
healed.
2) Do not drive for 1 month.
3) Do not lift greater than 10 pounds for 10 weeks.
4) Report any signs of infection. These include redness,
drainage or increased pain.
5) Report any fevers greater then 100.5.
6) Dr. [**Last Name (STitle) 26033**] will follow your PT/INR blood work and Coumadin
dosing. You will have your blood drawn on [**2158-2-28**], at Dr. [**Name (NI) 26034**] office at 10:30AM. Please take daily dose only as
instructed by Dr. [**Last Name (STitle) 26033**]. Your dose may change based on your
blood levels. Goal INR is 2.5-3.5 for atrial
fibrillation/Mechanical aortic valve.
7) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
8) Staples out on postoperative day 14 ->([**2158-3-3**])
9) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 26033**](cardiologist)in [**1-30**] weeks. ([**Telephone/Fax (1) 26035**]
Dr. [**Last Name (STitle) **](PCP)in 2 weeks. ([**Telephone/Fax (1) 26036**]
Dr. [**Last Name (STitle) 26033**] will follow your INR and adjust your Coumadin as he
did preoperatively. You will have a PT/INR checked [**2158-2-28**] in
his office at 10:30 AM.
Please call all providers for appointments.
Completed by:[**2158-2-27**]
|
[
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"427.31",
"428.0",
"440.20",
"V13.01",
"V45.81",
"357.2",
"424.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.19",
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
8262, 8315
|
298, 439
|
8575, 8581
|
1952, 3431
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1530, 1580
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6298, 8239
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8336, 8554
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6207, 6275
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8605, 9567
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9618, 10094
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3482, 6181
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239, 260
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467, 1123
|
1145, 1433
|
1449, 1514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,650
| 192,001
|
27513
|
Discharge summary
|
report
|
Admission Date: [**2180-4-8**] Discharge Date: [**2180-5-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Presented for mediastinoscopy in setting of mediastinal
lymphadenopathy and hypercalcemia.
Major Surgical or Invasive Procedure:
- Right anterior mediastinotomy, flexible bronchoscopy, drainage
of pleural effusion.
- Intubation and Bronchoscopy
- Central lines (right femoral and right internal jugular)
History of Present Illness:
HPI: This is an 82yom who initially presented to his PCP for
several weeks of somnolence, confusion and abdominal pain and
was found to have worsening renal function. During his
evaluation, he was found to have significant hypercalcemia to
15. He was admitted to [**Hospital **] Med center on [**2180-3-30**] for further
eval and treatment. He was treated with IV fluids, lasix,
calcitonin, and aredia. His calcium dropped to 10.9. CT torso
revealed extensive mediastinal lymnphadenopathy. A bone marrow
biopsy was read as 3% clonal B cells suggesting lymphoma.
Additional new findings at [**First Name9 (NamePattern2) **] [**Last Name (un) **] included RBBB with
Left anterior hemiblock, question of malignancy of unknown
origin, and ptosis of left eyelid with palsy. He had a bone scan
at [**Last Name (un) **] that was read as showing only
arthritic/degenerative/traumatic changes. He was transferred to
[**Hospital1 18**] for mediastinoscopy on [**2180-4-8**].
.
ROS - Positive at admission to outside hospital for fatigue,
lethargy, abdominal pain, one month of increasing back pain. He
denied chest pain, nausea, and vomiting. He was noted at the
outside hospital to have orbital edema of his left eye with
ptosis and restriction of left ocular movement. Wife describes
him as "not being himself" following a pneumonia several months
prior to the admission.
Past Medical History:
-Hypercalcemia
-New ptosis of left eye lid
-Hypertension
-CRI baseline Cr 1.7
-BPH
-Elevated PSA with prostatic nodule, deferred biopsy
-New RBB with left anterior hemiblock
-Gout
-Peptic ulcer disease s/p Gastric resection for perf gastric
ulcer
.
PSH:
- Right total knee arthroplasty (10 years ago)
Social History:
Lives with wife of 59 years. Recently returned from trip in
[**State 108**]. Smoked 1.5 packs for 45 years. Consumes 4
gin-containing drinks per day. Has 3 adult children, 2 sons [**Name2 (NI) **]
& [**Doctor Last Name **]), one daughter ([**Name (NI) **]). Family is very involved and
supportive.
Family History:
Brother passed away following MI in late 60's secondary to long
smoking history.
Physical Exam:
At time of admission:
97.2 120/74 140 24 99 2L
oriented to person and place, some difficulty with time, sleepy
but arousable
left eye with psosis and conjunctival erythema
Kyphotic, in no distress, wearing oxygen by nasal cannula
tachycardic, irregular
crackles b/l at bases
normal abdomen with old scar
no edema
chronic venous stasis changes
indwelling foley
normal neuro exam with exception of left eye ptosis
.
.
At time of discharge:
Vitals: Tm 99.3 Tc 97.3 HR 70 BP 107/52 RR 20 Sat(91-95%) 1.5L
General: Nonobese, elderly man, resting in bed.
HEENT: NCAT. Anicteric. No remaining orbital edema. Slight
ptosis of left eyelid.
Neck: Prominent JVD
Cardiac: rrr, II/VI holosystolic murmur heard throughout, no rub
or gallop.
Pulm: Tracheal breath sounds & slight crackles over mid to lower
lungs bilaterally. Decreased resonance to percussion at bases
bilaterally.
Abd: nontender, nondistended
Ext: No cyanosis, clubbing, no upper or lower extremity edema,
radial & dorsalis pedis pulses 2+.
Neuro: Alert, attentive, appropriate.
.
Weight: 86.1kg
.
I/O (last 24hrs): 780PO, 1210F + 250V, BMx1
.
Pertinent Results:
Bone Marrow Aspiration at [**Hospital **] Hospital
- Normocellular bone marrow with erythroid hyperplasia and 3%
clonal B cells.
.
ADMISSION LABS
[**2180-4-8**] 09:00PM
GLUCOSE-130* UREA N-73* CREAT-1.9* SODIUM-140 POTASSIUM-5.0
CHLORIDE-98 TOTAL CO2-34* ANION GAP-13
CALCIUM-11.5* PHOSPHATE-2.8 MAGNESIUM-1.9
WBC-7.0 RBC-3.20* HGB-10.9* HCT-32.3* MCV-101* MCH-34.0*
MCHC-33.6 RDW-14.0 PLT COUNT-186
PT-14.2* PTT-29.7 INR(PT)-1.3*
.
R/O MI
[**2180-4-16**] 03:43AM BLOOD CK(CPK)-15* cTropnT-0.03*
[**2180-4-19**] 11:30PM BLOOD CK(CPK)-13* cTropnT-0.02*
[**2180-4-20**] 06:20AM BLOOD CK(CPK)-16* cTropnT-0.04*
[**2180-4-20**] 11:35AM BLOOD CK(CPK)-27* cTropnT-0.03*
.
ANEMIA
HCT-32.3 on admission ([**2180-4-8**]), HCT-26.2 on discharge ([**2180-5-5**])
[**2180-4-16**] 03:43AM BLOOD TSH-3.7
[**2180-4-17**] 03:36AM BLOOD VitB12-1561* Folate-GREATER THAN ASSAY
(>20ng/ml)
[**2180-4-18**] 05:20AM BLOOD calTIBC-208* Ferritn-619* TRF-160*
[**2180-4-25**] 06:46AM BLOOD Hapto-125 (wnl), Reticulocyte count 2.3
[**2180-4-25**] 06:04PM BlOOD SMEAR: Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+
.
THROMBOCYTOPENIA
HIT Antibody Negative
Serotonin Release Assay: PENDING
.
[**2180-4-20**] 9:58 am BRONCHOALVEOLAR LAVAGE FOLLOWING RESPIRATORY
FAILURE
GRAM STAIN (Final [**2180-4-20**]):
3+ POLYS
2+ GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2180-4-22**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
.
MEDIASTINOSCOPY
.
[**2180-5-3**] 10:09 am PLEURAL FLUID (MISLABELED AS MEDIASTINAL
FLUID)
GRAM STAIN (Final [**2180-5-3**]): Corrected report showed no
polys, no microrganisms. Original report read as 3+ gram
negative rods, actually was debris on further evaluation.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2180-5-4**]): NO ACID FAST BACILLI BY
SMEAR.
ACID FAST CULTURE: Pending
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[**2180-5-3**] PLEURAL FLUID IMMUNOPHENOTYPING: PENDING
.
[**2180-5-3**] 10:41 MEDIASTINAL LYMPH NODE
GRAM STAIN (Final [**2180-5-3**]): 2+ Polys, No microorganisms.
TISSUE CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2180-5-4**]): NO ACID FAST BACILLI SEEN
BY SMEAR.
ACID FAST CULTURE: (Pending)
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (FINAL): NO FUNGAL ELEMENTS
SEEN.
.
[**2180-5-3**] Pathology Tissue: Lymph Node for immunophenotyping.
PATHOLOGY PENDING
.
[**2180-5-3**] 10:01AM PLEURAL FLUID (MISLABELED AS MEDIASTINAL FLUID)
CD45-DONE Kappa-DONE CD10-DONE CD19-DONE CD20-DONE Lamba-DONE
CD5-DONE
[**2180-5-3**] 10:01AM OTHER BODY FLUID CD4-DONE CD8-DONE
[**2180-5-3**] 10:01AM OTHER BODY FLUID IPT-DONE
PENDING REPORT FROM PATHOLOGY
.
[**2180-5-3**] Pathology Tissue: THIRD RIB CARTILAGE, [**2180-5-3**]
PATHOLOGY PENDING
.
[**2180-5-4**] 8:05 am BLOOD CULTURES X 2 (PENDING)
.
DISCHARGE LABS
[**2180-5-5**] 06:25AM
WBC-3.8* RBC-2.69* Hgb-8.8* Hct-26.2* MCV-97 MCH-32.8* MCHC-33.6
RDW-15.7* Plt Ct-152
Glucose-112* UreaN-28* Creat-1.4* Na-142 K-3.6 Cl-95* HCO3-43*
AnGap-8
Calcium-8.5 Phos-3.0# Mg-2.0
PT-15.6* PTT-27.0 INR(PT)-1.4*
.
STUDIES
.
Chest Xray ([**2180-5-4**]) - Moderate bilateral pleural effusion,
right greater than left. Mild pulmonary edema, basilar
atelectasis and mediastinal vascular engorgement are also
stable. There is no pneumothorax. Cardiac silhouette is
moderately enlarged but unchanged.
.
ECG ([**2180-5-4**])
Sinus rhythm with occasional ventricular premature beats.
Borderline first
degree A-V block. Probable left atrial abnormality. Left axis
deviation. Left anterior fascicular block. Right bundle-branch
block. Non-specific
inferolateral ST-T wave changes. Compared to the previous
tracing of [**2180-4-20**] diffuse low QRS voltage has resolved and
occasional ventricular premature beats are new. Otherwise, no
significant diagnostic change.
Intervals & Axes:
Rate PR QRS QT/QTc P QRS T
72 [**Telephone/Fax (3) 67286**]/473 23 -81 0
.
CT Chest/Abdomen/Pelvis ([**2180-4-25**])
IMPRESSION:
1. Superficial hematoma in the right groin, with a fluid-fluid
level, suggesting an acute hematoma, with such an appearance
often seen in anticoagulation, no extension into the pelvis.
2. Cholelithiasis.
3. Diverticulosis.
4. Multinodular substernal goiter.
5. Moderately large bilateral effusions with bibasilar
atelectasis.
6. Nodular ground-glass opacities in the aerated left lung,
suggestive of an inflammatory or infectious etiology. These are
atypical for both lymphoma and congestive heart failure.
7. Mediastinal lymphadenopathy.
.
Head CT ([**2180-4-20**])
Impression: No significant change compared to the prior study of
[**2180-4-18**]. Hyperdensity along the tentorium is again seen,
possibly due to dystrophic calcification.
.
Echocardiogram ([**2180-4-20**])
Conclusions:
1. The left atrium is moderately dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed.
4. The aortic valve leaflets are mildly thickened. Mild (1+)
aortic egurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-13**]+) mitral regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension.
7. Compared with the prior study (images reviewed) of [**2180-4-13**],
mitral and tricuspid regurgitation may be less.
.
Renal Ultrasound ([**2180-4-19**]) Impression: Normal Renal Ultrasound
.
SKELETAL SURVERY ([**2180-4-17**])
IMPRESSION: No suspicious lytic lesions identified.
.
MR/MRA of Orbit ([**2180-4-10**])
IMPRESSION:
Mild proptosis of the left globe, without evidence of
retroorbital mass or
without definite evidence of fistula on this MRI and MR
angiogram. For further evaluation, orbital CT and possible
coventional angiography is recommended to exclude a dural
fistula, if clinical suspicion for such an entity remains.
Brief Hospital Course:
[**2180-4-8**] - Following transfer from [**Hospital **] Hospital, patient
arrived on medical floor and was found to be in rapid afib with
rate around 150 bpm with SBP 112. He was given 50 mg of PO
metoprolol which per floor team he aspirated. After that pt
developed new hypoxia with sats down to 89% on RA with return to
95% on 2L. Pt was then given 5 mg IV metoprolol with out change
in heart rate. Pt was then left in his room briefly. At this
point he got up out of bed and pulled out his foley catheter
with the ballon inflated. Approximately 300cc blood were found
in the bed side comode. Pt was transferred to [**Hospital Unit Name 153**] for rapid
afib, hypoxia, bleeding, and hypercalcemia.
.
Upon arrival to [**Name (NI) 153**], pt in rapid afib with SBP in the 90s. He
was bolused with fluids prn and started on an amiodarone gtt
that was quickly converted to oral. His beta-blocker was
restarted and titrated up to 50mg tid w/out conversion of his
rhythm. He had an equivocal speech and swallowing study. He was
placed on thick liquids following a video swallow study that was
concerning for aspiration. He was seen by thoracics who remained
unwilling to intervene to sample tissue until his cardiac issues
were better controlled. Ophthalmology signed off on the patient
following an MRI that revealed no retroorbital mass to cause his
left proptosis and a resolution of his ocular findings with
continued use of erythromycin ointment. After the above
management, he remained afebrile & normotensive. With his
cardiac issues stabilized, he was sent for mediastinoscopy.
.
In the pre-op holding area, anesthesia noted his respiratory
rate to be in the 30s w/increased work of breathing and
diagnosed CHF. He was given 40mg of lasix and a MICU bed was
requested. In this second ICU stay, his respiratory failure was
treated with bi-pap resulting in improved O2sat's and arterial
blood gas results.
.
He returned to the floor and had an O2 saturation in the 90's on
3L nasal cannula. While on the floor, he was found to be
bradycardic (30's) and unresponsive with a O2Sat in the 60's. A
code blue was called, and the patient was intubated by the
responding anesthesia team. He was transferred to the MICU where
his course included respiratory failure likely secondary to
mucus plugging & collapse of the right lung in the setting of
CHF and pleural effusions. He was intubated and bronchoscopy was
performed which aspirated copious obstructing secretions and a
bronchial lavage grew oropharyngeal flora. Patient was shortly
extubated without complication. All antiarrhythmics were
stopped. Patient's cardiorespiratory status improved, repeat
chest xray demonstrated expansion of the collapsed right lung.
.
Patient returned to the floor from MICU stay with relative
volume overload. He remained alert & oriented X 3. Hct dropped 3
points in setting of this ICU stay, found to have right thigh
hematoma at site of femoral venous line placement.
Abdominopelvic CT showed confinement of the hematoma to the
thigh. Follow-up exams showed no signs of expansion of the
hematoma, hct remained stable, and there were no signs of
compartment syndrome noted. Beta-blockade was reinstituted, but
amiodarone was held. Diuresis was continued with 40mg IV lasix
[**Hospital1 **] & 1L fluid restriction with goal of -1L per day. Patient
responded with effective diuresis and improvement in clinical
hypervolemia. Respiratory status improved and pulmonary exam in
combination with chest xray showed decreasing signs of pulmonary
edema and effusions. Given continued lack of definitive
diagnosis regarding mediastinal lymphadenopathy for which the
patient was admitted, radiology was consulted regarding
CT-guided biopsy per thoracic surgery recommendations. A CTA was
performed with bicarbonate prophylaxis against contrast-induced
nephropathy. Radiology determined that the lymphadenopathy was
not amenable to CT-guided biopsy. Thoracic surgery was again
consulted and at that time agreed for plan of mediastinoscopy on
[**2180-5-3**] following several more days of diuresis. Thoracic
surgery also recommended ultrasound-guided thoracentesis of
right pleural effusion to improve respiratory status
pre-operatively. The procedure team was unable to perform the
thoracentesis as there was no safe entry point for thoracentesis
bilaterally due to a reported relatively high risk of
pneumothorax by ultrasound, though a significant pleural
effusion was noted.
.
Following improvement in the patient's upper and lower extremity
edema in addition to bilateral pleural effusion following
diuresis, the patient underwent Right anterior mediastinotomy
w/flexible bronchoscopy on [**2180-5-3**]. His systolic pressure was in
the 70's for a brief period during the procedure, which required
phenylephrine and 1L of fluids intraoperatively. He tolerated
extubation well following the procedure, but was sent to the
MICU for hypoxia and hypercarbia postoperatively. He was placed
on bi-pap in the MICU with improvement in ABG results. He
returned to the floor the following day ([**2180-5-4**]). His foley
catheter was removed that evening, and he was able to void
250cc's over several attempts on the morning of [**2180-5-5**]. He
remained afebrile and normotensive with an O2 saturation of
91-95% on 1.5L O2. Postoperatively, his hct remained stable. He
experienced a slight elevation in creatinine from 1.2 to 1.5 one
day postoperatively, with a decrease to 1.4 on the 2nd day after
surgery.
.
Briefly, this is an 82 year old man with a PMH of CHF & chronic
renal insufficiency admitted for tissue diagnosis by
mediastinoscopy of mediastinal lymphadenopathy in the setting of
symptomatic hypercalcemia whose course was complicated by
multiple ICU stays for atrial fibrillation with rapid
ventricular response, congestive heart failure and hypercarbic
respiratory failure and aspiration.
.
1) Hypercarbic/Hypoxic Respiratory Failure - Patient does not
have previous diagnosis of COPD, but has 45 year history of
smoking. Persistent bilateral pleural effusions may be due to
CHF or may be secondary to suspected malignancy. Previous ICU
stay for hypoxic respiratory failure was found to be secondary
to mucous plug with right lung collapse that improved following
evacuation of mucous plug by suction through endotracheal tube.
Most likely etiology for most recent respiratory compromise is
secondary to volume given at surgery as well as sedation. Goal
Co2 60s (baseline 50s-60s due to COPD). Pt's CO2 slightly
improved w/ BiPap, but pt refused to wear it after 3am [**5-4**].
Still hypercarbic in 80s at 9am on [**5-4**]. Pt comfortable on room
air with oxygen saturation ~95% at 5/25 afternoon.
- Goal for patient was to maintain O2 saturation in low 90s to
maintain respiratory drive.
.
2) Hypercalcemia & mediastinal lymphadenopathy work-up: The
patient had his w/u started at the outside hospital. His chest
CT showed mediatinal LAD and a bone marrow bx showed 3% clonal
population suggestive of lymphoma. His PTHrp was normal and
SPEP/UPEP negative. Of note, he has a history of taking a large
number of herbal remedies at home, some of which included
calcium and vitamin D as ingredients. Endocrinology team
thought his herbal remedies were contributory in regard to his
hypercalcemia, but did not explain the extreme degree of
elevation. He was bolused with fluid and given calcitonin w/
improvement of his mental status and normalization of his serum
calcium. He is underwent surgical lymph node sampling sd above.
S/p mediastinoscopy & bronchoscopy - widened mediastinum most
likely from lymphoma, but awaiting pathology results for
confirmation.
- counseled patient regarding avoidance of herbal remedies
- f/u pending pathology
- 'mediastinal fluid growing GNR' per initial Micro report, but
clarified with Micro and Surgery that fluid is pleural fluid,
and GNR is actually debris and not true bacteria per final
microbiology report.
- f/u blood ctx
- 500 keflex q12hrs per thoracic surgery (slight erythema at
wound edge, no drainage, pain)
.
3) Pancytopenia - Current Hct 26.2. He has required multiple
transfusions of pRBC's both secondary to ICU stays (bleeding
following self-removal of inflated foley as well as right thigh
hematoma following femoral vein TLC placement). He received 2
units of pRBC's preoperatively as well. Hct has been stable
postoperatively. Reticulocyte count of 2.3, which is low in
setting of his anemia. Currently with increasing plts (152),
considered HIT but not likely given a negative HIT antibody and
negative serotonin release antibody. Slowly decreasing WBC count
during admission, but now stable at 3.3 to 4.3 over last week.
Iron studies consistent with anemia of chronic inflammation.
Possibly related to suspected lymphoma, but bone marrow
aspiration from outside hospital showed normocellular bone marow
with erythroid hyperplasia (despite 3% clonal B cells). Chronic
renal insufficiency with low Epo may be contributing, have not
yet checked Epo levels.
- transfuse for hct less than 21
- follow counts, awaiting mediastinal path results
- recommend checking Epo levels as outpatient with
supplementation as needed
.
4) CHF - Patients recent echo with LVEF 70% however severe 3+ MR
calls into question the clinical utility of this measurement,
pulmonary edema on CXR, persistent bilateral effusions. Right
effusion drained of 500cc's during mediastinoscopy with
improvement in f/u chest Xray. Goal for patient over last
several days was to maintain O2 saturation in low 90s to
maintain respiratory drive and mild diuresis with -500cc
negative per day. At time of discharge, patient considered
euvolemic vs slightly hypovolemic.
- Goal to maintain current fluid status and weight
- Strict I/O, goal for neutral to -500cc daily fluid balance
- Fluid restrict to 1L/day
- Consider lasix 80mg po qd if does not maintain euvolemia
- Consider follow-up echocardiogram as outpatient considering
valvular disease
.
5) Atrial Fibrillation - Recent onset and unclear if has ever
happened before. It was associated with hypotension initially on
the floor and this prompted ICU transfer. In the ICU, he was
amiodarone loaded and started on metoprolol before call out to
the floor. On the floor, the patient converted to NSR w/
increases in his metoprolol dosage but was mildly bradycardic
upon conversion to the high 40s/low 50s. He maintained his BP
despite this bradycardia. Cardiology was consulted at the
request of thoracic surgery and they recommended lowering both
his amiodarone and metoprolol doses in the setting of his
bradycardia. He was being fluid resuscitated as below but was
stable on transfer to [**Hospital Ward Name **] for mediastinoscopy. An
echocardiogram done in the setting of his new afib showed 3+
MR/TR. He had three further ICU stays on [**Hospital Ward Name **], and his
amiodarone was discontinued secondary to a bradycardic episode
that was the precipitant of one of these ICU stays. Telemetry
was discontinued on day prior to discharge.
- rate controlled on beta blocker
- back on coumadin, INR 1.1, continue to follow INR; goal INR
[**1-14**].
.
6) Renal Failure - The pt had some history over weeks of acute
on chronic renal failure. This was thought to be related to
hypercalcemia and improved on the floor w/ IVF. In the 2 days
prior to transfer, his mucus membranes appeared dry and his UOP
dropped w/ resultant creatinine increase. Urine lytes at that
time were consistent with a prerenal picture and he was bolused
with IVF. He received IV fluids in the setting of hypotension
and multiple ICU stays during this hospitalization, requiring
diuresis upon return to the floor for volume overload and
worsening CHF. The patient's creatinine is currently 1.4, which
is at baseline
- Avoid over-diuresis
- Avoid obstructive symptoms with medical treatment of prostatic
hypertrophy
.
7) Urethral trauma - After he pulled out his foley while the
balloon was inflated, he was noted to have bleeding from his
urethra and his HCT dropped 3 pts acutely. This resolved with no
further bleeding. Post foley removal the patient had difficulty
with urination, he will need to be straight cath'd qshift and if
the urinary retention does not resolve, he will need to f/u with
his urologist.
.
8) Left eye swelling - The patient presented to [**Hospital1 18**] with about
10 day history of left eye swelling and conjunctival erythema.
He was evaluated by opthalmology who gave an initial
differential diagnosis to include conjunctivitis vs orbital
metastasis. CT of the head showed subdural bleed vs
calcification (calcification felt to be most likely after
repeat) which was followed by another f/u CT per neurosurgery 10
days later which confirmed that there was no evidence of
intracranial bleeding. MRI showed no retroorbital mass or AVM
to produce his symptoms. He was treated w/ erythromycin
ointment and he was improving on transfer. Per ophthalmology,
diagnosis is idiopathic inflammatory conjunctivitis.
- continue erythromycin
.
9) FEN - The patient had a questionable aspiration event and was
evaluated by a swallowing video. This test was somewhat
equivocal and he is on a thickened liquids and ground solids,
cardiac & renal diet, patient agrees to use
swallow-cough-swallow technique to avoid aspiration.
Recommendations were for thick liquids with small amounts of
thin liquids between meals, but patient insists upon taking thin
liquids. Crush all pills.
.
10) Prophylaxis
- PPI, bowel regimen, tylenol, pneumoboots/TEDs, sc heparin
being held out of concern for HIT (serotonin release assay
pending)
.
11) Code: DNR/DNI
.
12) Access: Right Peripheral IV
.
13) Dispo: Discharge to rehab per PT recommendations, case
management located rehab facility available for morning of
[**2180-5-6**].
.
Comm: Wife([**Name2 (NI) 7019**]): ([**Telephone/Fax (1) 67287**]
Son [**Doctor First Name **]: ([**Telephone/Fax (1) 67288**]
Son [**Doctor Last Name **]: ([**Telephone/Fax (1) 67289**]
[**Doctor First Name **] ([**Telephone/Fax (1) 67287**]
Medications on Admission:
HOME MEDS:
KCl 10meq
Doxazosin Mesylate 2mg
Cozaar (Losartan Potassium) 50mg
Furosemide 40mg
Claritin 50mg
Colchicine 0.6mg
Detrol LA 4mg
Allopurinol 150mg
Avodart 0.5mg
TRANSFER MEDS:
levaquin 250
cozzar 25
atenolol 50
allopuerinol 300
metolazone 5
lasix 40 IV qd
zymor
alphagan0.15%
calcitonin 4 u/kg sc BID
avodart(dutasteride) 5 (changed to proscar 5 for formulary)
aredia(pamidronate) 30mg IV on [**2180-4-4**]
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID
(4 times a day): To left eye only.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: not to exceed 4g/day.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Starting [**5-6**].
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for incision pain: Not to
exceed 4g/day total of acetominophen.
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) as needed for surgical site erythemia for 2
weeks.
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
hypercalcemia
s/p mediastinal lymph node biopsy
acute on chronic renal insufficency (baseline creatinine 1.7)
congestive heart failure
bilateral pleural effusions
atrial fibrillation with rapid ventricular response
RBBB with left anterior hemifascicular block
anemia
hypertension
idiopathic inflammatory conjunctivitis left eye
cholelithiasis
diverticulosis
Discharge Condition:
Good, sat'ing 90's on 1.5L nasal cannula, hemodynamically
stable.
Discharge Instructions:
Please take medications as prescribed. Please discontinue all
herbal/vitamin OTC medications that you had been taking at home
since they may have contributed to high calcium levels in your
blood. Please have your INR checked daily and have your
physician adjust your warfarin dose accordingly for goal INR
2.0-3.0.
.
Fluid restrict 1 liter per day and strictly monitor
input/output. Also, check daily weights. Have your physician
adjust your lasix dose based on your fluid status and above
measurement.
.
Please keep follow-up appointments.
.
If you have any difficulty breathing, fevers/chills,
palpitations or any other worrying symptoms, please [**Name6 (MD) 138**] your MD
or return to the ED.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] (Primary Care) Phone:
[**Telephone/Fax (1) 56850**] within 1 week of discharge. Consider follow-up with
a cardiologist if you do not already have one per your PCP's
recommendation.
.
Please follow-up with Dr. [**Last Name (STitle) **] (Thoracic Surgery) Phone:
[**Telephone/Fax (1) 170**] within 10-14 days of discharge.
.
Please follow-up in Eye Clinic Phone: [**Pager number **] within 1-2 months
of discharge.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
Completed by:[**2180-5-7**]
|
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] |
icd9cm
|
[
[
[]
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] |
[
"34.26",
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icd9pcs
|
[
[
[]
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,269
| 109,697
|
47266
|
Discharge summary
|
report
|
Admission Date: [**2162-10-3**] Discharge Date: [**2162-12-1**]
Service: MEDICINE
Allergies:
Opioid Analgesics / Iodine; Iodine Containing / Nitrostat
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
"Weakness all over my body"
Major Surgical or Invasive Procedure:
[**10/2162**]: Vtach/vfib arrest s/p cardioversion now on chronic
amiodarone therapy
[**2162-10-25**]: Percutaneous gastrostomy tube placement.
[**2162-10-25**]: Open tracheostomy tube placement.
[**2162-10-29**]: Flexible bronchoscopy with therapeutic aspiration
of bloody secretions.
Ultrafiltration with removal of 18L of fluid
History of Present Illness:
84 yo male with multiple medical problems, including
hypertension, hypercholesterolemia, CAD, and history of CVA's
who presented to the ED with a 24 history of weakness, cough,
SOB and nausea. He denied fevers, chills, chest pain, abdominal
pain. Emesis x 1 that AM. In ED he was found to be hypoxemic w/
sats 85% on RA, pulmonary edema on CXR and SBP in the 80's. On
presentation, however, the patient was alert and oriented,
appropriate and mentating well. He initially received 2L NS for
IVF hydration, as well as antibiotics including ceftriaxone,
azithromycin, vancomycin for suspected community acquired
pneumonia. The patient then went into rapid afib with HR in the
140's. He was given 5 mg Lopressor IV and his HR decreased to
100. However, the patient's respiratory status declined
precipitously and his sats dipped to 86% on a 100% face mask. He
was placed on a nonrebreather and subsequently intubated in the
setting of impending respiratory failure. Peri-intubation the
patient again became hypotensive with SBP in the 80-60's and was
started on dopamine and dilt for rate control. After intubation
and central line placement, the patient was transferred to the
MICU and admitted with a running diagnosis of sepsis caused by
an underlying community acquired pneumonia.
Although the patient had a extensive medical history and problem
list, prior to presentation and subsequent admission to the
hospital he was fairly independent and ambulatory, living at
home with his wife.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Acromegaly since [**2108**]
4. Transient ischemic attacks in [**2129**] and [**2146**] and [**2155**]
5. Subacute bacterial endocarditis
6. High-grade ventricular ectopy
7. Status post prostate surgery in [**2140**]
8. Squamous cell carcinoma
9. CAD w/ PTCA of LAD in [**2160**]
10. Hernia in [**2146**] with recurrence in [**2154**]
11. Paget's disease in [**2148**]
12. Hyponatremia in [**2148**]
13. Mitral regurgitation
14. Polymyalgia rheumatica
15. Macular degeneration in the right eye in [**2153**]
16. Prosthesis in the left eye since [**2149**]
17. History of dizziness and motion sickness/falls
18. History of pituitary tumor, s/p resection with resulting
panhypopituitarism requiring chronic steroid therapy
Social History:
Married, worked as an accountant, no tobacco x 45 years, minimal
ETOH.
Son who lives in [**Location 3340**], Daughter who lives in [**Country **].
Family History:
Mo died 79 of CVA, Fa died at 90 of "old age", sister died 47 of
breast cancer
Physical Exam:
[**2162-10-4**] on admission from ED to MICU
Temp 99.1, HR 70, BP 90's/palp, (101/53 on dopamine), sats 97%
on AC, TV 550, RR16, PEEP 5 FiO2 70
GENL: elderly male, sedated, intubated
HEENT: L eye prosthetic, R eye minimally reactive, no icterus,
no JVP, no LAD, Left IJ TLC in place
CV: distant HS, + very loud holosystolic murmur heard throughout
the chest with PMI at the apex and radiation to the left axilla
Lungs: End exp wheezes at apices, clear with decreased movement,
crackles at bilateral bases
ABD: soft, obese, non-distended, +BS, no HSM
EXT: 1+DP pulses, WWP, minimal edema
Pertinent Results:
CTA CHEST W&W/O C &RECONS [**2162-10-4**] 1:24 PM
IMPRESSION:
1. No CT evidence of pulmonary embolus.
2. Bilateral large pleural effusions with bibasilar
collapse/consolidation.
3. Multiple hepatic cysts.
TTE ECHO Study Date of [**2162-10-4**]
Conclusions:
1. The left atrium is moderately dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed.
3. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
4. The mitral valve leaflets are moderately thickened with the
posterior
leaflet be calcified and prolapsing. Mild to moderate ([**12-11**]+)
mitral
regurgitation is seen.
5. Compared with the findings of the prior report (tape
unavailable for
review) of [**2158-5-2**], left ventricular systolic function may have
decreased.
TEE ECHO Study Date of [**2162-10-6**]
Conclusions:
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%)
(intinsic LV systolic function may be depressed given the
severity of mitral regurgitation). Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild to moderate ([**12-11**]+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is moderate/severe mitral valve prolapse. There is partial
posterior mitral leaflet flail. There is a echodense mass on the
posterior leaflet consistent with probable old vegetation on the
mitral valve; small mobile echodense mass is associated that may
represent a possible new vegetation. Eccentric, anteriorly
directed, moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. No
vegetation/mass is seen on the tricuspid or pulmonic valves.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Probable old (healed) mitral valve vegetation;
cannot exclude
small superimposed new vegetation. Mitral valve prolapse with
partial flail of the posterior leaflet and moderate to severe
(3+) mitral regurgitation. Mild to moderate (2+) aortic
regurgitation. Mild to moderate (2+) tricuspid regurgitation.
Normal biventricular systolic function (LVEF 60-70%)(intrinisic
LV systolic function may be depressed given the severity of
mitral regurgitation).
ECHO Study Date of [**2162-10-10**]
Conclusions:
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. There is
partial mitral leaflet flail. Moderate to severe (3+) mitral
regurgitation is seen. Tricuspid regurgitation is present but
cannot be quantified. There is a trivial/physiologic pericardial
effusion.
Compared with the findings of the prior report (tape unavailable
for review)of [**2162-10-6**], there is no significant change
ECHO Study Date of [**2162-11-1**]
Conclusions:
1. The left atrium is normal in size.
2.Left ventricular wall thicknesses are normal. 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 valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
5.The mitral valve leaflets are moderately thickened. There is
partial mitral leaflet flail. Mitral regurgitation is present
but cannot be quantified.
6.There is no pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2162-10-10**], the mass on the posterior mitral valve leaflet is more
prominent. This may
represent a flailed mitral valve leaflet with chordae or it may
represent a vegetation. If the mass is a vegetation, and because
this mass appears
calcified, this mass might be a healed vegetation. The mitral
regurgitation is hard to quantify in this present study.
TEE ECHO Study Date of [**2162-11-3**]
Conclusions:
The left atrium is markedly dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function may be
more depressed given the severity of mitral regurgitation.]
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm, non-mobile) atheroma in the aortic
arch. The aortic valve leaflets (3) are mildly thickened, but no
aortic stenosis is present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is partial
flail of the posterior leaflet with leaflet tethering and a very
small (~2mm) mobile echodensity at the leaflet tip that likely
represents a ruptured chordae (cannot exclude a vegetation if
clinically suggested).. An eccentric jet of severe (4+) mitral
regurgitation is seen. An echodense "mass" is seen in close
proximity to the mitral annulus. This may represent a healed
abscess or
atypical mitral annular calcification. A mobile mass is seen
attached to the posterior leaflet. This may represent a torn
chordae or a healed vegetation. The tricuspid valve leaflets are
mildly thickened. No vegetation/mass is seen on the pulmonic
valve or tricuspid valve. There is no pericardial effusion.
CT CHEST W/O CONTRAST [**2162-11-5**] 11:09 AM
IMPRESSION:
1) Worsening pulmonary edema.
2) Moderate bilateral pleural effusions,which have increased
compared to [**2162-10-4**]. There is bibasilar atelectasis as
well. A pneumonia in these consolidative areas cannot be fully
excluded.
CT ABDOMEN W/O CONTRAST [**2162-11-15**] 2:48 PM
CT CHEST WITHOUT IV CONTRAST: As on the prior study, there are
large bilateral effusions, stable since the prior study. The
previously noted bilateral upper lobe air space disease has
progressed and appears more densely consolidated, particularly
within the right upper lobe, and to a lesser extent the left
upper lobe. Additionally, Hounsfield units within the areas of
dense consolidation measure up to approximately 67 Hounsfield
units, which is denser than simple fluid, indicating complex
fluid, possibly hemorrhage.
A tracheostomy tube is noted. No mediastinal adenopathy.
Bibasilar collapse is once again identified, unchanged. Mitral
valve calcifications as well as coronary calcifications are
seen. A right subclavian line is noted, with its tip in the
superior vena cava.
CT ABDOMEN WITHOUT IV CONTRAST: Multiple low-attenuation lesions
are seen within the liver, measuring up to approximately 6 cm,
probably representing cysts. A gastrostomy tube is noted.
Unenhanced gallbladder, adrenals, kidneys, and spleen appear
normal. The pancreas contains a few punctate calcifications,
with extensive calcifications noted within the splenic artery.
CT PELVIS WITHOUT IV CONTRAST: The unenhanced colon, urinary
bladder and seminal vesicles are grossly normal. An open left
inguinal ring containing fat is identified.
BONE WINDOWS: There is severe demineralization within the sacrum
and left iliac bone, with degenerative changes noted within the
remainder of the spine.
IMPRESSION: Dense consolidation within the upper lobes, which is
increased since the prior study dated [**2162-11-5**]. The
density of the consolidation suggests complex fluid and is
compatible with hemorrhage, particularly given the clinical
history.
ECHO Study Date of [**2162-11-17**]
Conclusions:
The left atrium is markedly dilated. The left ventricular cavity
size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is partial mitral leaflet flail.
There is moderate thickening/calcification of the mitral valve
chordae (no definite vegetation seen; cannot exclude
vegetation/healed vegetation). Severe (4+) mitral regurgitation
is seen. The mitral regurgitation jet is eccentric. There is no
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2162-11-1**],
there is no
significant change.
[**2162-12-1**]: Cardiac catheterization: Report pending at the time of
transfer.
Brief Hospital Course:
The patient was admitted to the MICU with a diagnosis of sepsis
and community acquired pneumonia. He had a long and complicated
hospital course that will be described by system.
1. Respiratory: The patient was intubated on the day of
admission for hypoxic respiratory failure presumably related to
sepsis and CAP in the setting of baseline CHF. In the ED, the
patient received a dose of ceftriaxone, azithromycin, and
vancomycin. He was initially continued on Vancomycin and also
started on Levaquin for ABx coverage for presumed community
acquired pneumonia. Blood cultures drawn on the date of
admission [**10-4**] showed 1/2 bottles positive for Staph Coag Neg.
Further blood cultures were negative. He then developed
ventilator associated pneumonia with MRSA. He was given
Linezolid for coverage of MRSA and completed a 2-week course on
[**2162-10-25**]. He required trach placement on [**2162-10-25**] for failure
to wean. His sputum cultures were repeatedly positive for MRSA
and pseudomonas and enterobacter cloacea througout his
hospitalization. He was treated with vancomycin and meropenem
from [**2162-10-31**] through [**2162-11-13**]. The vancomycin was restarted on
[**2162-11-15**] after he spiked a fever and had MRSA in sputum again and
this was continued until his discharge. He was started on
ceftazidime on [**2162-11-23**] and that was also continued until his
discharge. He was also treated with Flagyl early in the
hospitalization for presumed aspiration pneumonia. Most recent
sputum cultures from [**2162-11-29**] were positive for MRSA and
pseudomonas sensitive to ceftazidime. His latest ventilator
settings were AC/0.4/TV=600/RR=10/PEEP=5. He had repeated trials
with a Passy-Miur valve that were unsuccessful leading to
coughing fits.
2. CV: The patient was initially hypotensive at the time of
admission, likely related to sepsis +/- possible adrenal
insufficiency. On admission, he was started on stress dose
steroids and overnight remained on dopamine. The patient was
able to be weaned off pressors after the first night, but
subsquently required intermitent use of pressors to maintain his
SBP.
2.1. Rhythm: He was in afib with a rapid ventricular response on
admisison that was treated with a diltiazem drip, lopressor and
digoxin. He developed polymorphic VT with a transition to Vfib
on [**2162-10-23**] that responded to defibrillation. He was started on
a lidocaine drip and then switched to amiodarone. The amiodarone
dose was decreased on [**2162-11-28**] in attempt to decrease the beta
blocker effect in the face of CHF. He is to remain on Amiodarone
200 mg PO daily. He also went into atrial fibrillation early in
the hospital course that resolved with discontinuation of
dobutamine. He was in normal sinus rhythm at the time of
discharge.
3. Mitral Regurgitation: Per echo he has 4+ MR, which has been
refractory to medical therapy. Fluid overload was a major issue.
He underwent ultrafiltation in the CCU for several days with
removal of 18L of fluid. Upon completion of ultrafiltration he
was diuresed unsuccessfully with lasix boluses. He was started
on a lasix drip with a goal of even to negative fluid balance.
However, we were limited given his hypotension and had to be
held frequently. His blood pressure also did not tolerate
nesiritide. Captopril was added at a dose of 12.5 mg TID for
afterload reduction, along with Lasix drip as tolerated by BP.
Digoxin was also added for inotropic effect. Close to discharge,
the patient was tolerating captopril plus intermittent lasix
drip of 2mg/hr titrated to blood pressure. The lasix drip was
converted to a standing dose of 40mg IV BID. Metolazone 5mg po
BID was also added for synergy. Pt did well on this regimen x
48hrs prior to the time of discharge. Pt was initially informed
that he may be candidate for MV replacement surgery, but was
subsequently refused this surgery by the CT [**Doctor First Name **] service who
felt that his operative risk was too high given his significant
comorbities.
4 History of endocarditis ([**2127**]'s): TEE showed a question of a
vegetation on MV. Subsequently, low suspicion.
5. Agitation: Pt was kept on a standing dose of haldol 2.5 mg
TID which was effective.
7. Nutrition: Mr. [**Known lastname **] has a PEG tube and was tolerating tube
feeds using Respalor Full strength at 50cc/hr. Vit C and Zinc
were added per nutrition recommendations.
8. Endocrine: Mr. [**Known lastname **] has known panhypopituitarism. He was
admitted on prednisone 5 mg daily (home dose). He required
stress dose steroids for his adrenal, subsequently tapered to 20
mg PO daily, on which he remains at the time of discharge.
Regarding his diabetes, serum glucose was well controlled on an
insulin sliding scale starting with 5 units for FSG > 150 and
incrementing by 2 units.
9. Hematology: He had thrombocytopenia initially on admission.
HIT antibody was negative. His thrombocytopenia was subsequently
attributed to Linezolid, and resolved several days after
linezolid was discontinued. Platelet count 170s on day of
discharge.
10. Prophylaxis: Pt was treated with Carafate for GI prophylaxis
(given thrombocytopenia) and Heparin SQ for DVT prophylaxis.
11. Physical Therapy: Pt was felt to be progressing well from a
PT standpoint. He will need continued aggressive PT follow-up.
12. Access: A right subclavian was placed on [**2162-11-14**] and a PICC
line was placed on [**2162-11-30**].
Medications on Admission:
Metoprolol 12.5 mg [**Hospital1 **]
ECASA 325 mg daily
Plavix 75 mg daily
Folic acid 2 mg [**Hospital1 **]
Zocor 30 mg QHS
Vit B6 100 mg daily
Vit B12 100 mcg daily
CaCO3
MVI
Meclizine prn
Vitamin E
Prednisone 5 mg daily
Temezepam prn
Discharge Medications:
1. Furosemide 40 mg IV BID
2. Heparin 5000 UNIT SC TID
3. Metolazone 5 mg PO BID
4. Vancomycin HCl 1000 mg IV Q24H (Please hold Vanco for random
level >20)
5. Meclizine HCl 12.5 mg PO Q8H:PRN
6. Amiodarone HCl 200 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Ceftazidime 2 gm IV Q8H [**11-23**]
9. Captopril 12.5 mg PO TID (Hold for MAP<50) [**11-20**]
10. Ascorbic Acid 500 mg PO BID [**11-19**]
11. Zinc Sulfate 220 mg PO DAILY [**11-19**]
12. Morphine Sulfate 2-4 mg IV Q2H:PRN [**11-18**]
13. Psyllium 1 PKT PO TID:PRN [**11-16**]
14. Haloperidol 2.5-5 mg IV BID:PRN agitation [**11-14**]
15. Haloperidol 2.5 mg PO TID [**11-14**]
16. Oxybutynin 5 mg PO BID:PRN [**11-13**]
17. Insulin SC (per Insulin Flowsheet)
18. Bisacodyl 10 mg PO/PR [**Hospital1 **]:PRN (hold for diarrhea) [**11-10**]
19. Lactulose 30 ml PO Q8H:PRN (hold for diarrhea) [**11-10**]
20. Senna 1 TAB PO BID:PRN (hold for diarrhea) [**11-10**]
21. Nystatin Oral Suspension 5 ml PO QID:PRN [**11-10**]
22. Miconazole Powder 2% 1 Appl TP QID groin [**Female First Name (un) **] [**11-10**]
23. Milk of Magnesia 30 ml PO Q6H:PRN [**11-10**]
24. Simethicone 40-80 mg PO QID:PRN [**11-10**]
25. Acetaminophen 325-650 mg PO Q4-6H:PRN [**11-10**]
26. Sucralfate 1 gm PO QID [**11-10**] @ 2126 View
27. Prednisone 20 mg PO DAILY [**11-10**]
28. Cyanocobalamin 1000 mcg PO QD [**11-10**]
30. Docusate Sodium (Liquid) 100 mg PO BID
31. Simvastatin 30 mg PO QHS
32. Folic Acid 3 mg PO BID
33. Thiamine HCl 100 mg PO/NG DAILY
34. Artificial Tears 1-2 DROP OU PRN
35. Albuterol-Ipratropium [**12-11**] PUFF IH Q4H:PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1)Respiratory failure
2)Congestive heart failure
3)Mitral regurgitation
4)Community-acquired pneumonia
5)Ventilator associated pneumonia
6)Tracheostomy
7)Anemia
8)Thrombocytopenia
9)Hypopituitarism
Discharge Condition:
Fair
Discharge Instructions:
To [**Hospital6 **]
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **]
Completed by:[**2162-12-1**]
|
[
"V09.0",
"112.2",
"507.0",
"428.0",
"V58.65",
"253.0",
"518.84",
"369.3",
"424.0",
"482.1",
"427.1",
"E936.0",
"250.00",
"511.9",
"253.2",
"427.31",
"995.92",
"482.41",
"287.4",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.24",
"00.13",
"96.6",
"96.72",
"88.53",
"88.72",
"00.14",
"99.78",
"96.04",
"31.1",
"37.23",
"34.91",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
19903, 19918
|
12563, 17760
|
293, 625
|
20159, 20165
|
3821, 12540
|
20233, 20309
|
3118, 3198
|
18280, 19880
|
19939, 20138
|
18021, 18257
|
20189, 20210
|
3213, 3802
|
17778, 17995
|
226, 255
|
653, 2143
|
2165, 2938
|
2954, 3102
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,282
| 189,247
|
2048
|
Discharge summary
|
report
|
Admission Date: [**2109-3-20**] Discharge Date: [**2109-3-21**]
Date of Birth: [**2048-10-25**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
female with a history of metastatic pancreatic cancer who
presented to the Emergency Department on the day of admission
with dyspnea and shortness of breath. She was noted to have
slightly more labored breathing that evening prior to
admission following 2 units blood transfusions earlier that
afternoon. The patient denied chest pain, fevers or chills,
headache, abdominal pain, nausea and vomiting per family. On
the morning of admission the patient was found to be dyspneic
with increased work of breathing, which progressively
worsened over the next several hours. The patient was
brought to the oncology Clinic. Initially the patient was
oriented, but became progressively more confused and
lethargic. In the [**Hospital **] Clinic the patient's blood
pressure was 100/60, pulse 84, respiratory rate 32, O2 sat
90%, which decreased to 80% despite being on 15 liters of O2
by nonrebreather mask. The patient became more increasingly
more somnolent and lethargic and was transferred to the
Emergency Room via EMS.
In the Emergency Department the patient was observed to have
an ineffective agonal breathing. Blood pressure 160/63.
Heart rate 120. O2 sat 76% on 100% nonrebreather mask. The
patient was started on BiPAP with improvement of her O2 sats
98 to 100%. The patient was empirically treated with 20
intravenous Lasix, Ceftriaxone 1 gram intravenous, Flagyl 500
mg intravenous and Ampicillin 1 gram intravenous. The
patient became transiently hypotensive to 70s/40s, which
responded well to 500 cc normal saline bolus. The patient's
arterial blood gas was 7.29, 38, 54 and BiPAP of [**10-26**], FIO2
of 1. The patient's bicarb was 14 and she was given one amp
of bicarb.
PAST MEDICAL HISTORY: 1. Pancreatic cancer diagnosed in
[**2101**] status post partial Whipple procedure in [**2102**] for
palliative treatment, status post x-ray therapy and resection
of lung nodule, question whether it was metastatic
adenocarcinoma versus new primary. History of bone
metastasis in [**9-/2107**] status post chemotherapy completed
2/[**2108**]. Also status post palliative x-ray therapy to pelvis,
shoulders and thighs. Diffuse metastases of bone including
spine. Status post endoscopic retrograde
cholangiopancreatography and sphincterotomy for biliary
obstruction. History of ascites and omental mets.
Questionable history of breast cancer. Questionable history
of primary lung cancer. Also history of diabetes, recent
history of urinary tract infection. Klebsiella pneumonia
treated with Cipro.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION: Megace, Methadone,
Neurontin, Naprosyn, Insulin, Prozac, Prilosec, _______,
Fentanyl patch, Ativan, Dilaudid, Cipro.
SOCIAL HISTORY: The patient lives at home with husband. She
continues to smoke one and a half packs a day.
PHYSICAL EXAMINATION: Temperature 97.9. Pulse 101. Blood
pressure 100/60. Respirations 20, sating 98% on BiPAP 10/5,
FIO2 of 1. In general, the patient is stuporous, not
responsive to voice, minimally arousable to sternal rub.
HEENT sclera icteric. Pupils equally round and reactive to
light and accommodation. Neck supple with no
lymphadenopathy. Chest with bilateral expiratory wheezes and
coarse inspiratory rhonchi. Cardiovascular normal S1 and S2.
Tachycardic. No rubs or gallops. Abdomen slightly
distended. No masses, nontender. No rebound or guarding.
Skin warm extremities well perfuse. Positive jaundice on
torsos. Extremities no clubbing, cyanosis or edema.
Neurological Babinski down going bilaterally.
LABORATORY DATA: White blood cell count was elevated at
24.9, hematocrit 35.7. Differential was 86% neutrophils, 11%
lymphocytes, 2 monos. INR was elevated at 1.7. The patient
had normal liver function tests, elevated LDH at 356,
alkaline phosphatase 2188, total bili 7.8. She also had
troponin and CK leak and elevated lactate at 5.8. Bedside
echocardiogram was negative for pericardial effusion. Chest
x-ray showed reticular nodular pattern interstitial with
superimposed multifocal ___________ consolidations consistent
with infection or adult respiratory distress syndrome. Chest
CT revealed no evidence for PE positive for diffuse reticular
nodular pattern consistent with lymphangitic spread of
carcinoma. Also left greater then right air space
consolidation consistent with pneumonia or other alveolar
process. Head CT on [**2109-3-15**] was negative for metastases.
MRI of the spine on [**2109-3-15**] showed diffuse bony metastases.
MRI of the abdomen on [**2109-2-12**] showed no evidence of recurrent
tumor within postop region, positive for ascites and positive
for bone metastases. CT of the abdomen and pelvis [**2109-2-11**]
showed numeral pulmonary nodules at the lung bases
bilaterally, positive for pneumophila, positive for ascites
with nodular component concerning for omental metastases.
Electrocardiogram showed sinus tachycardia with new right
bundle branch block.
HOSPITAL COURSE: It was the patient's wishes to not be
intubated, so she was continued on BiPAP ventilatory support.
She was also continued on broad spectrum antibiotics for
presumed sepsis/ARDS including Vancomycin, Flagyl and
Levaquin. The patient was rehydrated with intravenous
fluids. Throughout the night the patient's respiratory
status became increasingly tenuous. After further discussion
with the family the patient was made DNR/DNI and comfort
measures only. The patient expired at 4:40 a.m. on [**2109-3-21**] from respiratory arrest secondary to sepsis/ARDS in
the setting of a patient with metastatic pancreatic cancer.
The family is requesting postmortem evaluation. The family
was present at the time of death. Attending was notified.
Oncologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was also notified.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2109-3-21**] 10:10
T: [**2109-3-21**] 11:06
JOB#: [**Job Number 11174**]
|
[
"518.89",
"250.00",
"518.82",
"038.9",
"599.0",
"276.2",
"198.5",
"V10.09",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5164, 6273
|
2787, 2905
|
3038, 5146
|
163, 1888
|
1911, 2754
|
2922, 3015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,207
| 149,789
|
34871
|
Discharge summary
|
report
|
Admission Date: [**2193-12-11**] Discharge Date: [**2193-12-20**]
Date of Birth: [**2144-10-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2193-12-16**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending, with
saphenous vein grafs to diagonal, ramus, and PDA.
History of Present Illness:
Mr. [**Known lastname 19772**] is a 49 year old male with known coronary artery
disease. In [**2193-10-9**], he underwent PTCA of an occluded mid
left anterior descending artery. Following the procedure, he
noted significant improvement in his angina. However on
[**2193-12-3**], he experienced some mild chest heaviness when jogging.
His chest pain did improve with rest but continued to linger for
several days. Subsequent stress test on [**2193-12-9**] showed return of
his anginal symptoms. Myoview showed LVEF of 51%. Troponins were
noted to be elevated at that time. Repeat cardiac
catheterization at [**Hospital1 **] revealed severe three vessel
coronary artery disease with restenosis of the mid left anterior
descending artery. Based upon the above, he was transferred to
the [**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
- Coronary artery disease with history myocardial infarction
- Hypertension
- Dyslipidemia
Social History:
Denies tobacco and ETOH. Employed as software developer.
Married, lives with wife.
Family History:
Father underwent CABG at age 62.
Physical Exam:
VS: HR 65 108/71 RR 20
Gen: No acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: supple full range of motion
CV: RRR
Abd: soft nontender nondistended + bowel sounds
Ext: warm well perfused no edema
Neuro grossly intact
Pertinent Results:
[**2193-12-20**] 09:55AM BLOOD Hct-30.6*
[**2193-12-20**] 05:30AM BLOOD WBC-12.4* RBC-3.40* Hgb-10.0*# Hct-27.7*
MCV-81* MCH-29.5 MCHC-36.2* RDW-14.3 Plt Ct-280
[**2193-12-11**] 07:34PM BLOOD WBC-8.0 RBC-4.86 Hgb-13.8* Hct-38.4*
MCV-79* MCH-28.4 MCHC-35.9* RDW-13.2 Plt Ct-240
[**2193-12-20**] 05:30AM BLOOD Plt Ct-280
[**2193-12-11**] 07:34PM BLOOD PT-13.4 INR(PT)-1.1
[**2193-12-11**] 07:34PM BLOOD Plt Ct-240
[**2193-12-13**] 01:51AM BLOOD ESR-22*
[**2193-12-16**] 04:00PM BLOOD Fibrino-218
[**2193-12-20**] 05:30AM BLOOD UreaN-15 Creat-0.8 K-4.0
[**2193-12-11**] 07:34PM BLOOD Glucose-84 UreaN-14 Creat-1.0 Na-141
K-4.6 Cl-105 HCO3-28 AnGap-13
[**2193-12-12**] 11:41AM BLOOD ALT-71* AST-29 LD(LDH)-158 CK(CPK)-72
AlkPhos-97 Amylase-94 TotBili-0.8
[**2193-12-12**] 11:41AM BLOOD Lipase-62*
[**2193-12-12**] 11:41AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2193-12-19**] 04:11AM BLOOD Mg-2.5
[**2193-12-11**] 07:34PM BLOOD %HbA1c-6.0*
[**2193-12-19**] 04:11AM BLOOD TSH-1.1
[**2193-12-13**] 01:51AM BLOOD TSH-0.026*
[**2193-12-13**] 01:51AM BLOOD T4-9.8
[**2193-12-13**] 01:51AM BLOOD antiTPO-LESS THAN
[**2193-12-12**] 11:41AM BLOOD C3-162 C4-58*
[**Known lastname **],[**Known firstname 79830**] [**Medical Record Number 79831**] M 49 [**2144-10-20**]
Radiology Report CHEST (PA & LAT) Study Date of [**2193-12-20**] 9:53 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2193-12-20**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79832**]
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
Provisional Findings Impression: DLnc FRI [**2193-12-20**] 12:06 PM
Small left pleural effusion. Resolution of left upper lobe
atelectasis.
Final Report
REASON FOR EXAMINATION: Followup of a patient after CABG.
PA and lateral upright chest radiograph were compared to
[**2193-12-18**].
There is resolution of previously demonstrated left upper lobe
atelectasis.
Cardiomediastinal silhouette is stable. There is still present
small left
pleural effusion. There is no pneumothorax or evidence of
failure.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2193-12-20**] 1:49 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 79830**] [**Hospital1 18**] [**Numeric Identifier 79833**] (Complete)
Done [**2193-12-16**] at 3:06:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2144-10-20**]
Age (years): 49 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2193-12-16**] at 15:06 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study..
POST-CPB: On infusion of phenylephrine, a-pacing. Preserved
biventricular systolic function post cpb with LVEF now 55%.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2193-12-17**] 07:58
Brief Hospital Course:
Mr. [**Known lastname 19772**] was admitted directly to the cardiac surgical service.
On admission, he was noted to have upper airway swelling and
slurred speech. He was treated with intravenous Benadryl, h2
blocker, and steroids. He was transferred to the CVICU given
risk for airway obstruction. Within 24 hours, the airway
swelling and speech showed significant improvement. Allergy
service was consulted and recommended steroid taper, along with
discontinuing the ACE inhibitor(common cause of angioedema),
will hold on ACE inhibitor at discharge until follow up with
allergist and cardiologist, will need to re evaluate as
outpatient. Preoperative evaluation was otherwise unremarkable
and he was cleared for surgery. Surgery was delayed for several
days given recent Plavix use. He remained pain free on medical
therapy/nitroglycerin drip. On [**12-16**], Dr. [**Last Name (STitle) **]
performed coronary artery bypass grafting surgery. Given
inpatient stay greater than 24 hours, Vancomycin was used for
perioperative antibiotic coverage. For surgical details, please
see separate dictated operative note. Following the operation,
he was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. He maintained good hemodynamics and transferred to the
SDU on postoperative day one. Physical therapy worked with him
on strength and mobility. He continued to progress and was
ready for discharge home with services. He will continue with
steroid taper and follow up with allergist on [**12-24**] as
outpatient.
Medications on Admission:
Crestor 20 qd, Lisinopril 5 qd, Toprol 150 qd, Plavix 75 qd,
Aspirin 325 qd, Imdur 30 qd, Fish Oil
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. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: see taper Tablet PO once a day
for 6 days: [**12-21**] - 15 mg
[**12-22**] - 15 mg
[**12-23**] - 10 mg
[**12-24**] - 10 mg
[**12-25**] - 5 mg
[**12-26**] - 5 mg
15mg on [**12-21**] and [**12-22**]
10 mg on [**12-23**] and 12.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Non ST Elevation Myocardial Infarction
Angioedema
Hypertension
Dyslipidemia
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**]
Please follow up with allergist prior to completion of steroid
taper - you have an appointment [**12-24**]
If you experience any swelling in tongue, mouth, throat, seek
medical attention immediately
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 2weeks - call [**Hospital1 **] heart center for
appointment - for [**Hospital 8784**] clinic with Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 5874**] in [**2-10**] weeks
Dr. [**Last Name (STitle) 27187**] in 1 week
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11427**] (allergist) [**Hospital1 79834**]. [**Location (un) 47**],
[**Numeric Identifier 79835**] - in pediatrics clinic Tuesday [**2193-12-24**] at
11am
Completed by:[**2193-12-20**]
|
[
"401.9",
"414.01",
"272.4",
"995.1",
"E942.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61",
"99.05",
"88.72",
"99.00",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11677, 11736
|
8441, 10034
|
335, 518
|
11891, 11898
|
2003, 3502
|
12608, 13186
|
1616, 1650
|
10183, 11654
|
3542, 3572
|
11757, 11870
|
10060, 10160
|
11922, 12585
|
1665, 1984
|
285, 297
|
3604, 8418
|
546, 1386
|
1408, 1500
|
1516, 1600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,963
| 110,965
|
36409
|
Discharge summary
|
report
|
Admission Date: [**2120-8-21**] Discharge Date: [**2120-8-24**]
Date of Birth: [**2064-11-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Glucocorticoids,Systemic Classifier
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Posterior Fossa Mass
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 82489**] is known to have metastatic melanoma. Her melanoma
history starts with some ulcerating lesions in the posterior
shoulder about [**Doctor Last Name **] years ago. She was eventually seen when it
has got such a big size and there was
ulceration and exudation when an MRI showed a 9.7 x 7.1 x 7.9 cm
mass in that shoulder, which was lobulated. A CT scan on [**3-29**], [**2119**], showed multiple bilateral pulmonary nodules. She
underwent surgical resection of this lesion, which confirmed
melanoma. She was seen in the [**Hospital1 188**] for consideration of high-dose IL-2. She had a staging
brain MRI in [**2120-4-19**], which showed no metastatic lesion. She
had a short course of high-dose IL-2, which was completed in
[**2120-6-19**].
Her neurological and neuro-oncological history starts when she
was noticed to have a 3-week history of some dizziness and
decreased coordination in her left hand. She went to the [**State 1727**]
emergency room and had a head CT, which showed a posterior fossa
mass. She was sent to the [**Hospital1 69**]
and an MRI was done. This showed a central 1.7 cm mass deep in
the left cerebellum along with dentate nucleus, which
contributed to her symptoms. She was commenced on Decadron,
which improved her symptoms and she was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the Neurosurgery for consideration for radical resection.
Dr. [**Last Name (STitle) **] thought this is a deep seated and resection of which
might moisten her coordination and left upper limb symptoms and
the patient was not keen to have surgery. Hence, she was asked
to be seen by me for consideration of stereotactic radiosurgery.
Ms. [**Known lastname 82490**] symptoms of left-sided hand upper limb incoordination
have improved somewhat with Decadron. She does not have any
other higher function, cranial nerve, sensory, motor, or
neurological dysfunction.
Past Medical History:
as noted in HPI
Social History:
She is married. She is seen with her husband. She lives in
[**State 1727**]. She has two grown sons and she is active in her farm
with animals and gardening. She quit smoking in [**2104**], but she
smoked for about 14 years. She does not abuse alcohol.
Family History:
Her father has had some nonmelanoma skin cancers. Her one
paternal uncle who died of metastatic melanoma. She has two
sisters who have nonmelanoma skin cancers as well. No other
history of cancers in the family.
Physical Exam:
On Discharge:
She is alert, oriented to person, place and date. PERRL, she has
no pronator drift, or alternate cerebellar findings. Full
strength and power throughout all extremities
Pertinent Results:
Labs on Imaging:
[**2120-8-21**] 08:00PM BLOOD WBC-7.0 RBC-5.14 Hgb-14.6 Hct-44.7 MCV-87
MCH-28.4 MCHC-32.6 RDW-13.6 Plt Ct-363
[**2120-8-21**] 08:00PM BLOOD Neuts-83.0* Lymphs-15.1* Monos-1.0*
Eos-0.2 Baso-0.5
[**2120-8-21**] 08:00PM BLOOD PT-11.9 PTT-22.3 INR(PT)-1.0
[**2120-8-21**] 08:00PM BLOOD Glucose-222* UreaN-13 Creat-0.8 Na-139
K-4.5 Cl-100 HCO3-26 AnGap-18
[**2120-8-21**] 08:00PM BLOOD ALT-31 AST-23 AlkPhos-84 TotBili-0.6
[**2120-8-21**] 08:00PM BLOOD Calcium-11.3* Phos-4.5 Mg-2.2
Labs on Discharge:
[**2120-8-24**] 06:55AM BLOOD WBC-10.0 RBC-4.87 Hgb-14.1 Hct-42.9
MCV-88 MCH-28.9 MCHC-32.8 RDW-13.4 Plt Ct-391
[**2120-8-24**] 06:55AM BLOOD Plt Ct-391
[**2120-8-24**] 06:55AM BLOOD Glucose-177* UreaN-25* Creat-0.8 Na-141
K-4.2 Cl-101 HCO3-28 AnGap-16
[**2120-8-24**] 06:55AM BLOOD Calcium-10.4* Phos-3.9 Mg-2.4
-------------
IMAGING:
-------------
Head CT [**8-21**]:
FINDINGS: Non-contrast head CT is performed. As on the outside
hospital
study, there is a left cerebellar lesion measuring 1.5 x 1.4 cm
with
surrounding vasogenic edema causing slight mass effect on the
fourth
ventricle. There is no evidence of hemorrhage or obstructive
hydrocephalus. No additional lesions are seen.
IMPRESSION: Left cerebellar lesion with surrounding vasogenic
edema,
concerning for metastasis. Correlation with MRI is advised.
MRI Head [**8-22**]:
FINDINGS: As seen on the preceding CT scan, there is a mass
centered within the anterior medial aspect of the left
cerebellar hemisphere, demonstrating predominant T2
hyperintensity and T1 hypointensity. There is extensive adjacent
edema involving the dentate nucleus and more superior cerebellar
hemisphere, as well as extending into the brachium pontis. The
mass does bulge into, though is not situated within the fourth
ventricle. There is heterogeneous enhancement. No associated
leptomeningeal enhancement is identified and no additional
lesions are seen. Restricted diffusion is present along the
lateral margin of the mass. Overall dimensions are 1.4 x 1.5 x
1.8 cm. There are otherwise scattered T2 hyperintensities within
the subcortical and deep white matter in a pattern suggestive of
small vessel disease. Ventricles are normal, despite mass effect
upon the fourth ventricle as detailed. The flow voids are
normal.
IMPRESSION: Solitary heterogeneously enhancing mass within the
left
cerebellar hemisphere with mild mass effect. Primary
differential
considerations would include metastatic disease or lymphoma,
primary tumors such as hemangioblastoma and abscess. The
restricted diffusion without significant susceptibility artifact
suggests a highly cellular tumor as seen in lymphoma. WE favor
metastasis or lymphoma.
Brief Hospital Course:
Patient was admitted for newly diagnosed posterior fossa lesion.
She was seen and evaluated by Neuro and Radiation oncology who
determined cyberknife to be the best treatment at this point in
time. She received her cyberknife treatment on [**8-23**], and was
determined to be appropriate for disposition to home on [**8-24**]. She
was discharged with instructions for follow up in the brain
tumor clinic.
Medications on Admission:
Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Atenolol 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
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. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*120 Tablet(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. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection three times a day: administer per sliding scale.
Disp:*QS 1 vial* Refills:*0*
9. BD Insulin Syringe 1 mL 28 x [**12-22**] Syringe Sig: One (1)
Miscellaneous three times a day.
Disp:*qs 1 box* Refills:*0*
10. Glucometer
Please dispense one glucometer
11. Glucometer Strips
Please dispense glucometer testing strips(To test TID)
12. Lancets(Device)
Please dispense one lancet device and lancets for one month
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior Fossa Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? 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 shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call the The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. You should request to be seen within 4wks.
Completed by:[**2120-8-24**]
|
[
"197.0",
"V87.41",
"781.3",
"729.89",
"171.2",
"V15.82",
"198.3",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.32",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
7655, 7661
|
5796, 6202
|
336, 343
|
7726, 7750
|
3084, 3581
|
9437, 9773
|
2651, 2866
|
6453, 7632
|
7682, 7705
|
6229, 6430
|
7774, 9414
|
2881, 2881
|
2895, 3065
|
276, 298
|
3600, 5773
|
371, 2321
|
2343, 2360
|
2376, 2635
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,034
| 199,614
|
38056
|
Discharge summary
|
report
|
Admission Date: [**2168-7-31**] Discharge Date: [**2168-8-6**]
Date of Birth: [**2126-12-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
hematemasis, abdominal pain
Major Surgical or Invasive Procedure:
ERCP
EGD
History of Present Illness:
Mr. [**Known lastname 84380**] is a 41 yo M with PMH ETOH abuse, cholelithiasis,
HTN, obesity who presented to [**Hospital3 **] with hematemasis.
He reports that for the past 6 years he has been drinking [**11-27**] of
a 1.7L bottle of vodka daily. On Friday evening he had several
episodes of vomiting of bright and dark red material for which
he presented to [**Hospital3 **]. He had an NG tube which
reportedly failed to clear with lavage and patient self d/c'd
the NGT because he was vomiting around the tube. He was given
4mg IV morphine for abdominal pain, ativan 2mg IV for
withdrawal, protonix 40mg IV, zofran 8mg IV, octreotide 50mcg
IV, and 1 unit of platelets. He had a CT scan at [**Hospital1 **] which per their read showed stigmata of portal venous
hypertension and hepatic cirrhosis with a large amount of
ascites and varices, splenomegaly. It also showed mild
peripancreatic stranding suggesting mild pancreatitis with no
loculated collection. He has cholelithiasis and cholecystitis
could not be excluded based on the available images.
.
In the ED, initial vs were: T 98.6 P66 BP145/89 R16 O2 sat 98%
RA. He was started on a protonix gtt and octreotide gtt given
his elevated LFT's. He was also given a bananna bag. He had a
RUQ ultrasound which demonstrated gallstones and sludge and per
ED resident report ascites. As such given new ascites and
abdominal pain he was given levofloxacin 750mg IV and flagyl
500mg IV reportedly for SBP prophylaxis. He was evaluted by GI
in the ED.
.
On the floor, he reports that he had two episodes of vomiting of
dark red emesis. Per his nurse it was about 75ml and was
gastrocult positive. He otherwise endorese RUQ pain radiating
to his back. He also reports slow increase in abdominal girth
with more acute distention and lower extremity swelling over the
two days prior to admission.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness.
Past Medical History:
Alcohol abuse
hypertension
cholelithiasis
gout
obesity
depression
Social History:
lives alone, divorced x2, has three children, currently drinking
[**11-27**] of a large bottle of vodka daily, denies tobacco or drug
use.
Family History:
NC
Physical Exam:
Vitals: BP:153/92 P:64 R: 20 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, dry mucous membranes
Neck: supple, obese, JVP not elevated
Lungs: bibasilar crackles, no wheezes
CV: Regular rate and rhythm, [**1-1**] soft nonradiating systolic
murmur
Abdomen: obese/distended, RUQ and epigastric tenderness to
palpation, normoactive bowel sounds, no rebound or guarding.
Ext: warm, well perfused, 1+ pitting edema bilaterally, 2+
pulses
Pertinent Results:
EGD ([**7-31**]):
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed prior to administering sedation. The
patient was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the second part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The procedure was not difficult. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus: 3 cords of grade 1 nonbleeding varices were
noted in the middle and distal third of the esophagus.
Stomach: Portal hypertensive gastropathy was noted in the fundus
of stomach.
Duodenum: Duodenitis of the bulb.
.
RUQ US ([**7-31**]):
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for portal venous thrombus.
Recanalized
paraumbilical vein consistent with portal hypertension.
2. Echogenic and nodular liver consistent with cirrhosis.
.
CXR ([**8-1**]):
FINDINGS: There are no old films available for comparison. The
heart is
mildly enlarged. The right hemidiaphragm is mildly elevated.
There is no
focal infiltrate or effusion.
IMPRESSION: No acute infiltrate.
[**2168-7-31**] 02:25AM BLOOD WBC-3.7* RBC-3.11* Hgb-12.5* Hct-37.5*
MCV-120* MCH-40.0* MCHC-33.3 RDW-17.6* Plt Ct-33*
[**2168-8-6**] 06:20AM BLOOD WBC-3.8* RBC-2.53* Hgb-10.3* Hct-32.0*
MCV-126* MCH-40.6* MCHC-32.1 RDW-17.2* Plt Ct-61*
[**2168-7-31**] 02:25AM BLOOD Neuts-84* Bands-1 Lymphs-8* Monos-4 Eos-1
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2168-8-6**] 06:20AM BLOOD PT-20.6* PTT-37.2* INR(PT)-1.9*
[**2168-7-31**] 02:25AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-138
K-3.9 Cl-105 HCO3-25 AnGap-12
[**2168-8-6**] 06:20AM BLOOD Glucose-73 UreaN-13 Creat-0.8 Na-136
K-5.0 Cl-102 HCO3-28 AnGap-11
[**2168-7-31**] 02:25AM BLOOD ALT-35 AST-170* AlkPhos-141* TotBili-6.4*
[**2168-8-4**] 12:27PM BLOOD CK(CPK)-86 DirBili-8.0*
[**2168-8-5**] 09:32AM BLOOD ALT-79* AST-303* AlkPhos-106
TotBili-11.9*
[**2168-8-6**] 06:20AM BLOOD TotBili-12.6*
[**2168-8-1**] 04:24AM BLOOD Lipase-404*
[**2168-8-6**] 06:20AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2168-8-2**] 05:20AM BLOOD calTIBC-156* Ferritn-GREATER TH TRF-120*
[**2168-7-31**] 08:43AM BLOOD VitB12-1232* Folate-GREATER TH
[**2168-8-2**] 05:20AM BLOOD Triglyc-109
[**2168-8-2**] 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2168-8-2**] 05:20AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2168-8-2**] 05:20AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2168-8-2**] 05:20AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2168-7-31**] 02:25AM BLOOD ASA-NEG Ethanol-129* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-8-2**] 05:20AM BLOOD HCV Ab-NEGATIVE
[**2168-7-31**] 02:33AM BLOOD Lactate-2.8*
[**2168-8-2**] 05:20AM BLOOD CERULOPLASMIN-Test
[**2168-8-2**] 05:20AM BLOOD ALPHA-1-ANTITRYPSIN-Test
Brief Hospital Course:
# Hematemasis: Admitted to MICU, EGD with evidence of portal
hypertensive gastropathy and gastritis. No evidence of
continued bleeding at this time and he didn't require any blood
transfusion other than 1 bag of plateletes. He was found to have
grade 1 varices but no evidence of bleeding. Patient was on
octreotide gtt for 48 hours and protonix gtt for 48 hours. His
Hct was stable. Patient was switch to IV Protonix then Protonix
PO. Diet was advanced as tolerated. There was no hematemesis
during admission.
.
# Pancreatitis: This is a possible explanation for patient's
abdominal pain given elevated lipase, radiation to the back and
evidence of pancreatic inflammation on OSH CT scan. Given
concurrent findings of gallstones and possible cholecystitis on
CT scan possibility of gallstone pancreatitis vs etoh
pancreatitis which seems more likely. Amylase and lipase were
followed daily. Diet was slowly advanced initially but since his
lipase increased, patient was put back on NPO. Patient had no
evidence of pancreatic cyst on OSH CT scan. On transfer to
floor, patient stated he was hungry with no N/V. Diet was
advanced as tolerated. Abdominal pain improved, narcotics were
used sparingly. MRCP was done due to history of gallstone
pancreatitis which showed cholelithiasis but no dilitation of
CBD or pancreatic obstruction. ERCP was done which showed no
ductal abnormalities. They placed 7 FR biliary stent to see if
LFTs improved.
.
# Elevated LFTs and Tbili - Likely [**12-28**] alcoholic hepatitis.
Patient's billirubin and INR rose and plateaued during the
admission. Ultrasound, MRCP and ERCP were done as above. ERCP
stent done empirically to see if LFTs improved. Billirubin had
2 days of imrpovement on day of discharge.
.
# Cirrhosis, portal hypertension, ascites, pancytopenia,
coagulopathy: All these findings are consistent with chronic
liver disease and chronic etoh abuse. Now with evidence of
acute decompensation, precipitant is unclear, ddx included
infection/sbp (ruled out by paracentesis and peritoneal fluid
studies), pancreatitis, portal vein thrombosis (which was ruled
out on RUQ US). Patient was on PPI gtt and octrotide gtt. He
was given 1u platelets at OSH, and didn't require any blood
products since admission here. Diagnostic paracentesis was
performed which showed no evidence of SBP. Patient was put on
ciprofloxacin for SBP prophylaxis. Patient was not on lacutlose
as mental status was clear. Complete cirrhosis workup was done
and negative, likely [**12-28**] alcohol use.
.
# ETOH Abuse: no h/o seizures or DT's. Patient was put on CIWA
scale with decreasing valium requirements. Social work consulted
to help patient with attempt to stay sober. Recieved mv,
thiamine and folic acid daily.
.
# Gout - Continued on Allopurinol.
Medications on Admission:
Allopurinol 300mg daily
BP medication (can't remember the name)
Wallmart pharmacy in [**Location (un) **]
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic Hepatitis
Alcoholic Cirrhosis
Cholelithiasis
Pancreatitis
Secondary:
Obesity
Alcohol abuse
Discharge Condition:
Good. Hemodynamically stable with normal vitals.
Discharge Instructions:
You were admitted to the hospital after coughing up blood. You
had a EGD (camera into the esophagus and stomache) which showed
signs of high blood pressure in the liver's drainage system. One
of these findings is called varices. To prevent progression of
varices, you should take nadolol daily. This lowers the pressure
in the liver drainage system. Please be aware that varices are
blood vessels...they can break open and cause life-threatening
bleeds.
An ultrasound of your stomach showed signs of cirrhosis
(scarring) in your liver. This is likely from alcohol. Several
other tests were checked for other causes and were unrevealing
of another cause. You MUST stop drinking to prevent worsening
liver disease.
It was not clear initially whether or not your jaundice
(yellowing) was because of alcohol or gallstones so you
underwent an ERCP to look for obstructing stones in the liver
drainage system. No stones were seen but a stent was placed as
sometimes there is a block that isnt seen that can be relieved
by stenting. This is a temporary stent and should be removed in
[**2-29**] weeks. You may follow up in [**Location (un) 3320**] or with Dr [**Last Name (STitle) **] at
[**Hospital1 18**] for stent removal ([**Telephone/Fax (1) 1983**]). You should also be seen
by a gastroenterologist or a liver specialist for your liver
disease.
The abnormal labs and jaundice were likely caused by alcoholic
hepatitis. Please have your liver function tests and bilirubin
checked in 1 week. If they are improved, please have them
checked every 2-4 weeks until they return to normal. Please have
the results reported to Dr [**First Name (STitle) **] in [**Location (un) 3320**]. Should the
numbers worsen, you should go back to be
Followup Instructions:
Please follow up with Dr [**First Name (STitle) **] and a gastroenterologist for
labs and stent removal as above.
|
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icd9cm
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[
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[
[
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9854, 9860
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6165, 8957
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301, 312
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10015, 10066
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3155, 6142
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,072
| 198,295
|
43022
|
Discharge summary
|
report
|
Admission Date: [**2184-11-19**] Discharge Date: [**2184-11-24**]
Date of Birth: [**2143-11-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
CC: shortness of breath
MICU admission: respiratory failure
Major Surgical or Invasive Procedure:
Intubation
Central Line Placement
History of Present Illness:
HPI: 40yoF obesity, diastolic CHF, afib presents from clinic
with shortness of breath, diaphoresis, and tachycardia to 160s.
En route to the clinic this AM, pt reported worsening SOB, but
has been increased for past few days. Has had decreased PO
intake past two days, unsure of which meds were not taken.
In ED, initially had SBPs <120, with tachycardia to 160s,
mentating well. Then became unstable with BP 70/30, received
100J shock, with resumption of normal BP and conversion to NSR.
Pt intubated for increasing respiratory distress/airway
protection; noted report unresponsive with eye twitching
(etomidate/succ, versed). Received diltiazem drip for AFIB/RVR,
lasix (80IV) with diuresis, versed drip. Post intubation cxr
showed RLL infiltrate, concering for PNA - initiated on
vanco/levo/flagyl.
ROS - on transfer to unit prior to fentanyl sedation, pt
hand-squeezed to locate pain location - reported pain in chest
area, none in head or abdomen, but also R and L LE pain.
Past Medical History:
PMH:
1. Hypertension
2. Diastolic CHF, EF 55%, 1+MR
3. Pulmonary HTN - home O2, BIPAP
4. Afib - diagnosed [**3-3**]
5. Morbid Obesity
6. PFTs --> restrictive lung disease
7. h/o influenza [**3-3**]
8. pre-diabetes?
9. h/o ETOH abuse
10. sleep apnea
Social History:
SH: Single mother, 2 children (19 and 12). Tobacco history.
EtOH in past, has been in rehab. Reportedly has been without
tobacco/EtOH for months. Lives with children/mother. Cocaine
use years prior. Denies any IVDU. Lives in [**Location 686**], worked
as cashier at [**Last Name (un) 59330**].
Family History:
NC
Physical Exam:
PE: 98.5, 107, 128/91, 140kg, ac 99%
GEN: semi-awake upon arrival on versed gtt, eye tracking,
HEENT: EOMi, mild conj injection, ETT in place
NECK: cannot assess JVP due to obesity
CV: distant heart sounds, irregular, no m/g/r.
PULM: difficult to assess [**2-27**] obesity, crackles bil, no wheeze.
ABD: soft, obese, NT, ND, +BS
EXT: trace to 1+ edema to knees bilaterally. Moving all extrs.
Pertinent Results:
LABS:
[**2184-11-19**] 10:24AM BLOOD WBC-12.5* RBC-5.13 Hgb-10.8* Hct-39.6
MCV-77* MCH-21.1* MCHC-27.3* RDW-20.7* Plt Ct-525*
[**2184-11-24**] 03:50AM BLOOD WBC-48.2*# RBC-3.43* Hgb-7.5* Hct-26.9*
MCV-79* MCH-21.9* MCHC-27.9* RDW-21.2* Plt Ct-62*
[**2184-11-19**] 10:24AM BLOOD Neuts-82.0* Lymphs-12.0* Monos-3.0
Eos-2.6 Baso-0.4
[**2184-11-23**] 04:15AM BLOOD Neuts-71* Bands-13* Lymphs-8* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 NRBC-44*
[**2184-11-22**] 04:16AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Schisto-1+
Ellipto-2+
[**2184-11-23**] 04:15AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-1+ Stipple-1+ How-Jol-1+
[**2184-11-19**] 10:24AM BLOOD PT-22.1* PTT-35.8* INR(PT)-2.2*
[**2184-11-24**] 03:50AM BLOOD PT-104.9* PTT-96.3* INR(PT)-14.7*
[**2184-11-23**] 11:50AM BLOOD Fibrino-109*
[**2184-11-24**] 01:17AM BLOOD Fibrino-82*
[**2184-11-19**] 10:24AM BLOOD Glucose-105 UreaN-11 Creat-1.1 Na-144
K-4.0 Cl-101 HCO3-37* AnGap-10
[**2184-11-24**] 03:50AM BLOOD Glucose-490* UreaN-31* Creat-5.2* Na-134
Cl-73* HCO3-28
[**2184-11-19**] 10:24AM BLOOD CK(CPK)-118
[**2184-11-24**] 03:50AM BLOOD CK(CPK)-5236*
[**2184-11-21**] 03:08AM BLOOD Lipase-50
[**2184-11-22**] 11:16PM BLOOD Lipase-129*
[**2184-11-19**] 10:24AM BLOOD CK-MB-6 proBNP-4524*
[**2184-11-19**] 10:24AM BLOOD cTropnT-0.05*
[**2184-11-24**] 03:50AM BLOOD CK-MB-76* MB Indx-1.5 cTropnT-0.97*
[**2184-11-19**] 10:24AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.7*
[**2184-11-24**] 03:50AM BLOOD Calcium-7.9* Phos-5.5* Mg-1.5*
[**2184-11-21**] 03:08AM BLOOD Hapto-47
[**2184-11-21**] 03:08AM BLOOD Cortsol-35.3*
[**2184-11-22**] 04:16AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
[**2184-11-23**] 03:44AM BLOOD IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2184-11-21**] 03:08AM BLOOD HCG-<5
[**2184-11-19**] 10:24AM BLOOD Acetmnp-NEG
[**2184-11-22**] 04:16AM BLOOD ASA-NEG Ethanol-11* Acetmnp-18.3
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2184-11-22**] 10:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2184-11-22**] 04:16AM BLOOD HCV Ab-NEGATIVE
[**2184-11-19**] 10:37PM BLOOD Type-ART Temp-37.2 pO2-91 pCO2-62*
pH-7.37 calTCO2-37* Base XS-7 -ASSIST/CON Intubat-INTUBATED
[**2184-11-24**] 01:05PM BLOOD Type-ART pO2-33* pCO2-78* pH-7.28*
calTCO2-38* Base XS-6
[**2184-11-19**] 12:12PM BLOOD Lactate-2.9*
[**2184-11-24**] 01:05PM BLOOD Lactate-22.3*
[**2184-11-20**] 06:53AM BLOOD freeCa-1.18
[**2184-11-24**] 01:05PM BLOOD freeCa-1.33*
.
MICROBIOLOGY:
Blood Cx ([**11-19**], [**11-21**]) NGTD x4
Urine Cx ([**11-19**]): Negative for Legionella
Sputum Cx ([**11-21**]): MRSA
Urine Cx ([**11-21**]): No growth
Stool Cx ([**11-22**]): Negative for C. diff
.
EKG:
[**8-31**] - Afib 114 BPM, Right axis deviation, NI, no ST/T changes
compared to [**2184-8-4**].
.
CXR ([**11-19**]): IMPRESSION:
1. Status post intubation.
2. Congestive heart failure and cardiomegaly.
3. New focal right upper lobe opacity. Differential
considerations include aspiration and asymmetric pulmonary
edema, given the rapid onset.
.
CTA Chest ([**11-20**]): IMPRESSION:
1. Suboptimal study without evidence of central or segmental
pulmonary embolism.
2. Moderate right and small left pleural effusion with
associated compressive atelectasis.
3. Stable severe cardiomegaly with findings suggestive of CHF.
.
Liver Gallbladder U/S ([**11-21**]): IMPRESSION:
1. Cholelithiasis and asymmetric gallbladder wall edema which
may be due to hepatic inflammation or third spacing (due to
hypoalbuminemia or cirrhosis). Nondistention of the gallbladder
makes cholecystitis unlikely.
2. No evidence of ascites.
3. Small right pleural effusion.
.
Abdomen Film ([**11-21**]): The study is limited due to the inability
to sufficiently penetrate this individual. Some air-filled bowel
loops are seen which I suspect within either stomach or large
intestine. There is no pneumatosis and there was no free air
visualized. Sensitivity for the latter will be low considering
the underpenetrated technique, a consequence of the patient's
body habitus. An NGT is seen projecting in the expected location
of the stomach.
.
TTE ([**11-21**]): IMPRESSION: Sub-optimal study due to technical
limitations. At least moderate dilatation of the right ventricle
which also appears hypokinetic. It appears that there is
abnormal systolic septal motion consistent with right
ventricular pressure overload. No significant mtiral or aortic
regurgitation seen, making endocarditis less likely. However a
small vegetation cannot be excluded.
.
CXR ([**11-24**]): FINDINGS: In comparison with the study of [**11-23**],
there is again substantial enlargement of the cardiac silhouette
with evidence of vascular congestion. The retrocardiac area
cannot be evaluated due to underpenetration of the image.
Otherwise, little change.
Brief Hospital Course:
In ED, the patient initially had SBPs <120, with a fib/RVR to
160s, mentating well. She then became unstable with BP 70/30,
received 100J shock, with resumption of normal BP and conversion
to NSR. Patient was intubated for increasing respiratory
distress/airway protection; noted report unresponsive with eye
twitching. Received diltiazem drip for AFIB/RVR, lasix (80IV)
diuresis for acute on chronic heart failure, versed drip. Post
intubation cxr showed RLL infiltrate, concering for PNA
-initiated on vanco/levo/flagyl. CTA Chest showed no evidence
of PE, moderate right and small left pleural effusion with
associated compressive atelectasis.
Overnight on day 2 of admission, she developed a fib/a flutter
with RVR into the 150s after receiving albuterol for wheezing.
HR decreased to 80-100 after IV Lopressor and Diltiazem.
On day 3, she continued to have hypotension into the 90s and was
started on Neo/Vasopressin/Levophed. Her HR was increased and
she was started on amiodarone IV, then her HR decreased for
which she received [**1-27**] amp atropine. She was cardioverted a
second time. She had a lactic acidosis with elevated lactate to
9.9, pH to 6.99; and WBC to 20.9. She was started on IV
Hydrocortisone for possible adrenal insufficiency. She received
Lasix and Diuril without improvement in her respiratory status.
There was concern the patient may have ischemic bowel vs.
worsening septic shock, but was too unstable to travel off the
MICU to CT scanner. A TTE showed no significant mtiral or
aortic regurgitation seen, making endocarditis less likely. RUQ
U/S showed Cholelithiasis and asymmetric gallbladder wall edema
which may be due to hepatic inflammation or third spacing (due
to hypoalbuminemia or cirrhosis). Abdominal film showed no free
air. Xigris was considered, however patient had INR up to 9.4.
Renal was consulted and recommended continuous HCO3 IV. ID was
consulted and recommended adding Cipro for extended gram
negative coverage (already on Vanco/Levo/Flagyl). Toxic shock
syndrome was considered as an etiology, but there was no tampon
in her vaginal vault and her LMP was [**11-29**]. Urine Legionella
antigen negative, blood cultures with NGTD x4, stool negative
for C. diff, sputum grew MRSA.
On Day 4 of admission, she had developed multi-system organ
failure with cardiogenic and vasodilatory shock, ARDS, ARF, and
shock liver. The patient continued to have episodes of acute
hypotension requiring 3 pressors complicated by both a fib/RVR
and bradycardia. Her PEEP was increased to 24 and an esophageal
balloon was placed to help better assess airway pressures.
Xigris was considered but ultimately not given as INR 9.4. ID
determined patient was not stable enough to drain the
gallbladder. Hepatology was consulted and felt that the patient
had shock liver with AST and LDH into the 10,000s. A Tylenol
level was added on to her admission labs which was negative. A
hepatitis panel is negative so far. EP was consulted and no
furhter medications for chemical cardioversion. Surgery was
consulted but the patient was too clinically unstable without a
chance for meaningful recovery, so an exploratory laparotomy was
not performed.
On Days 5 and 6, a LIJ was placed to begin CVVH. The patient
continued to require multiple amps of HCO3 for lactic acidosis
and calcium gluconate IV for decreased free Ca. She had
episodes of hypotension down to the 40s requiring atropine. She
did not have identifiable brainstem activity -- with fixed and
dilated pupils to 9 mm, no corneal reflex, no cough reflex, no
gag reflex, and no oculocephalic reflex. However, she was too
unstable for either apnea testing or confirmatory imaging. We
had discussed her declining status throughout the day with her
family; however, they had not been able to come into the
hospital. The social work service was therefore consulted. She
then developed progressive hypotension and we provided
high-intensity resuscitative efforts for several hours.
However, she developed full cardiac arrest. Rhythm was
initially PEA, and she received CPR, epi, bicarbonate, calcium,
and atropine. She then developed VF and recieved 2 shocks, but
then developed VT and eventual PEA. After 20 minutes she still
did not have a pulse on maximal epi, levophed, vasopressin, and
neo, and time of death was 1:16 pm. The family was notified and
received support from the physician, [**Name10 (NameIs) **], and social work
staff.
Medications on Admission:
Meds:
1. Aspirin 81 mg Daily
2. Quetiapine 37.5 mg QAM and Qnoon, 50mg QPM
3. Warfarin 2.5 mg QHS
4. Citalopram 10mg Daily
5. Lisinopril 5 mg Tablet QD
6. Metoprolol Tartrate 200 mg QD
7. Lorazepam 2 mg Q6hrs PRN
8. Furosemide 40 mg QD (40mg + 80mg qday?, unsure)
9. Pantoprazole 40mg daily
10. Percocet PRN
11. Advair/albuterol
12. Bupropion
13. thiamine
.
All: Pcn, morphine, unknown reactions
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
998
| 171,544
|
12863
|
Discharge summary
|
report
|
Admission Date: [**2153-9-5**] Discharge Date: [**2153-9-18**]
Date of Birth: [**2099-6-21**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Endstage renal disease, here for living
unrelated kidney transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with endstage renal disease secondary to type 1 diabetes
who presents for kidney transplant from wife. [**Name (NI) **] was started
on dialysis in [**2152-7-4**] after having 47 years of diabetes
which was complicated by both retinopathy, requiring
bilateral laser surgery as well as right vitrectomy. History
of neuropathy in both hands and legs. He has had a CVA with
some left sided weakness. History of coronary artery disease.
He has had an myocardial infarction on several occasions in
the past and 6 stents were placed in [**2152-7-4**]. He also had
significant peripheral vascular disease with bilateral lower
extremity bypass and toe amputations bilaterally.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Cholecystectomy.
ALLERGIES: Ativan and non-steroidal anti-inflammatory drugs.
MEDICATIONS: The patient was taking:
1. Isordil - 60 mg once daily.
2. Aspirin, that was stopped on the day of admission.
3. Plavix, discontinued on [**9-1**].
4. Toprol 100 mg once daily.
5. Nephrocaps one once daily.
6. Lipitor.
7. Aciphex.
8. Temazepam.
9. Insulin - 12 units NPH q.a.m. and 6 units q p.m. Regular
Insulin 8 units q.a.m. and 4 units q p.m.
PHYSICAL EXAMINATION: GENERAL: In no acute distress. Alert
and oriented. No thyromegaly. Dentures upper and lower. NECK
- free range of motion. HEART: Regular rate and rhythm. No
murmurs or bruits. LUNGS: Clear to auscultation. ABDOMEN:
Nontender. Nondistended. EXTREMITIES: No clubbing, cyanosis
or edema. Mildly atrophic. Height 68 inches. Weight 160
pounds. Blood pressure 137/51, heart rate 66, oxygen
saturations 99% in room air.
LABORATORY DATA ON ADMISSION: White blood cell count 5.2,
hematocrit 36.2, platelet count 177, sodium 144, potassium
4.3, chloride 99, PO2 32, BUN 36, creatinine 2.8, glucose 89,
EKG was within normal limits. Chest x-ray showed no bone
destruction, bilateral effusions, right greater than the
left, and enlarged cardiac silhouette. The patient was taken
to the OR on [**2153-9-5**], for living unrelated renal
transplant. Surgeons were Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 9768**], and Dr.
[**Last Name (STitle) 39567**].
The patient received general anesthesia. Estimated blood loss
was 400 cc. The patient did well intraoperatively. Please
seen operative note. The patient intraoperatively required
take down of the renal artery anastomosis secondary to poor
arterial inflow. He required iliac arteriotomy and
embolectomy. Post procedure he was managed in the post
anesthesia care unit doing well. Urine output was marginal
over several hours. Vital signs were stable. Duplex of the
kidney revealed good arterial wave forms with resistive
indices of 0.57 to 0.61. There was no perinephric fluid
collection.
The patient was given intraoperative immunosuppression with
500 of Solu-Medrol, 1 gram of CellCept, ATG 100 mg Ancef,
Valcyte and heparin assay preoperatively. Postoperative urine
output was 10 to 20 cc an hour with half normal saline cc per
cc replacement with a background IV of D5.5 of normal saline
at 50 cc an hour. The patient was treated with morphine PCA
for pain and was managed on insulin subcutaneous injections
for glucose control.
Postoperative hematocrit was 32.3, white blood cell count
4.6, K of 4.3, and creatinine of 3.3. The patient was
transferred when stable to the medical surgical unit. Urine
output remained on the low side. Nephrology was consulted and
followed closely throughout the hospital course. IV fluid was
decreased. Breath sounds were decreased half way up on
bilaterally. Oxygen saturations were 98% on 2 liters, blood
pressure 100/58. Low dose Lopressor was started on
postoperative day 1.
Chest x-ray was repeated after placement of an NG tube for
abdominal distention, nausea. Repeat duplex revealed poorly
visualized venous outflow. The patient returned to the
operating room for reexploration of the kidney under general
anesthesia by Dr. [**First Name (STitle) **] [**Name (STitle) **] with assistant Dr. [**Known firstname **]
[**Last Name (NamePattern1) 9768**], resident on [**2153-9-6**]. Please see operative note.
Minimal estimated blood loss. Urine output q 1 hour 10 to 40
cc an hour. The patient was given IV dopamine and maintained
on an IV of normal saline at 10 cc an hour.
Repeat chest x-ray to assess endotracheal tube was done. ET
tube was pulled back 5 cm. The patient was treated with
morphine for pain, restarted on heparin 5000 units t.i.d. The
kidney was noted to be pink with good arterial and venous
flow. The patient was started on clear liquids on
postoperative day 1. He did complain of some nausea. [**Last Name (un) **]
was consulted for management of hyperglycemia. Blood sugars
ran in the 300s. IV insulin drip was started and then later
discontinued with adjustment of subcutaneous insulin.
The patient underwent a TEE on [**2153-9-6**] with notation
of severely depressed right ventricular systolic function
with moderate dilatation. Systolic function was noted to be
severely depressed globally. The apex was noted to be
akinetic with moderate to severe ..... Comments were noted
that mitral valve flow was normal. The patient was
transferred to the surgical intensive care unit postoperative
reexploration of the kidney transplant.
Postoperative hematocrit was 27.7 with a white blood cell
count of 6.6, creatinine was noted to be 3.7 and BUN of 58,
potassium 4.1. The patient ws intubated and sedated. He was
on propofol for sedation and dopamine to increase cardiac
output with goal to keep greater than cardiac index of 2 with
blood pressure greater than 120. The patient was started on a
Lasix strip. The patient was extubated on postoperative day
2, 1.
The patient was transferred from the post anesthesia care
unit to the medical surgical unit on [**2153-9-7**], with
renal attending reviewed this case. The patient produced 1270
cc of urine over the prior 17 hours on Lasix drip. Prograf
was deferred. The patient continued on ATG. He received a
total of 4, 100 mg once daily doses on postoperative day 4
and postoperative day 5. He received half dose for white
blood cell count of 2.3 and 2.1 respectively. NG tube
continued to drain minimal greenish drainage. The abdomen was
soft and nontender, nondistended with no bowel sounds heard.
Lasix was weaned off on postoperative day 4. Urine output for
the previous 24 hours had been 1102 with a creatinine of 3.5.
Vital signs remained stable. Repeat chest x-ray revealed
worsening CHF with notation of right large pleural effusion
with moderate left effusion with left lower lobe
consolidation.
Prograf was started on postoperative day 4 at 2 mg b.i.d,
Solu-Medrol was tapered down to 25 mg PO twice a day and then
stopped on postoperative day 7. He continued in CellCept 1
gram b.i.d until postoperative day 8 when this was decreased
to 500 mg QID. Prograf level returned on postoperative day 7
with a left of 20. Prograf was adjusted to 3 mg b.i.d. IV
Lasix was continued orally at 80 mg b.i.d Foley was removed.
The patient was unable to urinate. Foley was replaced. The
patient was given a second attempt at Foley beig removed and
again unable to void. Foley was replaced and the patient was
started on Flomax 0.4 mg PO qhs.
Of note the patient underwent biopsy of the transplant kidney
on [**9-6**], postoperative 1, during reexploration of the
transplanted kidney. Biopsy results demonstrated no
rejection. One unit of packed red blood cells was
administered on [**9-11**] for a hematocrit of 27.6. Post
transfusion hematocrit was 32.7. Urine output was 1 liter.
Improved graft function was noted with a creatinine of 3.5
and BUN of 88. The patient was advanced to renal diet.
Physical therapy was consulted. It was felt that the patient
would require 2 to 3 treatments to improve endurance, balance
and gait and see if safe for stair climbing. Right lower
quadrant incision remained intact with clips with scant
serosanguineous drainage. [**Location (un) 1661**]-[**Location (un) 1662**] output initially was
300 cc. This diminished postoperatively. [**Location (un) 1661**]-[**Location (un) 1662**] was
discontinued on postoperative day 7 and 6. Epogen was started
at 10,000 units 3 times a week. The patient was not iron
deficient. Protonix was started b.i.d for persistent nausea.
PhosLo was stopped. The patient was started on Colace for
complaints of inability to move bowels. The patient was
passing flatus. CellCept was decreased to 500 QID for
complaints of frequent stools. Colace was held.
Creatinine was noted to increase on postoperative day [**12-13**].
Creatinine increased to 4.5 with a BUN of 111. Previous day
urine output had been 755 cc with a combined PO and IV intake
of 300 cc. The patient had complained of nausea. IV fluid was
given. Urine output increased slightly for the subsequent 24
hours at a liter. Repeat creatinine was 4.2. The patient
remained afebrile. Blood pressure 110 to 120/68 to 81. Oxygen
saturations on room air 96%. Urine output averaged
approximately 20 cc an hour despite an extra dose of Lasix.
The patient received inpatient nutritional assessment for
decreased intake. Napro was recommended. Calorie counts were
started. Hemodialysis was deferred.
Cardiology was consulted on [**9-14**]. Cardiology was asked
to see the patient for persistent congestive heart failure
that was noted on x-ray and weight remained increased at 98
kg. Recommendations were to decrease IV fluids, to continue
with IV Lasix 80 mg and to restart aspirin and Plavix if
surgically acceptable. In addition it was recommended to
restart low-dose Toprol 25 mg PO once daily for low EF.
Dialysis was considered. A decision was made to hold off on
dialysis and to monitor urine output and creatinine. Repeat
duplex revealed no hydro, no perinephric fluid collection.
Arterial wave forms were normal. The renal vein appeared to
have a biphasic flow pattern consistent with right heart
failure.
Given the stabilization of creatinine to 4.1, BUN of 106, and
urine output of 700 cc, it was decided to discharge the
patient to home on Prograf 2.5 mg twice a day for Prograf
level of 8.9. CellCept [**Pager number **] mg QID, to monitor the patient for
the next few days. The patient was to be seen 2 days post
discharge in the transplant office after a.m. labs were to be
drawn. He was cleared by physical therapy. He was tolerating
PO intake with a fair intake. Vital signs were stable.
Visiting nurse was set up for home PT. Given the patient
appeared somewhat depressed, it was felt that he would
benefit by being at home with a hope that nutritional intake
would improve in home environment.
VNA was consulted to continue wound care. It was noted that
the patient had a 2.5 x 1.5 cm right gluteal stage 2 pressure
ulcer as well as a 2 x 1.5 cm inferior pressure ulcer on the
right gluteal area. Recommendations by wound skin care nurse
were to cleanse with normal saline, apply DuoDerm gel to the
open areas, with no-sting barrier wipe to peri-wound skin and
then leave in foam adhesive 4 x 4 dressing to be changed
every 3 days. These recommendations were conveyed to the VNA
for outpatient management. The patient was discharged with a
rolling walker to home to have physical therapy at home per
recommendations.
DISCHARGE MEDICATIONS:
1. Nystatin 5 ml po QID.
2. Bactrim single strength 1 tab once daily.
3. PhosLo 2 tabs PO t.i.d.
4. Valcyte 450 mg PO every other day.
5. Percocet 1 to 2 tabs PO q 4 to 6 hours.
6. Flomax 0.4 mg PO qhs.
7. Protonix 40 mg once daily
8. Colace 100 mg PO b.i.d.
9. CellCept [**Pager number **] one tab PO QID.
10. Lasix 40 mg PO once daily.
11. Toprol 25 sustained release tab once daily
12. Prograf 3 mg PO b.i.d.
13. Atorvastatin 10 mg PO once daily.
14. Insulin regular sliding scale QID. NPH insulin 8
units q a.m, NPH insulin subcutaneous q p.m.
15. Nephro one cap PO t.i.d.
Follow up appointment was made with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], on
[**2153-9-20**].
DISCHARGE DIAGNOSIS:
1. Endstage renal disease status post living unrelated kidney
transplant [**2153-9-5**].
2. Reexploration of transplanted kidney with biopsy on [**9-6**], [**2153**].
3 Coronary artery disease.
1. Congestive heart failure.
2. Hyperlipidemia.
3. Type 1 diabetes.
4. Peripheral vascular disease.
5. Gastroesophageal reflux disease.
6. Peptic ulcer disease.
7. Gluteal fold decubitus.
8. Failure to thrive.
9. Delayed graft kidney function.
The patient was ambulatory and stable upon discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Doctor Last Name 31787**]
MEDQUIST36
D: [**2153-9-20**] 21:29:31
T: [**2153-9-21**] 00:33:46
Job#: [**Job Number 39568**]
|
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icd9cm
|
[
[
[]
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[
"55.24",
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"38.93",
"55.69",
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icd9pcs
|
[
[
[]
]
] |
11584, 12356
|
12377, 13135
|
1054, 1500
|
1523, 1953
|
171, 241
|
270, 973
|
1968, 11561
|
996, 1030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,981
| 174,009
|
3036
|
Discharge summary
|
report
|
Admission Date: [**2193-10-26**] Discharge Date: [**2193-11-8**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
joint aspiration
joint washings by orthopaedics.
MRI head
CT head
TTE
History of Present Illness:
[**Age over 90 **] y.o female with chronic kidney disease, [**Age over 90 499**] CA s/p
hemicoloectomy, HTN, DVT and recently hospitalized here from
[**Date range (1) 14455**] with falls, mental
status changes and found to have Klebsiella pneumoniae UTI and
was treated with Cipro. She now returns to ER with family with
complaint of a few weeks of generalized weakness and confusion.
Per the family she has been complaining of right shoulder pain
and right foot pain over the last few weeks. She also had
difficulty getting off of the commode a few days ago. Prior to
this episode she has been living independently at home.
On admission to the ER she was found to be hypothermic with
temps
of 90.1 in ER. Her U/A on admission with + nitrite and she was
given Cipro and Flagyl for possible UTI. A CXR and head CT done
in the ED were without any acute abnormalities.
Overnight she was found to be minimally responsive. She has
remained hemodynamically stable but with blood pressure below
her baseline. Temperatures have increased to 97 after warm
saline and bear hugger blanket. Now urine cx with S. aureus,
blood cultures with GPC in pairs and clusters. Patient also
noted to have loud systolic heart murmur that is felt to be new.
After blood cultures and urine cultures reported she was given 1
dose of Vancomycin 1 gram IV x 1.
Past Medical History:
CRI
1)[**Date range (1) **] cancer - s/p R hemicolectomy; 5FU, leucovorin
2)Venous insufficiency
3)HTN
4)Glaucoma
5)Hyperlipidemia
6)Osteoarthritis
7)DVT
8)Anemia
9)Hyperparathyroidism
10)GERD
11)IBS
12)Serous Cystadenofibroma; s/p E-lap, BSO
13)Lung nodule? (no change in CT scan [**2184**] -> [**2187**])
Social History:
Lives alone. Nephew is HCP/POA and helps pt with
shopping/chores. Never married and no children. Denies tobacco
and alcohol.
Family History:
Mother w/ ovarian cancer and brother w/ [**Name2 (NI) 499**] cancer. No CAD to
her knowledge.
Physical Exam:
VS: Temp: 96.8 BP: 108/52 HR: 83 RR: 16 O2sat: 95 RA
.
Gen: In NAD, A+O x2
HEENT: EOMI. MM slightly dry
Neck: Supple, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, SEM, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 2, knows its [**2192**], is unsure
who is president
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
Pertinent Results:
EKG: SR at 70 RBBB, not significantly changed from ECG [**2193-10-7**]
.
Imaging:
Head CT: wet read
No acute IC process
.
CXR:
IMPRESSION: No acute intrathoracic pathology.
Brief Hospital Course:
Patient is a [**Age over 90 **] year old female with medical history pertinent
for CKD, [**Age over 90 499**] cancer, DVT who presents with delirium secondary
to MRSA sepsis. Source was not initially clear but repeat blood
cultures were negative. She was continued on Vancomycin with
dose increased to 1500 mg Q24. She had MRI shoulder most
consistent with a neuropathic joint but effusion was noted. The
Joint was aspirated with results are as follows: WBC 12.5K, 100%
Polys, but gram stain and cultures showing staph aureus. She
underwent surgical washout of the joint which did not reveal any
pus. She had TTE which was negative for endocarditis. We did not
do [**Age over 90 **] because of the family's hesitancy with pursuing [**Age over 90 **]. Now
She will at least be treated with 6 weeks of antibiotics given
joint involvement, it may not be unreasonable to not pursue [**Age over 90 **].
We discussed with nephew, [**Name (NI) 122**] [**Name (NI) 14456**], also the HCP, that [**Name2 (NI) **]
is the more sensitive study but more invasive. Family does not
want to pursue [**Name2 (NI) **]. Her altered Mental Status was attributed to
MRSA sepsis (delirium) but this resolved completely. Head CT X2
on admission was negative for acute event. MRI brain limited
study but negative for acute changes as well. She also developed
thrombocytopenia related to sepsis and resolved completely. She
also developed progressive anemia requiring 2 units of RBC's.
She will go to rehab to receive long term antibiotics. Her last
Vancomycin dose will be by the end of [**Month (only) 1096**]. The ID fellow
Dr. [**Last Name (STitle) 976**] will follow up with weekly labs and appointment on
[**Month (only) **]/30th.
.
#. Chronic Kidney Disease, Stage III.
- stable, monitor
.
#. HTN: controlled w metoprolol. she was restarted on lower dose
of Lasix because of poor PO intake ( full dose of 40 MG can be
restarted if she drinks well)
.
#. Diet: thickened liquids, pureed solids only when awake with
assistance. Speech pathology was following her.
.
#. DNR/DNI - discussed with HCP, [**Name (NI) **] (nephew)
.
#. Contact: [**Name (NI) **], HCP (nephew)--[**Telephone/Fax (1) 14457**] or [**Telephone/Fax (1) 14458**];
[**Name (NI) **] wife, [**Name (NI) 2808**], [**Telephone/Fax (1) 14459**]
.
.
.
Total discharge time 68 minutes.
Medications on Admission:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Alendronate-Vitamin D3 70-5,600 mg-unit Tablet Sig: One (1)
Tablet PO once a week.
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. ELESTAT 0.05 % Drops Sig: One (1) drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
6. Vancomycin 1250 mg IV Q 24H for 6 weeks starting from
[**2193-10-27**].
7. Alendronate-Vitamin D3 70-5,600 mg-unit Tablet Sig: One (1)
Tablet PO once a week.
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
weekly CBC and Creatinine/BUN levels. Please fax the results to
Dr.[**Name (NI) 14460**] Office at [**Telephone/Fax (1) 14461**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) **]
Discharge Diagnosis:
MRSA sepsis/endovascular infection
possible septic arthritis
Acute confusional state related to sepsis
Discharge Condition:
Excellent
Discharge Instructions:
you will receive vancomycin for about 6 weeks for possible
endovascular infection/[**Doctor Last Name 14462**] arthritis. your first dose was on
[**2193-10-27**]. Last dose should be 0n [**2193-12-7**]. you should have
weekly blood tests and the results faxed to Dr [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) **]
office with infectious disease. His Fax is [**Telephone/Fax (1) 14461**].
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 1144**]
Dr [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) **] office on [**2193-12-10**] with infectious disease.
|
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icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93",
"99.04",
"80.21",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7129, 7202
|
2986, 5317
|
233, 304
|
7349, 7361
|
2788, 2871
|
7819, 8025
|
2156, 2251
|
6020, 7106
|
7223, 7328
|
5343, 5997
|
7385, 7796
|
2266, 2769
|
184, 195
|
332, 1667
|
2880, 2963
|
1689, 1997
|
2013, 2140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,927
| 179,544
|
36741
|
Discharge summary
|
report
|
Admission Date: [**2155-3-26**] Discharge Date: [**2155-6-10**]
Date of Birth: [**2098-11-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Autologous BMT
Major Surgical or Invasive Procedure:
continuous renal replacement therapy
hemodialysis
intubation and mechanical ventilation
tracheostomy
paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old male who was diagnosed with
follicular lymphoma transitioning to a marginal zone lymphoma in
01/[**2154**]. He had a long preceding history of night sweats and dry
cough, followed by the development of right leg swelling and a
right inguinal mass.
In [**2154-1-31**] he developed swelling in his right lower
extremity and a mass in his inguinal area. CT scan of his
abdomen and pelvis on [**2154-2-18**] revealed generalized
lymphadenopathy beginning at the crural lymph nodes and
extending inferiorly into the periaortic, mesenteric, celiac,
pararenal, common iliac, and external iliac chains. In the right
groin, there was a large lymph node mass approximately 6 x 5 x
6.6 cm. There was also a rounded low-density area just medial to
the femoral artery which was felt to represent thrombosed
femoral and external iliac veins. Overall, the findings were
concerning for lymphoma. He was referred for a CT of his chest
on [**2154-2-19**] which showed prominent adenopathy, principally in
the left supraclavicular and left axillary regions, with the
largest mass measuring 2.6 cm in his left axilla. Based on that,
he was referred for excisional biopsy of the right inguinal
adenopathy on [**2154-2-26**] which revealed follicular lymphoma with
partial marginal zone differentiation, grade I-II by large cell
quantitation. These cells were CD19 and CD20 positive and also
co-expressed CD5 and CD10. They were also kappa light chain
restricted. There was no expression of CD-23 or cyclin D1. Ki67
was 20-30%. His lymphoma was felt to represent a transitional
state between follicular lymphoma and marginal zone B-cell
lymphoma. He was then started on R-CVP. He tolerated therapy
fairly well, but suffered from fatigue, hyperglycemia, flushing,
and hypertension. His prednisone dose during treatment was
eventually lowered from 200 mg daily to 100 mg daily. He
received 2 days of neupogen after each cycle of chemotherapy.
After three cycles of R-CVP, the vincristine was discontinued
due to neuropathy. He underwent a PET scan on [**2154-5-1**] after the
third cycle and this continued to show extensive FDG avid
disease. However, his night sweats and leg swelling had
improved. He continued on R-CVP for two additional cycles, but
after the fifth cycle, he noticed the recurrence of right
inguinal lymphadenopathy. He had also developed recurrent night
sweats and cough. The lymphadenopathy grew quite quickly and
became the size of a quarter over the span of 24 hours. He
underwent a second PET scan on [**2154-6-12**] which showed little
significant change, with hyperactive adenopathy at the left
axilla and extensively below the diaphragm in the mesentery,
para-aortic and pelvic regions. He underwent a second excisional
biopsy on [**2154-7-2**] which again showed follicular lymphoma, grade
I-II. The decision was made to hold on further R-CVP as his
lymphoma was no longer responding to the current therapy.
CYTOGENETICS
CD19 and CD20 positive, also co-expressed CD5 and CD10, and
kappa light chain restricted; no expression of CD-23 or cyclin
D1; Ki67 was 20-30%.
CHEMOTHERAPY HISTORY
[**Date range (1) 83066**]: He received cyclophosphamide, vincristine,
prednisolone plus rituximab (R-CVP) x 3 cycles; the vincristine
was discontinued due to neuropathy. Night sweats and leg
swelling improved.
[**2154-5-1**]: PET Scan showing extensive FDG avid disease
[**Date range (1) 83067**]: continued on R-CVP for two additional cycles, but
after the fifth cycle, he noticed the recurrence of right
inguinal lymphadenopathy. He had also developed recurrent night
sweats and cough.
[**2154-6-12**]: repeat PET - little interval change
[**2154-7-2**]: repeat lesion biopsy - similar findings
[**2154-8-5**]: transferred care to [**Hospital1 **], presented with bilateral
inguinal lymphadenopathy; received 4 cyclyes R-Bendamustine by
local oncologist at time of transfer; planned for two more
cycles of R-bendamustine
[**2155-1-22**]: Mobilization HiDAC, final cumulative CD-34 yield of
5.19 x 10e CD-34 cells/kg over three days, discharged on Cipro,
Neupogen and Compazine. WBC at discharge 20.9. Two weeks later
WBC 0.7 and one week later 0.5 w/ANC 0, asymptomatic. Started on
Moxifloxacin and neupogen. Stem cell harvesting [**Date range (1) 83068**].
[**2155-2-25**]: W1 Rituxan/Zevalin: WBC 7.3, Hct 34.9, Plt 244.
[**2155-3-4**]: W1 Rituxan/Zevalin: WBC 5.4, ANC 4560, Hct 32.5, Plt
292.
Today he presents for admission for his BEAM autologous BMT. No
current complaints. Denies headache, nausea, vomiting, diarrhea,
abdominal pain, weakness, fevers, chills, recent night sweats,
blurry vision, shortness of breath. Reports only mild ongoing
cough significantly improved from prior and occasional fatigue
when his counts get low.
Past Medical History:
Diagnosed with follicular lymphoma transitioning to a marginal
zone lymphoma in [**1-/2154**] (These cells were CD19 and CD20
positive and also co-expressed CD5 and CD10. They were also
kappa light chain restricted. There was no expression of CD-23
or cyclin D1. Ki67 was 20-30%.)
Right thigh lymphedema (significantly improved, per patient)
RLE DVT from compression (was on coumadin until [**2154-11-25**])
Mild diverticulitis
s/p vasectomy, tonsillectomy
Social History:
Works in a management position at a metal fabrication plant
overseeing production and quality control. He is married and has
four children, ages [**8-17**]. He and his family live in Hooksett,
[**Location (un) 3844**]. He denies any current tobacco use. He previously
smoked but quit 15 years ago after a 20-pack-year history. He
generally drinks several martinis a day but has decreased his
drinking while on treatment.
Family History:
father - died at 80, lung cancer, Charcot-[**Doctor Last Name **]-Tooth disease,
pulmonary embolism
mother - alive at 80, diabetes and asthma
three brothers - all in good health
no family history of leukemia or lymphoma
has 2 children from previous marriage and 2 children from his
current marriage
Physical Exam:
ON ADMISSION:
VS: 96.6 132/96 109 18 98/ra 195lbs 71"
GENERAL: NAD
HEENT: Sclerae are anicteric. PERRLA. EOMI. O/P clear.
Neck: Supple.
Lymph: No cervical, supraclavicular, or axillary
lymphadenopathy; some left supraclavicular fullness; possible
right inguinal lymphadenopathy although possibly just scar
tissue from biopsy
CARDIAC: RRR Normal S1/S2 No R/G/M
LUNGS: CTAB
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds; no HSM
EXTREMITIES: no edema
.
ON DISCHARGE: [**2155-6-10**]
Tmax: 36.5 ??????C (97.7 ??????F)
Tcurrent: 36.3 ??????C (97.3 ??????F)
HR: 117 (109 - 117) bpm
BP: 79/57(62) {64/40(48) - 93/59(68)} mmHg
RR: 30 (21 - 30) insp/min
SpO2: 95%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 80.3 kg (admission): 98.2 kg
Height: 72 Inch
24 HR: SMN:
Total In: 1,807 mL 722 mL
PO:
TF: 1,017 mL 602 mL
IVF:
Blood products:
Total out: 0 mL 0 mL
Urine: 0 mL 0 mL
NG:
Stool:
Drains:
Balance: 1,807 mL 722 mL
Respiratory support:
O2 Delivery Device: Trach mask 50%
SpO2: 95%
Physical Examination:
General Appearance: Well nourished, No acute distress, Thin,
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Tracheostomy in place,
NG tube in place
Lymphatic: No Cervical or Supraclavicular adenopathy
Cardiovascular: PMI Normal, S1: Normal, S2: Normal, No murmurs,
rubs, gallops.
Chest: Expansion: Symmetric Excursion, No Dullness, CTAB.
Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +
fluid wave. Non-tender.
Extremities: No edema, Cyanosis, Clubbing, 2+ Peripheral pulses.
Musculoskeletal: Muscle wasting, Unable to stand,
Skin: Warm, No Rash, No Jaundice
Neurologic: Attentive, Follows commands, Responds to verbal
stimuli, Oriented x3, Moving all extremeties equally, Strength
[**4-2**] in UE & LE bilat, Dizzy if not in supine position, Moving
all extremeties equally, sensation intact.
Pertinent Results:
LABS ON ADMISSION:
[**2155-3-26**] 10:15AM BLOOD WBC-3.9* RBC-4.62 Hgb-13.8* Hct-41.5#
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.7* Plt Ct-144*#
[**2155-3-26**] 10:15AM BLOOD Neuts-88.5* Lymphs-4.0* Monos-6.4 Eos-0.7
Baso-0.3
[**2155-3-26**] 10:15AM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9
[**2155-3-28**] 12:00AM BLOOD Gran Ct-4380
[**2155-3-26**] 10:15AM BLOOD UreaN-14 Creat-0.8 Na-141 K-4.6 Cl-102
HCO3-32 AnGap-12
[**2155-3-26**] 10:15AM BLOOD ALT-35 AST-33 LD(LDH)-157 AlkPhos-102
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2155-3-26**] 10:15AM BLOOD TotProt-7.0 Albumin-4.5 Globuln-2.5
Calcium-10.0 Phos-3.8 Mg-2.0 UricAcd-8.3*
LAB TRENDS DURING ADMISSION:
WBC: MAX 47.8 on [**2155-5-13**] --> 35.3 on [**2155-5-20**] --> 25.9 on
[**2155-5-28**] -->18.9 on [**2155-6-3**] --> 15.5 on [**2155-6-10**]
HCT: stable at 28-33 for past 2 weeks
PLT: stable at 40-70 for past 2 weeks.
COAGS: have been within normal limits.
CHEM7: Patient on HD Tues, Thurs, Sat
LFTS:
AST: 1341 & ALT: 2472* MAX on [**2155-4-12**] trended down to AST: 59*
ALT: 40 by [**2155-4-23**] and AST & ALT have been normal since [**2155-5-28**].
LDH: 1466 MAX on [**2155-4-12**] trended down to normal by [**2155-5-17**]
ALK PHOS: 170 on [**2155-4-12**] trended up to MAX on 248 on [**2155-4-15**] and
then down to 172 on [**2155-6-10**].
TBILI: 10.0 MAX on [**2155-4-12**] trended down to 2.9 on [**2155-6-10**]
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD
LDLcalc
[**2155-5-8**] 08:46AM 173 196* 11 15.7 123
CORTISOL Stimulation Test:
[**2155-5-25**] 03:30PM 29.4*1
[**2155-5-25**] 02:37PM 17.91
HEPATITIS HBsAg HBsAb HBcAb HAV Ab
IgM HAV
[**2155-4-10**] 03:46AM NEGATIVE POSITIVE NEGATIVE POSITIVE
NEGATIVE
HEPARIN DEPENDENT ANTIBODIES: Negative [**2155-5-27**]
12:00PM
ASPERGILLUS ANTIGEN: 0.1 <0.5 considered to be negative
[**2155-5-20**]
B-GLUCAN: 65 pg/mL Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to
80 pg/mL
LABS ON DISCHARGE:
[**2155-6-10**] 04:21AM BLOOD WBC-15.5* RBC-2.61* Hgb-10.0* Hct-31.1*
MCV-119* MCH-38.1* MCHC-32.0 RDW-19.6* Plt Ct-40*
[**2155-6-10**] 04:21AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.1
[**2155-6-10**] 04:21AM BLOOD Plt Ct-40*
[**2155-6-10**] 04:21AM BLOOD Glucose-140* UreaN-54* Creat-5.0* Na-139
K-5.5* Cl-103 HCO3-23 AnGap-19 ****PRIOR TO HD TODAY*****
[**2155-6-10**] 04:21AM BLOOD ALT-27 AST-34 AlkPhos-172* TotBili-2.9*
IMAGING:
RUQ ULTRASOUND [**2155-4-8**].
IMPRESSION:
1. Apparent reversed flow in the main portal vein with normal
flow direction in the left and right portal veins. These
findings are discrepant and do not appear to be artifactual in
nature. Given that the etiology of these findings is unclear,
whether there is true portal vein reversal or possibly more
proximal thrombus, we would recommend focused MRI of the abdomen
including 2D time-of-flight sequences (with saturation bands to
determine directionality of
flow) through the portal vein to clarify this issue.
2. Cholelithiasis but no other evidence of acute cholecystitis.
3. Small amount of ascites.
MRI Abdomen. [**2155-4-9**].
IMPRESSION:
1. Reversal of flow within the main portal vein, both on
breath-hold imaging and free breathing.
2. Reversal of flow within the right anterior portal vein on
breath-hold imaging.
3. Suggestion of reversed flow within the right posterior portal
vein during breath-hold, but antegrade flow during free
breathing. This may reverse depending on phasicity of
respiration.
4. Directionality of flow within the left portal vein is not
clearly
demonstrated on this examination.
5. Interval increase in ascites since yesterday's examination.
6. No evidence of focal hepatic lesion or hepatic or portal vein
thrombus.
7. Suggestion of siderosis within the spleen. Possibility of
iron deposition within the liver cannot be excluded without
dual-echo gradient-echo images (omitted in this abbreviated
examination due to patient intolerance of examination).
8. Cholelithiasis. No biliary abnormalities noted.
MR HEAD W/O CONTRAST Study Date of [**2155-5-2**] 12:31 PM
IMPRESSION:
1. Hyperintense subarachnoid material, involving the sulci of
both cerebral
hemispheres, most likely representing subarachnoid hemorrhage,
less likely
proteinaceous material as seen in meningitis. Oxygen therapy can
also have
this appearance.
2. No evidence of masses, mass effect or infarction.
ECHO: [**2155-5-23**] at 3:47:46 PM Conclusions:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2155-4-21**],
the findings are similar.
CT TORSO: [**2155-5-23**] 1:53 PM
CHEST CT: Bilateral small pleural effusions, on the left
increased as
compared to the prior study and the right slightly increased as
compared to the prior study. Linear atelectasis in the right
lower lobe and left lower lobe accompanied by small patchy
consolidations in the left lower lobe. This is new as compared
to the previous study.
Small amount of pericardial effusion is noted (series 2, image
34). Central line catheter is noted with its tip in the right
atrium. Tracheostomy. Nasogastric tube with its tip in the
stomach.
ABDOMINAL CT: Small-to-moderate amount of ascites is
demonstrated. Limited
evaluation of the liver due to lack of i.v. contrast and
artifacts. There is no evidence of intrahepatic or extrahepatic
bile duct dilatation. The
pancreas is within normal limits. Gallbladder is nondistended.
Adrenals are unremarkable bilaterally. Spleen is of normal size
and attenuation on this non-contrast scan. Visualized small
bowel demonstrate diffuse mucosal
thickening without evidence of dilatation. The findings may
caused by ascites or GVHD.
Retroperitoneal and mesenteric lymphadenopathy, small but
numerous, measuring up to 1 cm in mesentery and 1.4 cm in the
retroperitoneum.
PELVIC CT: Moderate amount of fluid is seen in the pelvis.
Urinary bladder
is not distended. Rectal tube is seen in the rectum.
OSSEOUS STRUCTURES: Degenerative changes in the lumbar and
sacral vertebra.
IMPRESSION:
1. Bilateral small pleural effusions, slightly larger as
compared to the
prior study.
2. Linear atelectasis in the right lower lobe and left lower
lobe and left
lower lobe patchy consolidation which is new as compared to the
prior study.
3. Moderate amount of ascites.
4. Limited evaluation of the liver due to artifacts.
CXR: [**2155-6-6**]
FINDINGS: Indwelling support and monitoring devices are similar
in position, and cardiomediastinal contours are unchanged. There
is a suggestion of increasing layering effusions on this
semi-upright projection. Persistent left retrocardiac opacity is
probably due to atelectasis. Patchy opacities in right mid and
right lower lung could be due to either atelectasis or early
sites of pneumonia, and followup radiographs may be helpful in
this regard.
Brief Hospital Course:
This is a 56 year old male with PMH of follicular lymphoma
transitioning to a marginal zone lymphoma s/p R-CVP admitted for
BEAM auto-SCT (C1D1 ([**2155-3-26**]) and as per BMT protocol,
initiated carmustine day -7, followed by etoposide/cytarabine on
days -6 to -3, then melphalan on day -2 ([**2155-3-31**]). He then
underwent Autologus stem cell transplant on [**2155-4-2**].
Post-transplant course was complicated by mucositis, diarrhea,
febrile neutropenia, and transient hyperuricemia that responded
to 1 dose of allopurinol. On [**2155-4-11**], the patient was
transferred to the ICU for respiratory distress, altered mental
status, renal failure, and transaminitis secondary to
[**Last Name (un) **]-occlusive disease.
1. Respiratory distress - The patient was tachypneic to the 40s
on admission to the ICU and had an increasing oxygen
requirement, thought to represent attempted compensation for
metabolic acidosis and low lung volumes with atelectasis. The
patient failed a trial of bipap and was intubated and placed on
A/C mechanical ventilation. He had no evidence of pneumonia but
was noted to be >7L fluid positive on admission, with increasing
ascites secondary to his hepatic complications. Serial CXRs
over course of his ICU stay demonstrated reduced lung volumes
with small amounts of atelectasis but no new consolidation,
effusion, or intravascular congestion. Patient remained
intubated in the [**Hospital Unit Name 153**] for a) impaired mental status and b)
restrictive physiology [**3-4**] increased intra-abdominal pressure.
The patient remained on the ventilator for approximately three
weeks; his respiratory status remained relatively stable but his
mental status precluded extubation. He did experience an episode
of leukocytosis, detailed below, and was treated for a
pseudomonas ventilator associated pneumonia with improvement in
his leukocytosis. The patient eventually received a tracheostomy
and was subsequently weaned down to trach collar, which
coincided with an improvement in his mental status.
2. Hypotension - The etiology was initially thought to be a
combination of a) intravascular volume depletion [**3-4**] decreased
effective circulating volume and splanchnic vasodilation from
liver failure, and b) sedation. Sepsis thought to be a
contributing factor as well, but he was maintained on
broad-spectrum antimicrobial coverage, with no infectious source
identified for the majority of his hospitalization. CT imaging
was unremarkable for an infectious source. The patient was
initiated on levophed [**4-12**] and had a prolonged ongoing pressor
requirement without an obvious cause for hypotension. Although
cortisol levels were normal, suggesting against adrenal
insufficiency, the patient was trialed on a three day course of
steroids, which temporarily improved his pressures and removed
his pressor requirement. Following the conclusion of the
steroid trial, the patient again required vasopressor support to
maintain his blood pressure. A cortisol stimulation test was
performed to better assess for impaired adrenal response, did
not reveal any significant abnormal findings. Ultimately,
vasopressin was started and levophed was weaned. After his CVVH
was stopped, the patient had an episode of symptomatic
hypotension, for which vasopressin was briefly restarted. For
the rest of his ICU course, the patient was maintained off of
pressors and perfusion was monitored by assessing mental status.
He was initiated on HD, and tolerated this well without
ultrafiltration. His hypotension may be related to his liver
disease in addition to severe deconditioning. He is
persistently orthostatic which has somewhat improved with
restarting midodrine. He mentates well with a blood pressure of
60s systolic. Please continue to encourage thigh high
compression stockings to increase peripheral resistance. Please
elevate head of bed as patient tolerates and continue passive
motion in bed. Autonomics was consulted prior to discharge and
feels like hypotension is not likely related to dysautonomia
given his hypotension even while supine. Autonomics recommended
continuation of midodrine and a trial of florinef to be started
at rehabilitation. Florinef will be started at low dose (0.1 mg
daily) and can be uptitrated based on patient response to a
maximum of 0.4 mg daily. It is felt that the hypotension is
likely related to deconditioning and aggressive PT should be
pursued.
3. Leukocytosis - Elevated WBC count beginning [**4-13**] with
persistent hypotension. Filgrastim discontinued [**4-12**]; therefore,
this could not account for the persistent leukocytosis. Patient
was at high risk for nosocomial infection (critically ill,
ascites, multiple tubes/lines) with difficult-to-interpret fever
curve on CVVH. He was empirically started on broad spectrum
antibiotics with a mild improvement in his leukocytosis but with
no obvious source on cultures. Multiple paracenteses were
negative for SBP. Much later in the [**Hospital 228**] hospital course,
a re-elevation in his white blood cell count corresponded with a
new positive sputum culture for Pseudomonas. The patient was
treated with seven days of ceftazidime per infectious disease
recommendations, after which his leukocytosis improved but still
remained dramatically elevated. A large volume paracentesis was
performed with fluid sent for cytology and flow cytometry, which
was not revealing. Ultimately, only his CVVH catheter tip grew
out the same strain of pseudomonas on [**6-4**] that was in his sputum
on [**5-12**]. It is felt that this was a colonizer only as
surveillance blood cultures were negative. No other infectious
sources were identified. His antibiotics were ultimately all
discontinued and he did well. He should no longer be on
precautions as he has no active infections. His leukocytosis
continues to improve, but does remain elevated. A component of
this elevation may be due to auto splenectomy that appears to
have occurred during this hospitalization.
4. Transaminitis/Hepatic Failure - Right upper quadrant
ultrasound and abdominal MRI demonstrated reversal of flow
through portal vein, suggestive of cirrhosis. On admission to
the intensive care unit, he was noted to have new significant
ascites. Rising INR and worsening mental status were suggestive
of progression to hepatic failure. Liver biopsy confirmed a
diagnosis of [**Last Name (un) **]-occlusive disease. Infectious workup of
hepatitis was negative. Per Hepatology, patient would not be a
candidate for liver transplant. The patient was then started on
a defibrotide treatment protocol on [**2155-4-9**] with close
monitoring of coags, plts, hct, fibrinogen due to concern of
bleeding (goal INR < 1.5, plts > 30, Hct > 30, Fibrinogen >
150). LFTs peaked [**Date range (1) 14806**] with TBili 10, then trended down
gradually. After 25 days of treatment for defibrotide, a head
MRI revealed a subarachnoid hemorrhage, which necessitated
discontinuation of the treatment. The patient subsequently
continued to show gradual, mild improvement in functional
status, but continued to have large ascites on exam requiring
periodic taps. Currently he is requiring paracentesis every
10-14 days and his ascites should continue to be monitored and
tapped PRN. Through his ICU course, his LFTs gradually
improved; however, his bilirubin did remain elevated at 2.9 on
discharge. He should have liver clinic follow-up with Dr. [**Last Name (STitle) 497**]
within one month after discharge.
5. Depression: The patient appears to be extremely frustrated
and depressed about his current state. He was started on low
dose amphetamine salts at 5mg [**Hospital1 **] to increase his energy and
blood pressure. His cardiac status should be monitored closely
as well as his mood on this new medication. It can also be
titrated up slowly in an attempt to increase his energy.
6. Thrombocytopenia: His platelets have fallen dramatically
during his hospitalization. They have remained stable around
50. There was initial concern for HIT, but antibody returned
negative on [**5-28**]. Platelets should be transfused only if the
patient is actively bleeding. Caution should be used with blood
thinners due to his low platelet level.
7. Ileus - Attributed to critical illness with ascites and
opioid -based sedation. Abdominal x-ray and CT scan were
negative for obstruction. The patient was started on reglan and
an aggressive bowel regimen. Following withdrawal of sedation
as patient's respiratory status improved, his ileus improved as
well. Lactulose was continued less frequently as prophylaxis
against hepatic encephalopathy and was eventually discontinued.
The reglan was stopped. He developed loose stools/ diarrhea that
was treated as below.
8. Diarrhea - Patient has had continued loose stools ever since
his ileus resolved. His stool frequency has improved after
stopping lactulose but have continued to remain loose. C diff.
toxin has been checked multiple times and has remained negative.
It is likely that the diarrhea is related to tube feeds and
banana flakes have been added recently with subsequent
improvement in diarrhea.
9. Altered mental status - Attributed to hepatic encephalopathy
in addition to sedating meds for treatment of his abdominal
pain. Standing lactulose was started for therapy of hepatic
encephalopathy and was also given broad spectrum antibiotics for
treatment of possible infections. Patient had a protracted
hospital course with minimal improvement in mental status but
began to show dramatic improvement in mid [**Month (only) 547**], approximately
one month after initiation of defibrotide. His mental status
continued to improve throughout his ICU course and he is now
able to interact appropriately. His antibiotics and lactulose
were ultimately discontinued.
10. Renal failure - The patient was found to have new renal
failure that began on [**2155-4-10**]. Per renal, the etiology was most
consistent with ischemic ATN. His initial hypotensive insult
was likely secondary to hepatorenal syndrome. The patient was
started on CVVH on [**2155-4-12**] for worsening metabolic acidosis. He
continued to be severely oliguric throughout his admission with
no restoration in renal function. The patient's severe volume
overload was corrected gradually via CVVH while he continued to
have an ongoing pressor requirement. Midodrine was started in
an effort to improve the patient's blood pressures so that he
could be transitioned to HD. He was eventually transitioned to
HD without ultrafiltration, and has tolerated it well.
11. EKG Changes: The patient had subtle ST depressions at the
beginning of [**Month (only) 116**] in the setting of decreased mentation and
hypotension. He was ruled out for an MI and these depressions
have since resolved. It was likely related to demand in setting
of hypotension.
12. Neutropenic fevers - On admission, patient was kept on broad
spectrum antibiotics for neutropenic fevers
(vancomycin/cefepime/ganciclovir/micafungin). Infectious disease
was consulted. Patient was culture negative and no source of
infection was identified. Antibiotics were stopped [**4-12**]
following recovery of his neutrophil counts. He was treated
later in his hospital course for a pseudomonas pneumonia (see
above).
13. Hyperglycemia: Patient with blood sugars persistently
between 200-300. Regular insulin was added to the TPN, and the
patient was placed on a Regular Insulin SS. This may represent
diabetes. He will need ongoing monitoring and upon discharge
from rehabilitation center follow-up with his primary care
provider.
14. Follicular Lymphoma: Patient is status post BEAM Auto SCT on
[**2155-4-2**]. Patient engrafted. Received IV solumedrol x1 for
anti-inflammatory effect. Received filgrastim until ANC>1000
(discontinued [**2155-4-12**]). He was continued on atovaquone
prophylaxis for PCP but there was concern that it was not being
absorbed as it appeared to be present in his diarrhea. He was
given one dose of inhaled pentamidine on [**2155-6-9**] and will be
continued on atovaquone. If his diarrhea continues to improve,
he can remain on atovaquone and will likely not need another
dose of inhaled pentamidine one month from [**2155-6-9**]. He also
remains on Acyclovir prophylaxis.
15. Deep Vein Thombosis Prophylaxis: Patient not started on
heparin due to low platelets. Patient repeatedly offered
pneumoboots, but usually declined to wear the pneumoboots.
Encourage aggressive physical therapy.
Medications on Admission:
Multivitamin
No other current medications
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a
day).
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours): give every day, on dialysis days give daily dose after
dialysis.
4. 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.
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
8. Insulin Regular Human 100 unit/mL Solution Sig: per scale
Injection ASDIR (AS DIRECTED).
9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
10. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): uptitrate as tolerated.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
- Follicular Lymphoma
- Renal Failure, Acute tubular necrosis, now requiring
hemodialysis.
- Respiratory Failure
- Hepatic Failure Secondary to Venous Occlusive Disease
- Hypotension
- Multi-Drug Resistant Pseudomonal Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Blood pressure: SBPs 50-80s with good mentation. If concerned
about blood pressure, monitor for change in mental status.
Patient tolerating very low blood pressures attributed to
deconditioning.
Discharge Instructions:
You were admitted for bone marrow transplant. You had a
prolonged hospital course that was complicated by liver failure,
infection, persistent low blood pressure, kidney failure, and
respiratory failure that ultimately required trach tube
placement. Your clinical status ultimately improved. You are now
being discharged to a rehab facility for further care.
You were started on many different medications during your
hospital course. You should follow the medication list provided
at the time of discharge.
It was a pleasure taking part in your medical care.
Followup Instructions:
You will need to see the following providers within the
timeframe below. We are working to schedule appointments for
you, please call the following offices in [**2-1**] days time to get
the appointment information:
PROVIDER: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
SPECIALTY: HEMATOLOGY/ONCOLOGY
TELEPHONE: ([**Telephone/Fax (1) 3936**]
TIMEFRAME: within 2-4 weeks
PROVIDER: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
SPECIALTY: LIVER
TELEPHONE: ([**Telephone/Fax (1) 1582**]
TIMEFRAME: within 2-4 weeks.
You will need to see you primary care doctor within 2 weeks
after discharge from the rehab facilty.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,821
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43239
|
Discharge summary
|
report
|
Admission Date: [**2149-7-3**] Discharge Date: [**2149-7-17**]
Date of Birth: [**2073-7-6**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Hypoxemia, olecranon bursitis, renal failure
Major Surgical or Invasive Procedure:
PICC [**2149-7-6**]
incision and drainage of abscess left elbow
History of Present Illness:
Mr. [**Known lastname 31823**] is a 75 year old M w/ h/o CAD s/p CABGx3, DM, ESRD,
CHF, AF on coumadin, and SSS s/p PPM who is transferred to [**Hospital1 18**]
from OSH with hypoxemia and concern for septic bursitis. Patient
presented to [**Hospital **] Hospital on [**7-1**] from skilled care with
complaint of drainage from left elbow. Plain films were not
suggestive of osteomylitis and patient was started on vancomycin
empirically for olecrenon bursitis. Cultures of fluid reportedly
grew MSSA (but also documented as resistant to penicillin) and
antibiotics were transitioned to zosyn. Prior to this he had
been having swelling of his LUE after his AV fistula placement,
after his angioplasty a compression bandage was placed to help
with the swelling and not removed for an unknown period of time,
when removed skin was removed as well. Shortly after this he
developed what sounds like a superficial cellulitis that
continued to progress.
.
Patient was transferred from OSH floor to ICU after developed
hypoxemia w/ worsening bilateral infiltrates on CXR. Blood gas
showed PaO2 of 45 on FIO250% on venti mask. Was diuresed with 80
mg lasix w/ UOP of 1850 and received another 80 mg of lasix this
AM w/ improvement of oxygenation with sats in high 90s on 6L.
Bilateral infiltrates were attributed to pulmonary edema
secondary to cardiac etiology (h/o CHF, reportedly preserved EF
on echo in past 6 months) vs. sepsis [**12-25**] bursitis. Patient has
been afebrile over past 24 hours, but with rising WBC count,
most recently 19.4. Blood pressures in the 90s-110s systolic,
with home anti-hypertensives held.
.
Plan was to I&D olecrenon bursitis pending INR reversal,
received vitamin K 10 mg x2 with improvement of INR from 3.27 to
1.74. However, patient also with acute on chronic kidney failure
(on HD , refusing to see [**Location (un) **] nephrologists, so was transferred
to [**Hospital1 18**] for further management. On transfer, afebrile, BPs
90s-110s, HR 110s-120s (atrial fibrillation), RR20s, O2 sat 99%
on 6L NC.
.
In the ICU initial VS were: 97.8, 128, 91/57, 24, 99% on NRB.
He was complaining of shortness of breath that is slowly
improving, denies any CP, n/v/d, abdominal pain, fever/chills.
Also complaining of some left arm pain with movement.
Past Medical History:
-Coronary Artery disease s/p CABG x3 ([**2148-4-30**])
-Peripheral vascular disease (Significant claudication)
-Diabetes mellitus on lantus and ISS at home
-Carotid disease with occluded left carotid artery
-Renal artery stenosis s/p prior left renal artery stent in
[**Location (un) 24402**] in [**2146-5-24**]
-PMR on 15 prednisone at home
-End-stage renal disease previously on HD (stopped in [**11-1**],
followed by nephrology at [**Hospital 1727**] Medical Center)- baseline
creatinine ? >2
-Complex aortic atheroma
-Hyperlipidemia
-Atrial fibrillation with sick sinus syndrome status post
permanent pacemaker in [**2137**] complicated by subsequent amiodarone
toxicity
-H/o cholesterol embolization syndrome
-Hypothyroidism
-Congestive heart failure (EF 45-50% in [**5-2**])
-Home oxygen (to sleep and as needed during day)
.
Past Surgical History:
- PPM placement [**12-31**] for sick sinus syndrome
- Abdominal port placement
- AV fistula placement with history of multiple peritoneal
dialysis procedures
- Renal artery stent [**2145**]
- Cholecystectomy [**10-30**]
- Cataract surgery
- Partial right toe amputation
- Failed angioplasty in [**2126**]
.
Social History:
Lives with: his family
Occupation: Retired
- Tobacco: Denies tobacco use, though significant second-hand
smoke
from his wife's chronic smoking history
- ETOH: occasional alcohol
- Illicits: denies
Family History:
Family History: Significant for both brother and sister having
coronary artery disease. Sister with CABG in her 40's
Physical Exam:
Physical Exam on Admision:
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
Pertinent Results:
Labs on Admission:
[**2149-7-3**] 04:40PM WBC-16.3*# RBC-3.26* HGB-8.7* HCT-27.6*
MCV-85 MCH-26.7* MCHC-31.6 RDW-17.4*
[**2149-7-3**] 04:40PM NEUTS-93* BANDS-2 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2149-7-3**] 04:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
[**2149-7-3**] 04:40PM SED RATE-115*
[**2149-7-3**] 04:40PM CRP-297.7*
[**2149-7-3**] 04:40PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-2.2
[**2149-7-3**] 04:40PM ALT(SGPT)-40 AST(SGOT)-43* CK(CPK)-42* ALK
PHOS-112 TOT BILI-0.8
[**2149-7-3**] 04:40PM GLUCOSE-191* UREA N-54* CREAT-2.8* SODIUM-144
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-20
[**2149-7-3**] 11:13PM URINE HOURS-RANDOM UREA N-576 CREAT-68
SODIUM-12 POTASSIUM-62
[**2149-7-3**] 11:13PM URINE OSMOLAL-415
[**2149-7-3**] 11:13PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2149-7-3**] 11:13PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-7-3**] 11:13PM URINE RBC-63* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2149-7-3**] 11:13PM URINE GRANULAR-2* HYALINE-9*
[**2149-7-3**] 11:13PM URINE AMORPH-RARE
[**2149-7-3**] 11:13PM URINE MUCOUS-RARE
[**2149-7-3**] 11:13PM URINE EOS-NEGATIVE
.
Micro:
Microbiology: wound culture ([**7-3**]): STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
blood cultures ([**7-3**]): pending
urine culture ([**7-3**]): no growth
Imaging:
CXR [**7-3**]:
IMPRESSION: AP chest compared to most recent prior chest
radiograph [**2148-5-9**].
Moderate cardiomegaly, mediastinal widening. A small right
pleural effusion and interstitial abnormality predominantly in
the right lung are most readily explained by biventricular heart
failure. Intervening chest radiograph should be consulted to see
if this is consistent with the recent course. Transvenous right
atrial and right ventricular pacer leads are in expected
locations. No pneumothorax.
.
TTE [**7-4**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Regional
left ventricular wall motion is normal. There is mild global
left ventricular hypokinesis (LVEF = 50%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with mild
global systolic dysfunction. Mild right ventricular systolic
dysfunction. Minimal calcific aortic stenosis. Moderate mitral
and tricuspid regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2148-5-7**],
pulmonary hypertension is now detected. The other findings are
similar.
.
Renal US [**7-5**]:
1. No evidence of hydronephrosis bilaterally.
2. Multiple anechoic right renal lesions consistent with simple
cysts.
3. Bilateral cortical thinning, left greater than right.
.
Left Extremity US [**7-4**]:
Limited evaluation of the area of concern was performed using
Grayscale and color flow ultrasound. There is subcutaneous
edema. There is no evidence of a defined abscess collection. The
AV fistula was not evaluated.
IMPRESSION: Subcutaneous edema without evidence of abscess
formation.
.
CXR [**7-7**]:
FINDINGS: In comparison with the study of [**7-6**], there is little
change in the diffuse bilateral pulmonary opacifications
bilaterally. The right central catheter has been pulled back
into the axillary region. Other monitoring and support devices
remain in place.
.
LENIs [**7-7**]:
IMPRESSION: No evidence of DVT in bilateral lower extremity
veins.
.
CT CHEST [**7-8**]:
IMPRESSION: Confluent upper lobe peribronchiolar opacification
overlying
diffuse ground glass and reticular opacification that is new
since [**2148-6-20**] and raises concern for superimposed infection in
the setting of pulmonary edema. Moderate bilateral left greater
than right pleural effusions. The study and the report were
reviewed by the staff radiologist.
.
CXR [**7-11**]:
FINDINGS: PICC line is terminating into lower SVC. There is
asymmetric
improvement in the moderate to severe pulmonary edema, left side
more than
right side, since [**2149-7-7**]. Pleural effusions bilaterally
are
persistent without interval increase. Left pectoral dual-lead
chest wall
pacemaker leads are terminating into the right atrium and right
ventricle.
Heart size is enlarged and unchanged. Cardiomediastinal contours
is stable.
.
Brief Hospital Course:
Mr. [**Known lastname 31823**] is a 75M with a complicated PMH including CAD s/p
CABG, PMR on prednisone, AF s/p PPM and ESRD previously on HD
through left AV fistula who was transferred from [**Hospital **] Hospital
with a left upper extremity abscess with overlying cellulitis
distal to his AV fistula.
.
#LUE CELLULITIS
Cellulitis secondary to skin breakdown from recent trauma. No
underlying abscess or joint involvement. Wound cultures grew
out MSSA and patient started on vancomycin for 14 d course (Day
1 = [**7-3**], got final dose on [**7-15**]). Blood cultures were negative.
Decided not to switch to nafcillin because of high salt load
and actively trying to diurese patient. Patient remained
afebrile during admission. Swelling improving on exam. Per
transplant surgery outlet stenosis and AVF are likely making pt
susceptible to wounds of the area and ultimate management will
involve angioplasty of stenosis vs. tying off fistula. Ortho and
wound care teams have followed the fistula and provided wound
care recommendations. Underwent bedside I and D near left elbow
while in the ICU by orthopedics. He will need continued wound
care.
.
#RESPIRATORY DISTRESS/HYPOXEMIA/ACUTE ON CHRONIC SYSTOLIC
CHF/CAD
CT chest [**7-8**] shows residual pulmonary edema despite ongoing
diuresis. Pulmonary edema likely combined cardiogenic (CHF) and
due to capillary leak secondary to inflammatory process. Patient
was initially on 6L nasal cannula and oxygen by face mask, but
eventually respiratory status improved with diuresis. LOS fluid
balance from the ICU was negative 7L here (likely was
hypervolemic on transfer, dry weight unknown). When patient was
discharged from ICU, was satting 95-100 on 4L, which appears to
be his baseline. Diuresis was continued. He used 2-3L oxygen
intermittently (as he does at home), but reported that his
breathing felt back to baseline. Continued ASA, beta blocker,
fenofibrate. Not on statin or ACE-inhibitor.
He was on lasix 40mg twice daily with nearly matched I/Os (at
home was on 80mg in AM/40mg in PM). He was maintained at 40 mg
twice daily given mildly low blood pressures (asymptomatic)
.
#ATRIAL FIBRILLATION (AFIB)
Has history of A-fib on Coumadin. Rates were controlled with
diltiazem and metoprolol. Diltiazem dose was reduced to 120 mg
daily (rather than 160 mg daily on admission). Warfarin dosing
was adjusted for goal INR 2-2.5.
.
#DIABETES MELLITUS (DM), TYPE II: On levemir 40units and ISS at
home. Insulin glargine (Lantus) was administered and titrated,
ultimately to a dose of 34 units in the evening. He was still
having blood sugars in 300s in the afternoon, but fasting blood
sugars 110s. [**Month (only) 116**] need to be titrated up further, though may in
part be due to prednison.
.
#RENAL FAILURE, ACUTE ON CHRONIC (ACUTE RENAL FAILURE, ARF)
Patient was very hypervolemic on admission, and was started on a
lasix gtt for diuresis. BUN and Cr continue to slowly climb in
setting of diuresis, but still within baseline range. Diuresis
was continued with furosemide. Cr stabilized in 1.9-2.1 range,
which is lower than recent value pre-hospitalization. He has a
AV fistula in the left arm but no imminent plan for dialysis
(had been on dialysis previously, this was stopped in 12/[**2147**]).
.
# Mental status/Agitation: In the ICU, patient repeatedly became
agitated overnight, taking off his oxygen, becoming hypoxemic,
and getting more agitated. He was initially given ativan, which
controlled his symptoms but made him confused. Eventually, he
was transitioned to PO Tylenol 650 standing to prevent pain
while not making patient somnolent. On the general medical
[**Hospital1 **], there were no episodes of agitation, and he remained calm,
alert, and oriented.
.
# Polymyalgia rheumatica: Patient takes prednisone prescribed by
outpatient rheumatologist, the patient was on prednisone 15mg at
his appointment 2 weeks ago. Planned to taper to 10mg now for 2
weeks, then continue to taper down. Dose adjusted to prednisone
10mg daily on Wed [**7-9**], next planned taper [**7-23**].
.
#Anemia: Hct stable in mid-20s, below baseline of 30, no
transfusions this admission. Stool guaiac negative; hemolysis
labs negative for hemolysis. Likely secondary to renal failure.
.
#DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID DISORDER):
Continue home fenofibrate.
.
#HYPOTHYROIDISM: Continue levothyroxine 75mcg home dose
.
#Sacral wounds: Will need continued wound care.
.
#Esophageal Ulcers/GERD: Continued PPI
Medications on Admission:
Metoprolol 5mg Q6H
- Solu-medrol 15mg daily
- Pantoprazole 40mg IV daily
- Fenofibrate 145mg daily
- levothyroxine 75mcg daily
- Furosemide 80mg IV daily
- Piperacillin/Tazobactam 2.25g IV Q6H
- Haloperidol 5mg IV Q6H prn confusion
- Fentanyl 50mcg IV 14H prn pain
- Norco (APAP 325/Hydromorphone 5) [**11-24**] tab Q4Hr PRN
- Insulin sliding scale
- Feosol 325mg daily
- Sucralfate 1gm before meals and QHS
Discharge Medications:
1. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) GRAMS PO DAILY (Daily) as needed for constipation.
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
12. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
13. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
15. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
17. insulin glargine 100 unit/mL Cartridge Sig: Thirty Four (34)
UNITS Subcutaneous at bedtime.
18. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 83785**] Pines
Discharge Diagnosis:
#Hypoxemia
#CHF (acute on chronic, systolic)
#CAD s/p CABG
#LUE cellulitis
SECONDARY DIAGNOSES
#Atrial Fibrillation
#Diabetes mellitus type 2, controlled, with complications
#Acute on Chronic Renal failure
#Polymyalgia rheumatica
#Anemia
#Hypothyroidism
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 for low oxygen levels and cellulitis
(infection of the skin). Your oxygen levels improved with lasix
and may in part have been due to fluid on your lungs.
The infection of your skin also improved with antibiotics.
You will need ongoing physical therapy and therefore will go to
rehab
Followup Instructions:
Rehab will schedule follow-up with PCP; You should also schedule
follow-up with your nephrologist and address the need for
ligating the AV fistula.
|
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12,048
| 114,910
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27973
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Discharge summary
|
report
|
Admission Date: [**2157-9-23**] Discharge Date: [**2157-10-3**]
Date of Birth: [**2095-10-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Erythromycin Base / Latex / Nsaids
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Tracheobronchomalacia, diffuse, and
mucopurulent tracheobronchitis.
Major Surgical or Invasive Procedure:
Dr. [**Last Name (STitle) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
1. Right thoracotomy with posterior membranous wall
tracheoplasty with mesh.
2. Right mainstem and bronchus intermedius posterior
membranous wall plasty with mesh.
3. Left main posterior membranous wall bronchoplasty with
mesh.
4. Flexible bronchoscopy.
.
Dr. [**Last Name (LF) **],[**First Name3 (LF) **]:
Bronchoscopy
History of Present Illness:
[**Known lastname 68103**] is a 61-year-old classical singer who developed a
severe cough two
years ago, which has continued to worsen to the point that it is
intractable, severe and debilitating. It was initially felt to
be potentially related to upper respiratory tract infection for
which she has been treated with without any improvement in her
cough. Her cough has become so severe that it results in stress
incontinence and syncopal episodes. She ultimately underwent a
bronchoscopy by Dr. [**Last Name (STitle) 1712**] and was found to have thick
inspissated
secretions throughout the trachea. These were removed and her
breathing improved. Dynamic bronchoscopy was perforemed and she
was diagnosed severe tracheobronchomalacia. Her associated
symptoms have also been
dyspnea on exertion and wheeze. However, she suffers from
postpolio syndrome and therefore does not exert herself
particularly. She has no significant orthopnea although she has
a sleep disturbance. She has had significant colds but has had
no severe infection such as pneumonias. Despite the treatment
for her gastroesophageal reflux disease with proton pump
inhibitors, she has had no improvement in her cough.
She now presents for surgical intervention.
Past Medical History:
HTN, postpolio syndrome, tracheobronchomalacia, s/p lap chole,
TAH-BSO, mult RLE surgeries, and b/l knee replacements
Social History:
former opera singer. non-smoker. Rare ETOH use
Family History:
non-contributory
Pertinent Results:
[**2157-10-3**] 05:36AM BLOOD WBC-9.0 RBC-3.66* Hgb-11.4* Hct-32.8*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.8 Plt Ct-305
[**2157-10-3**] 05:36AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-27 AnGap-17
[**2157-10-3**] 05:36AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.9
.
[**2157-10-2**] 10:25 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT [**2157-10-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2157-10-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2157-10-1**] 4:27 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2157-10-2**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2157-10-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
CHEST PORT. LINE PLACEMENT [**2157-9-30**] 3:16 PM
REASON FOR THIS EXAMINATION:
please check placement of right median cub. PICC line 50 cm
please page IV nurse [**First Name (Titles) 151**] [**Last Name (Titles) **] [**Location (un) 1131**] thanks [**Doctor First Name **] #[**8-/2590**]
INDICATION: Right PICC placement. Patient is status post
tracheoplasty.
IMPRESSION: Right pleural effusion, unchanged. Right PICC tip in
distal SVC.
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] with respiratory symptoms. She
underwent bronchoscopy on [**2157-9-25**] that showed moderate
tracheomalacia and inspisated sputum. On [**2157-9-26**] she underwent
a right thoracotomy with posterior membranous wall tracheoplasty
with mesh, right mainstem and bronchus intermedius posterior
membranous wall plasty with mesh, left main posterior membranous
wall bronchoplasty with mesh, flexible bronchoscopy. For
operative details, seed dictated report. She was continued on
antibiotics (Zosyn, Nafcillin). She tolerated the procedure well
and was extubated and transferred to the ICU for monitoring.
Chest tube was maintained on suction. Pain was well controlled
with an epidural catheter that was managed by the Acute Pain
Service team.
On POD 1 aggressive pulmonary toilet was begun. Pain was well
controlled and incentive spirometry was encouraged. Diet was
advanced. CXR showed patchy opacity in the right upper lobe and
right lower lobe consistent with a developing air space disease
or atelectasis. Linear atelectasis in the left base, findings
consistent with post-operative changes. There was no evidence of
pneumothorax.
On POD 2, physical therapy service was consulted. She continued
to do well. Diet was advanced.
ON POD 3, chest tube was removed.
ON POD 4, she continued to do well. Antibiotics were continued.
Epidural and IV pain medications were adjusted to achieve better
control. CXR showed a small right loculated air collection most
likely due to loculated pneumothorax. This was unchanged from
previoius study and was thought to be due to post-operative
changes.
POD 5, Bronchoscopy performed and showed a normall right and
left bronchial tree with no airway colapse with expiration,
inspiration or cough. Epidural was removed and patient was
transitioned to PO and IV medications with adequate results.
PICC line was placed for long-term IV antibiotic administration.
Patient developed a significant yeast infection requiring
topical creams as well as Diflucan.
POD 6, patient developed several episodes of loose stool.
C.difficile cultures were negative. Chest PT/physical PT and
incentive spirometry was continued.
POD 7, her C.diff cultures were sent and were negative. She
continued to remain afebrile and her antibiotics was continued,
with empiric flagyl started.
POD 8, she continued to remain afebrile and with return of her
sensitivities, her antibiotics were switched from naficillin to
levofloxacin, and the zosyn and flagyl were continued. She was
deemed stable for discharge and will be discharged home with
VNA. She will continue to zosyn and levofloxacin for 3 weeks,
flsgyl for 4 weeks and was instructed to call Dr.[**Name (NI) 1816**]
office to schedule a follow-up appointment.
Medications on Admission:
Percocet
Atenolol
Nexium
Zantac
Colace
Senna
Amytriptyline
Lamictal
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 21 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Zosyn in Saline 4.5 g/100 mL Piggyback Sig: One (1)
Intravenous every eight (8) hours for 21 days.
Disp:*qs qs* Refills:*0*
3. Heparin Flush 100 unit/mL Kit Sig: Five (5) ml Intravenous
once a day: 5 ml (100unit/mL) heparin to each lumen Daily via
SASH.
Disp:*qs qs* Refills:*2*
4. Normal Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection
once a day: 5 mL NS to each lumen Daily via SASH.
Disp:*qs qs* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 26 days.
Disp:*78 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for 21 days.
Disp:*qs qs* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lamotrigine 25 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 1* Refills:*2*
13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6
times a day).
Disp:*1 1* Refills:*0*
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Tracheobronchomalacia
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Last Name (STitle) 952**]/ Thoracic Surgery office ( [**Telephone/Fax (1) 170**] ) for:
fever, shortness of breath, chest pain, exscessive foul smelling
drainage from incision sites
.
Call to schedule your follow up appointment.
.
Please follow-up with your primary care physician as soon as
possible.
.
*Continue medications as previous to surgery as stated on
discharge instructions. Please discontinue your percocet and
atenolol until follow-up with your primary care physician.
.
*Take new medications as directed and as needed, stated on
discharge instructions.
.
You may shower.
No tub baths or swimming for 3-4 weeks.
Followup Instructions:
Call Dr.[**Last Name (STitle) 68104**]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] to schedule
your follow up appointment.
|
[
"729.89",
"787.91",
"519.19",
"138",
"311",
"715.90",
"112.1",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"33.23",
"31.79",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8072, 8133
|
3637, 6408
|
389, 824
|
8199, 8208
|
2348, 3226
|
8894, 9029
|
2311, 2329
|
6526, 8049
|
8154, 8178
|
6434, 6503
|
8232, 8871
|
281, 351
|
3255, 3614
|
852, 2089
|
2111, 2230
|
2246, 2295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,527
| 109,566
|
30702
|
Discharge summary
|
report
|
Admission Date: [**2148-7-1**] Discharge Date: [**2148-7-9**]
Date of Birth: [**2074-1-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
AMS, low urine output
Major Surgical or Invasive Procedure:
[**2148-7-1**]: s/p Right knee replacement
History of Present Illness:
74 yo male with h/o DM2, HTN, CAD with stent placement, one
kidney, Parkinson's dz. End-stage tricompartmental OA, presented
for right TKR.
After surgery, patient was somnolent and with low urine output.
In OR/PACU patient received 4L liters fluids + 500 cc 5%
albumin, with UOP 376cc (10-20 cc/hr). Patient developed
increasing somnolence throughout the day. Received total 1.5mg
dilaudid per PCA in PACU. He also received 1g tylenol and 4U
insulin SC. Creatinine was 1.3 (baseline 1.0-1.2). Hematocrit
25 at 5pm, subsequently 23 (baseline 30-33). ABG 7.42/44/64/30.
Vitals in PACU:
T 96.8-97.4 HR 50-100 BP 120s/50s RR 15-20 O2Sa 98-99% on 2L
Vitals on arrival to the MICU:
T 100.1 HR 102 BP 141/62 RR 22 SaO2 96% on 2L NC
Upon transfer to the MICU he was transfused 1U RBC followed by
20mg Lasix, after which UOP rose to ~100cc/hr.
Past Medical History:
1)3VCAD
- s/p STEMI and PTCA of LAD [**2141**] at [**Hospital1 2177**]
- s/p PTCA & DES to OM1 [**2146-2-18**]
- s/p DES to prox/mid-LAD & OM1 [**2147-2-16**]
- s/p stent & balloon angioplasty to LAD [**2147-12-20**]
- ECG [**2148-6-26**]: notable for SR, PR 214, poor R wave progression,
nonspecific lateral lead ST-T wave abnormalities
2)Hypertension
3)Dyslipidemia
4)BPH
5)Type 2 diabetes with peripheral neuropathy
6)s/p R nephrectomy ~10 years ago at [**Hospital1 2177**] - path benign per
patient
7)Parkinson's disease:
- diagnosed age 70
- followed as outpatient by Dr. [**First Name (STitle) 951**].
- Carbidopa/levodopa
8)Bells' palsy ([**2-1**] HTN) [**6-8**] s/p valtrex
9)CKD Stage II baseline 1.0-1.2
10)Depression
11)Microcytic anemia-stable all his life-?thalassemia. neg,
[**Last Name (un) **]-egd in past
12)Elevated PSA
13)Urinary frequency and incomplete emptying on UDS
14)Knee arthritis
Social History:
Lives with his wife and son. Retired [**Name2 (NI) 13222**] at [**Hospital1 **]. No
smoking, drinking or illicit drug use. Does work part-time now
at a gun and rifle club. Notes that his diet is not good -->
pizza, sandwiches.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Foley catheter, remove [**2148-7-13**] at 6am
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Sanguinous drainage from proximal wound, dressed with silver
nitrate and steristrips placed on [**7-6**], good effect
* Eccymosis medial/lateral knee and shin
* Thigh full but soft
* No calf tenderness
* SILT, NVI distally
* Toes warm
* +cap refill
* WEAK PT, -AT
Pertinent Results:
CXR [**2148-7-1**]: Low lung volumes. Interval appearance of mild
interstitial edema and engorged pulmonary vasculature. Heart
size is increased. Bibasilar opacities likely atelectasis.
Stomach is distended with gas.
[**2148-7-9**] 07:30AM BLOOD WBC-9.9 RBC-3.66* Hgb-9.2* Hct-28.6*
MCV-78* MCH-25.1* MCHC-32.1 RDW-17.6* Plt Ct-331
[**2148-7-8**] 07:05AM BLOOD WBC-8.6 RBC-3.62* Hgb-9.5* Hct-28.2*
MCV-78* MCH-26.3* MCHC-33.7 RDW-16.9* Plt Ct-268
[**2148-7-8**] 01:00AM BLOOD WBC-8.4 RBC-3.53* Hgb-9.3*# Hct-27.0*
MCV-76* MCH-26.2* MCHC-34.3 RDW-16.9* Plt Ct-262
[**2148-7-7**] 05:30AM BLOOD WBC-6.6 RBC-2.99* Hgb-7.3* Hct-22.6*
MCV-76* MCH-24.4* MCHC-32.2 RDW-16.9* Plt Ct-205
[**2148-7-6**] 08:00AM BLOOD WBC-7.8 RBC-3.26* Hgb-7.9* Hct-24.3*
MCV-75* MCH-24.2* MCHC-32.4 RDW-16.8* Plt Ct-187
[**2148-7-5**] 08:00AM BLOOD WBC-8.4 RBC-3.54* Hgb-8.8* Hct-26.4*
MCV-75* MCH-24.8* MCHC-33.2 RDW-16.6* Plt Ct-145*
[**2148-7-4**] 07:55AM BLOOD WBC-10.0 RBC-3.36* Hgb-7.9* Hct-24.5*
MCV-73* MCH-23.4* MCHC-32.2 RDW-16.6* Plt Ct-116*
[**2148-7-3**] 07:35AM BLOOD WBC-11.7* RBC-3.60* Hgb-8.3* Hct-25.5*
MCV-71* MCH-23.2* MCHC-32.7 RDW-15.3 Plt Ct-130*
[**2148-7-2**] 03:22AM BLOOD WBC-9.6 RBC-4.06* Hgb-9.4* Hct-28.8*
MCV-71* MCH-23.1* MCHC-32.6 RDW-15.6* Plt Ct-119*
[**2148-7-1**] 05:30PM BLOOD WBC-9.8 RBC-3.58*# Hgb-7.9*# Hct-25.2*#
MCV-70* MCH-22.0* MCHC-31.4 RDW-15.7* Plt Ct-145*
[**2148-7-1**] 05:30PM BLOOD Neuts-78.4* Lymphs-15.8* Monos-5.0
Eos-0.5 Baso-0.3
[**2148-7-8**] 07:05AM BLOOD PT-11.5 INR(PT)-1.1
[**2148-7-9**] 07:30AM BLOOD Glucose-184* UreaN-23* Creat-0.9 Na-133
K-4.2 Cl-98 HCO3-26 AnGap-13
[**2148-7-8**] 07:05AM BLOOD Glucose-204* UreaN-28* Creat-0.9 Na-134
K-3.9 Cl-97 HCO3-27 AnGap-14
[**2148-7-7**] 05:30AM BLOOD Glucose-168* UreaN-33* Creat-1.1 Na-134
K-3.6 Cl-98 HCO3-26 AnGap-14
[**2148-7-8**] 07:05AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
[**2148-7-7**] 05:30AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.3
[**2148-7-6**] 08:00AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.4
[**2148-7-1**] 07:37PM BLOOD Type-ART O2 Flow-2 pO2-64* pCO2-44
pH-7.42 calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2148-7-1**] 07:37PM BLOOD Hgb-7.8* calcHCT-23 O2 Sat-91
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. Admit to [**Hospital Unit Name 153**] for post op medical management. [**Hospital Unit Name 153**] course as
below. transferred to the floor late in the evening on POD1
2. Geriatric c/s for medical co-management
3. Post-op anemia - POD2 Hct 25.5 -> 1u PRBC, POD3 Hct 24.5,
asymptomatic -> Transfused additional 1u PRBCs. POD5 HCT 24.3
-> 1u PRBCs, POD6 -> HCT 22.6 -> 2u PRBCs
4. Neuro consult for R foot motor deficit - incomplete study,
but no obvious nerve compression.
5. Hematuria and urinary retention - Started on Bactrim
prophylactically. Hematura cleared spontaneously. Patient was
unable to void, straight cathed x many, when urine culture
confirmed negative, stopped Bactrim and foley placed [**7-5**]. Foley
removed [**2148-7-9**] at 6am but patient failed voising trial, bladder
scanned > 400cc after 6 hrs. Foley replaced, increased terazosin
15mg daily, repeat voiding trial [**2148-7-13**] at 6am.
Otherwise, pain was initially controlled with IV pain meds
followed by a transition to oral pain medications on POD#1. The
patient received lovenox for DVT prophylaxis starting on the
morning of POD#1. The surgical dressing was changed on POD#2 and
the surgical incision was found to be clean and intact without
erythema or abnormal drainage. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Mr. [**Known lastname 17922**] is discharged to rehab in stable condition.
[**Hospital Unit Name 13533**]:
74M with DM, HTN, CAD, Parkinson's s/p R TKR experienced low UOP
and AMS in PACU and transferred to MICU. AMS likely secondary to
narcotics, low urine output secondary to under-rescuscitation.
ACUTE ISSUES:
# Anemia: Received 4L crystalloid + 0.5L colloid in the OR
during the procedure. He also received 1 unit PRBCs. He was
given another 1 un PRBCs with lasix upon arrival to the ICU. His
Hct responded appropriately with an increase from 25.2 to 28.8.
# AMS: Pt was very somnolent on arrival but was arousable.
Attributed to a combination of narcotics and underlying
Parkinson's disease. The patient had no focal neurologic
deficits so further imaging of the head was not obtained. He
became significantly more interactive throughout his course and
on transfer was at baseline.
# CAD/hyperlipidemia: Requires antiplatelet therapy s/p stents.
The patient's [**Hospital Unit Name **] and [**Hospital Unit Name 4532**] were restarted after consulting
with orthopedics.
# s/p TKR: Patient was in repositiong device during stay.
Started on Lovenox for DVT prophylaxis.
STABLE ISSUES:
# [**Last Name (un) **]/low UOP: Cr on admission was slightly higher than baseline
(1.3 vs 1.0-1.2). The patient is s/p nephrectomy, which
combined with intraop blood loss probably contributed to his
[**Last Name (un) **]. Urine output responded to lasix
# DM2: Patient was placed back on home insulin at 40 units of
70/30 [**Hospital1 **] and sliding scale. Sugars remained well controlled.
# HTN: SBPs were up to 160s in MICU. The patient was restarted
on home metoprolol dose. His home valsartan and HCTZ were held
pending followup creatinine. Cr remained stable at 1.3 at the
time of transfer.
# Parkinson's: Stable. Continued on home carbidopa-levodopa.
# BPH: Stable, home finasteride and terazosin continued.
TRANSITIONAL ISSUES: F/u outpatient as per ortho.
Medications on Admission:
[**Hospital1 **], diovan, HCTZ, insulin, carbidopa, levodopa, finasteride,
mirtazapine, clopidogrel, pravachol, hytrin, metoprolol
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. clopidogrel 75 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 once a day.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO once a day as needed for constipation.
13. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 4 weeks: Restart: [**2148-7-10**]
Last dose: [**2148-7-29**].
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day: [**Month (only) 116**] resume 325mg daily after Lovenox completed.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Hold for sedation or confusion.
Disp:*50 Tablet(s)* Refills:*0*
16. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous twice a day: Home dose, but
has been held while inpatient [**2-1**] poor appetite.
17. terazosin 5 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime): Dose increased from 10mg daily [**2-1**] urinary retention.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right knee osteoarthritis
Urinary retention
Post-op anemia due to blood loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out at your follow-up visit in three (3)
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
[**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
visit in three (3) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, and wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment. Left foot AFO at
all times when ambulating.
Physical Therapy:
RLE WBAT
Intensive ROM
CPM 2-3x/day for 2hr sessions, maximum flexion as tolerated
Left foot AFO AAT when ambulating
Mobilize frequently
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice and elevation
TEDs
D/c foley catheter [**2148-7-13**] at 6am and repeat voiding trial
*Staples will be removed at follow-up appointment in 3 weeks*
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2148-7-23**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 31415**]
Date/Time:[**2148-11-12**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2149-2-5**] 4:00
Completed by:[**2148-7-9**]
|
[
"403.10",
"599.70",
"V45.82",
"292.81",
"311",
"997.5",
"600.01",
"998.11",
"781.99",
"287.5",
"788.20",
"250.60",
"E935.2",
"276.1",
"285.1",
"E878.1",
"332.0",
"V58.66",
"276.8",
"280.9",
"584.9",
"428.33",
"E934.2",
"412",
"272.4",
"357.2",
"428.0",
"780.52",
"V58.67",
"715.36",
"414.01",
"585.2",
"293.0",
"V45.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
11550, 11620
|
5385, 9471
|
337, 382
|
11741, 11741
|
3210, 5362
|
15277, 15824
|
2465, 2554
|
9704, 11527
|
11641, 11720
|
9548, 9681
|
11917, 14096
|
2569, 3191
|
14878, 15016
|
15038, 15254
|
9492, 9522
|
276, 299
|
14108, 14860
|
410, 1258
|
11756, 11893
|
1280, 2202
|
2218, 2449
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,546
| 116,607
|
5007+5008
|
Discharge summary
|
report+report
|
Admission Date: [**2188-5-27**] Discharge Date: [**2188-6-4**]
Date of Birth: [**2112-8-21**] Sex: F
Service:
ADDENDUM:
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Acute renal failure.
2. Urinary tract infection.
3. Dependence on ventilator.
4. Diabetes mellitus.
5. Pseudomonal colonization of airways.
DR [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 11.685
Dictated By:[**Last Name (NamePattern4) 20726**]
MEDQUIST36
D: [**2188-6-3**] 13:52
T: [**2188-6-3**] 21:24
JOB#: [**Job Number 20727**]
Admission Date: [**2188-5-27**] Discharge Date: [**2188-6-4**]
Date of Birth: [**2112-8-21**] Sex: F
Service:
PRESENT ILLNESS:
1. Acute renal failure.
2. Resolving urinary tract infection, status post klebsiella
urosepsis.
3. Prolonged ventilator dependence.
4. Status post [**Last Name (un) 3696**] syndrome.
5. Diabetes mellitus.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 20728**] is a 75-year-old
female with a history of insulin dependent diabetes,
hypertension, morbid obesity, coronary artery disease, status
post three vessel coronary artery bypass graft in [**2188-3-25**], paroxysmal atrial fibrillation, congestive heart
failure with normal ejection fraction who was transferred
from [**Hospital1 **] for evaluation and therapy of acute
renal failure, [**Last Name (un) 3696**] syndrome and persistent ventilator
dependence with metabolic acidosis and resolving Klebsiella
urosepsis.
Patient initially presented to [**Hospital1 188**] on [**2188-3-14**] for evaluation of congestive heart
failure and was found to have severe three vessel disease by
cardiac catheterization. She underwent three vessel coronary
artery bypass graft on the [**3-18**] with initial
postoperative complication of pneumonia and urinary tract
infection that were treated with Ciprofloxacin. She was then
transferred to [**Hospital1 **] for further rehabilitation
on the [**2-28**]. There, she developed left lower lobe
pneumonia and sternal wound infection/dehiscence which grew
out staphylococcus and enterococcus. She was started on
levofloxacin and vancomycin, and then transferred back to the
SICU at [**Hospital3 **] on [**4-1**] for further evaluation and
management. There, she was found to have a left pleural
effusion that required placement of a chest tube. On the
[**4-3**], she was taken to the Operating Room for
debridement and flap reconstruction over her sternal wound.
Her postoperative course after this procedure was complicated
by pressor requirements, persistent hypoxia and metabolic
alkalosis of unclear etiology treated with diamox. Also, she
failed extubation and underwent a percutaneous tracheostomy
on the [**4-18**], and several bronchoscopies were
significant only for chronic inflammatory changes. During
this period, she also developed left arm weakness which was
evaluated by Neurology. Their differential was a brachial
plexopathy versus cord injury versus a right MCA stroke.
She was discharged at [**Hospital1 **] again on the [**4-23**] with a PICC line in place and her flaps intact. Her
total course of intravenous vancomycin was scheduled for six
weeks.
While at the rehabilitation facility, she developed multiple
medical issues that complicated her management.
1. [**Last Name (un) 3696**] syndrome: On [**5-6**], she developed increasing
abdominal distention, discomfort and occasional emesis on
tube feeds. Gastrointestinal evaluated her the [**5-13**]
and recommended bowel arrest, rectal and nasogastric tube
decompression. A KUB on [**5-19**] showed that the cecum was
still dilated to 16.5 cm and so she was continued NPO. Her
exam had no improved at the time of transfer to Medical
Intensive Care Unit.
[**Unit Number **]. Klebsiella urosepsis: Patient apparently had
intermittent temperature spikes with leukocytosis concerning
for continued sternal wound infection. Vancomycin was
continued past the six week course but on [**5-19**], she was
started on levofloxacin and Flagyl for broader coverage. The
Flagyl was begun for concern of toxic megacolon. On [**5-22**],
both urine and [**2-27**] blood culture bottles grew out generally
pansensitive Klebsiella pneumonia. She was given a single
dose of gentamicin on the 28th and vancomycin was
discontinued secondary to worsening renal failure.
Levofloxacin and Flagyl were continued. At the time of
transfer back to the Medical Intensive Care Unit, it was felt
that her sepsis was resolving.
3. Acute renal failure: Creatinine on [**5-15**] was 0.8. On
[**5-22**], it was 3.0 and on [**5-26**] was 5.0. While at [**Hospital1 5593**], she was seen by the renal attending Dr.
[**Last Name (STitle) **]. Her urinalysis at the time was notable for granular
casts. It was the feeling of the renal team, that Mrs.
[**Known lastname 20728**] had developed acute renal failure secondary to acute
tubular necrosis induced by sepsis and intravascular
depletion. She was started on a Lasix drip and renal dosed
dopamine. The documentation is unclear, but she appears to
have been anuric for some time but on the [**6-23**], her
urine output is noted to be 300-400 cc. While she was at the
rehabilitation facility, an ultrasound was obtained that
showed no evidence of hydronephrosis but there was a question
of horseshoe kidney.
4. Ventilatory dependence: The patient has been unable to
be weaned off the ventilator for unclear reasons.
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 97.9
(rectal). Heart rate 64. Blood pressure 117/42.
Respiratory rate 14. Oxygen saturation 100% ventilatory
setting: SIMV 14/750/5/5/30%. General: She was alert and
oriented times three in no acute distress. The tracheostomy
was in place and she was able to respond to verbal commands.
Head, eyes, ears, nose and throat: Pupils equal, round and
reactive to light. The extraocular movements were intact.
The oropharynx was moist. There was no sinus tenderness and
an nasogastric tube was in place in the right naris.
Cardiovascular: The heart had a regular rhythm and normal
rate. No appreciable murmurs, rubs or gallops were
auscultated. Pulmonary: Rhonchus breath sounds bilaterally
with upper airway secretion, no wheezes, no crackles.
Abdominal exam: Obese, moderately distended, diffusely
tender, no rebound, no guarding, scant bowel sounds, right
longitudinal surgical wound with inferior aspect wound and
packed with mild erythema. Midline longitudinal surgical
with subxiphoid aspect open and packed. Extremities: 3+
pitting edema with venous stasis changes in both lower
extremities. Pulses in feet barely palpable but warm.
Neurological: Strong grasp right hand, weak grasp left hand.
Can wiggle toes, but cannot move legs.
LABORATORY DATA: White blood cell count 10.8, hematocrit
27.4, platelets 184,000, PT 15.3, PTT 29.6, INR 1.5, sodium
126, potassium 2.9, chloride 93, bicarbonate 16, BUN 88,
creatinine 5.2, anion gap 17, calcium 7.5, magnesium 1.8,
phosphorus 5.6. Arterial blood gases 7.45/25/131. KUB: No
air fluid levels, no free air, no cecal dilation noted.
Chest x-ray: Persistent left lower lobe collapse with
consolidation and left pleural effusion. Cannot exclude
infectious etiology.
HOSPITAL COURSE:
1. Pulmonary: The patient was brought to [**Hospital3 **] on
SIMV for unclear reasons. A tracheostomy was in place and
she was quickly changed over to pressure support ventilation,
pressure support of 10. PEEP 7.5, FIO2 40% which she
tolerated very well. She was also given Atrovent nebulizers
every six hours. This appeared to lower her plateau
pressures. On [**5-29**], she was placed on a trachea mask and
was able to tolerate that for two hours, though she did
demonstrate a thoracoabdominal breathing pattern. Through
the rest of her admission, the trachea mask trials were
advanced on a daily basis. By [**6-3**], she was able to go
six hours on 50% trachea mask with no signs of distress or
discomfort.
2. Renal failure: Mrs. [**Known lastname 20728**] was closely followed by the
Medical Intensive Care Unit Team and the Renal consult team.
It was the feeling of all involved, that most of her acute
renal failure at this point was due to acute tubular
necrosis. In support of this, she had muddy brown casts in
her urine, a urine sodium of 69 and a calculated FeNA of
greater than 1. Her Lasix strip was discontinued upon
admission to our Medical Intensive Care Unit. However, she
continues to generate a good urine output, approximately 50
cc per hour without any diuretic support. In addition to
this, the patient appeared to have a nongap metabolic
acidosis. Electrolyte studies were sent away on the urine
and stool and they suggested renal wasting of bicarbonate,
therefore, the patient was started on a bicarbonate drip D5W
with three amps of sodium bicarbonate to replete bicarbonate
losses. On admission, her bicarbonate was 16. By [**5-31**],
the bicarbonate was 18 and on [**6-3**], it was 25. Because
she was generating a good urine output, there was no need for
acute dialysis. Our volume goals with her were to maintain
euvolemia. However, the creatinine trended up from 5.2 on
admission ([**5-27**]) to 6.1 on [**6-2**]. On [**6-3**], the creatinine
was down to 5.8. Throughout her admission she has not
experienced oliguria, and we have mainly given her supportive
care in this regard. Central venous line was placed early in
the admission and we have been following CVPs in her to help
guide for volume repletion. The central venous pressure to
which she has appeared to respond well is between 10 and 12.
Study of the urine sediment revealed only rare urine
eosinophils, no white blood cell casts, no red blood cell
casts to suggest a glomerulonephritis or tubular interstitial
nephritis. A renal ultrasound was obtained which showed the
right lower pole of the kidney going inferiorly and towards
the midline, however, this study was limited by the patient's
body habitus and immobility. A question still remains as to
whether she has abnormal renal anatomy.
3. Infectious Disease: The patient was transferred to our
Medical Intensive Care Unit with resolving Klebsiella
urosepsis. She received levofloxacin at 250 mg q.o.d. until
[**5-29**]. Her urine culture grew out multiple drug resistant
Klebsiella and pneumonia. This pathogen was resistant to
Ciprofloxacin and levofloxacin, but was sensitive to third
generation cephalosporins and Bactrim. On [**5-30**], she was
started on Bactrim with a planned duration of therapy of 14
days. Surveillance urinalyses have subsequently revealed
pyuria in the setting of Bactrim therapy. On [**6-1**], the
urinalysis showed positive nitrate and 260 white blood cells
per high powered field. On [**6-3**], the nitrates were
negative but she had 86 white blood cells per high powered
field. This raises the question of a possible genitourinary
tract abnormality predisposing her to developing resistant
infections, however, it is also possible that her initial
Klebsiella infection was cleared with levofloxacin and she
became subsequently reinfected with a resistant strain of
Klebsiella.
The patient was also noted to have a sputum Gram stain that
showed no polymorphonuclear leukocytes but did show [**11-27**]+ gram
negative rods. A subsequent sputum culture grew out sparse
Pseudomonas aeruginosa that is pansensitive. However, in
light of the lack of inflammation on the sputum Gram stain,
we have treated this as colonization of the airways. We have
also followed serial sputum Gram stains to detect an evolving
inflammation in the airways but as of date of discharge, no
inflammation has been noted.
The patient has remained afebrile with a stable white blood
cell count between 11 and 12,000 throughout her admission.
4. Gastrointestinal: 1) [**Last Name (un) 3696**] syndrome. The patient
was evaluated serially with KUBs which were normal. Her
clinical exam improved significantly within the first three
days of her admission here. She was started on a small dose
of Reglan and tube feeds were begun. No notable residuals
have occurred as she is now at her target rate of 35 cc per
hour of Nepro. Flagyl was discontinued after two C.
difficile toxin titers were negative and the patient showed
no clinical evidence of toxic megacolon or antibiotic related
diarrhea.
5. Diabetes mellitus: Blood sugar control has been
difficult in Mrs. [**Known lastname 20728**] for several days as she was
receiving both parenteral and enteral nutrition and her blood
sugars trended up into the high 300s requiring 40 mg
subcutaneous b.i.d. of NPH insulin plus 40 units of regular
insulin and her TPN bag and up to 52 units of regular
subcutaneous insulin off a sliding scale. However, once the
TPN was discontinued after we felt comfortable that her
gastrointestinal tract was handling the tube feedings, the
blood sugars trended down to the mid 200s. Her NPH was
subsequently advanced to 45 units subcutaneous b.i.d. and her
blood sugars have remained under 200 since.
6. Acidosis: The patient, as discussed above, was admitted
with a nongap metabolic acidosis. The source of bicarbonate
loss appeared to be the kidneys secondary to renal failure.
However, at the time of discharge, her bicarbonate is stable
at 25 requiring no bicarbonate repletion.
7. Wound care: The patient was seen by Plastic Surgery here
who agreed with supportive care of the subxiphoid and right
abdominal open wounds. The management has consisted of
wet-to-dry sterile packing and dressings twice a day.
Granulation tissue has come in over the time of her admission
in the Medical Intensive Care Unit, the minimal erythema
surrounding the wounds have resolved. Granulation tissue has
come in to both wounds. There is little to no purulent
drainage from either wound. The patient also has stasis
dermatitis over both lower extremities and several stasis
ulcers. She has grade 2 skin breakdown over the ischial
region and a small ulcer over her left heel. The patient has
been kept in a pneumatic mattress to minimize progression of
decubitus ulcers. She has also received antibiotic ointments
and dressings to prevent infection in these areas.
8. Physical Therapy: While the patient was in the Medical
Intensive Care Unit, Physical Therapy was formally consulted.
It was there feeling that she is in a severely deconditioned
state, secondary to her prolonged stay in medical settings
and lack of mobility. She was begun on a regimen of upper
and lower extremity exercises. She has also been up and out
of bed twice a day.
9. Lines: The patient comes with a left subclavian line
that was put in eight days prior to discharge. With no
evidence of bacteremia and no clinical evidence of blood
stream infection, this line has been left in. The patient is
off parenteral nutrition.
10. Psychiatric: By both the nurses report and her sister's
report, the patient is chronically withdrawn and depressed.
We have advanced her Zoloft to 100 mg q.d. and we have
encouraged her family to come visit her often. Her
motivation will be an important part of her recovery,
especially in terms of weaning her from the ventilator. This
issue will need further follow-up in rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**First Name3 (LF) 20729**]
MEDQUIST36
D: [**2188-6-3**] 19:54
T: [**2188-6-3**] 19:54
JOB#: [**Job Number 20730**]
|
[
"V44.0",
"276.2",
"250.01",
"584.5",
"V46.1",
"599.0",
"428.0",
"427.31",
"560.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
191, 963
|
7304, 13388
|
14285, 15573
|
13401, 14266
|
992, 5506
|
5521, 7286
|
161, 170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,141
| 155,422
|
12934+56422
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-9-14**] Discharge Date: [**2167-9-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Insertion right radial line
History of Present Illness:
HPI: 83 male w/ oropharyngeal carcinoma s/p laryngectomy, copd,
reported frequent aspiration pna, now being admitted for further
evaluation and monitoring of acute respiratory distress. History
and records limited but apparently pt recently d/c'd from VA for
reported RLL PNA for which recently completed course of
Ceftriaxone and Zithromax. Apparently, staying at [**Hospital3 1186**]
and today had a witnessed episode of aspiration following
Nystatin swish and swallow. Reportedly became diaphoretic,
tachypneic and hypoxic to low 80's, improving to low 90's on
several liters of nasal cannula. Transferred to [**Hospital1 18**] for
further evaluation where upon arrival found afebrile, tachy to
100's, normotensive but tachypneic to 40 and satting in high
90's on NRB. Given Levaquin and Flagyl empirically for presumed
aspiration PNA. Wet read CXR demonstrates r. sided pleural
effusion, mildly enlarged cardiac silohette. Labs unremarkable
and ABG shows 7.36/43/213 on NRB. Pt subjectively still SOB but
feeling improved. Given concerns about persistent tachypnea and
poor functional status, transferrd to [**Hospital Unit Name 153**] for closer
monitoring. While awaiting transfer, pt reportedly was weened
to 4l NC and RR of 30. Immediately prior to transfer, EMS
states that pt had a large amount of emesis, unclear if
aspirated.
.
On arrival to [**Name (NI) 153**], pt in respiratory distress with RR 40, HR
130s, SBP 160s, diaphoretic, accessory muscle use. Had very
prominent course upper airway rhonchi. Deep suctioning by RT
returned thick, copious secretions but minimal improvement in
respiratory status. ABG on NRB = 7.25/59/100. Patient was
subsequently intubated given substantial distress. Of note, he
had previously signed a DNR/DNI order but in the ED the patient
reportedly expressed to Dr. [**Last Name (STitle) **] the desire to undergo a
limited intubation if there was a reversible process. Although
in significant distress, the pt confirmed this wish in the [**Hospital Unit Name 153**].
The patient was subsequently intubated and placed on assist
control mechanical ventilation.
Past Medical History:
-squamous cell carcinoma of right tongue base, s/p supraglottic
laryngectomy and radical neck dissection with postoperative
radiation therapy
-depression
-COPD
-vocal cord paralysis
-recurrent aspiration pna s/p recent admit to VA for reported
RLL and RML PNA
-s/p G tube
-OA
-asbestosis
bilateral knee athroplasty
-bilateral frozen shoulder s/p XRT
-chest wall pain
Social History:
Patient came to [**Hospital1 18**] from [**Hospital3 1186**] where he had been for
rehab after recent VA hospitalization. Previously had been
living in apartment downstairs from daughter. Daughter reports
that patient does not have smoking history.
Family History:
NC
Physical Exam:
PE: 97.3, hr 102, 101/58, rr 22, 100% on AC 600/16/5/0.60
gen: intubated, calm, sedated
heent: PERRLA, anicteric, ET tube in lf nares
neck: stiff, indurated w/ post-operative changes; unable to
assess JVP
cv: tachycardic, regular
lungs: coarse rhonchi t/o, scattered wheezes, decreased bs at rt
base
abd: +bs, soft, ntnd; G-tube in place w/o evidence of infection
ext: 1+ LE edema, warm, 1+dp pulses b/l
neuro: following commands, moving all extremities
Pertinent Results:
[**2167-9-14**] 09:35PM TYPE-ART TEMP-36.7 RATES-/40 O2-100 PO2-213*
PCO2-43 PH-7.36 TOTAL CO2-25 BASE XS--1 AADO2-477 REQ O2-79
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2167-9-14**] 09:35PM LACTATE-1.1
[**2167-9-14**] 09:35PM freeCa-1.25
[**2167-9-14**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2167-9-14**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2167-9-14**] 07:42PM GLUCOSE-103 UREA N-16 CREAT-1.0 SODIUM-136
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17
[**2167-9-14**] 07:42PM WBC-9.7 RBC-4.28* HGB-13.7* HCT-40.9 MCV-96
MCH-32.0 MCHC-33.5 RDW-14.9
[**2167-9-14**] 07:42PM NEUTS-75.9* LYMPHS-16.9* MONOS-4.1 EOS-2.6
BASOS-0.4
[**2167-9-14**] 07:42PM MACROCYT-1+
[**2167-9-14**] 07:42PM PLT COUNT-539*
[**2167-9-15**] 05:49AM BLOOD WBC-19.2*# RBC-3.43* Hgb-11.1* Hct-32.7*
MCV-95 MCH-32.4* MCHC-34.0 RDW-14.5 Plt Ct-384
[**2167-9-17**] 03:20AM BLOOD WBC-10.9 RBC-3.83* Hgb-12.2* Hct-35.8*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.4 Plt Ct-370
[**2167-9-17**] 03:20AM BLOOD Plt Ct-370
[**2167-9-15**] 05:49AM BLOOD PT-12.7 PTT-27.7 INR(PT)-1.1
[**2167-9-17**] 07:22AM BLOOD Glucose-97 UreaN-8 Creat-0.9 Na-135 K-4.4
Cl-99 HCO3-27 AnGap-13
[**2167-9-17**] 07:22AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9
[**2167-9-17**] 11:12AM BLOOD Vanco-13.1*
ABGs
[**2167-9-14**] 09:35PM BLOOD Type-ART Temp-36.7 Rates-/40 FiO2-100
pO2-213* pCO2-43 pH-7.36 calHCO3-25 Base XS--1 AADO2-477 REQ
O2-79 Intubat-NOT INTUBA Comment-NON-REBREA
[**2167-9-15**] 12:10AM BLOOD Type-ART pO2-100 pCO2-59* pH-7.25*
calHCO3-27 Base XS--2 Intubat-NOT INTUBA
[**2167-9-17**] 07:44AM BLOOD Type-ART Temp-37.1 PEEP-5 pO2-274*
pCO2-44 pH-7.42 calHCO3-30 Base XS-4 Intubat-INTUBATED
Microbiology
GRAM STAIN (Final [**2167-9-15**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2167-9-17**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ecg: nsr, nl intervals/axis; isolated q-wave III, PRWP, no
ischemic ST/T wave changes
CXR
[**9-14**]: 1. Mild pulmonary edema superimposed on emphysematous
changes. Bilateral
pleural effusions, right greater than left.
2. Ill-defined opacity over right mid lung zone. Proper PA and
lateral chest
film should be obtained when the patient is able.
Brief Hospital Course:
83m w/ significant h/o oropharyngeal carcinoma s/p laryngectomy
and [**Hospital 2182**] transferred from rehab facility following witnessed
aspiration event, subsequently intubated [**3-11**] respiratory
distress.
1. Respiratory failure: Patient was intubated shortly after his
arrival to the ICU [**3-11**] significant respiratory distress in the
setting of copious secretions/ mucous plugging. He was
initially placed on assist control but was able to transition to
Pressure Support for much of the time. He maintained good
oxygen saturations and he experienced no further respiratory
distress. After two days on mechanical ventilation he an SBT
with a RSBI of 42 and was subsequently extubated without
complication. After being extubated he maintained good O2 sats
and was able to handle his secretions with much less difficulty
than on admission. His respiratory status was much improved
prior to discharge.
2. Pneumonia
He was started on Clindamycin initially for anaerobic coverage
of a presumed aspiration pneumonia. Shortly after he was put on
Vancomycin when a sputum culture on admission grew out gram
positive cocci in pairs and clusters. Given his multiple
hospitalizations it was thought that he was likely colonized
with MRSA. Patient should complete a 10 day course of treatment
with Vancomycin and Clindamycin which would be completed on
[**2167-9-24**]. Sputum culture later more suggestive of oropharyngeal
flora but continued Vancomycin as he had clinically improved and
he was recently hospitalized with a pneumonia. A PICC line was
inserted so that patient can receive IV antibiotics at rehab.
Patient kept NPO as patient seemed to have an aspiration event
that triggered his respiratory decompensation. It is possible
that he never fully recovered from his recent pneumonia and that
it may have worsened at rehab precipitating his current
admission.
As noted above, unclear as to whether or not patient had primary
bacterial PNA or aspiration PNA. It is clear however that
hospitalization was precipitated by aspiration event after
witnessed episode of emesis. Reportedly patient has had
recurrent aspiration events and has had frequent episodes of
emesis for a long period of time. Etiology unclear and we have
incomplete records from VA so we cannot be sure what workup has
already been done. Would recommend that this issue be followed
up as an outpatient. Patient currently tolerating tube feeds
with no nausea and vomiting.
3. Hypotension/Fluid Balance: Patient became hypotensive after
intubation. This was thought [**3-11**] to sedation and decreased
preload. His BP responded appropriately to a brief period on
pressors and aggressive IVF resuscitation. BP was monitored
closely with a radial arterial line and he received prn boluses
for MAP<65 and low u/o. He was diuresed around the time of
extubation for possible fluid overload after receiving several
liters of IVF. Patient hemodynamically stable.
4. Oropharyngeal CA: Patient was treated in [**2160**] and has
appeared to be disease-free since this time. He has residual
scarring in the neck area and has had swallowing difficulties
subsequent to his treatment, likely contributing to his
significant aspiration history. Patient had right clavicle
osteomyelitis following his treatment and subsequently had part
of his clavicle removed. This is currently stable but is source
of significant pain. He also has bilateral frozen shoulders
from his treatment.
5. Pain Management: Patient has significant pain from his
shoulders, right clavicle OM and bilateral knees. His home
regimen includes a Fentanyl patch, Lidocaine patch and MSO4 30mg
daily. His patches were continued during his admission and he
initally received IV Fentanyl while intubated. Once extubated he
was maintained on Lidocaine and Fentanyl patches with good
effect. [**Month (only) 116**] need another [**Doctor Last Name 360**] if pain worsens again.
6. FEN: Patient has had G tube for long period of time.
Nutrition was consulted and tube feeds were continued during his
admission. Was kept NPO in setting of recurrent aspirations.
Electrolytes were monitored closely and repleted on as needed
basis.
7. PPx - ppi, sc heparin
8. CODE status: Patient was noted to be DNR/DNI on admission.
However, in ED and later in [**Hospital Unit Name 153**] patient indicated that he
wanted to be intubated for a short period and his wishes were
implemented. Prior to extubation we discussed goals of care at
length with his daughter who is also his HCP. It was determined
that should the patient redevelop respiratory distress we would
NOT reintubate. He is now DNR/DNI.
9. Contact = pt's daughter [**Name (NI) 402**] [**Name (NI) 39722**] - is here today
-[**Telephone/Fax (1) 39723**] (h); [**Telephone/Fax (1) 39724**] (c)
Medications on Admission:
albuterol
atrovent
titratropium qd
ASA 81 qd
Celexa 20 qd
Reglan 5 q 8
Fentanyl patch 100 q72
hep sc 5000 tid
prilosec 20 qd
senna 1 tab [**Hospital1 **]
lactulose qd
MSO4 IR 30 mg po q4hr prn
percocet prn
nystatin swish and swallow
TF = 2 Cal HN cans 8am/6pm and 1 can at noon
azithromycin 500mg - completed [**9-10**]
ceftriaxone completed [**9-10**]
metronidazole 500mg tid - completed [**9-10**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO Q 8 HR ().
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
9. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours): Please continue through [**9-24**].
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): Please continue through
[**9-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1.Pneumonia
2.COPD
3.s/p laryngectomy and radiation for oropharyngeal carcinoma in
[**2160**]
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to [**Hospital 1319**] rehab facility.
Followup Instructions:
Follow up with PCP.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2167-9-19**] Name: [**Known lastname 7199**],[**Known firstname 77**] Unit No: [**Numeric Identifier 7200**]
Admission Date: [**2167-9-14**] Discharge Date: [**2167-9-19**]
Date of Birth: [**2083-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
1.) Patient's antibiotic regimen of Vancomycin and Clindamycin
should be continued for a total of 10 days. He is currently on
day [**6-16**] and therefore last day of both antibiotics should be on
[**9-24**].
2.) With regard to patient's fluid status, he is nearly 7 L
positive at time of transfer to [**Hospital1 **]. He has been
clinically stable and his chest Xrays show improvement. Patient
should no longer receive free water as he is not hypernatremic
and does not need the extra fluid.
Chief Complaint:
Please see original discharge summary.
Major Surgical or Invasive Procedure:
Please see original discharge summary.
History of Present Illness:
Please see original discharge summary.
Past Medical History:
Please see original discharge summary.
Social History:
Please see original discharge summary.
Family History:
Please see original discharge summary.
Physical Exam:
Please see original discharge summary.
Pertinent Results:
Please see original discharge summary.
Brief Hospital Course:
Please see original discharge summary.
Medications on Admission:
Please see original discharge summary.
Discharge Medications:
Please see original discharge summary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Please see original discharge summary.
Discharge Condition:
Please see original discharge summary.
Discharge Instructions:
Please see original discharge summary.
Followup Instructions:
Please see original discharge summary.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2167-9-19**]
|
[
"V10.02",
"507.0",
"518.82",
"285.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.93",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14468, 14538
|
14276, 14316
|
13857, 13897
|
14620, 14660
|
14213, 14253
|
14747, 14958
|
14099, 14139
|
14405, 14445
|
14559, 14599
|
14342, 14382
|
14684, 14724
|
14154, 14194
|
13779, 13819
|
13925, 13965
|
13987, 14027
|
14043, 14083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,551
| 163,130
|
24954
|
Discharge summary
|
report
|
Admission Date: [**2135-10-19**] Discharge Date: [**2135-10-23**]
Date of Birth: [**2088-5-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 53626**]
Chief Complaint:
N/V/Abdominal pain
Major Surgical or Invasive Procedure:
EGD
Intubation
History of Present Illness:
47 yo male presents to ed with 1 mo h/o abdominal pain, nausea
and vomiting with an increase in severity over the past [**2-11**]
days. Pt denies any association of the pain with food, but does
admit to N/V after eating. Patient denies any diarrhea or
constipation, but does recall one episode of dark black loose
stool 2 days ago, no BRBPR, no use of iron or pepto bismol. He
admits to 1-3 episodes of bloody emesis, approximately "half
gallon" at a time. Without any lightheadedness or dizziness. He
describes his abdominal pain as "25/10" sharp, stabbing pain,
with no radiation.
.
He reports decreased po intake, increased urination, inability
to take po meds and poorly controlled DM with "400lbs wt loss".
.
In the ED the patient received Anzemet, Insulin, and dilaudid
2mg x2. After the second dose of dilaudid the patient became
extremely itchy, improved with diphenhydramine. No urticaria
noted in ED. Denies F/C, CP, SOB
Past Medical History:
Diabetes
Leg amputation (post-trauma)
Neuropathy
Esophagitis on EGD [**8-15**]
Seizures - stated his most recent seizure was 2 days ago, has
been vomiting his dilantin for the past few days
PVD
HTN
s/p appy
h/o DVT
Social History:
Lives with his wife and two children. Has worked on a hog farm
for 25 years. Smokes 1 ppd for past 3 years. Heavy EtOH use 3+
years ago. Heavy drug use 25+ years ago.
Family History:
Sister with [**Name (NI) 4522**] Disease
Physical Exam:
Vit: 98.1 92 138/68 16 95% RA
Gen: middle aged male, scratching furiously throughout
interview, twisting and turning in no apparent pain, very drowsy
once he stopped scratching for more than one minute, no
respiratory distress
HEENT: NC/AT, EOMI, no nystagmus, sclera nonicteric, PERRLA, MM
dry, OP clear
Neck: no JVD
CV: tachycardic, regular rhythm, nl s1, s2, no MGR
PULM: CTAB, no w/c/r
ABD: + BS, soft, NT to light and deep palpation with
distraction, no guarding
GU: normal rectal tone, brown stool in vault, Guaiac neg (per
ED)
EXT: R BKA, removal of multiple digits on left foot, no
peripheral edema, 2+ radial pulses
Neuro: very agitated, moving all extremities equally
Skin: several bleeding excoriations and 1-2 cm ulcerations on
extremities, abdomen, back, buttocks, and legs.
Pertinent Results:
[**10-19**]: SUPINE AND LEFT LATERAL DECUBITUS ABDOMEN: An inferior
vena cava filter is noted, with the apex angle to the patient's
right. The configuration is unchanged compared to the scout view
of the CT of the abdomen in [**2135-8-11**]. Air and stool are
seen throughout the colon and within the rectum. Air is noted
within a couple of nondilated small bowel loops. No soft tissue
masses or calcifications are noted. No free air is visualized on
the left lateral decubitus view.
IMPRESSION: No evidence of obstruction, with air and stool
throughout the colon and in the rectum.
.
[**10-20**]: Repeat Ab films:
IMPRESSION: No evidence of free air. Nonspecific small bowel gas
pattern.
.
EKG: NS, rate 90, left axis, QRS 0.88, PR and QT interval nl, no
STE or STD, TWI in I and aVR
.
EEG:
IMPRESSION: Abnormal portable EEG due to the low-voltage, slow
background. This indicates a wide-spread encephalopathy
affecting both
cortical and subcortical structures. Medications, infections,
and
metabolic disturbances are among the most common causes. The
superimposed faster alpha frequency suggests a medication
effect. There
were no areas of prominent focal slowing, but encephalopathies
may
obscure focal findings. There were no epileptiform features.
.
EGD:
Linear erosions with exudate in the lower third of the esophagus
compatible with erosive esophagitis. Fluids in stomach. Mass in
the cardia. Mass in the gastroesophageal junction. Otherwise
normal egd to second part of the duodenum
.
Admission Labs:
[**2135-10-19**] 04:20PM BLOOD WBC-11.5*# RBC-4.30* Hgb-10.8* Hct-32.4*
MCV-76* MCH-25.1* MCHC-33.2 RDW-16.6* Plt Ct-383#
[**2135-10-19**] 04:20PM BLOOD Neuts-70.2* Bands-0 Lymphs-26.0 Monos-3.0
Eos-0.6 Baso-0.2
[**2135-10-19**] 04:20PM BLOOD PT-12.3 PTT-21.1* INR(PT)-1.0
[**2135-10-19**] 04:20PM BLOOD Glucose-319* UreaN-7 Creat-0.7 Na-134
K-4.1 Cl-97 HCO3-23 AnGap-18
[**2135-10-19**] 04:20PM BLOOD ALT-9 AST-19 AlkPhos-112 Amylase-52
TotBili-0.3
[**2135-10-19**] 04:20PM BLOOD Lipase-32
[**2135-10-19**] 04:20PM BLOOD CK(CPK)-24* CK-MB-NotDone cTropnT-<0.01
[**2135-10-20**] 03:15AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.4*
[**2135-10-19**] 04:20PM BLOOD Phenyto-<0.6*
[**2135-10-20**] 05:29AM BLOOD Phenyto-11.6
[**2135-10-21**] 04:05AM BLOOD Phenyto-9.6*
[**2135-10-22**] 05:00AM BLOOD Phenyto-6.7*
.
Microbio:
[**10-21**] blood cx - no growth
[**10-21**] urine cx - no growth
[**10-21**] sputum cx GRAM STAIN >25 PMNs and <10 epithelial
cells/100X field.
4+ (>10 per 1000X FIELD): GPC IN PAIRS, CHAINS, AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2135-10-23**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
Brief Hospital Course:
# N/V/abdominal pain/GIB - Pt was admitted to medicine for
treament of N/V and abdominal pain, attributed to gastroparesis
and esophagitis (nl amylase and lipase, normal cardiac enzymes,
no SBO on KUB). The night of admission he had an episode of
coffee ground emesis, but refused NG lavage. The following
morning the patient became hypotensive, developed tonic clonic
seizures, and was transferred to the MICU for further
evaluation. In the MICU his hct continued to trend down
32->29->27->23 but bumped to 28 after 2U. Pt was electively
intubated for an EGD which showed esophagitis but no active
bleeding and possible masses at the GE junction, no biopsies
taken. Patient was extubated, returned to floor, diet advanced,
and pt was discharged to home with plans to follow up with Dr.
[**First Name (STitle) 2643**] for repeat EGD and possible PEG placement in the future
given poor nutritional status secondary to recurrent abdominal
pain/gastroparesis.
.
# Hypotension: Pt became hypotensive on the morning of HD#2.
Etiology was felt to be multifactorial including, dehydration
from N/V, volume loss from hematemesis, and multiple medications
for pain and seizure control, in the setting of betablockade.
During the repeated tonic-clonic seizures his BP dropped to 60/p
with HR in the 50's. He required IVF and levophed to maintain
SBP 70-80's. He was transferred to the MICU, received 2 units
PRBCs, IVF, and was able to be weaned from the levophed with
stable BP prior to returning to the floor.
.
# Seizures: The pt has a known history of grand mal seizures,
most recent had been 2 days prior to admission. Due to N/V he
had been unable to hold down his medications. Dilantin level on
admission was <0.6. He was loaded with IV phenytoin 1000mg and
then started on 100 mg IV Q8hrs. However on HD#2 despite his
phenytoin level of 11.6, he had a series of [**4-15**] tonic clonic
seizures requiring ativan IV. Neurology was consulted and pt was
reloaded on phenytoin after transfer to the MICU. CT head showed
unchanged old infarction of the left cerebellar hemisphere and
no acute changes. EEG did not show any epileptiform activity.
Pt had no further seizures while hospitalized. Patient was
eventually restarted on 300 mg dilantin PO QD. Would recommend
follow up of dilantin level as outpatient as pt may require
further dose titration to maintain therapeutic level.
.
# Fever: Patient had a mild fever during his hospitalization and
mild leukocytosis on admission to 11.5. No localizaing symptoms.
Urine cx and blood cx negative. CXR clear. Sputum grew oral
flora and sparse GNR. No treatment given as WBC and fever
resolved.
.
# DM: Continued insulin SS with FS QID. Had patient return to
outpatient regimen at discharge.
.
# Neuropathy - due to DM and PVD. Continued pain control with
oxycodone PO or dilaudid IV in house. Returned to outpatient
regimen with oxycodone and oxycontin at discharge.
.
# FEN: Pt was tolerating a regular diet at d/c.
.
# Psych: Prior to discharge patient was cleared by psychiatry as
competent to make the decision to go home, and understood the
risks of completing further work up as an outpatient.
.
# Dispo: He was very anxious to leave the hospital so that he
would be able to smoke (left the floor once against medical
advice to smoke outside and became very dizzy upon returning to
floor, all VSS). Ultimately the patient was discharged to home
with his wife after his dizziness had resolved.
Medications on Admission:
Meds (per list from his wife):
[**Name (NI) 44137**] 2 pills [**Hospital1 **]
Atenolol 20 mg QD PO
Captopril 25 mg PO BID
Oxycontin 80 mg PO BID
Dilantin 300 mg PO QD
Seroquel 300 mg PO QHS
Maalox PRN
Benadryl PRN
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for gastroparesis.
Disp:*60 Tablet(s)* Refills:*0*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for for pain.
Disp:*6 Tablet(s)* Refills:*0*
5. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO once a day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
bid () as needed for gastroparesis.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastroparesis
Upper GI bleed
Seizure disorder
Diabetes
Discharge Condition:
Fair
Discharge Instructions:
If you develop worsening abdominal pain, nausea/vomiting,
dizziness, bloody stool or if you start vomiting blood, return
to the emergency room immediately.
Followup Instructions:
Please call your PCP ([**Last Name (LF) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 58549**]) tomorrow for
follow up on either Monday or Tuesday of this coming week. You
will need follow up on for your pain management and diabetes
control.
.
Please call 1-[**Telephone/Fax (1) 1983**] to make a follow up appt with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] in the Gastroenterology department.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 53627**]
Completed by:[**2135-11-5**]
|
[
"536.3",
"401.9",
"530.19",
"357.2",
"272.4",
"285.1",
"530.82",
"V58.67",
"250.60",
"V49.75",
"412",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9819, 9825
|
5270, 8730
|
291, 308
|
9933, 9940
|
2575, 4072
|
10145, 10732
|
1708, 1751
|
8995, 9796
|
9846, 9912
|
8756, 8972
|
9964, 10122
|
1766, 2556
|
233, 253
|
336, 1270
|
4088, 5247
|
1292, 1508
|
1524, 1692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,187
| 186,466
|
14365+14366+14367
|
Discharge summary
|
report+report+report
|
Admission Date: [**2171-6-3**] Discharge Date: [**2171-8-23**]
Date of Birth: [**2116-4-4**] Sex: M
Service: MEDICINE
SUMMARIZING THE PREDOMINANCE OF THE [**Hospital **] HOSPITAL
COURSE: The patient was initially admitted to the Trauma
Surgical Service. The patient was admitted from [**Hospital 8641**]
Hospital with the diagnosis of cellulitis of his right thigh.
The patient was transferred for question of necrotizing
fasciitis. The patient was noted to be in atrial
fibrillation, when he arrived at [**Hospital3 **] Hospital. The
patient was also in sepsis with questionable DIC. The
patient also showed elevated liver function tests and
abdominal pain on arrival. In brief, the [**Hospital 228**] hospital
course on the Trauma Service included multiple leg
debridement for necrotizing fasciitis, coverage with
Clindamycin and Oxacillin antibiotics for group A Strep. The
patient was admitted to the Surgical Intensive Care Unit and
antibiotic coverage was expanded at that time to include
Zosyn and Flagyl, as well as fungal coverage with
Fluconazole. The Infectious Disease Service was consulted
and followed the patient through the most of his hospital
course. After several further debridements, in the operating
room, the patient had a skin graft placed on [**7-18**].
Further debridement was done on [**7-20**]. Final skin graft
was performed on [**7-29**]. Wound cultures eventually showed
clean results and antibiotics were discontinued by the
beginning of [**Month (only) 216**].
With regard to the cardiac function, the patient suffered
from volume depletion issues because of insensible losses
from skin wounds during the month of [**Month (only) **] and [**Month (only) 205**]. He had
Swan-Ganz catheter placed in the Surgical Intensive Care
Unit. The patient received IV fluids and diuresis as
necessary to maintain his hemodynamically stability. The
Cardiology Service was consulted at that time for EKG changes
and management of heart failure. CTA was done to rule out
pulmonary embolism. The patient was started on Aspirin,
Lopressor, Beta blockade, ACE inhibitor, and Lovenox. The
patient was stabilized on this cardiac regimen. The patient
was evaluated by the Psychiatric Service during his lengthy
hospital stay. The patient was determined to be depressed,
and he was started on Remeron.
Management of the patient's cardiac function was complicated
by acute renal failure due to antibiotic treatment and
hypotension, which reversed with aggressive fluid repletion.
The patient was also placed on a Fentanyl PCA for pain
control from his multiple surgeries and wound infections.
The patient was determined to be stable from a surgical
standpoint by the Trauma Service by [**2171-8-8**]. The
patient was transferred to the General Medical Service for
further management of cardiac issues and infectious disease
issues. At that time, the Infectious Disease Service
determined that there was no further clear evidence of active
infection. They recommended narrowing and tapering the
patient's antibiotic regimen, which was done successfully and
the patient showed no further evidence of infection by white
count, fever, or hemodynamics. The Surgical Service
continued to follow the patient and recommended open-air
healing for his right thigh wound. They planned more skin
grafts in the future to repair the patient's skin integrity.
The patient's two primary issues with regard to the
cardiovascular status included the following:
FIRST ISSUE: Potential ischemia. The Department of
Cardiology advised continuing Aspirin, titrating up the
patient's beta blockade as tolerate for heart rate and blood
pressure control; Lovenox therapy while being loaded on
Coumadin; and echocardiography.
SECOND ISSUE: Sinus tachycardia, believed to be secondary to
anxiety, pain, and relative hypovolemia. The patient was
continued on his PCA and transitioned to PO narcotic therapy.
Anxiety was continued to be treated with supportive therapy,
pain control, and Remeron. The patient's nutrition was
encouraged with supplemental Boost with meals and aggressive
electrolyte repletion with particular attention to magnesium
and potassium.
The patient was evaluated by the Department of Physical
Therapy and remained in fairly stable condition throughout
his week on the Medicine Service. The patient had an
echocardiogram on [**8-5**], which demonstrated mild
tricuspid regurgitation, depression left ventricular
function, mitral regurgitation, although not quantifiable.
It was determined that the patient had suffered a non ST
elevation MI in the course of his hospitalization due to
hypovolemia and volume shifts as a result of his skin wounds.
Although, it was determined that cardiac catheterization
would not be pursued given his complicated medical and
surgical course.
Medical therapy for his cardiac issues was continued and beta
blockade was titrated as tolerated. In preparation for
discharge to a rehabilitation facility, the patient was
switched from PCA to oral pain control regimen according to
the recommendations of the Pain Control Service.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 7118**]
MEDQUIST36
D: [**2171-8-13**] 16:13
T: [**2171-8-13**] 16:31
JOB#: [**Job Number 42583**]
Admission Date: [**2171-6-3**] Discharge Date: [**2171-8-23**]
Date of Birth: [**2116-4-4**] Sex: M
Service: MEDICINE
CONTINUATION:
At time of this dictation, the plan per the Trauma Surgery
service was for the patient to undergo further skin grafting
to his right thigh site, but that rehabilitation for
approximately one month's time for nutritional
supplementation and strengthening would be advisable. The
patient's ace inhibitor was held near the end of his
hospitalization due to decreasing blood pressure with
increasing beta blockade. The patient remained fairly
tachycardic but this was determined to be secondary to pain
and anxiety, not necessarily to fluid status and intravenous
fluids were discontinued as the patient had good p.o. intake.
PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2160**], with 100%
occluded left anterior descending and right coronary artery
disease. The patient was in paroxysmal atrial fibrillation
on Coumadin as an outpatient.
2. History of congestive heart failure.
3. History of deep vein thrombosis and pulmonary embolus
since football injury, status post inferior vena cava
ligation.
4. Peripheral vascular disease.
5. Depression.
PRESENT ILLNESS: Necrotizing fasciitis. Non ST elevation
myocardial infarction. Tachycardia.
ALLERGIES: No known drug allergies.
DISCHARGE DIAGNOSES:
1. Necrotizing fasciitis.
2. Non ST elevation myocardial infarction.
3. Skin grafting.
4. Congestive heart failure.
5. Tachycardia.
Condition at the time of this dictation was stable.
DISCHARGE STATUS: To be discharged to rehabilitation with
return for further skin grafting when appropriate.
MEDICATIONS AT TIME OF DICTATION:
1. Hydroxyzine 25 mg p.o. twice a day.
2. Tylenol 325 to 650 mg p.o. q4-6hours p.r.n.
3. Calcium Carbonate 500 mg p.o. three times a day p.r.n.
4. Oxycodone 30 mg p.o. q8hours.
5. Zofran 2 mg intravenously q6hours p.r.n.
6. Valium 2 mg p.o. q6hours p.r.n.
7. Nitroglycerin sublingual p.r.n. times three.
8. Sucralfate one gram p.o. four times a day.
9. Lovenox 120 mg subcutaneous q12hours until INR
therapeutic.
10. Enteric Coated Aspirin 325 mg p.o. once daily.
11. Mirtazapine 15 mg p.o. q.h.s.
12. Ferrous Sulfate 325 mg p.o. once daily.
13. Magnesium Oxide 800 mg p.o. three times a day.
14. Warfarin 5 mg p.o. q.h.s.
15. Metoprolol 150 mg p.o. twice a day.
The patient was on a house diet with Boost supplement for
breakfast, lunch and dinner. Wound care to right lower
extremity was left to open air. Wound care to back site,
skin graft donor site, xeroform with absorbable pads changed
as needed only and heat lamp once daily. The patient was
given pneumatic boots for deep vein thrombosis prophylaxis
until INR is therapeutic.
The remainder of hospital course and any updates in
medications, discharge diagnoses or discharge condition will
be updated in a further addendum as needed at the time of
discharge.
GLEM [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M. D.
Dictated By:[**Last Name (NamePattern1) 7118**]
MEDQUIST36
D: [**2171-8-13**] 16:26
T: [**2171-8-13**] 18:29
JOB#: [**Job Number 42584**]
Admission Date: [**2171-6-3**] Discharge Date: [**2171-8-23**]
Date of Birth: [**2116-4-4**] Sex: M
Service: MEDICINE
HOSPITAL COURSE: 1. Cardiac: The patient had three issues
during his hospital course. Ischemia, his non ST elevation
myocardial infarction on [**8-5**] was treated with Lovenox for
72 hours 120 mg b.i.d. and he was also continued on a daily
adult size aspirin and a beta blocker. He had no more
episodes of chest pain during the remainder of his hospital
course and in terms of his ischemic heart disease was deemed
to be stable. Sinus tachycardia, his rate was controlled
with Lopressor, which was titrated up to 150 mg b.i.d. It
was a sinus tach secondary to a hypovolemia after his last
skin graft at the end of [**Month (only) 205**], which is believed to have
caused his non ST elevation myocardial infarction, so his
rate was maintained with the Lopressor at a baseline in the
90s to low 100s with a baseline blood pressure of 80 to
90s/50s to 60s. In addition in order to control the sinus
tachycardia, the patient's pain and anxiety were controlled.
The third cardiac issue is a past medical history significant
for paroxysmal atrial fibrillation. The patient was treated
for 72 hours for his non ST elevation myocardial infarction
with Lovenox and he was started on Coumadin. Lovenox and
Coumadin were overlapped until they became therapeutic on his
Coumadin and INR between 2 and 3 at which point the Lovenox
was discontinued.
2. Infectious disease: In terms of the patient's
necrotizing fasciitis as mentioned in the previous portion of
this discharge summary the patient was treated with multiple
skin debridement and a long course of antibiotics and a skin
graft a donor site from his back to his right thigh. The
antibiotics were discontinued on [**8-8**]. Infectious
disease had signed off saying that he had no further evidence
of infection and during his hospital stay at the Medicine
Service his skin graft was followed by the Trauma Surgery
Service and was deemed to be steadily improving. On [**2171-8-17**] the patient had a PICC line in the right antecubital
area, which was pulled, because the area of insertion was
erythematous and slightly indurated. At that time the
patient did not have an elevated white blood cell count and
was not afebrile. A culture from the PICC line tip was sent,
which on [**2171-8-19**] revealed an MRSA culture greater
then 15 colonies. At this point the patient still had no
evaluated white count and his highest temperature was 100.4.
Infectious disease was reconsulted and the patient was begun
on a course of intravenous Vancomycin 1 gram q 12 hours. On
[**8-20**] the patient had a PICC line placed in the left arm
by interventional radiology for the administration of the
intravenous Vancomycin. The patient's white count had still
be stable and not elevated. On [**8-21**] it is 6.2 and his
temperature today is 99.3.
3. Fluids, electrolytes and nutrition: During his hospital
course when admitted to the Medical Service on a intravenous
fluids of normal saline with 40 milliequivalents of potassium
chloride and was on Boost for breakfast, lunch and dinner and
house diet. Eventually the intravenous fluids were
discontinued and the patient's electrolytes were followed
closely. They were repleted as necessary. The patient over
the course of his hospital stay gradually started taking
better po, drinking his Boost and eating his meals and his
urine output was adequate and he did have adequate bowel
movements.
4. Hematology: The patient had a stable hematocrit in the
low 30s. On [**2171-8-13**] the patient was transfused one
unit of red blood cells, because of concern that his sinus
tachycardiac might be due to his decreased oxygen delivery
with his substantial wound healing. His hematocrit increased
the next day to 32.7. The patient was administered 325 mg of
iron three times a day. His anemia is likely an anemia of
chronic disease as iron studies were drawn and laboratories
were consistent with this picture.
5. Pain: The patient was admitted on a Fentanyl PCA with
Oxycodone in addition 30 mg every eight hours. This was
discontinued and the patient was placed on oral morphine 60
mg every eight hours with instant relief for breakthrough
pain. On [**2171-8-20**] this was deemed to be inadequate
for the patient's pain coverage and he was placed on a
morphine PCA. The plan is pain wise is to monitor how much
morphine he is using and then switch him back to the
analgesic equivalent dose of oral morphine so that we can
transition him to a po medication rather then a PCA.
6. Psychiatric: The patient had a psychiatry consult while
in the hospital and they recommended Remeron 30 mg every
evening for depression and Zyprexa 2.5 mg as needed for
anxiety.
7. Physical therapy: They have been following him and
seeing him approximately three times a week. They have been
taking him to the chair and they feel that he is improving.
The condition of the patient at this time is stable.
DISCHARGE DIAGNOSES:
Necrotizing fascitis.
He is to follow up at his rehabilitation hospital.
DISCHARGE MEDICATIONS: Lopressor 150 mg b.i.d., aspirin 325
mg q.d., Coumadin 2.5 mg q.h.s., Vancomycin 1 gram q 12 hours
delivered by intravenous today is day two of what should be a
seven day course. He is on a morphine sulfate PCA without a
basal rate, a 1.5 mg injection every time he presses the
button with a six minute lock out. He is on a fluocinolone
ointment and _________ ointment, sublingual nitro prn for
chest pain, Benadryl prn for urticaria, Hydroxizine 25 mg
b.i.d., _______________ 30 mg q.h.s., iron sulfate 325 mg
t.i.d., magnesium oxide 800 mg t.i.d., calcium carbonate 500
mg t.i.d. as needed and sucralfate 1 gram q.i.d.
The plan is for Mr. [**Name13 (STitle) **] is to follow up at his
rehabilitation hospital to eventually wean him off of his PCA
and to discontinue the intravenous Vancomycin once his blood
cultures come back from [**8-19**] and he is to see the
attending surgeon Dr. [**Last Name (STitle) **] in two weeks for follow up
to discuss the next skin graft, which should be in a few
months.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**First Name8 (NamePattern2) 42585**]
MEDQUIST36
D: [**2171-8-22**] 14:12
T: [**2171-8-22**] 09:55
JOB#: [**Job Number 42586**]
|
[
"410.91",
"728.86",
"428.0",
"682.6",
"276.5",
"427.31",
"584.9",
"286.6",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.69",
"86.11",
"86.22",
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
13653, 13728
|
13752, 15007
|
8741, 13404
|
13423, 13632
|
6182, 6743
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,286
| 188,083
|
5419
|
Discharge summary
|
report
|
Admission Date: [**2116-4-3**] Discharge Date: [**2116-4-13**]
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with
a history of coronary artery disease, status post myocardial
infarction at age 35 and six vessel coronary artery bypass
graft in [**2108**] who presented with new onset of chest pressure
associated with shortness of breath, dizziness, palpitation
and nausea starting at around 10 AM on the day of admission.
The pain started at breakfast and it radiated to her throat
and left arm. It was 7 out of 10 in onset and progressed to
10 out of 10 about one hour later. She took one sublingual
nitroglycerin without significant improvement. She called
her cardiologist, Dr. [**Last Name (STitle) 11679**] who told her to call 911. She
was brought in by Emergency Medical Services and she felt
better after being given oxygen and two baby Aspirin (the
patient had taken her baby Aspirin 81 mg in the morning
before the episode). Of note, the patient also fell during
the episode secondary to her left leg weakness. In the
Emergency Room she was found to be in rapid atrial
fibrillation with heartrate of 170, blood pressure 148/78,
oxygen saturation 99% on 2 liters. She was given one dose of
25 mg intravenous Diltiazem and her rhythm went back into
sinus. She was admitted for rule out myocardial infarction.
PAST MEDICAL HISTORY: Coronary artery disease, status post
myocardial infarction at age 35, status post six vessel
coronary artery bypass graft in [**2108**]. Aortic stenosis.
Echocardiogram in [**2115-7-6**] showed moderately severe aortic
stenosis with significant progression since [**2114-8-5**],
aortic valve increased from 3 to 4.1 and gradient from 36 to
69. The aortic valve area estimated to be .7 cm. Recent
admission to [**Hospital 882**] Hospital three weeks ago or syncopal
episode, etiology thought to be vasovagal in the setting of
moderately severe aortic stenosis. Rheumatoid arthritis in
the past three years on chronic Prednisone and Methotrexate.
History of upper gastrointestinal bleeding, secondary to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, status post right carotid endarterectomy
in [**2112**]. Status post episode of pneumonia. Status post from
outside hospital, exercise stress test in [**2113-7-6**].
Heartrate maximum at 123, stopped secondary to shortness of
breath, no chest pain or anginal symptoms. No significant
electrocardiogram changes. Perfusion scan is normal. Normal
wall motion, normal ejection fraction. Echocardiogram in
[**2115-7-6**] showed left atrial dilatation. Concentric left
ventricular hypertrophy, aortic valve peak gradient 69.6,
mean of 31.9, aortic valve area estimated to be .7 cm, 2 to
3+ mitral regurgitation. PA pressure increased to 45 mm
mercury. Left ventricular ejection fraction estimated to be
60%. No wall motion abnormality. Left ventricular size and
function were normal. Right ventricular size and function
were normal.
ALLERGIES: Motrin and Aspirin causing bleeding.
MEDICATIONS ON ADMISSION: Baby Aspirin 81 mg p.o. q.d.;
Zocor 80 mg p.o. q.d.; Prilosec 20 mg p.o. q.d.; Methotrexate
7.5 mg q. Saturday; Prednisone 5 mg p.o. q.d.; Atacand 16 mg
p.o. q.d.; Folgard 1 p.o. q.d.; Fosamax 70 mg q. Sunday;
Lasix 40 mg p.o. q.d.; Vitamin E; multiple vitamin; Atrovent
2 puffs t.i.d.
SOCIAL HISTORY: No cigarettes for 45 years. Had a history
of 60 pack year history. Social alcohol, has not been
drinking for two years. Lives alone. Never married and had
no children.
FAMILY HISTORY: Mother died at age 67, father died at age
72, brother died at age 62 all secondary to heart disease,
sister at age 71 with heart problems.
REVIEW OF SYSTEMS: Syncopal episode three weeks ago,
admitted to [**Hospital 882**] Hospital, etiology thought to be
vasovagal in the setting of moderate severe aortic stenosis.
Has been feeling tired in the past one to two weeks. Three
pillow orthopnea in the past year. Increased from two pillow
orthopnea, had been feeling increasingly weak in the past
year, with decreased activity. Positive for claudication and
paroxysmal nocturnal dyspnea.
PHYSICAL EXAMINATION: Physical examination on admission
revealed the patient to be afebrile, temperature 97.3, blood
pressure 116/72, heartrate 76, respirations 22, oxygen
saturation 96% on room air. In general, pleasant elderly
lady, lying in bed in no acute distress. Head and neck
examination anicteric, sclera, jugulovenous pressure not
elevated. Mucous membranes moist. Cardiovascular, regular
rate and rhythm, IV/VI systolic ejection murmur, loudest at
the left upper sternal border, radiating through the
precordium and bilateral carotids can be heard. Lungs, clear
to auscultation bilaterally. Abdomen soft, nondistended,
nontender. Bruit can be heard at bilateral renal artery,
(questionable radiating murmur from the aortic stenosis).
Extremities, no edema, good distal pulses, bilateral bruits
can be heard at the femoral artery sites (questionable
radiating murmur from aortic stenosis).
LABORATORY DATA: Laboratory studies on admission revealed
hemoglobin 13.7, hematocrit 33.3, platelets 368, 85%
neutrophils, 8% lymphocytes, 4% monocytes and 3 eosinophils.
MCV 80, sodium 137, potassium 4.1, chloride 103, bicarbonate
21, BUN 37, creatinine 1.3, glucose 103. PT 12.6, PTT 26.6,
INR 1.0. Chest x-ray, slight prominence of pulmonary
vasculature and upper zone with distribution suggestive of
congestive heart failure, no effusions or infiltrates.
Electrocardiograms on admission showed atrial
fibrillation/atrial flutter, rhythm at a rate of 152, normal
axis, Q waves in III and AVF, questionable left ventricular
hypertrophy.
HOSPITAL COURSE: The patient was given sublingual
nitroglycerin and Diltiazem in the Emergency Room. Her
atrial fibrillation and atrial flutter was terminated with
one dose of intravenous Diltiazem. She has remained chest
pain free in the Emergency Room. She was started on
Amiodarone for atrial fibrillation and Lovenox for acute
coronary syndrome. She was worked up with seronegative
cardiac enzymes. She has remained in sinus rhythm on
telemetry while she was on the floor. She had a repeated
echocardiogram which showed mildly dilated left atrium and
normal left ventricle with ejection fraction of about 55%.
The right ventricle is normal. She had moderate aortic
stenosis, mild aortic regurgitation, 2+ mitral regurgitation,
no effusion was seen on the examination. She also had an
magnetic resonance imaging scan, magnetic resonance
angiography of her brain given her history of right carotid
endarterectomy and syncopal episode three weeks ago which
showed mild narrowing of the left carotid artery at the
bifurcation, small irregularity at the right carotid artery
bifurcation. There was also found chronic microvascular
ischemia changes. No major vascular territory infarction.
She went for diagnostic catheterization on [**4-7**], to
evaluate her coronary artery bypass graft paths and aortic
stenosis which showed right dominant situation disease with
proximal aneurysm with severe native three vessel deep
coronary artery disease, left main coronary artery was
diffusely diseased with 80% distal narrowing. The left
anterior descending was aneurysmal dilated at its ostium and
was staying diffusely diseased throughout its course with
stenosis up to 90% and finally it occluded in the mid vessel.
The left circumflex was diffusely diseased with a 90% ostial
lesion. The right coronary artery was diffusely diseased and
subtotally occluded to 99% throughout its course. The graft
angiograph demonstrated a treated left internal mammary
artery which was totally occluded in the mid vessel,
saphenous vein graft to posterior descending artery was
widely patent and filled moderately sized posterior
descending artery and PLV branches as well as diffusely
diseased distal right coronary artery via retrograde flow.
Saphenous vein graft to D1 with jump graft to obtuse marginal
2 was widely patent, though seemed to fill left anterior
descending, left circumflex and left main coronary artery via
retrograde flow. Saphenous vein graft to obtuse marginal 1
(likely cord saphenous vein graft to R1 in the coronary
artery bypass graft report), was widely patent. Attempts to
find additional proximal saphenous vein graft to distal left
anterior descending were unsuccessful. Resting hemodynamics
revealed mildly elevated left ventricular field pressure with
left ventricular end diastolic pressure of 17 mm of mercury
in the setting of mild systemic arterial hypertension. There
was evidence of some primary pulmonary hypertension with PA
pressure of 43/10/25 mm of mercury and pulmonary vascular
resistance of 209. The cardiac output was preserved at 4.6
liters/minute. The aortic valve assessment revealed a mean
gradient of 48 mm of mercury and a calculated aortic valve
area of .7 cm to a left ventricular graft, demonstrating mild
anterior and apical hypokinesis with a calculated left
ventricular ejection of 48%. Moderate (2+) mitral
regurgitation was seen. Unfortunately, post catheterization
the patient developed the sudden onset of dense right-sided
hemiplegia. Urgent magnetic resonance imaging scan and
magnetic resonance angiography was performed which revealed a
new area of restricted effusion involving a portion of two
post superior left frontal gyri and underlying white matter
in the region of the distal left right coronary artery
territory consistent with acute embolic stroke. Magnetic
resonance angiography revealed good flow in the distal
internal carotid artery, the distal vertebral artery and
basilar artery. There is some irregularity at the junction
of the distal vertebral artery and the basilar artery,
unchanged from the magnetic resonance angiography scan two
days ago. The major branches of the cerebral artery remained
symmetric and good flow is seen in both segments without
change. No evidence of major vascular occlusion. No
thrombolytics were given for the acute strokes since the
patient just had cardiac catheterization. The patient was
admitted to CCU over night for observation after two strokes.
She received one unit of packed red blood cells in the unit
for a hematocrit of 29.3. She was also given Hydrocortisone
50 mg intravenously q. 6 for episodes of hypotension. Her
systolic blood pressure will be maintained between 130s to
170s for severe perfusion after acute strokes. Plavix was
also started after acute stroke. Lasix was also added. The
patient's right-sided cranial nerve deficits including facial
droop, speech and swallow improved significantly after acute
stroke. However, her right arm and leg weakness remained
severe. She can only move her right fingers and right thigh
a little bit. She had repeated magnetic resonance imaging
scan, magnetic resonance angiography two days later which
revealed subacute infarction of the left parietal lobe
involving the premodel and model cortex. The majority
tributaries of bruits are patent. No mass effect was seen.
The patient has remained relatively stable otherwise.
Metoprolol was discontinued given her relative hypotension
with systolic blood pressure 110 to 130. The patient was
evaluated by a physical therapist and rehabilitation was
recommended for acute stroke.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: [**Location (un) 511**] [**Hospital 13247**] Hospital for acute
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Acute left anterior cerebral artery stroke
2. Unstable angina, rule out myocardial infarction
3. New onset atrial fibrillation
4. Aortic stenosis
5. Coronary artery disease, status post six vessel coronary
artery bypass graft
6. Rheumatoid arthritis
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Metoprolol 12.5 mg p.o. b.i.d., hold for systolic blood
pressure less than 140
4. Zocor 80 mg p.o. q.d.
5. Amiodarone 400 mg p.o. q.d., switched to 200 mg p.o. q.d.
[**4-13**]
6. Prevacid 30 mg p.o. q.d.
7. Prednisone 5 mg p.o. q.d.
8. Iron Sulfate 325 mg p.o. q.d.
9. Atrovent 2 puffs q.i.d.
10. Multivitamin one tablet p.o. q.d.
11. Alendronate 70 mg p.o. q. Sunday
12. Methotrexate 7.5 mg p.o. q. Saturday
13. Flovent 2 puffs b.i.d.
14. Colace 100 mg p.o. b.i.d.
15. Dulcolax 10 mg p.o. q.d., hold for bowel movements
greater than two per day
16. Maalox prn for heartburn
17. Tylenol prn for pain
Diet - Cardiac diet.
DISCHARGE FOLLOW UP: Follow up with Dr. [**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**]
(patient's cardiologist) as an outpatient. Please call Dr.[**Name (NI) 21977**] office at [**Telephone/Fax (1) 21978**] for appointment. Dr.
[**Last Name (STitle) 11679**] can also follow the patient at [**Hospital1 21979**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 21981**]
MEDQUIST36
D: [**2116-4-12**] 15:18
T: [**2116-4-12**] 15:26
JOB#: [**Job Number 21982**]
|
[
"416.0",
"414.01",
"E878.8",
"427.31",
"496",
"396.2",
"411.1",
"996.72",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"38.91",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
11416, 11525
|
3628, 3768
|
11829, 12527
|
11546, 11806
|
3134, 3421
|
5790, 11394
|
12539, 13104
|
4242, 5772
|
3788, 4219
|
131, 143
|
172, 1417
|
1440, 3107
|
3438, 3611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,350
| 121,841
|
44697
|
Discharge summary
|
report
|
Admission Date: [**2133-7-29**] Discharge Date: [**2133-8-1**]
Service: MEDICINE
Allergies:
Flagyl / Proton Pump Inhibitors (Benzimidazole)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PICC line placed
History of Present Illness:
Mr [**Known lastname 9779**] is an 85 year old man with history of diastolic heart
failure, copmlete heart block (now s/p PPM [**6-7**]) ESRD, now on
HD, h/o MRSA bacteremia and thrombocytopenia, likely secondary
to drug reaction (PPI?) presenting with abdominal pain and
altered mental status from rehab facility. Of note, patient had
been discharged on [**7-27**] after a 10 day admission for MRSA
Bacteremia (last positive culture [**2133-7-16**]).
.
Patient has had a complicated recent history, starting with
elective admission for d/c cardioversion of atrial fibrillation
on [**6-7**], complicated by tachy/brady syndrome requiring permanent
pacemaker, c diff infection, acute on chronic renal failure
requring initiation of dialysis and most recently MRSA bactermia
[**1-31**] HD line infection.
.
Patient transferred from [**Hospital3 **] after we was
found to have a temp of 94.5 (no information of route) HR 82-112
RR: 22 BP: 98/78 O2 sat 94% @2L NC. Paitent was found to have
nausea, vomiting, increased lethargy and upper abominal pain /
tenderness.
In ED (per report) patient's son refused new blood draws. CT
abdomen/pelvis was performed and did not reveal any acute
process. OSH labs:
WBC: 10.5, HCT: 27.9, PLTS: 104.
Na 140, K 4.5, Cl 99, CO2 31, BUN 25, Cr 6.0.
ALB 3.0, PHOS 4.9, T Bili 1.0, ALK PHOS 140, AST 23, ALT 18, [**Doctor First Name 674**]
76, LIP 42, TnI 0.17.
VANC: 19.3
.
.
ROS: Patient reports abdominal pain, denies chest pain, fevers,
cough, or difficulty breathing. Otherwise per HPI.
Past Medical History:
# Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% &
severe LVH
# Atrial fibrillation previously on Coumadin (until GI bleed
[**6-7**]), failed cardioversion
# s/p Pacemaker placement [**6-7**] for complete heart block
# Peripheral vascular disease s/p right lower extremity bypass
# Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**]
CT)
# Hypertension
# Gout
# ?Prostate followed by Urology (denies symptoms of BPH)
# Chronic Kidney Disease ([**3-7**], Cr 2.2, stage III, est GFR 35)
Social History:
Patient has an insurance business and worked daily until recent
sicknesses. No current tobacco use. There is no history of
alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Patient's daughter had "kidney disease" and is
now s/p renal transplant. 2 sons and 1 daughter.
Physical Exam:
Temp: 95.2 HR: 72 BP: 97/78 RR: 17 O2 Sat: 100% 4L NC
.
GEN: No acute distress, somnolent, arousable
SKIN: Dry, warm, lower extremity chronic venous changes
HEENT: EOMI, dry mucous membranes
NECK: No cervical lyphadenopathy, no thyromegaly
CV: Regular rate, no murmurs, rubs or gallops
LUNGS: Clear to auscultation bilaterally
ABD: Soft, some voluntary guarding, no rebound tenderness
NEURO: Somnolent, arousable, CN II-XII intact, (+) Asterixis
Pertinent Results:
==================
ADMISSION LABS
==================
[**2133-7-29**] 09:41PM BLOOD WBC-9.8 RBC-2.86* Hgb-9.7* Hct-31.2*
MCV-109* MCH-33.8* MCHC-31.1 RDW-16.8* Plt Ct-132*
[**2133-7-29**] 09:41PM BLOOD Neuts-80.1* Bands-0 Lymphs-9.9* Monos-2.5
Eos-7.3* Baso-0.3
[**2133-7-29**] 09:41PM BLOOD PT-14.3* PTT-44.7* INR(PT)-1.2*
[**2133-7-29**] 09:41PM BLOOD Glucose-110* UreaN-30* Creat-6.3* Na-139
K-5.5* Cl-100 HCO3-30 AnGap-15
[**2133-7-29**] 09:41PM BLOOD ALT-19 AST-32 LD(LDH)-275* AlkPhos-149*
Amylase-67 TotBili-0.6
[**2133-7-29**] 09:41PM BLOOD Albumin-3.7 Calcium-9.4 Phos-6.1*# Mg-2.6
UricAcd-7.4*
[**2133-7-29**] 09:41PM BLOOD Cortsol-29.6*
[**2133-7-29**] 09:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-7-30**] 01:31AM BLOOD Vanco-30.7*
[**2133-7-29**] 09:28PM BLOOD Type-ART pO2-117* pCO2-73* pH-7.23*
calTCO2-32* Base XS-0
[**2133-7-29**] 09:28PM BLOOD Glucose-109* Lactate-1.0 Na-137 K-4.9
Cl-97* calHCO3-32*
Brief Hospital Course:
#. Altered mental status: Differential diagnosis was very broad
in this frail patient with several medical conditions, including
intracraneal process, systemic infection, delirium, etc. At
presentation, given x-ray findings this was felt to most likely
represent hospital acquired pneumonia. Patient was initiated on
Vancomycin, add Zosyn and azithromycin for atypical coverage.
Cultures were obtained and after very prompt improvement,
antibiotic regimen was narrowed. After no evidence of infection
was found, antibiotics were discontinued and the patient
continued to improve. It appears this episode of altered mental
status and somnolence was not far from his baseline, currently
there is no evidence of systemic infection.
.
#. Hypotension: On admission, concern for sepsis physiology,
although as above no signs of infection at this time. Patient
also evaluated for adrenal insufficiency, with a normal
cosyntropin stimulation response. Patient placed back on
midodrine at time of discharge, tolerating dialysis well.
.
#. Hypoxia / Hypercarbia: Likely secondary to restrictive
process from intrathoracic stomach. Episode has improved without
further intervention, patient discharged on 2L NC.
.
#. H/O MRSA Bacteremia: Cultures remained negative this
hospitalization, 14 day course of Vancomycin completed [**2133-8-1**],
patient given last dose after dialysis.
.
#. End Stage Renal Disease: We continued HD per outpatient
schedule on [**Month/Day/Year 766**], Wednesday, Friday.
.
#. C Diff colitis: Patient with (+) C diff tox x 3 during last
admission, completing 14 day course of Abx, currently on PO
Vancomycin x 4 more days.
.
#. Pleural Effusions: Chronic effusions bilaterally, do no
appear to be changed at this time.
.
#. Diastolic heart failure: Last ECHO [**2133-7-17**] with EF >55% and
mild mitral regurgitation.
.
#. Atrial Fibrillation: Currently paced, not active issue. We
continued amiodarone 200mg [**Hospital1 **], and did not anticoagulate given
recent history of lower GI bleeding, defer restarting
anticoagulation to primary care team.
.
#. Thrombocytopenia: Per OMR, Drug reaction vs MDS. , with HIT
panel negative, not active during this admission.
.
#. FEN: Diet advanced to regular
.
#. Prophylaxis: SC Heparin
.
#. CODE: Patient remained DNR/DNI, clarified with son, [**Name (NI) **]
(HCP)
.
#. Access: Tunneled HD line ([**2133-7-24**])
.
#. Contact: [**Name (NI) **], [**Name (NI) **] ([**Telephone/Fax (1) 95637**]
Medications on Admission:
Ferrous Sulfate 325mg
Amiodarone 200mg [**Hospital1 **]
simethicone 80mg
Acetaminophen
Calcium Acetate 667mg TID
Vanc igm with HD
Midodrine 5mg TID
Vancomycin 250mg PO (last day [**2133-8-3**])
Lactulose PRN
Bisacodyl
Senna
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
8. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO three
times a day.
11. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ml PO
twice a day as needed for constipation.
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
13. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] [**Hospital 24920**] Rehab
Discharge Diagnosis:
PRIMARY:
Respiratory distress
Altered Mental status
Discharge Condition:
Hemodynamically stable, with systolic blood pressure in 90's to
100's
Discharge Instructions:
You were admitted to the hospital after you were found to be
somolent and less interacive. We evaluated you for any signs of
infection and did not find any indication that you are currently
infected. You improved back to baseline and you are now ready
for discharge back to your rehabilitation facility.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please take all medications as prescribed and keep all doctors
[**Name5 (PTitle) 4314**]. If you experience any chest pain, shortness of
breath, or any other new symptom that concers you, please seek
medical attention.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-31**] weeks.
|
[
"780.09",
"274.9",
"038.11",
"403.91",
"V45.01",
"585.6",
"426.0",
"008.45",
"995.91",
"428.0",
"V09.0",
"427.81",
"511.9",
"518.83",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8073, 8145
|
4208, 4219
|
276, 295
|
8241, 8313
|
3219, 4185
|
8986, 9071
|
2559, 2737
|
6940, 8050
|
8166, 8220
|
6691, 6917
|
8337, 8963
|
2752, 3200
|
215, 238
|
323, 1845
|
4234, 6665
|
1867, 2387
|
2403, 2543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,583
| 160,132
|
6412
|
Discharge summary
|
report
|
Admission Date: [**2140-4-12**] Discharge Date: [**2140-4-14**]
Date of Birth: [**2065-8-1**] Sex: M
Service: SURGERY
Allergies:
Sulfonamides / Lipitor / Naprosyn / Penicillins / Amoxicillin /
Chocolate Flavor / Crestor / Morphine / Ativan / Vancomycin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Left carotid stenosis
Major Surgical or Invasive Procedure:
[**2140-4-12**] Left CEA
History of Present Illness:
This 75-year-old gentleman has been followed for a number of
years with left carotid stenosis, progressively worsening over
time without associated symptoms
and now in a very critical greater than 90% range
Past Medical History:
1 CAD - s/p LAD and OM1 stent in [**8-2**], s/p RCA PTCA in '[**28**]
2. NIDDM
3. HTN
4. PVD s/p bilat LE bypass surgeries (Dr.[**Last Name (STitle) **])
5. ESRD on HD MWF
6. cataracts
7. gout
8. BPH
9. Abd hernia
10. s/p CCY, ex-lap w/abd hernia resulting
11. Incarcerated ventral hernia containing strangulated small
bowel and requiring small bowel resection. This was complicated
by a leak leading to re-operation and intubation.
Social History:
Worked as head [**Doctor Last Name 7051**]. Hx Etoh abuse x 20 yrs, but quit [**2124**]. 86
ppy tob. Multiple family memebrs live nearby.
Family History:
Fa: died secondary to colon ca
Mo: died secondary to PNA
Siblings: Etoh abuse, HTN
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
Pertinent Results:
[**2140-4-14**] 04:03AM BLOOD WBC-7.0 RBC-3.05* Hgb-9.5* Hct-29.2*
MCV-96 MCH-31.0 MCHC-32.5 RDW-14.9 Plt Ct-191
[**2140-4-14**] 04:03AM BLOOD PT-13.8* PTT-25.5 INR(PT)-1.2*
[**2140-4-14**] 04:03AM BLOOD Glucose-109* UreaN-49* Creat-7.9*# Na-138
K-4.3 Cl-91* HCO3-32 AnGap-19
[**2140-4-14**] 04:03AM BLOOD Calcium-8.9 Phos-6.1* Mg-1.8 UricAcd-7.1*
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname 1955**] was admitted on [**4-12**] with Left carotid artery
Stenosis. He agreed to have an elective surgery.
Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a Left carotid artery
endarectomy.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note pt was on IV Nitro for BP control. He denied HA at this
time. On DC his SBP is less then 140.
Pt staples were taken out from neck wound. He was clipped and
stripped. He has an follow-up appointment with arterial duplex
in 4 weeks with Dr [**Last Name (STitle) **].
Medications on Admission:
Amlodipine 10', Lisinopril 40', Colchicine 0.6', Prilosec 40'',
Pravastatin 60', Zoloft 25', Renagel 1600''', ASA 81'
Discharge Medications:
1. Colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
3. Pravastatin 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Sertraline 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
6. Sevelamer HCl 400 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-1**]
Drops Ophthalmic PRN (as needed).
9. Lisinopril 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Percocet 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO four times a
day for 10 days: prn.
Disp:*20 Tablet(s)* Refills:*0*
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Day (2) **]: One (1) Cap
PO DAILY (Daily).
13. Sertraline 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
asymptomatic left carotid stenosis (pre-op)
PMH:
ESRD on HD
Complete heart block (paced)
CHF (EF 45%)
HTN
Gout
Chol
NIDDM
GERD
MRSA bacteremia
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Month/Day (2) **] and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call [**Month/Day (2) 1106**] surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2140-5-17**]
10:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-5-16**]
1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2140-5-16**] 2:00
Completed by:[**2140-4-14**]
|
[
"600.00",
"366.9",
"998.12",
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"443.9",
"250.00",
"414.01",
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"403.91",
"428.22",
"426.0",
"433.10",
"E878.8",
"274.9",
"V45.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.12",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5260, 5266
|
2252, 3755
|
404, 431
|
5453, 5462
|
1880, 2229
|
8490, 8891
|
1299, 1384
|
3923, 5237
|
5287, 5432
|
3781, 3900
|
5486, 7776
|
7802, 8467
|
1399, 1861
|
343, 366
|
459, 667
|
689, 1126
|
1142, 1283
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,518
| 104,847
|
9113
|
Discharge summary
|
report
|
Admission Date: [**2101-7-11**] Discharge Date: [**2101-8-18**]
Date of Birth: [**2050-8-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
nausea, vomiting, dysuria
Major Surgical or Invasive Procedure:
[**2101-7-22**] Incision and Drainage of perinephric Mass
[**2101-7-27**]: Resection of medial [**1-24**] of right clavicle. Resection
of sternoclavicular joint. Partial resection of sternum and
costochondral junction of the 1st rib.
[**2101-8-3**] 1. Surgical preparation of chest wound 12 x 12 cm.
2. Pectoralis myofascial flap.
3. Local tissue advancement and rearrangement of skin for
closure of chest defect 12 x 12 cm.
Right thoracentesis with chest tube placement and subsequent
removal
History of Present Illness:
This is a 50 year old female with PMH of asthma, questionable
TIA vs. complex migraine 2 months ago, poorly controlled DM1
with last A1C of 13 and HTN c/b ESRD s/p living related donor
renal transplant in [**2092**] presenting with 4 days of dysuria and 2
days of nausea and non-bloody, non-bilious emesis. She was seen
today at her PCP's office and referred to the ED after being
found to be orthostatic with a BP of 118/62 lying, 82/36
sitting, and 70/40 standing. She has had no urinary frequency or
hematuria and was noted to be extremely anxious about potential
renal failure. Of note, she was also seen last week for fever to
102, cough, and diarrhea and prescribed azithromycin with
resolution of her symptoms. She currently denies any F, abd
pain, diarrhea, constipation, or cough. She has been having some
chest burning likely related to esophageal irritation from
frequent vomiting. She has also been having some right shoulder
pain which she attributes to an injury she had from grabbing the
toilet in an episode of violent vomiting. She has also noted
dyspnea on exertion and chills as of late.
.
In ED, vitals were 98.2 82 129/58 16 97% RA. Per her PCP's exam,
she was noted to have some difficulty standing for orthostatics
and mild epigastric tenderness. She was also noted to have right
shoulder pain worse with movement, coughing, and lifting. On ED
exam her graft was not TTP. Per the [**Last Name (LF) **], [**First Name3 (LF) **] EKG did not show any
changes from prior. A CXR was also performed and did not show
any acute cardiopulmonary abnormality per the ED. A renal
transplant ultrasound was performed but not reviewed in the ED.
Labs were significant for a WBC count of 25.4, thrombocytosis to
980, floridly positive UA, hyponatremia to 127, creatinine of
2.5, and an anion gap of 15. She was given
Maalox/simethicone/lidocaine which did not help her chest
burning and she reported vomiting it up, morphine 4mg IV for
right shoulder pain, cipro 400mg IV, and 2L of NS. Blood
cultures were performed, but urine culture was not sent. She was
admitted for UTI and acute renal failure. Most recent vitals:
97.8 108 124/56 18 100RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest tightness,
palpitations. Denied diarrhea, constipation.
Past Medical History:
-Hypertension
-Type 1 diabetes since [**2063**], poorly controlled with last A1C of
13
-Asthma
-ESRD s/p living-related renal transplant in [**2092**]
-TIA vs. complex migraine in [**5-2**], started on Plavix thereafter
Social History:
She lives with her mother at home and is her mother's primary
caretaker. [**Name (NI) **] brother has flown in from [**Name (NI) 4565**] to care for
her while she is hospitalized. She does not have any children
but reports good social support from friends and [**Name2 (NI) **]-workers. She
works for the Massport website full-time. She does not smoke or
drink EtOH.
Family History:
Father had ALS but otherwise not significant.
Physical Exam:
ADMISSION:
VS - Temp=99.2, BP=102/60, HR=110, R=20, O2-sat 99% RA
GENERAL - well-appearing female in NAD, comfortable,
appropriate, with intermittent chills noted
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no JVD.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tachycardic, 2/6 SEM noted
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-26**] throughout, sensation grossly intact throughout.
DISCHARGE:
General: no longer with intermittant rigors
Heart: RRR, 2/6 SEM at RUSB
Lungs: rales at the bases of the posterior lung fields
bilaterally
Extremities: 2+ pitting edema in the lower extremities
bilaterally
Otherwise unchanged from admission
Pertinent Results:
ADMISSION LABS:
[**2101-7-11**] 02:16PM BLOOD WBC-25.4*# RBC-4.34 Hgb-11.1* Hct-35.1*
MCV-81*# MCH-25.4* MCHC-31.4 RDW-13.0 Plt Ct-980*
[**2101-7-11**] 02:16PM BLOOD Neuts-92.1* Lymphs-5.5* Monos-1.6*
Eos-0.7 Baso-0.2
[**2101-7-11**] 02:16PM BLOOD Plt Ct-980*
[**2101-7-13**] 04:35AM BLOOD PT-14.2* PTT-33.9 INR(PT)-1.2*
[**2101-7-11**] 02:16PM BLOOD Glucose-187* UreaN-70* Creat-2.5*#
Na-127* K-4.6 Cl-91* HCO3-21* AnGap-20
[**2101-7-11**] 02:16PM BLOOD ALT-13 AST-15 AlkPhos-108* TotBili-0.3
[**2101-7-11**] 04:22PM BLOOD Type-[**Last Name (un) **] pO2-66* pCO2-29* pH-7.30*
calTCO2-15* Base XS--10 Comment-GREEN TOP
PERTINENT LABS:
[**2101-7-16**] 04:20AM BLOOD ESR-24*
[**2101-8-11**] 06:40AM BLOOD ALT-14 AST-28 LD(LDH)-366* AlkPhos-120*
TotBili-0.3
[**2101-8-8**] 04:55AM BLOOD Lipase-8
[**2101-8-8**] 04:55AM BLOOD cTropnT-<0.01
[**2101-7-13**] 04:35AM BLOOD calTIBC-139* Hapto-362* TRF-107*
[**2101-7-16**] 12:50PM BLOOD CRP-194.9*
[**2101-7-22**] 04:25AM BLOOD PEP-NO SPECIFI
[**2101-7-26**] 11:05AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2101-7-26**] 11:05AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2101-7-22**] 04:25AM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA
BASED-Test
[**2101-7-18**] 12:46PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2101-7-16**] 12:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
[**2101-7-16**] 12:50PM BLOOD B-GLUCAN-Test
[**2101-7-15**] 05:45PM BLOOD ADENOVIRUS PCR-Test Name
MICROBIOLOGY:
BLOOD CX [**2101-7-11**]: neg
URINE CX [**2101-7-11**]: lactobacillus species
VRE Swab negative
Urine Cx [**7-14**]:neg
Blood culture [**7-14**], [**7-15**]: neg
Mycobacteria and Fungal cultures 6/25: neg
[**7-17**] Stool culture-neg,
[**7-17**] C. Diff Toxin A and B-neg,
[**7-17**] Campybacterium culture-neg
[**7-17**] stool viral culture -prelim neg
[**7-22**] CMV viral load neg
[**7-22**] perinephric mass biopsy culture: PMNs seen on gram stain.
culture beta streptococcus group B
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- S
ANAEROBIC CULTURE (Final [**2101-7-26**]): NO ANAEROBES ISOLATED
[**7-22**] chest swab PMNs on gram stain; beta strep group B on
culture.
[**7-22**] fluid from chest PMNs, no growth on culture
[**7-22**] peri-nephric mass fluid beta strep group B.
[**7-27**] right sternoclavicular joint first rib ***
[**7-27**] pectoralis muscle ***
[**7-27**] sternoclavicular fluid ***
[**7-19**] Urine cytology: Urothelial cells, histiocytes, and
neutrophils.Many squamous cells, anucleate squames, and bacteria
consistent with vaginal contamination.Note: Atypical squamous
cells consistent with low grade squamous intraepithelial lesion
(LSIL) are present.
no other blood/urine cultures positive
PATHOLOGY:
PeriNephric Mass Biopsy [**7-20**] Fragments of fibrovascular tissue
and chronic inflammation. See note.
Note: The biopsy is mostly comprised of fibrous tissue and
lymphocytes with some crush artifact. A separate discrete
aggregate of plasma cells are identified. These plasma cells
are small with eosinophilic cytoplasm and eccentrically located
nuclei. No atypical forms are seen. By immunohistochemistry
the plasma cells are positive for CD138 and Bcl-2 and are
polytypic by Kappa and Lambda staining. CD20 and CD10 are
negative in the plasma cells with CD20 staining scattered
B-cells. CD3 and CD5 highlight admixed T-cells. Overall, the
findings are non-specific. The differential diagnosis includes
a reactive process (favored). Since an early evolving
(hyperplasia) post-transplant lymphoproliferative disorder
cannot be excluded (due to sampling) a repeat excision may be
warranted if clinically indicated.
Addendum: Kappa and lambda ISH reveals a mixed polytypic plasma
cell population. [**Last Name (un) **] is negative. Overall features do not
suggest a clonal process; No evidence of PTLD seen. The above
diagnosis remains unchanged.
Immunophenotyping [**7-22**] Three color gating is performed (light
scatter vs. CD45) to optimize blast/lymphocyte yield. Due to
paucicellular nature of the specimen, a limited panel is
performed to determine B-cell clonality.
B cells are scant in nature precluding evaluation of clonality.
[**7-22**] Biopsies of Chest wall and Perinephric Mass
1. Mass, right chest wall (A-B):
a. Skeletal muscle with chronic, patchy mildly active
inflammation.
b. Fibroadipose tissue.
c. No malignancy identified.
2. Mass, peri-nephric (C):
Fibroadipose tissue with acute and chronic inflammation and
fat necrosis consistent with abscess wall.
[**8-10**] Pleural Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS.
ULTRASOUNDS:
RENAL U/S [**2101-7-11**]:
IMPRESSION:
1. Abnormal intrarenal waveforms with blunted waveforms and lack
of diastolic flow in the interpolar region. Findings concerning
for graft dysfunction.
2. A 3.7 x 3.2 x 2.8 cm hypoechoic lesion with internal
vascularity in the
interpolar region of the transplant kidney is concerning for a
neoplasm.
Further assessment with MR is recommended.
U/S Chest Wall [**7-21**] Soft tissue mass which is hypoechoic,
predominantly solid, but with areas of partial liquefaction.
This is avascular and most likely represents a focus of PTLD as
the appearance is not dissimilar from the peri-transplant
masses, which were biopsied yesterday.
[**2101-7-21**] Chest U/S:
CONCLUSION: Soft tissue mass which is hypoechoic, predominantly
solid, but
with areas of partial liquefaction. This is avascular and most
likely
represents a focus of PTLD as the appearance is not dissimilar
from the
peri-transplant masses, which were biopsied yesterday.
[**2101-7-21**] Right Upper Extremity U/S 1. No right upper extremity
DVT.
2. Extensive right supraclavicular lymphadenopathy.
[**7-26**] LENIs: No evidence of deep vein thrombosis in either leg.
CT SCANS
[**2101-7-21**] CT Chest without contrast 1. Chest wall abnormality
could represent PTLD, but extention into the thoracic cavity and
associated bone destruction raises concern for infection. In an
immunocompromised host, this could be due to invasive fungal
organisms, actinomycosis, and TB, among others. 2. Lung
consolidation, pleural effusions and interlobular septal
thickening are nonspecific. Such findings have been associated
with PTLD but can also be associated with infection and
hydrostatic edema.
[**2101-7-26**] CT Abdomen and Pelvis
IMPRESSION:
1. Multiloculated rim-enhancing fluid collection in the right
anterior chest with internal foci of gas and minimal osseous
destruction of the encased first rib, thought to represent
abscess has had a minimal decrease in size.
2. Bilateral pleural effusions with worsening right lower lung
opacification, may represent ateletasis but underlying pneumonia
cannot excluded.
3. Four fluid collections identified around the transplanted
kidney in the
left lower quadrant. Two had recent instrumentation and
drainage, superior
and lateral, and are decreased in size compared to recent MRI.
Two larger
collections noted medial and inferior demonstrate rim
enhancement and
intermediate density fluid concerning for infectious process.
4. Foci of gas in the collecting system of the transplanted
kidney, likely
due to air reflux from bladder foley placement, less likely
pyelitis.
5. Hyperdensities in native kidneys, particularly in the right
upper pole
likely represent hemorrhagic cysts, particularly given
appearance on recent
MRI.
6. Volume overload is demonstrated by bilateral pleural
effusions,
pericardial effusion, anasarca, periportal edema and mild
ascites.
7. Linear lucency in right second rib likey due to recent
surgery. Please
correlate with operative note when available.
[**8-8**] CT Chest Abdomen and Pelvis:
IMPRESSION:
1. Increased size of mild pericardial effusion with
hyperenhancing
pericardium.
2. Right labia is enlarged with indurated subcutaneous fat
without focal
fluid collection.
3. Decrease in size of anterior right chest wall abscess with
two drains in
place and minimal residual fluid.
4. Increased bilateral pleural effusions and atelectasis.
5. Increase in periportal and pericholecystic fluid with
hyperenhancing
gallbladder wall suggestive of edema versus gallbladder
contraction.
6. Decrease in size of collections surrounding the transplanted
kidney and
collection along the lateral abdominal wall measuring 3.3 and
2.0 cm
respectively from 4.8 and 2.1 cm on prior examination.
7. Air again seen in transplanted kidney, likely refluxing air.
MRI:
[**2101-7-15**] MRI Abdomen and Pelvis: IMPRESSION:
1. Transplanted kidney in left lower quadrant. At least three
perirenal
masses suspicious for PTLD or lymphoma. The lesions are
accessible by
percutaneous biopsy.
2. Multiple native renal cysts, some of them with
hemorrhagic/proteinaceous
content.
3. Bilateral pleural effusions, right moderate amount, on the
left small
amount.
[**7-19**] shoulder MRI:IMPRESSION:
1. Motion-degraded study. No evidence of septic arthritis.
2. Nonspecific mild edema involving the infraspinatus, teres
minor, and teres major.
3. Abnormality adjacent to the coracoid process which is
suboptimally
evaluated on this motion-degraded study - recommend further
evaluation with
contrast-enhanced CT, as this could represent a mass or
lymphadenopathy;
collection of fluid is less likely given imaging
characteristics.
4. Large signal intensity abnormality in the peripheral aspect
of the right
upper lung, corresponding to known consolidation.
[**8-4**] MRI/MRA: IMPRESSION:
1. Acute infarct involving rostrum of corpus callosum.
2. Multiple focal dilatations involving ACA and MCA branches
bilaterally.
3. Both the infarction and the vascular abnormalities suggest
multiple septic emboli.
ECHOCARDIOGRAMS
ECHO [**2101-7-18**]:
MPRESSION:No endocarditis or abscess seen. Moderate symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild mitral regurgitation.
Moderate pulmonary artery systolic hypertension.
ECHO [**2101-7-27**]:
This is a limited examination to r/o endocarditis.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is an echo
dense mass a probable vegetation on the P2 portion of the mitral
valve. It measures 2- 3mm in size. Dr [**First Name (STitle) 6507**] present to confirm
findings as well. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
was notified in person of the results on [**2101-7-27**] at 1245pm.
ECHO [**2101-8-8**]:
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. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). A mid-cavitary gradient (30mmHg peak) is
identified. 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 masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The estimated pulmonary artery
systolic pressure is normal. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2101-7-18**],
the pericardial effusion and mid-cavitary gradient are now
identified.
Serial evaluation is suggested.
ECHO [**2101-8-10**]:
IMPRESSION: Very small echodensity attached to the posterior
mitral annular calcification at the level of the P2 scallop.
Compared to the prior study dated [**2101-7-27**] (images reviewed),
the echodensity is smaller and less mobile and probably c/w with
healing vegetation. Small circumferential pericardial effusion
without evidence of tamponade.
ECHO [**2101-8-15**]: NO effusion: The left atrium is elongated. 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 (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild mitral regurgitation with
mild leaflet thickening, but no discrete vegetation. Compared
with the prior study (images reviewed) of [**2101-7-18**], the
findings are similar.CLINICAL IMPLICATIONS:
Based on [**2097**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CHEST X-RAYS
[**2101-7-11**]: IMPRESSION: No acute cardiopulmonary abnormality.
[**2101-7-16**]:FINDINGS: There are bilateral pleural effusions with
volume loss at both bases. There is new right mid lung
infiltrate. Overall, the pulmonary appearance has worsened
compared to the film from five days ago.
[**2101-7-18**]:FINDINGS: Largely loculated moderate dependent bilateral
pleural effusions with associated atelectasis are new or
substantially larger from [**2101-7-11**]. Difference in effusion size
from [**2101-7-16**] is likely due to depth of inspiration. Improved
aeration in the non-dependent lungs on the lateral
decubitus views is secondary to positioning. The right upper
lobe pneumonia is unchanged. No new consolidation is seen in the
left lung. No pneumothorax.
[**2101-7-21**]: IMPRESSION: Stable chest findings in comparison with
preceding study of [**2101-7-18**]. Recommend CT examination to
evaluate alleged new anterior chest wall mass.
[**2101-7-25**]: There are low inspiratory volumes and slightly less
penetration of the film compared with [**2101-7-21**]. Allowing for
this, no significant interval change is detected. Again seen are
small effusions at the right and left bases, with underlying
collapse and/or consolidation. There is a hazy opacity in the
right mid zone, corresponding to the right lung abnormality seen
abutting the anterior chest wall on the [**2101-7-21**] CT scan. There
is upper zone redistribution, without other evidence of CHF.
[**2101-7-27**]: AP UPRIGHT VIEW OF THE CHEST: There is new moderate
right-sided pneumothorax with partial collapse of the entire
right lung following resection of the medial one-third of the
right clavicle and first anterior rib. Minimal leftward shift of
the mediastinum may be related to large left lower lung
atelectasis. Small right effusion is present. Heart size is
enlarged.
[**2101-7-27**]: There is still present right large pneumothorax with
significant collapse of the right lung, left mediastinal chest
and left lower lobe consolidation. Pneumomediastinum cannot be
excluded. The patient is after recent resection of the part of
the clavicle and adjacent chest wall debridement.
[**2101-7-27**]: On the current study, there is evidence of significant
decrease in the right pneumothorax with only small amount of
pneumothorax is seen. There is still present pneumomediastinum.
Reexpanding right lung is noted associated with small pleural
effusion. Left lower lobe consolidation is unchanged.
[**2101-7-28**]: Current study demonstrates bibasal consolidations,
bilateral pleural effusions and small amount of pneumothorax is
still present as well as potentially small amount of
pneumomediastinum.
[**2101-7-29**]: Previous mild pulmonary edema has largely cleared,
moderate right pleural effusion is smaller, but bibasilar
atelectasis is still severe. No
pneumothorax. Heart size normal. Stomach is moderately distended
with air
and fluid. Medial right clavicle has been resected.
[**2101-7-31**]: There are low inspiratory volumes. There are small
bilateral effusions with underlying collapse and/or
consolidation. There is borderline cardiomegaly. There is upper
zone redistribution, but no overt CHF. The medial aspect of the
right clavicle is not visualized, consistent with history of
resection, and the medial right clavicle is inferiorly displaced
with respect to its normal position. Of note, there is some
faint opacity in the right suprahilar region, more pronounced
than on [**2101-7-29**], which may represent a re-developing pneumonic
infiltrate.
[**2101-8-1**]: Persisting bilateral pleural effusion and bibasilar
atelectases.
Stable right suprahilar opacity which likely represents
atelectasis/consolidation
[**2101-8-1**]: Stable bilateral pleural effusion and bibasal
atelectasis No evidence of pneumothorax
[**2101-8-2**]: IMPRESSION:
1. Tip of the PICC line is 5.4 cm below the cavoatrial junction.
2. Stomach has been consistently distended since at least [**7-21**], [**2101**]. Such distension might increase the likelihood of
aspiration.
3. No acute cardiopulmonary changes compared with last chest
x-ray.
[**2101-8-3**]: Mild interstitial edema. Left lower lobe atelectasis.
No pneumothorax.
[**2101-8-4**]: IMPRESSION: Little overall change.
[**2101-8-4**]: FINDINGS: In comparison with the earlier study of this
date, there again is evidence of increased pulmonary venous
pressure, mild enlargement of the cardiac silhouette, bilateral
pleural effusions, and evidence of resection of the medial
aspect of the right clavicle. Central catheter remains in place.
Dilatation of the gas-filled stomach persists, for which a
nasogastric tube might be helpful.
[**2101-8-8**]: FINDINGS: In comparison with the study of [**8-4**], there
is little overall change. Continued enlargement of the cardiac
silhouette with evidence of elevated pulmonary venous pressure
and bilateral pleural effusions with compressive atelectasis.
Evidence of resection of the medial half of the right clavicle
is again seen. Dilatation of the gas-filled stomach appears to
have resolved.
[**2101-8-10**]: There has been interval decrease in right pleural
effusion after positioning of right chest tube. Left pleural
effusion is unchanged. Bibasilar atelectasis are larger on the
left side. Cardiomegaly is stable. medial chest drains are again
noted. Surgical clips project in the right medial hemithorax.
There are low lung volumes.
Discharge Labs:
Brief Hospital Course:
Patient is a 50 year old female with PMH of asthma, poorly
controlled DM1 with last A1C of 13, HTN, ESRD s/p living related
donor renal transplant in [**2092**], who was admitted for fevers and
UTI, and found to have pneumonia, vegetative endocarditis and
abscesses of chest wall and perinephric growing group B strep.
Also with acute infarct of rostrum of corpus callosum and
possible mycotic aneurisms (neurologically intact), and episodic
hypotension.
.
Acute Care:
.
1. Endocarditis: A small vegetation seen on mitral valve with
mild mitral regurgitation on [**2101-7-27**]. This is the probable origin
of septic emboli seeding patient's perinephric abscess and chest
wall abscess. Microbiology from patient's abscesses grew
PCN-sensitive GBS. Given patient's history of PCN allergy, she
was started on IV vancomycin for coverage of the abscesses. When
patient was showing only slow improvement, and there were new
findings of infarct of the rostrum of patient's corpus callosum
and formation of mycotic aneurisms, it was decided that patient
should undergo PCN de-sensitization in the ICU and initiate PCN
therapy. After treatment with IV PCN, repeat echocardiogram on
[**2101-8-15**] was unable to revisualize the vegetation, consistent
with healing.
.
2. Right Chest Wall Abscess: Patient was found to have a large
abscess of the right chest wall involving the soft tissue,
clavicle, and first rib and extending to the pleural space.
Cardiothoracic surgery debrided the abscess and removed infected
portions of patient's clavicle and first rib. Plastic surgery
closed the wound with a flap, and patient was discharged with
instructions to follow up in office for suture removal and JP
drain removal. IV PCN therapy was administered as definitive
treatment for patient's GBS infection.
.
3. Perinephric Abscess: A mass discovered adjacent to patient's
grafted kidney was found by biopsy to be an abscess. In the OR,
the abscess was drained, but there were portions that were not
ammenable to drainage. Culture of the drainage grew GBS
sensitive to PCN, and served as the target organism for
antibiotic therapy with regards to patient's multiple areas of
infection. Repeat imaging showed decrease in size of abscess on
discharge. Patient was d/c'd with a PICC line and instructions
to follow up with infectious disease as she is completing PCN
therapy at rehab.
.
4. Infarct of Rostrum of Corpus Callosum and Mycotic Aneurisms:
Patient experienced several vasovagal syncopal episodes in
house, and during the workup of one of these episodes, the
findings of acute infarct of the rostum of the corpus callosum
and two areas of probable mycotic aneurism were seen on MRA.
Patient had no neurologic deficits on multiple neurologic exams.
Felt to be caused by septic emboli from patient's vegetative
endocarditis, these lesions were treated with IV PCN as were
patient's other infectious foci.
.
5. Vasovagal episodes: Patient had a total of 4 vasovagal
syncopal episodes in this hospital stay. Patient's heart rate
dipped below 40, she lost consciousness and quickly recovered
without lasting deficit within minutes each time. Two occured
after using the bathroom, one ocurred post-surgically, and one
occured after eating a large meal and was followed by vomiting.
These episodes can be explained by patient's rapidly changing
fluid status related to multiple surgeries, and by a degree of
relative adrenal insufficiency in the setting of prolonged
stress from surgery and infection. Telemetry revealed episodic
atrial tachycardia, so patient was placed on low dose
metoprolol. Patient was without further episodes for several
days with persistently stable vital signs for several days
before discharge.
.
6. Acute renal failure: On presentation, patient's creatinine
was as elevated to 2.2 from baseline 1.1. There was likely an
initial component of AIN due to NSAID use, but also a pre-renal
component related to fluid loss from vomiting and insensible
losses on presentation. Patient was given IV fluids during her
hospitalization and by discharge patient's creatinine recovered
to baseline.
.
7. Anasarca: With multiple surgeries and procedures, and with
possible relative AI and low vascular tone in the setting of
infection, patient intermittantly required administration of
crystalloid solution to support intravascular volume. This led
to the accumulation of large lower extremity edema, bilateral
pleural effusions, and pericardial effusion. Patient also
experienced asymetric labial swelling. The right pleural
effusion was tapped, a chest tube was temporarily placed, and
labs showed transudative fluid so chest tubes were discontinued.
With some days of accelerated diuresis with loop diuretics, the
pleural effusions, the pericardial effusion, the lower extremity
edema, and the labial swelling improved.
.
8. Oozing of blood from sites of intervention: Patient had a
drop of Hct on [**8-12**] and she had oozing of blood from previous
sites of intervention including site of chest tube. Her plavix,
which she was on for throbocytosis and previous episdode of TIA,
was held for concern of bleeding. Given vasocagal episodes
in-house concern for fall led to this being held as well, though
she was stable and without incident in-hospital for days before
discharge. She was discharged with instructions to follow up
with hematology for potential re-start of plavix.
.
Chronic Care:
.
1. S/p living related donor renal transplant. Patient was
transplanted in [**2092**]. On this stay her tacrolimus was continued.
Cellcept was held for concern of PTLD, but once ruled out and
patient was stable, cellcept was restarted. Prednisone was
continued but at stress dosing and was decreased on discharge.
.
2. DM1: A1c 13.6 most recently. The [**Hospital **] Clinic was consulted
on this admission and good glucose control was achieved on
insulin schedule.
.
3. hyperlipidemia: Patient was continued on home lipid-lowering
[**Doctor Last Name 360**].
.
4. Depression: Social work followed patient during this
admission.
.
5. TIA history: Patient had an episode of a migraine with
neurologic symptoms 2 months ago. She has a history of migraines
in the past with blurry vision. MRI from [**2-/2101**], showed Punctate
focus of slow diffusion in the left posterior frontal lobe
consistent with a tiny acute infarct. Background mild
microangiopathic small vessel disease as well. Patient was
taking plavix but because of concern for bleed and fall it was
held.
.
Transitional Care:
Patient has multiple follow-up appointments to keep with her
PCP, [**Name10 (NameIs) **], neurology, nephrology, transplant nephrology,
Hematology, Plastic Surgery, and [**Hospital **] Clinic.
Patient should have a repeat head MRA around [**2101-9-5**] to evaluate
status of mycotic aneurisms and infarct of corpus callosum.
Patient will have follow-up CT scan [**2101-9-5**] for imaging of
perinephric abscess.
Patient is to complete PCN G therapy in rehab until [**9-16**].
#. Contact - patient, her mother is [**Name (NI) **] [**Name (NI) 9780**] [**Telephone/Fax (1) 31412**]
brother, [**Name (NI) 401**] [**Name (NI) 9780**] cell [**Numeric Identifier 31413**] or home [**Telephone/Fax (3) 31414**]
# Full Code
Medications on Admission:
-ATORVASTATIN 10 mg by mouth once a day
-CLOPIDOGREL 75 mg by mouth daily
-FUROSEMIDE 20 mg by mouth once a day
-METOPROLOL TARTRATE 50 mg by mouth four times a day - taking
3x/day
-MYCOPHENOLATE MOFETIL 1000 mg by mouth twice a day
-PREDNISONE 1 mg by mouth once a day
-TACROLIMUS 2 mg by mouth twice a day
-INSULIN REGULAR sliding scale 5 units qam and prn
-NPH 40units sq qam, 10 units q pm
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous QAM.
3. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
QACHS: please follow sliding scale.
4. Outpatient Lab Work
Please check labs - Chem-7, CBC, and LFTs weekly while patient
is on penicillin and have the results faxed to ([**Telephone/Fax (1) 21403**]
5. penicillin G potassium 20 million unit Recon Soln Sig: 4
million Recon Solns Injection Q4H (every 4 hours): Until [**9-16**]
for a course of 6 weeks. .
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
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. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day.
13. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
14. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO four times a day as needed for heartburn.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO every
six (6) hours: hold for SBP<100 or HR<60.
17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
1) Vegetative endocarditis
2) Perinephric and chest wall abscess
3) Mycotic Aneurism and Infarct of Rostrum of Corpus Callosum
4) Urinary Tract Infection
5) Pneumonia
6) Acute Kidney Injury
Secondary:
1) s/p renal transplant
2) Type 1 Diabetes Mellitus
3) Hypertension
4) Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 9780**],
It was a pleasure taking part in your care. You were admitted to
the hospital with 4 days of painful urination and two days of
nausea and vomiting. In the hospital we found that you had a
urinary tract infection, a growth of bacteria on one of the
valves of your heart, and multiple areas of infection related to
this. One was around your kidney, another was in your chest
wall, and there were a few small areas of the brain that were
concerning for infection as well. You were treated with surgery
for the chest wall and kidney, and you were treated with
penicillin for ramaining infection. Repeat imaging was unable to
detect growth on your heart valves after receiving treatment.
Please make the following changes to your medications:
STOP clopidogrel
STOP Lasix
CHANGE Prednisone to 7.5mg by mouth daily
CHANGE Mycophenolate Mofetil to 500mg by mouth twice daily
CHANGE Metoprolol to 12.5mg by mouth every 12 hours
CHANGE Insulin to Lantus 40 units in the morning and sliding
scale with meals and before bed
CHANGE Tacrolimus to 5mg by mouth every 12 hours
START Penicillin G at 4million units by IV every 4 hours until
[**9-16**]
START Nystatin 5mL by mouth four times daily until [**9-16**]
Please continue all other medications you were taking prior to
this admission.
Please keep all of your follow-up appointments.
Followup Instructions:
Please follow-up with the following appointments:
- Please call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] for an appointment
2 weeks following discharge from rehab or hospital This is the
apopintment with transplant nephrology
- Please call [**Telephone/Fax (1) 4652**] for an appointment in Plastic Surgery
clinic for drain removal and suture removal. Your appointment
should take place on the first Friday after your discharge.
-Please call for a confirm your follow-up appointment with Dr.
[**First Name (STitle) 805**], your nephrologist. The appointment has been made, so
please confirm date and time. ([**Telephone/Fax (1) 3637**]
Department: RADIOLOGY
When: MONDAY [**2101-9-5**] at 3:00 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: MONDAY [**2101-9-5**] at 4:20 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2101-9-9**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 14591**], [**First Name3 (LF) 14590**] N. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Monday [**2101-8-29**] 2:30pm
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2101-9-21**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment in Neurology with Dr.
[**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**]. The office will contact
you at home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 31415**].
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
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31242, 31637
|
33931, 34677
|
23990, 23990
|
3982, 4815
|
18292, 23972
|
34707, 35297
|
267, 294
|
3037, 3275
|
863, 3019
|
4850, 5454
|
33795, 33907
|
5470, 18269
|
3297, 3520
|
3536, 3904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,020
| 196,583
|
5530
|
Discharge summary
|
report
|
Admission Date: [**2138-10-6**] Discharge Date: [**2138-10-22**]
Date of Birth: [**2072-12-5**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
woman with a past medical history significant for coronary
artery disease, status post myocardial infarction in [**2122**],
diabetes mellitus, hypertension and tobacco use, who
presented with one month of shortness of breath. The patient
first noticed the shortness of breath at night with
orthopnea. The shortness of breath worsened, so that the
patient had dyspnea on exertion. The patient also noticed
decreased exercise tolerance and, by the day of admission,
could only walk a half block without shortness of breath.
Previously, she had unlimited exercise tolerance. She
currently had shortness of breath at rest. The patient had
also complained of chest pressure which began several days
ago. The chest pressure began with activity and was
alleviated by rest.
In the emergency department, her chest x-ray was positive for
congestive heart failure. The patient was given Lasix 40 mg
intravenous push, nitroglycerin paste one inch and albuterol
and Atrovent nebulizers. Her blood pressure was 165/93. Her
oxygen saturation was 85% on room air, increasing to 92% on
two liters by nasal cannula.
PAST MEDICAL HISTORY: The past medical history was
significant for coronary artery disease, a myocardial
infarction in [**2122**], diabetes mellitus diagnosed in [**2122**], an
esophageal ulcer diagnosed in [**2138-4-27**] and hypertension.
MEDICATIONS ON ADMISSION:
Zestril 20 mg p.o. q.d.
Glucophage 500 mg p.o. t.i.d.
Glyburide 5 mg p.o. b.i.d.
Prevacid 30 mg p.o. q.d.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION: At the time of admission, the patient
had a temperature of 98.3??????F, a heart rate of 91, a blood
pressure of 165/93, a respiratory rate of 20 and an oxygen
saturation of 85% on room air, increasing to 92% on two
liters by nasal prongs. In general, this was a middle aged
woman, sitting, in no acute distress. On head, eyes, ears,
nose and throat examination, there was no jugular venous
distention. The mucous membranes were moist. The oropharynx
was clear. The heart had an S1 and S2 with no murmurs, rubs
or gallops. The lungs had bilateral crackles half way up.
The abdomen was soft and nontender with positive bowel
sounds. The extremities had 1+ pitting edema bilaterally.
The rectal examination was guaiac negative.
FAMILY HISTORY: The patient had a mother with diabetes.
There was no family history of heart disease known to the
patient.
SOCIAL HISTORY: The patient had a remote smoking history of
two and a half packs per day times 34 years; she quit in
[**2122**]. She had no alcohol use. She lived at home with her
son.
ELECTROCARDIOGRAM: The electrocardiogram showed sinus
tachycardia at 105 beats per minute with 1 mm ST segment
elevations in leads III an aVF, a new left bundle branch
block and flat T waves in V5 and V6.
RADIOLOGY DATA: A chest x-ray showed positive congestive
heart failure with small bilateral effusions.
LABORATORY DATA: The patient had a white blood cell count of
4700 with a hematocrit of 38.4 and platelet count of 136,000.
Prothrombin time was 12.7, partial thromboplastin time was
26.3 and INR was 1.1. There was a sodium of 139, potassium
of 4.3, chloride of 103, bicarbonate of 23, BUN of 15,
creatinine of 0.8 and glucose of 215. CK was 92 with a
troponin of 1.8.
HOSPITAL COURSE: The patient was admitted to the hospital
for a rule out myocardial infarction and for a possible
cardiac catheterization. On [**2138-10-8**], the patient was
brought to the cardiac catheterization laboratory, where she
underwent cardiac catheterization. Please see the
catheterization report for full details. In summary, the
catheterization showed 30% left main coronary artery, 60-70%
left anterior descending artery, total occlusion of the left
circumflex coronary artery with left to right collaterals and
70-90% right coronary artery with an ejection fraction of 35%
and mild mitral regurgitation.
The patient was then referred to the cardiothoracic surgery
service and, on [**2138-10-10**], she was brought to the operating
room where she underwent coronary artery bypass grafting
times three. Please see the operative report for full
details. In summary, she had coronary artery bypass grafting
times three with a left internal mammary artery graft to the
left anterior descending artery, a vein graft to the obtuse
marginal artery and a vein graft to the right posterolateral
artery. She tolerated the operation well and was brought
from the operating room to the cardiac surgery recovery unit.
At that time, she had an arterial line, a Swan-Ganz catheter,
two atrial pacing wires, two mediastinal chest tubes and a
left pleural chest tube. She also had milrinone, Levophed
and insulin infusing.
The patient did well in the immediate postoperative period.
Her anesthetics were reversed and she was taken off her
sedatives. She was weaned from the ventilator and extubated
on the day of the surgery. Her milrinone was weaned to off.
Her Levophed was titrated to a mean arterial blood pressure
of 60 and her insulin drip continued to infuse. She remained
in the intensive care unit overnight on the first
postoperative day, as her oxygenation levels remained
relatively low.
On the night of postoperative day #1, the patient experienced
several episodes of ventricular tachycardia and was begun on
a lidocaine drip. The patient continued to have difficulty
with oxygenation and she continued to be vigorously diuresed.
On postoperative day #3, the lidocaine was weaned to off and
the patient was begun on low dose beta blockers without
recurrence of her ventricular ectopy.
On postoperative day #4, the patient was noted to have a
right pleural effusion. She was sent to the interventional
radiology department, where she underwent a therapeutic
thoracentesis. At that time, 350 cc of clear, blood-tinged
fluid were removed from the right pleural space under
ultrasound guidance.
Over the next several days, the patient remained
hemodynamically stable. She did, however, remain in the
intensive care unit because of difficulty oxygenating. She
continued to be vigorously diuresed throughout that time. On
postoperative day #6, she was deemed stable and ready to be
transferred to the floor, where she underwent continued
recovery from her surgery and cardiac rehabilitation.
The patient remained on the cardiac stepdown unit for the
next five days, during which time she continued to be
diuresed. Her activity level was gradually accelerated with
the assistance of physical therapy. During this time, she
remained hemodynamically stable and her oxygenation continued
to gradually improve throughout that period of time. On
postoperative day #8, it was noted again that the patient had
reaccumulated her pleural effusion; however, it was not felt
at that time that she needed to have an additional
thoracentesis and that the effusion would improve with
continued diuresis.
On postoperative day #12, it was deemed that the patient was
stable and ready for discharge to a rehabilitation center,
where she would undergo continued increases in her activity
with the goal being increased strength and endurance.
DISCHARGE STATUS: At the time of discharge, the patient's
status is stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times three with a left internal mammary
artery graft to the left anterior descending artery and vein
grafts to the obtuse marginal artery and right posterolateral
artery.
2. Diabetes mellitus type 2.
3. Esophageal ulcer.
4. Hypertension.
PHYSICAL EXAMINATION AT DISCHARGE: Vital signs revealed a
temperature of 98.9??????F, a heart rate of 72 and sinus rhythm, a
blood pressure of 100/50, a respiratory rate of 20 and an
oxygen saturation of 94% on five liters by nasal prongs. Her
preoperative weight was 70.1 kg; her discharge weight is 74.3
kg. The patient was alert, oriented and conversant. The
respiratory examination revealed diminished breath sounds
bilaterally at the bases with crackles two-thirds of the way
up on the right and crackles at the apex on the left. The
heart sounds revealed a regular rate and rhythm with S1 and
S2. The sternum was stable with no erythema. The abdomen
was soft, nontender and nondistended with positive bowel
sounds. The extremities were warm and well perfused with 1
to 2+ pedal edema.
LABORATORY DATA AT DISCHARGE: The patient had a white blood
cell count of 7100 and hematocrit of 25.5. There was a
sodium of 134 (up from 127 on [**2138-10-21**]), potassium of 4.2,
chloride of 95, bicarbonate of 30, BUN of 27, creatinine of
1.1 and glucose of 202.
DISCHARGE MEDICATIONS:
Glyburide 5 mg p.o. b.i.d.
Glucophage 500 mg p.o. t.i.d.
Protonix 40 mg p.o. q.d.
Lopressor 25 mg p.o. b.i.d.
Colace 100 mg p.o. b.i.d.
Aspirin 81 mg p.o. q.d.
Lasix 100 mg p.o. b.i.d.
Atrovent and albuterol nebulizers every four to six hours
p.r.n.
Potassium chloride 20 mEq p.o. q.d.
Sodium chloride one tablet p.o. b.i.d.
NPH insulin 10 units subcutaneously q.p.m.
Regular insulin sliding scale every six hours p.r.n.
Ibuprofen 400 mg p.o. every six hours p.r.n.
Percocet 5/325 mg one to two tablets p.o. every four hours
p.r.n.
Serax 50 mg p.o. h.s. p.r.n.
DISPOSITION: The patient is to be discharged to
rehabilitation.
FO[**Last Name (STitle) 996**]P: The patient is to have follow up in the wound
clinic in two weeks, follow up in Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office in
one month and follow up with her primary care physician in
three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2138-10-22**] 14:57
T: [**2138-10-22**] 15:15
JOB#: [**Job Number 2547**]
|
[
"414.01",
"428.0",
"250.00",
"530.2",
"411.1",
"441.4",
"511.9",
"276.1",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"37.23",
"39.61",
"88.57",
"36.15",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2557, 2665
|
7494, 7831
|
8902, 10047
|
1624, 1785
|
3556, 7473
|
1808, 2540
|
8641, 8879
|
166, 188
|
217, 1355
|
1378, 1598
|
2682, 3538
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,024
| 125,777
|
29437
|
Discharge summary
|
report
|
Admission Date: [**2161-12-23**] Discharge Date: [**2161-12-28**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. PTCA w/stent (2) placement in right posterior descending
artery.
2. ECHOCARDIOGRAM
3. endotracheal intubation
History of Present Illness:
[**Age over 90 **]F c HTN, CRI, p/w CP. The pt noted sudden onset of epigastric
pain without radiation at 9:30pm at home. Pain was severe up to
[**8-20**] and associated with SOB, no palpitations. The pain at first
thougt it was GI pain and took mylanta without relief. The pain
remained constant and the pt presented to [**Hospital1 **] [**Location (un) 620**] at midnight
on [**11-23**]. T 98 p 85 154/68 22 100% 2L NC. Pt was noted to have [**Street Address(2) 13234**] elevations in II, III, aVF and V5, 6. The pt was also
noted to be in A-fib. She was given asa, morphine, metoprolol
IV, started in Nitro gtt and transferred to [**Hospital1 18**] for cath. The
pt received IVF with bicarb as well when she was found to have
cr 1.5 with unknown baseline although prior h/o L nephrectomy.
The plan was non-emergency cath in the am. In the ED at [**Hospital1 18**], T
96.7 76 101/60 12 98% 2L. Pt continued to have intermittent CP,
was given SL NTG, started on heparin gtt, given plavix load.
Past Medical History:
1. STEMI - stenosis right PDA, PTCA, stent placement
1. Atrial fibrillation - undocumented as per history, treatment
attempts as outpatient.
2. Hypertension
3. CRD - s/p L nephrectomy
4. Hypothyroidism
Social History:
Patient is an ex-smoker quit 30 years ago, occasional, social
alcohol, no drug use. Swims daily at home.
Family History:
non-contributory
Physical Exam:
VS: Temp: BP: MAPs 63-75, HR 74-88, Initially vented on return
from cath lab TV 550, RR 12, FiO2 50%, Peep 5, sats 97-100%
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps (this neuro exam
following extubation)
Pertinent Results:
[**2161-12-23**] 06:29AM BLOOD WBC-9.5 RBC-2.96* Hgb-9.8* Hct-27.5*
MCV-93 MCH-33.1* MCHC-35.6* RDW-14.1 Plt Ct-197
[**2161-12-25**] 06:32AM BLOOD WBC-9.9 RBC-3.40* Hgb-10.6* Hct-31.2*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.4 Plt Ct-163
[**2161-12-23**] 06:29AM BLOOD Plt Ct-197
[**2161-12-23**] 07:58AM BLOOD PT-12.3 PTT-101.3* INR(PT)-1.1
[**2161-12-23**] 06:29AM BLOOD Glucose-261* UreaN-34* Creat-1.2* Na-132*
K-4.4 Cl-99 HCO3-25 AnGap-12
[**2161-12-25**] 06:32AM BLOOD Glucose-104 UreaN-26* Creat-1.3* Na-135
K-3.6 Cl-99 HCO3-27 AnGap-13
[**2161-12-23**] 06:29AM BLOOD ALT-34 AST-42* LD(LDH)-271* CK(CPK)-180*
AlkPhos-41 TotBili-0.5
[**2161-12-23**] 01:58PM BLOOD CK(CPK)-309*
[**2161-12-24**] 06:16AM BLOOD CK(CPK)-431*
[**2161-12-24**] 10:13PM BLOOD CK(CPK)-389*
[**2161-12-25**] 06:32AM BLOOD CK(CPK)-307*
[**2161-12-23**] 06:29AM BLOOD CK-MB-19* MB Indx-10.6* cTropnT-1.12*
[**2161-12-23**] 01:58PM BLOOD CK-MB-35* MB Indx-11.3*
[**2161-12-24**] 06:16AM BLOOD CK-MB-27* MB Indx-6.3*
[**2161-12-24**] 10:13PM BLOOD CK-MB-16* MB Indx-4.1
[**2161-12-25**] 06:32AM BLOOD CK-MB-11* MB Indx-3.6
[**2161-12-23**] 06:29AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.5
[**2161-12-23**] 01:58PM BLOOD Calcium-7.8* Phos-2.7 Mg-2.1
[**2161-12-24**] 06:16AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3
[**2161-12-25**] 06:32AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.5
.
CXR: 1. Marked widening and tortuosity of the ascending thoracic
aorta which may reflect aneurysmal dilatation. If there is
clinical concern for aortic dissection, a CT angiogram of the
chest is recommended.
2. No evidence of pneumonia or CHF.
.
Cardiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had no
angiographicallly apparent flow limiting disease. The LAD had a
70% stenosis in its mid vessel. The LCX had a 70% lesion in its
mid vessel. The RCA had a 90% mid/distal lesion with thrombus.
There was total
occlusion at the mid PDA. 2. Resting hemodynamics were
performed. The right sided filling pressures were elevated (mean
RA pressures were 13mmHg and RVEDP was 13mmHg). The pulmonary
artery pressures were elevated measuring 35/27mmHg. The left
sided filling pressures were elevated (mean PCW pressures were
25mmHg). The systemic arterial pressures were within
normal range measuring 125/61mmHg. The cardiac index was within
normal
range measuring 2.9 L/m2/Min. 3. Successful PCI of the mid RCA
using overlapping Cypher and bare-metal stents complicated by no
reflow which responded to intracoronary vasoactive substances
resulting in near TIMI 3 flow. 4. Successful POBA of the PDA
with mild residual stenosis (10-20%).
1) PROXIMAL RCA NORMAL
2) MID RCA DIFFUSELY DISEASED 90
3) DISTAL RCA DIFFUSELY DISEASED 90
4) R-PDA DIFFUSELY DISEASED 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
7) MID-LAD TUBULAR 70
12) PROXIMAL CX NORMAL
13) MID CX TUBULAR 70
RIGHT ATRIUM {a/v/m} 16/14/13
RIGHT VENTRICLE {s/ed} 35/13
PULMONARY ARTERY {s/d/m} 35/27/33
PULMONARY WEDGE {a/v/m} 28/29/25
**CARDIAC OUTPUT
HEART RATE {beats/min} 70
RHYTHM ATRIAL FIBRILLATION
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 43
CARD. OP/IND FICK {l/mn/m2} 4.8/2.9
**RESISTANCES
PULMONARY VASC. RESISTANCE 133
.
ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%)
secondary to hypokinesis of the inferior wall. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function appears depressed. The number of aortic valve leaflets
cannot be determined. 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. There is no pericardial effusion.
Impression: inferior and right ventricular infarct
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave Deceleration Time: 201 msec
TR Gradient (+ RA = PASP): 19 to 22 mm Hg (nl <= 25 mm Hg)
.
[**2161-12-26**], CTA Chest: 1) No PE or aortic dissection. 2) Coronary
artery calcification involving the proximal LAD. Small focus of
nonenhancing myocardium involving the left ventricular apex,
likely from prior or current MI. 3) Small RLL pleural effusion
with dependent atelectasis and nonspecific peribronchovascular
thickening involving the RLL branches.
4) 4mm left apex nodule; in the abscence of prior studies or a
known primary malignancy, this could be followed up in 1 year.
.
Brief Hospital Course:
92-year old white female with PMH of HTN presented to [**Hospital1 18**] ED
from OSH with complaints of unresolving epigastric discomfort,
found to have ST elevations in the inferior and lateral leads,
resulting in PTCA/stent IMI.
.
# CV: Patient initally treated as per ACS protocol, loaded with
plavix, taken emergently to cath lab, which revealed
multi-vessel CAD (see report), most noteable for 100% stenosis
with thrombus in the R-PDA which was treated with balloon
angioplasty and stent placement (cypher and bare metal). The
catheterization was complicated by episode of bradycardia,
hypotension, and airway compromise, resulting in intubation.
Flow was restored through PDA post-stent with TIMI-3 flow, and
pt transferred to CCU. Patient was extubated the following day
without complication, continued on asa, plavix, and high-dose
statin. Her blood pressures remained on the lower side for this
hypertensive patient, which prompted resuscitation with 1uPRBCs
for a hct of 28 and holding of her anti-hypertensive
medications, but initiated on metoprolol. Subsequently, she was
initiated on small doses of captopril for cardiac benefit as her
blood pressures allowed. One day after her cardiac
catheterization, she had an episode of chest pain that was
described as pleuritic in nature, as well as radiating to her
back, but was also tender upon palpation of the chest wall and
sternum. The pain persisted and a CTA was performed to rule out
dissection as well as PE. The patient was hydrated with IVFs
and bicarb prior to the CTA. The CTA was found to be negative
for PE and dissection. The patient's chest pain resolved
shortly afterwards and she has had no further episodes of chest
pain. Upon discharge, she was started on a regimen of statin,
BB, ACEI, Aspirin 81mg daily, Plavix, and Coumadin for her new
atrial fibrillation. Her heart rate ranged from 70s-90s and her
BB was uptitrated and will likely need further uptitration as an
outpatient. The patient was scheduled for an outpatient INR
check on Thursday, as well as outpatient appointments with her
PCP for Coumadin dose adjustment, and an outpatient cardiology
followup appointment.
.
# New Onset A-fib: Patient was well rate controlled during this
admission. She was continued on BB for rate control and was
started on Coumadin for anticoagulation.
.
# Pulmonary: She was intubated initially for airway security
during the episode of hypotension in the cath, but extubated
without difficulty or compromise. She had no evidence of heart
failure on her exam or by chest xray. By hospital day 2,
patient was without any shortness of breath and breathing on
room air.
.
# GI: There were no acute issues. She was placed on a PPI given
her double anti-platelet therapy but had no symptoms of
dyspepsia during her hospital stay.
.
# FEN/proph: she received subcutaneous heparin, PPI, and cardiac
diet.
.
# Dispo - discharge to rehab.
Contacts: [**Name (NI) **] [**Name (NI) 976**], [**First Name3 (LF) **] [**Telephone/Fax (1) 70683**]
Medications on Admission:
levoxyl 88 mcg qd
spironolactone 25
HCTZ 12.5
Benicar 40mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*1*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
1. STEMI - stenosis right PDA, PTCA, stent placement
2. Atrial fibrillation - undocumented as per history, treatment
attempts as outpatient.
3. Hypertension
4. CRD - s/p L nephrectomy
5. Hypothyroidism
Discharge Condition:
.
Patient discharged to in stable condition, tolerating PO feeds,
passing her urine and stool without difficulty, and ambulating
on her own.
.
Discharge Instructions:
.
1- Please return to the ED if you experience chest pain,
shortness of breath, nausea, vomiting, or any pain that is out
of the ordindary for you. Please call your doctor if you
experience chest pain at rest or with exertion.
.
2- Please take all of medications as prescribed. The following
medications were added to your regimen:
- Please stop taking your hydrochlorothiazide.
- Please take aspirin 325mg daily.
- You need to take Plavix 75mg PO daily uninterrupted for 12
months. This is a very important medicine to protect the stent
placed in your heart.
- Additionally, you were started on some additional blood
pressure medications including metoprolol and captopril.
- Please stop taking your Benicar.
- You were started on a medication to lower cholesterol called
Atorvastatin.
- Additionally, you were started on a medication, Coumadin, to
thin your blood since you are in atrial fibrillation.
.
Followup Instructions:
.
Please have your INR checked on Thursday [**12-31**] at
Northhill. Your Coumadin dose may need to be adjusted and you
will see your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] the following
day ([**1-1**]).
.
Please follow-up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
([**Telephone/Fax (1) 70684**]) on [**2166-1-1**]:15. At your appointment with
Dr. [**Last Name (STitle) **], please have your CBC and electrolytes checked (please
check Cr to make sure it is not rising after getting IV contrast
and Hct to ensure it is stable). Additionally, your INR needs
to be checked on Thursday at Northhill and your Coumadin
adjusted at your appointment with Dr [**Last Name (STitle) **].
.
Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **], at
[**Location (un) 70685**] Hospital, (1-[**Telephone/Fax (1) 18278**]) on [**1-13**], 3:00pm.
.
Completed by:[**2161-12-30**]
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,933
| 115,681
|
17820+17845+56892+56897
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2187-3-19**] Discharge Date: [**2187-4-6**]
Date of Birth: Sex:
Service:
ADDENDUM: This is an addendum to the previous discharge
summary.
DISCHARGE STATUS: Discharged to extended care facility.
DISCHARGE INSTRUCTIONS: Nasogastric tube replaced; tube
feedings Lovenox full strength, ProMod 20 grams per day,
starting at 10 mls per hour, advance by 20 mls q. six with a
goal rate of 80 mls per hour.
Therapeutic paracentesis prn.
Give albumin with each tap.
Transfuse red blood cells as needed for hematocrit less than
25.
Neutropenic precautions for ANC less than 500.
Consider initiating cyclophosphamide and tapering high dose
steroids for [**Doctor Last Name 11586**]-[**Doctor First Name **] syndrome once nutritional status
is improved.
Monitor pancreatic enzymes while on tube feeds.
Consider starting Disphosphinate such as LNGE, given high
dose steroids.
Consider bone mineral density examination with high dose
steroids.
Continue checking platelet antibodies to 2B, 3A and factor 9.
If positive, would argue for ITP and possible treatment with
Rotoxamine.
FINAL DIAGNOSES:
Probable [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11586**] syndrome, no unifying diagnosis
possible at this time.
Catalyst ascites.
Pancreatitis.
Ileus.
Pancreatic/splenic infarct.
Pulmonary edema.
Thrombocytopenia.
Anemia.
Leukopenia.
Malnutrition.
Adrenal insufficiency.
Steroid induced diabetes mellitus.
Depression.
DISCHARGE CONDITION: Fair.
The patient remained in the hospital until [**2187-4-6**] when she
was transferred, by plane, to a hospital in [**Country **].
MEDICATIONS ON DISCHARGE:
Phyllglastin 1 mls of 300 mcg q. 24 hours.
Epoetin 4,000 mg q. Thursday.
Lorazepam 0.5 to 2 mls intravenous q. four to six hours prn.
Hydromorphone 4 mg p.o. every four to six hours prn.
Lorazepam 0.5 mg one to two tablets p.o. every four to six
hours prn.
Methylprednisolone 100 mg intravenous q. day.
Hydromorphone 0.5 mg intravenous every three to four hours
prn.
Serchilene 50 mg p.o. q. day.
Furosemide 40 mg p.o. q. day.
Ferrous gluconate 300 mg p.o. q. day.
Sopra 30 mg p.o. q. day.
Multi-vitamin liquid, 5 mls p.o. q. day.
Regular insulin sliding scale.
Calcium 500 mg p.o. three times a day.
Vitamin D 400 mg p.o. twice a day.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2187-6-11**] 06:13
T: [**2187-6-12**] 03:37
JOB#: [**Job Number 49456**]
Admission Date: [**2187-3-19**] Discharge Date:
Date of Birth: [**2154-6-20**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 32 year old
female with a history of chylous ascites of unknown etiology
who presents for a second opinion after extensive work-up in
[**Country **]. She was originally diagnosed with systemic lupus
erythematosus four years ago, then three years ago had a CT
scan which noted small ascites. One year ago she had another
CT scan showing moderate ascites. She has had a diagnostic
tap which revealed chylous ascites with triglycerides 5 mol
per liter, tuberculous culture negative. No malignancy, but
abnormal cells with "glutocytoplasm of unknown etiology".
Abdominal ultrasound showed possible lymphangioma next to
spleen.
She had an exploratory laparoscopy which showed thick white
peritoneum with fibrotic fat containing effusion and fibrotic
bands and she was admitted to a hospital in [**Location (un) 49506**] on
[**2187-1-24**], for further work-up. At the outside hospital
Discharge Summary is provided in English and it appears that
the patient had an extensive work-up, [**Doctor First Name **] and ascitic fluid,
occasionally positive one out of three. Lymph scintography
revealed no leak or obstruction, increased uptake in the
supraclavicular mediastinal lymph nodes after four hours and
after 24 hours. CT scan of the body revealed small
consolidation in the right lower lobe, bronchial fields,
BOOP. She had steroids with partial resolution. No
lymphadenopathy; density in the left mediastinum. Biopsy
revealed gelatinous fluid, no malignancy. She had a bone
marrow biopsy which showed initially a myeloid left shift
with a normal endoscopy, small bowel with no lymph
angiectasias. She had a transjugular liver biopsy which was
normal. PET scan showing increased uptake in the left
shoulder, right chest. MRI showing fatty infiltration of
mediastinum, pleural, bone marrow, left humerus, and
clavicle. She had a biopsy of the edge of left clavicle
which only showed small pieces of necrotic bone.
She had a repeat bone marrow biopsy due to severe
thrombocytopenia which revealed [**Last Name (un) 2432**] karyocytes, erythroid
lineage, reticula seen negative, hairy cell leuk negative.
The patient underwent therapy with corticosteroids, IVIG,
cyclosporin A, octreotide with little improvement. She was
referred here for work-up and treatment.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus like syndrome presented four
years ago with weakness and pleurisy, no rash, no
arthralgias, pancytopenia, [**Doctor First Name **], plus/minus double stranded
DNA. No clinical improvement despite steroids times three.
Work-up revealed B12 deficiency; HIV negative. Serial
serology revealing past Parvo virus. Bone marrow biopsy with
slight hypocellular bone marrow.
2. Chronic headaches; lumbar puncture normal. No venous
thrombosis. Amitriptyline led to improvement.
3. Status post motor vehicle accident nine years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Prednisone 10 mg p.o. q. day.
2. Padma, a homeopathic medicine.
3. High protein drink.
4. Kosher lactose free, gluten free diet.
SOCIAL HISTORY: She is from [**Country **]. She teaches ages 17 to
18 students from [**Country 4812**]. There was a tuberculosis
outbreak. She denies tobacco or alcohol use.
PHYSICAL EXAMINATION: On admission, 97.8 F.; 100/64; 100;
20; 100% on room air. In general, a thin Caucasian woman
with large ascites, grossly ill appearing, but in no apparent
distress. HEENT: Pupils equal, round and reactive to light,
5 millimeters to 3 millimeters bilaterally. Conjunctivae
clear. Positive scleral icterus. Oropharynx clear without
exudate. Mucous membranes were moist. Neck is supple, no
lymphadenopathy, no jugular venous distention. Lungs clear
to auscultation bilaterally. Dullness to percussion at
bilateral bases. Coronary: Regular rate and rhythm, normal
S1, S2. II/VI blowing systolic murmur at left lower sternal
border. Abdomen with tense ascites. Positive shifting
dullness. Positive prominent veins. Could not palpate liver
or spleen secondary to tense ascites. Normoactive bowel
sounds. Extremities with trace edema bilateral lower
extremities. No clubbing or cyanosis palpable. Dorsalis
pedis and posterior tibial, radial pulses. Neurological:
Alert and oriented times three. Five out of five upper and
lower extremity strength. Deep tendon reflex equal and
intact bilaterally. Skin with petechiae scattered on the
abdomen, back. Ecchymosis of bilateral lower extremities.
LABORATORY: Labs were initially pending on admission and
returned revealing white blood cell count 0.6, hematocrit
23.6, hemoglobin 8.0, MCV 78, RDW 16.8, platelets 45. INR
1.1, PT 12.8, PTT 23.3. Granulocytes 470, reticulocyte count
2.7.
Sodium 119, potassium 6.7, chloride 93, bicarbonate 21, BUN
58, creatinine 0.8, glucose 115. ALT 23, AST 24, LDH 91,
alkaline phosphatase 99, amylase 995, total bilirubin 0.5,
lipase 1810. Albumin 101.8, calcium 7.5, magnesium 2.3,
phosphorus 3.3, TSH 3.6. Cortisol 13.9 at 06:13 a.m.
Hepatitis B surface antigen negative. Hepatitis B surface
antibody negative. Hepatitis C antibody negative. Hepatitis
A antibody positive. Anti-smooth muscle negative. [**Doctor First Name **]
positive 1:80 titer, pattern speckled, double stranded DNA
negative.
HOSPITAL COURSE: The patient is a 32 year old female with a
history of an systemic lupus erythematosus like illness now
with chylous ascites, pancreatitis, pancytopenia,
hyperkalemia, hyponatremia. On the day of admission, she had
a therapeutic paracentesis which revealed total protein 0.6,
glucose 95, creatinine 0.7, amylase 302, total bilirubin 0.2,
triglycerides 772, albumin less than 1.0. White blood cell
count [**Pager number **], red blood cells [**Pager number **], polys 92, lymphs 3, monos 4.
1. GASTROINTESTINAL: Initially, the patient had a CT scan
of the abdomen and pelvis which revealed: 1) Massive ascites;
2) New splenic hypodensity which may represent contusion or
infarction when compared to CT scan from an outside hospital;
3) Enlargement of the pancreas, correlation the pancreatic
duct and intrahepatic bile ducts are not dilated; 4) moderate
right hydronephrosis and hydroureter likely mass effect from
massive ascites; 5) splenomegaly.
The patient's amylase and lipase continued to remain
elevated. Chylous ascites, chemical pancreatitis with
enlarged pancreas on CT scan. History of clear ascites when
diet changed to medium chain triglyceride or on total
parenteral nutrition suggesting a possible small
bowel/malabsorption cause.
The patient continued to be monitored and received several
additional therapeutic paracenteses for tense ascites.
2. INFECTIOUS DISEASE: Initially it was unclear whether to
initiate antibiotic treatment given difficulty in
interpreting white blood cell count in chylous ascites,
however, after repeat tap on [**3-20**] revealed similar amounts
of white blood cells and patient spiked temperature to 100.7
F., Infectious Disease consultation was obtained which
recommended additional tests to be sent on [**3-22**], given
concern over temperature to 100.7 F., white blood cells in
peritoneal fluid and neutropenia. The team wished to begin
antibiotics given concern over impending sepsis, however the
patient refused antibiotics at this time so they were not
initiated.
3. HEMATOLOGY: The patient with long-standing pancytopenia,
however, on admission, granulocyte count was 435. The
patient was placed on neurotropenic precautions as needed for
absolute neutrophil count of less than 500.
Hematology/Oncology consultation was obtained and reviewed
bone marrow biopsy slides from [**Hospital 49507**] Hospital. The patient
was started on epoetin on [**2187-3-22**]. S-PEP also sent. She
was started on GCSF for her neutropenia.
4. RHEUMATOLOGY: The patient with a history of systemic
lupus erythematosus like illness with a history of positive
double stranded DNA with pancytopenia, pleurisy and positive
[**Doctor First Name **]. There have been case reports of chylous ascites with
systemic lupus erythematosus and pancreatitis, therefore
repeat [**Doctor First Name **], anti-double stranded DNA were sent. Rheumatology
consultation was obtained, who recommended Dermatology
consultation to obtain biopsy of leg lesions.
5. PULMONARY: The patient with history of BOOP per
bronchoscopy at outside hospital, apparently improving after
steroids. Chest x-ray here was significant for
reticulonodular pattern. She remained stable.
6. RENAL: The patient was admitted with a BUN of 58,
creatinine 0.8. Urinalysis only significant for trace
proteins, hyponatremic and hyperkalemic. Urine electrolytes
were significant for a prerenal state. Renal consultation
was obtained who recommended beginning Lasix and transfusing
blood to increase intervascular volume. The patient was also
given multiple transfusions of albumin to increase
intervascular volume.
7. CARDIOVASCULAR SYSTEM: The patient with systolic murmur
on examination. She had a repeat echocardiogram which
revealed hyperdynamic left ventricular systolic function with
ejection fraction greater than 75%, mild aortic regurgitation
and small pericardial effusion. Based on [**2180**] AHA
endocarditis prophylaxis recommendations to echocardiogram
findings indicate a moderate risk; prophylaxis is
recommended.
8. ENDOCRINE: The patient's a.m. cortisol levels were
obtained to evaluate for possible adrenal insufficiency and
her a.m. cortisol was relatively low given high stress state.
9. FLUIDS, ELECTROLYTES AND NUTRITION: The patient
initially was hyperkalemic with EKG changes consistent with
hyperkalemia with peaked T waves. She was initially treated
with insulin, calcium, D50, Kayexalate and lactulose and her
subsequent potassium was normal. Given her hyponatremia with
a sodium of 118, she was fluid restricted and this improved
her sodium significantly. She was initially started on a
lactose free Kosher diet. Given her hyponatremia and
hyperkalemia she was free water restricted and potassium
restricted.
Given that she has total volume overload but intravascularly
dry, she was given albumin and blood as needed.
A Nutrition consultation was obtained. The patient remained
relatively stable until the morning of [**2187-3-23**], when she
was found febrile and hypotensive. She was emergently
transferred to the Medical Intensive Care Unit.
NOTE: Note that the Medical Intensive Care Unit course will
be dictated as an addendum to this dictation. This dictation
resumes when the patient was called out to the floor when she
was stable on [**2187-4-3**].
1. GASTROINTESTINAL: [**Doctor First Name **]-[**Doctor Last Name 11586**] Syndrome: A) Chylous
ascites. The patient remained with a soft abdomen, however,
she was still leaking from the tap site. Pressure dressing
was not adequate, therefore a single stitch was placed around
the tap sites.
B) Pancreatitis: Pancreatic enzymes were followed while she
was on tube feeds.
C) Ileus: Resolved; the patient continued with bowel
movements and flatus.
D) Splenic/pancreatic infarction: Query etiology secondary
to hypotension, deemed not a surgical candidate. She
remained stable with no back pain. She had a repeat MRI
which revealed stable infarctions.
2. CARDIOVASCULAR SYSTEM: Pulmonary edema; the patient was
hypoxic the day prior to transfer from Medical Intensive Care
Unit, however, she was given Lasix and diuresed with a good
effect. She was continued on standing Lasix 40 mg p.o. q.
day and remained stable with stable O2 saturations and normal
respiratory examination.
3. HEMATOLOGY: A) Thrombocytopenia: Platelets remained
critically low despite high dose steroids, IVIG treatment
times one and multiple platelet transfusions. The patient
had numerous petechiae. Continued to watch and platelet
count slowly increased to 12 on [**2187-4-6**].
B) Leukopenia: She was continued on GCSF. She remained
stable, not requiring neutropenic precautions for the rest
of her stay.
C) Anemia: She was continued on Procrit and transfused as
needed for hematocrit of less than 25. She remained above
25.
4. FLUIDS, ELECTROLYTES AND NUTRITION: She was severely
malnourished. She was started on tube feeds per nutrition
recommendations. Her electrolytes were checked and repleted
as needed.
5. RENAL: Her creatinine remained stable despite diuresis
with Lasix.
6. She was continued on Zosyn for broad spectrum coverage,
remained afebrile and cultures showed no growth to date.
7. ENDOCRINE: Presumed adrenal insufficiency - she was
continued on high dose steroids; steroid induced diabetes
mellitus. Sugars remained in high hundreds. She was covered
with a regular insulin sliding scale
8. PSYCHIATRY: Depression - she was started on Zoloft and
continued. She was given support with Social Work.
The patient remained stable on the floor.
DISCHARGE STATUS: Discharge via [**Location (un) 7622**] to [**Country **] for
further work-up and treatment.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. [**Doctor First Name **]-[**Doctor Last Name 11586**] Syndrome.
2. Chylous ascites.
3. Pancreatitis.
4. Splenic pancreatic infarction.
5. Pulmonary edema.
6. Thrombocytopenia.
7. Leukopenia.
8. Anemia.
9. Ileus.
10. Malnutrition.
11. Acute renal failure.
12. Sepsis.
13. Adrenal insufficiency.
14. Steroid induced diabetes mellitus.
15. Depression.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg p.o. q. day.
2. Neutra-Phos one packet three times a day.
3. Iron 300 q. day.
4. Lasix 40 q. day.
5. Sertraline 50 q. day.
6. Dilaudid p.r.n.
7. Methylprednisolone 150 mg intravenously q. day.
8. Zosyn q. eight hours.
9. Lorazepam p.r.n.
10. Regular insulin sliding scale.
11. Epoetin 40,000 units subcutaneously q. Thursday.
12. Filgrastim 300 micrograms subcutaneously q. 24 hours.
DISCHARGE INSTRUCTIONS:
1. Tube feeding: Vivonex full strength with additives of
ProMod 20 grams q. day; starting rate 10 ml per hour,
advanced by 20 ml q. six hours; goal rate 80 ml per hour,
residual check q. six hours. Hold tube feeding for residual
greater than 100 ml.
2. Diet, Kosher, fat free, and Enlive supplement, breakfast,
lunch and dinner.
3. The patient is also to take olive oil one teaspoon p.o.
q. day.
4. The patient is also to have four liter taps as needed for
abdominal distention. Each paracentesis should be followed
by albumin, 25% 50 gram intravenously during the
paracentesis.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2187-4-6**] 18:27
T: [**2187-4-6**] 22:26
JOB#: [**Job Number 49508**]
Name: [**Known lastname 9164**], [**Known firstname **] Unit No: [**Numeric Identifier 9165**]
Admission Date: [**2187-3-19**] Discharge Date: [**2187-4-4**]
Date of Birth: [**2154-6-20**] Sex: F
Service:
THIS ADDENDUM WILL COVER HOSPITALIZATION FROM [**3-23**]
THROUGH [**2187-3-31**]. FOR REST OF HOSPITAL STAY PLEASE SEE
DICTATION PER DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9166**].
HISTORY OF PRESENT ILLNESS: A 32-year-old female with a
systemic lupus erythematosus, positive double strand DNA and
positive [**Doctor First Name **] with pan cytopenia who has a history of chylous
ascites for the past five years who was transferred to [**Hospital1 1294**] for further management of her
illness. The patient has had an extensive workup of her
chylous ascites including numerous paracentesis with fluid
analysis for malignancy and tuberculosis, abdominal
ultrasounds with angiograms, peritoneal biopsies, exploratory
laparotomies as well as transjugular liver biopsies, PET
scans and MRIs which have all been negative. The patient has
been treated with steroids, IVIG, cyclosporin and octreotide
in the past but continues to have problems with her chylous
ascites. A bronchoscopy in the past also revealed GOOP. The
patient has also had numerous bone marrow biopsies in the
past for her pan cytopenia which have revealed hypocellular
marrow with a left shift but have not elucidated the origins
of her pan cytopenia. Finally, patient has also had an EGD
which also had a negative small bowel biopsy in the past.
Patient was transferred to [**Hospital1 1943**] where she would be seen by the Liver team under the
care of Dr. [**Last Name (STitle) 4829**] for a second opinion of her chylous
ascites.
The patient arrived at [**Hospital1 536**]
on [**2187-3-19**], was stable and was noted to be neutropenic
with an ANC of 470, patient was hyperkalemic with EKG
changes. Patient was given calcium, insulin and glucose with
resolution of her hyperkalemia. She was noted to be
hyponatremic and was seen by the Renal team here who decided
to start the patient on Lasix as well as to administered
[**Year (4 digits) 9167**] products secondary to the patient's intravascular
volume depletion. The patient also had two paracenteses on
the floor prior to MICU admission where four liters of creamy
fluid were taken off her abdomen on the day of admission and,
once again, on day number three status post a second
paracentesis, the patient developed low grade temperature and
some diffuse abdominal pain. The patient was followed very
closely by the Hematology Department. They reviewed the
patient's bone marrow biopsies with Pathology. They felt
that these studies were within normal limits and there was
nothing on the bone marrow biopsies that would explain the
patient's recurrent condition. She was started on GCSF and
Epogen as well as iron on the floor. The patient was also
followed by Infectious Disease consultants who sent off
numerous cultures from the paracenteses looking for
tuberculosis as well. The patient was seen by Rheumatology
and Dermatology and, given her history of lupus in the past,
she was found to be double strand DNA negative here and her
[**Doctor First Name **] titer was 1:80. The rheumatologist felt that a
rheumatologic process was not the primary cause of all her
current concerns. She also had a derm biopsy taken of some
erythematous macules noted on her tibial region which
revealed panniculitis consistent with pancreatitis. The
patient also had a CT of the abdomen prior to Intensive Care
Unit admission which revealed a large amount of ascites, no
focal liver abnormalities and some contrast in the right
renal collecting system which was nonspecific. The patient
also had a right upper quadrant ultrasound prior to admission
to the Intensive Care Unit which did not reveal any
intrahepatic biliary dilation and revealed patent portal and
hepatic veins. Of note, the CT of the abdomen did reveal
some enlargement of the head of the pancreas as well as a
very small splenic infarct. On the day of admission to the
ICU the patient's temperature spiked to 101.4 during a packed
red [**Doctor First Name 9167**] cell transfusion. Systolic [**Doctor First Name 9167**] pressure dropped
to 70/40. A diagnostic paracentesis with 60 cc of fluid
revealed purulent yellowish material which was sent to the
Laboratory for analysis. The patient was noted to be anuric
for 12 hours prior to ICU admission and patient was started
on empiric antibiotics for SBP and transferred to the MICU
for hemodynamic instability as well as impending respiratory
failure.
LABORATORY ON ADMISSION: White [**Doctor First Name 9167**] cell count 1.6 up from
0.6 on admission, hematocrit 29.6 from 26 status post one
unit packed red [**Doctor First Name 9167**] cell transfusion. Platelets 46.
Electrolytes: Sodium 127, potassium 4.0, chloride 97,
bicarbonate 19, BUN 55, creatinine 1.3 up from 0.8 on
admission, glucose 112, INR 1.2, PTT 26, ALT 26, AST 31, LDH
100, alk phos 104, amylase 840, lipase 1,256, total bilirubin
9.4 up from 1.3 on admission, ANC 1,340. Paracentesis from
the [**3-21**] revealed the following values: 300 white
[**Month (only) 9167**] cells, 5,425 red [**Month (only) 9167**] cells, 91% polys, 4%
lymphocytes, 5% monocytes. Albumin was less than 1. Amylase
was 328. LDH was 161, total protein 0.7, glucose 95.
MEDICAL INTENSIVE CARE UNIT COURSE: The patient was admitted
to the ICU on [**2187-3-23**], for hypotension. She was
started on stress dose steroids as well as Neo-Synephrine and
vasopressin since it was thought that the patient was
possibly septic. She was started empirically on antibiotics.
The patient was given vancomycin, ceftazidime and Flagyl
empirically for SBP coverage. The patient was subsequently
intubated on the 12th secondary to impending respiratory
failure. The patient's respiratory failure was thought to be
secondary to her loss of her renal function. The patient's
loss of renal function caused an acute on chronic metabolic
acidosis. The patient was forced to have respiratory
compensation for this metabolic acidosis and due to her large
restrictive process secondary to her chylous ascites she was
forced to breathe at respiratory rates as high as 40 to 45
breaths a minute. The patient's ABG revealed
pseudo-normalization of her pCO2 and it was thought that the
patient should be intubated for impending respiratory failure
at that time.
The patient was treated for SBP and was followed very closely
by the Infectious Disease team. Numerous cultures were taken
from her paracentesis as well as [**Year (4 digits) 9167**] cultures, urine
cultures and sputum cultures, all of which remained negative.
Sequentially, the vancomycin and Flagyl were taken off the
patient's antibiotic regimen and the patient was continued on
ceftazidime. It was later thought that the patient's
hypotensive episode and subsequent acute renal failure was
most probably due to pancreatitis and the spacing of fluids
as opposed to SBP since all culture data remained negative.
Subsequently, the patient's ceftazidime was stopped. The
patient did not spike any temperatures off antibiotics and
her hemodynamics continued to improved with aggressive volume
hydration, episodic packed red [**Year (4 digits) 9167**] cell infusion to
facilitate intravascular volume repletion and q. day albumin
according to the hepatology recommendations. The patient was
taken off her Neo-Synephrine and vasopressin on the [**3-26**]. Her systolic [**Month (only) 9167**] pressures remained well but she
was continued on stress dose steroids. Another thought of
component of her hypotension was considered. It was thought
that the patient may have abdominal compartment syndrome
given her large intra-abdominal pressures secondary to her
chylous ascites. Pre- and post-paracentesis bladder
pressures were measured and it was deemed that the patient
did not have significant abdominal compartment syndrome and
the patient's hemodynamics did not improve markedly after
paracenteses. The patient continued to do well off any
pressors and did not have any problems with [**Name2 (NI) 9167**] pressure
subsequently.
From a pulmonary standpoint, the patient was extubated on the
[**3-24**] but did have some problems with pulmonary edema
status post extubation. The patient required one episode of
noninvasive mask ventilation during which oxygenation and
ventilation remained good but the patient's respiratory rate
went up into the 30's. The patient was diuresed with 20 mg
of intravenous Lasix q. day for four days and this regimen
was changed over to 40 mg of p.o. Lasix until she was
discharged from the hospital. Subsequent chest x-rays
revealed resolution of her pulmonary edema and subsequent
pulmonary examinations revealed improvement in her lung
sounds.
The patient's pancreatitis continued to improve throughout
her Intensive Care Unit stay. On admission her amylase was
840 and lipase was 1,256 with a T. bili of 9.4. By the end
of her MICU stay after aggressive hydration, the patient's
amylase and lipase were in the 230's and her total bilirubin
came down to 3.2. The patient did not complain of any
epigastric abdominal pain. She was continued on albumin, had
a repeat CT which did not reveal very much secondary to
difficulty visualizing the intra-abdominal structures
secondary to her massive ascites. She had an MRI done
subsequently to rule out any pancreatic pseudocyst since she
did have one episode of back pain. The MRI revealed the
following studies. It revealed that the patient's spleen, in
fact, had a large splenic infarct and there was only sparing
of the anterior pole. The adrenals and the kidneys were
unremarkable. The pancreas was enlarged and the pancreatic
head was noted to have a 5 x 5 x 4.4 cm hypoenhancement
relative to the rest of the pancreas which was thought to be
worrisome for ischemia. The patient's gallbladder was
unremarkable. The portal vein was patent. The splenic vein
was also unremarkable. There was noted to be some distended
bowel loops and on CT's there was massive ascites discovered.
Due to these findings, the Surgery team was consulted as to
possibility for operative intervention given the patient's
infarcted spleen. The Surgery team saw the patient and
determined that surgical intervention would be untenable
given the patient's thrombocytopenia and relative
neutropenia. They advised that further medical management
would be the safest course of action. The patient's mean
pressures were maintained above 70 to facilitate end organ
perfusion and hypotensive insults were avoided. The patient
had a repeat MRI two days later which revealed that the
ischemia of the pancreas was unchanged and that the infarcted
spleen remained unchanged as well.
Throughout the hospital stay, it was thought that the patient
should be treated for this infarcted spleen with vancomycin,
Zosyn and fluconazole to ensure that the patient did not have
an intra-abdominal infection. Infectious Disease again was
consulted on the case and repeated [**Month (only) 9167**] cultures were taken.
Cultures of the paracenteses were taken as well which
revealed no growth. The patient did not have any abdominal
pain or symptoms and it was subsequently decided that the
vancomycin and fluconazole could be stopped once the second
MRI revealed no further signs of infection or bowel
inflammation. The Zosyn was continued at the time of
discharge from the Intensive Care Unit and Infectious Disease
team continued to follow to ensure that the patient did not
have any intra-abdominal infections.
Two diagnoses were considered for the patient's chylous
ascites. The first was Whipple's disease. The patient's
biopsies of her EGD were analyzed here and it was thought
that the findings were not consistent with Whipple's disease
but PCR could not be performed on these studies. The second
diagnosis that was considered was [**Doctor Last Name 3680**]-[**Doctor First Name **] syndrome.
It was thought that some of the patient's presentation was
consistent with [**Doctor Last Name 3680**]-[**Doctor First Name **] syndrome and the decision was
made to start the patient on high dose steroids but it was
decided to hold off on starting the patient on any other
immunosuppressive agents since throughout the hospital stay
there were numerous episodes in which it was thought that the
patient might be infected. The patient's acute renal failure
also played a role in holding off on starting any high dose
immunosuppressives and, finally, the patient's persistent
thrombocytopenia was also quite worrisome and it was decided
that any cyclophosphamides or other immunosuppressives should
be started when the patient is much more stable. Of note, no
histiocytes were noted on any marrow biopsies or in any
peripheral cultures according to the Liver team.
From a renal standpoint, the patient did have acute renal
failure secondary to a prerenal process since her __________
excreted sodium was less than 1% as well as an acute tubular
necrosis. The patient's ____ were maintained above 70% and
renal perfusion was maximized. All nephrotoxic agents were
avoided and the patient's creatinine came down from 1.3 on
admission down to 0.9 and the patient anuria resolved and the
patient was making normal amounts of urine at the time of
discharge from Intensive Care Unit.
As far as the patient's pan cytopenia, the patient's GCSF was
continued. Her white [**Doctor First Name 9167**] cell count was 0.6 on admission
and rose to 5.7 at the time of discharge. A repeat bone
marrow biopsy was considered but was held off since the
Hematology team felt that this would not add anything to the
patient's management. The patient was also continued on iron
supplements by Epogen for stimulation of the patient's
anemia. For the patient's thrombocytopenia, the patient was
given approximately 20 bags of platelets throughout her ICU
stay. The patient continued to consume her platelets. Her
platelets at the time of admission were 47 but dropped down
to 9 and as low as 5 throughout her ICU stay. The patient
did not have any overtly clinical signs of bleeding but did
have petechiae that were new on her anterior thorax as well
as a few area of petechiae over her abdomen. The Hematology
team sent off studies for antibodies to platelets which were
negative. There were thoughts of giving the patient single
donor platelets to improve the patient's response but the
studies revealed that the patient did not have any antibodies
to platelets and that multiple donor platelets would, in
fact, the choice that should be preferred since the patient
would possibly respond to one line. The patient was also
started on high dose steroids at 2 mg/kg a day with the hope
that not only would this possibly help her possible
[**Doctor Last Name 3680**]-[**Doctor First Name **] syndrome but would hopefully help her
thrombocytopenia. The patient's high dose steroids did not
have any effect on the thrombocytopenia. At the time of
discharge, the patient's platelets from MICU were 7. It was
also thought that the patient might be in DIC. Numerous DIC
screens were negative throughout her hospital stay and this
was not thought to be the cause of her thrombocytopenia.
As far as a nutrition standpoint, the patient was NPO on
admission to the Intensive Care Unit but once she was
extubated she was started on ___ and PPN. The patient could
not be started on TPN throughout this hospital stay since we
could not change the patient's central line over a wire to
get improved venous access and since the patient could not
have a PICC line placed due to her thrombocytopenia. The
nutritionist consulted on her case constantly and worked very
closely with the hepatologists and the patient did have a
nasojejunal feeding tube placed under fluoroscopy by
Interventional Radiology and was started on On-Live Kosher
supplements as well as _____ tube feeds at a goal rate of 80
cc/hour which was to be supplemented with 20 mg of ProMod and
this regimen was to be supplemented by p.o. intake and the
patient is quite aware of which foods she can and cannot
take. The patient is to be on a low fat diet since this was
thought to prevent stimulation of her chylous ascites.
From a psychiatric standpoint, the patient was quite
depressed about her ICU stay and was quite concerned about
her overall prognosis. The patient was seen and followed by
a social worker numerous times and was started on Zoloft for
her situational depression. At the time of discharge from
the ICU the patient's spirits were much better since she was
more mobile and was once again able to take p.o. intake.
DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor First Name 1763**] 12-899
Dictated By:[**Name8 (MD) 995**]
MEDQUIST36
D: [**2187-4-4**] 17:32
T: [**2187-4-4**] 16:44
JOB#: [**Job Number 9168**]
Name: [**Known lastname 9164**], [**First Name3 (LF) **] Unit No. [**Serial Number 9182**]
Admission Date: [**2187-3-19**] Discharge Date: [**2187-4-11**]
Date of Birth: [**2154-6-20**] Sex: F
Service:
ADDENDUM: The patient was discharged to a hospital in
[**Country **].
DISCHARGE INSTRUCTIONS:
1. If NJ tube replaced, tube feeding -Vivonex full strength,
ProMod 20 grams q.d. Goal rate 80 cc/hour.
2. Therapeutic paracentesis prn. Give albumin 50 grams with
each tap.
3. Transfused red blood cells if needed for hematocrit less
than 25.
4. Neutropenic precautions for ANC less than 500.
5. Consider initiating cyclophosphamide and tapering high
dose steroids for [**Doctor First Name **]-[**Doctor Last Name 3680**] syndrome once nutritional
status improved.
6. Monitor pancreatic enzymes while on tube feeds.
7. Consider starting bisphosphate such as alendronate given
high dose steroids.
8. Consider bone mineral density examination with high dose
steroids.
9. Consider checking a platelet antibiotics to TB3A and
Factor [**Doctor First Name 2237**]. If positive, would argue for ITP and possible
treatment with Rituxan.
FINAL DIAGNOSES:
1. Probable [**Doctor First Name **]-[**Doctor Last Name 3680**] syndrome (no unifying diagnosis
possible at this time).
2. Chylous ascites.
3. Pancreatitis.
4. Ileus.
5. Splenic infarct.
6. Pulmonary edema.
7. Thrombocytopenia.
8. Anemia.
9. Leukopenia.
10. Malnutrition.
11. Adrenal insufficiency.
12. Steroid induced diabetes mellitus.
13. Depression.
DISCHARGE MEDICATIONS:
1. Filgrastim 300 mcg q. 24 hours.
2. Epoetin 40,000 units q. week.
3. Lorazepam 0.5-2 mg intravenous q. 4 hours prn.
4. Hydromorphone 2 mg po q. 4-6 hours prn.
5. Lorazepam 0.5-1.0 mg po q. 4-6 hours prn.
6. Methylprednisolone 100 mg intravenous q.d.
7. Sertraline 50 mg po q.d.
8. Lasix 40 mg po q.d.
9. Ferrous gluconate 300 mg po q.d.
10. Lansoprazole 30 mg po q.d.
11. Multivitamin, Therapeutic liquid 5 mL po q.d.
12. Regular insulin sliding scale.
13. Calcium 500 mg po t.i.d.
14. Vitamin E 400 units po q.d.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 7895**]
Dictated By:[**Last Name (NamePattern1) 1464**]
MEDQUIST36
D: [**2187-5-2**] 11:25
T: [**2187-5-2**] 11:53
JOB#: [**Job Number 9183**]
|
[
"584.5",
"284.8",
"729.30",
"457.8",
"263.9",
"458.9",
"518.81",
"710.8",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"54.91",
"96.72",
"86.11",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1500, 1635
|
15836, 16198
|
36144, 36954
|
1661, 2718
|
5692, 5829
|
8063, 15782
|
34897, 35739
|
35756, 36121
|
6033, 8045
|
18021, 22224
|
22239, 34872
|
5064, 5666
|
5847, 6009
|
15808, 15815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,638
| 174,578
|
32540+57799
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-5-3**] Discharge Date: [**2194-5-26**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
BACK PAIN
Major Surgical or Invasive Procedure:
1) debridement and removal of hardware/ placement of VACS
2) wound debridement/removal VACS
3) Thoracic fusion
4) Wound washout/debridement
History of Present Illness:
HPI: 55 y/o male with metastatic renal Ca to spine, transferred
from rehab due to worsening drainage from surgical incision
site at midincision point (about 3cm opening), recent admit
[**Date range (3) 75880**] during which on [**2194-1-28**] he
underwent thoracic instrumented fusion T1-12 by Dr. [**Last Name (STitle) 548**] for
stabilization and due to increased difficulty walking and
numbness/weakness/pain in his legs. Prior to this the patient
was found to have a renal tumor in [**2190**] s/p resection. In [**6-21**]
the patient was found to have an extradural mass at T5 that was
felt to be metastatic. The patient is also known to have a
kyphotic collapse at T10. On [**1-28**] he underwent excisional
biopsy
T5, T19, T10 vertebrectomy; instrumented fusion
T1-T12 with pedicle screws; iliac crest bone graft.
Past Medical History:
rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA
Social History:
Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone.
Family History:
Family History: father deceased at 63 yo of heart disease.
Physical Exam:
PHYSICAL EXAM
General: lying in bed, NAD
HEENT: NCAT, dry and erythematous mucous membranes
Neck: supple, no carotid bruits
Pulmonary: CTA b/l
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, mildly distended with some echymoses,
normal bowel sounds
Extremities: radial deviation of MCP joints of both hands due to
RA. Left elbow open wound with exposed bone.
Back: covered in extensive tattoos, 2 JP drain sutures removed,
R
paraspinal hematoma unchanged, mild serosanguinous drainage from
wound, no wound dehiscence.
NEURO
MSE: alert, oriented times 3, follows commands all 4 extremities
CN: PERRL 4-->2mm bilat, EOMI without nystagmus, facial
sensation
intact, smile symmetric but weak orbicularis oculi bilat,
hearing
intact b/l to finger rubbing, palatal elevation symmetrical, SCM
[**5-19**], tongue midline without fasciculations.
MOTOR: Normal bulk. Normal tone. No pronator drift. Mild
asterixis.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
C5 C7 C6 C8 L2 L3 L4-S1 L4 L5 L5
RT: 5 5 5 5 5 5 5 5- 5 5- 5- 5 5- 5-
LEFT: 5 5 5 5 5 5 5 5- 5 5- 5 5 4+ 5
SENSATION: normal to light touch in bilateral upper extremites,
mild decreased sensation over bilateral lowers
REFLEXES: DTRs 1 + and symmetric, plantars upgoing bilat
COORDINATION: FNF intact with RUE, some tremor with LUE.
Pertinent Results:
[**2194-5-3**] 05:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2194-5-3**] 05:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-SM
[**2194-5-3**] 05:30PM URINE RBC-[**3-19**]* WBC-[**3-19**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2194-5-3**] 04:00PM GLUCOSE-115* UREA N-13 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-12
[**2194-5-3**] 04:00PM WBC-15.0*# RBC-3.95* HGB-11.0* HCT-33.7*
MCV-85 MCH-27.9 MCHC-32.7 RDW-15.4
[**2194-5-3**] 04:00PM NEUTS-90.5* BANDS-0 LYMPHS-4.1* MONOS-4.1
EOS-1.2 BASOS-0.1
[**2194-5-3**] 04:00PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+
[**2194-5-3**] 04:00PM PLT SMR-HIGH PLT COUNT-501*
[**2194-5-21**] 04:46AM BLOOD Hct-25.5*
[**2194-5-20**] 06:35AM BLOOD WBC-6.1 RBC-3.11* Hgb-8.5* Hct-25.6*
MCV-82 MCH-27.4 MCHC-33.3 RDW-15.2 Plt Ct-407
[**2194-5-20**] 06:35AM BLOOD Neuts-68.7 Bands-0 Lymphs-18.8 Monos-9.8
Eos-2.4 Baso-0.2
[**2194-5-20**] 06:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2194-5-20**] 06:35AM BLOOD Plt Smr-NORMAL Plt Ct-407
[**2194-5-21**] 04:46AM BLOOD K-3.3
[**2194-5-4**] 05:45AM BLOOD CRP-282.0*
[**2194-5-4**] 05:45AM BLOOD ESR-67*
[**2194-5-15**] 10:11 am PLEURAL FLUID
GRAM STAIN (Final [**2194-5-16**]):
4+ (>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 [**2194-5-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2194-5-21**]): NO GROWTH.
ACID FAST SMEAR (Final [**2194-5-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2194-5-14**] 12:25 pm BLOOD CULTURE Source: Venipuncture 2 OF
2.
**FINAL REPORT [**2194-5-20**]**
Blood Culture, Routine (Final [**2194-5-20**]): NO GROWTH.
[**2194-5-13**] 8:30 pm SWAB T9.
**FINAL REPORT [**2194-5-16**]**
GRAM STAIN (Final [**2194-5-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2194-5-16**]):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 75881**]
([**2194-5-7**]).
[**2194-5-4**] 1:20 pm BLOOD CULTURE
**FINAL REPORT [**2194-5-10**]**
Blood Culture, Routine (Final [**2194-5-10**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 249-7676P [**2194-5-3**].
Anaerobic Bottle Gram Stain (Final [**2194-5-5**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Pt was admitted to the hospital and monitored closely in ICU.
He was seen in consultation by ID and plastic surgery. He was
begun on antibiotics. He was brought to the OR [**2194-5-6**] for wound
debridement, removal of hardware and placement of VAC
dressing.He was also seen by pain service.He was kept at strict
bedrest while hardware was out. He returned to OR [**2194-5-9**] for
debridement and application of VAC device. He then returned to
OR [**2194-5-13**] for removal of instrumentation,
debridement,reinsertion of spinal instrumentation, revision
arthrodesis/pseudoarthrosis repair. He was extubated [**2194-5-15**]. He
was evalutaed by thoracic surgery for increasing plueral
effusions with recommendation to tap which was performed without
difficulty [**2194-5-16**]. He was transferred out of ICU to floor. His
drainage was monitored from JP. Incision is healing
well/clean/dry. He was followed closely by ID throughout his
hospital course. He had post op xrays that showed good hardware
positioning. He worked with PT/OT and was recommended for acute
rehab. His albumin and protein were low and he has been given
supplements at each meal.
Medications on Admission:
Active Medication list as of [**2194-5-3**]:
Medications - Prescription
Atenolol - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
Citalopram - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
Enoxaparin - (Prescribed by Other Provider) - 40 mg/0.4 mL
Syringe - 40mg subq daily
Folic Acid - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
Gabapentin - (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
Methadone - (Prescribed by Other Provider) - 10 mg Tablet - 3
Tablet(s) by mouth three times a day
Methotrexate Sodium - (Prescribed by Other Provider) - 15 mg
Tablet - 1 Tablet(s) by mouth q7days
Modafinil - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth daily
Omeprazole - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
Oxycodone - (Prescribed by Other Provider) - 60 mg Tablet
Sustained Release 12 hr - 1 Tablet(s) by mouth three times a day
Tizanidine - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
Medications - OTC
Ascorbic Acid - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
Docusate Sodium [Colace] - (Prescribed by Other Provider) - 100
mg Capsule - 1 Capsule(s) by mouth twice a day
Ferrous Sulfate [FerrouSul] - (Prescribed by Other Provider) -
325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth
three
times a day
Miconazole Nitrate - (Prescribed by Other Provider) - Dosage
uncertain
Senna - (Prescribed by Other Provider) - Dosage uncertain
Zinc Sulfate - (Prescribed by Other Provider) - 220 mg Tablet -
1 Tablet(s) by mouth MWF
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): You should continue this antibiotic until you complete
your course of other antibiotics. .
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
9. Hydromorphone 4 mg Tablet Sig: 2.5 Tablets PO Q3H (every 3
hours) as needed for breakthru.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): sliding scale coverage.
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
17. Methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
18. Nafcillin 2 gram Recon Soln Sig: One (1) Injection every
four (4) hours: this medication should continue until at minimum
[**2194-7-15**] per ID team .
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Rifampin 300 mg IV Q 8H
21. Outpatient Lab Work
to be fax'd to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic at [**Telephone/Fax (1) **]
CBC, Chem Panel, LFT's, CRP, ESR, LFT's please
thank you
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
wound infection
hardware failure
septecemia
poor nutrition
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean and dry / No tub baths or pools until cleared
by Dr. [**First Name (STitle) **] - plastic surgeon.
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for 2 weeks.
?????? Check incision daily for signs of infection
?????? You are required to wear your back brace while out of bed,
even if only for short distances or being out of bed to chair.
?????? You may shower without the back brace.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. - it decreases opportunity for
fusion.
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation.
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, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
[**Last Name (un) **] CALL DR. [**Last Name (STitle) **]' OFFICE/ PLASTIC SURGERY UPON PTS ARRIVAL
TO YOUR INSTITUTION TO SCHEDULE FOLLOW UP APPOINMENT WITHIN NEXT
2 WEEKS AT [**Telephone/Fax (1) 1416**].
PLEASE SCHEDULE AN APPOINTMENT TO SEE DR. [**Last Name (STitle) **] / NEUROSURGERY
AT [**Telephone/Fax (1) **] TO BE SEEN IN 6 weeks WITH XRAYS OF YOUR
THORACO-LUMBAR SPINE
YOU HAVE A SCHEDULED APPOINTMENT TO SEE DR [**Last Name (STitle) **]- INFECTIOUS
DISEASE
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2194-6-30**] 10:00
Completed by:[**2194-5-22**] Name: [**Known lastname 1799**],[**Known firstname 63**] Unit No: [**Numeric Identifier 12405**]
Admission Date: [**2194-5-3**] Discharge Date: [**2194-5-26**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2427**]
Addendum:
Mr [**Known lastname **] [**Last Name (Titles) 532**] a temperature to 101.6 [**2194-5-23**] and his
discharge was postponed. A fever work up did not reveal a
infection source. His antibiotics remained. His temperature
was monitored thoroughout the weekend and did not spike again.
He appeared clinically well. Drainage amount from his JPs are
trending down.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2194-5-26**]
|
[
"008.45",
"070.54",
"714.0",
"737.10",
"998.59",
"511.9",
"285.9",
"V10.52",
"V45.4",
"038.9",
"305.90",
"998.12",
"324.1",
"198.3",
"996.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.45",
"78.49",
"81.05",
"78.69",
"34.91",
"81.64",
"86.59",
"77.69",
"84.52",
"77.49",
"86.04",
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] |
icd9pcs
|
[
[
[]
]
] |
14091, 14318
|
6217, 7376
|
327, 469
|
11464, 11488
|
3322, 5199
|
12665, 14068
|
1815, 1860
|
9184, 11266
|
11382, 11443
|
7402, 9161
|
11512, 12642
|
1875, 3303
|
5229, 6194
|
278, 289
|
498, 1320
|
1342, 1547
|
1563, 1783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,331
| 160,382
|
20117
|
Discharge summary
|
report
|
Admission Date: [**2124-1-15**] Discharge Date: [**2124-1-20**]
Date of Birth: [**2063-6-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60 year old male with
a history of cerebrovascular accident, schizophrenia, status
post percutaneous endoscopic gastrostomy, status post
tracheostomy, indwelling Foley catheter who presented with
sepsis. The patient was well at home until approximately one
week ago when he had a temperature of 101 and reported
"congestion." Nurse practitioner at home started him on
seven days of Levofloxacin ending five days ago. The patient
had one episode of diarrhea following antibiotic treatment,
none at the present time. Wife noted three episodes of
vomiting, one of which was dark. She denies the patient
having paroxysmal nocturnal dyspnea, orthopnea or lower
extremity edema. Today, on the day of admission, the patient
pulled out Foley balloon, lodged to mid penis. [**First Name (Titles) 3429**] [**Last Name (Titles) 54109**] the balloon and replaced the Foley
flushed. Several hours later he was noted to be agitated
with fever to 103 and persistent bleeding. He came to the
Emergency Department on the request of the covering
physician. [**Name10 (NameIs) **] noted increased secretions from trach,
states normal bowel habits, no dark stool, no vomitus other
than that mentioned above.
ALLERGIES: Reported allergy to Aspirin, reaction unclear.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident in [**2117**] with residual aphasia,
left gaze preference, left hemiparesis, presumed to be
hemorrhagic, no history of atrial fibrillation or Coumadin.
2. Schizophrenia.
3. Ventriculoperitoneal shunt approximately ten years ago,
details unknown.
4. Percutaneous endoscopic gastrostomy, trache, indwelling
catheter, trach change approximately q. three months,
percutaneous endoscopic gastrostomy from [**2122-4-17**].
5. Hypertension.
6. Asthma.
MEDICATIONS: Medications at home, Tegretol 600 in the AM and
500 in the PM, Dilantin 600 unknown frequency of dosing,
Zantac 150 p.o. q.d., Verapamil 60 b.i.d., Albuterol/Atrovent
nebulizers.
SOCIAL HISTORY: Ten pack year history of smoking. No
reported past use of alcohol or drug use.
PHYSICAL EXAMINATION: Vital signs, temperature maximum of
104, heartrate 130, blood pressure systolic 90s to 110s/40s.
Respiratory 24 to 40, 100% on trach mask. Examination in
general, the patient was not communicative. Long history of
aphasia. Eyes, seen deviating to the right, anicteric. Neck
is supple, no lymphadenopathy noted. Oral mucosa was clear
without pharyngeal exudate or erythema. Lungs were
rhoncerous with bilateral crackles described on the
examination. Cardiovascular examination was tachycardiac,
regular rhythm, normal S1 and S2. No murmurs, rubs or
gallops auscultated. Abdomen was soft, nontender,
nondistended, palpable percutaneous endoscopic gastrostomy
tube was in place. There was paradoxical stomach motion with
breathing. Extremities, muscle wasting, no calf tenderness,
minimal peripheral edema. Neurological examination, notable
for right-sided contractures.
LABORATORY DATA: Laboratory values initially on presentation
showed white blood cell count 11.1, hematocrit 35.5,
platelets 260. On repeat white blood cell count increased to
20.5, hematocrit was 40, 222 noted to be 69% neutrophils, 18%
bands, a few lymphocytes. Chem-7, 134/3.0/101/20/13/1.0/87,
calcium 7.7, magnesium 1.4. Liver function tests, amylase
and lipase within normal limits. The patient was noted to
have a lactate of 4.2. Arterial blood gases initially showed
7.4/30/65/19 at 10:30 PM creatinine kinase of 228, MB
fraction 11, troponin of .27. Urinalysis was notable for
large blood, moderate leukocyte esterase and trace
proteinuria. Chest x-ray showed no obvious infiltrates.
Trachea in good position, no evidence of pneumonia. No
evidence of congestive heart failure, no effusions noted.
Electrocardiogram was described as sinus tachycardiac to 116,
no intervals, low voltage, inferior ST depressions with
additional 1 to [**Street Address(2) 2051**] depressions in V3 to V5.
HOSPITAL COURSE: In summary, this is a 60 year old male with
a history of cerebrovascular accident with severe residual
deficits, schizophrenia, status post percutaneous endoscopic
gastrostomy, status post tracheostomy who presented to the
Emergency Department with severe sepsis, progressing to DIC.
1. Sepsis/DIC - On initial presentation the patient was
febrile, tachycardiac and became hypertensive and
demonstrating sepsis physiology. He was initially enrolled
in the sepsis protocol in the Emergency Department, however,
given his Do-Not-Resuscitate, Do-Not-Intubate status, sepsis
protocol was not continued, and the patient was provided with
maximal ventilator support, supplying 100% tracheostomy mask.
The source of the infection was unclear on initial
presentation. There was some suggestion that a pulmonary
source was likely given the recent upper respiratory
infection, however, chest x-ray did not support that finding
without any evidence of infiltrate or increasing opacities in
the lung fields. The patient reportedly removed his Foley
catheter, resulting in a traumatic event. Computerized axial
tomography scan at the time of presentation did not show any
intra-abdominal pathology. However, a DT cystogram study
showed the suggestion of possible intraprostatic urethral
injury, demonstrating contrast adjacent to the Foley catheter
in this region. Subsequent urine cultures and urinalysis
were negative for infection. Consequently, initially the
patient was started on broad spectrum intravenous
antibiotics, and subsequently developed 4 out of 4 blood
cultures demonstrating gram negative Enterococcal sepsis.
The final sensitivity speciations demonstrated Escherichia
coli sensitive to Ceftriaxone and Ceftazidime and
Enterococcus sensitive to Penicillin, Ampicillin, and
Vancomycin. During this hospitalization, the initial
thoughts of the family and the primary medical team were to
withdraw care given the severity of the infection, however,
it was decided to continue antibiotics for one more day. The
patient had a maximal white blood cell count of 34.3,
however, following one day of intravenous antibiotics and
aggressive volume repletion with intravenous fluids, the
patient demonstrated marked improvement in his condition. He
became hemodynamically stable and began to recover from this
infectious event.
At the time of discharge the patient was hemodynamically
stable. His antibiotic regimen was tailored. He will be
discharged on Ceftriaxone 1 gm intravenously q. day and
Ampicillin 1 gm intravenously q. 6 hours for an additional
two weeks following discharge. The patient's primary care
giver and primary care physician were involved in the
decision-making process and the patient will ultimately go to
an extended care facility for a short period of time before
returning home for continued care. A PICC line was placed
for longterm antibiotics the day prior to admission. It
should be noted that it was the family's wishes that during
this event that no pressors, new blood products or additional
lines were to be instrumented while the patient was
experiencing sepsis.
2. Non-ST elevation myocardial infarction - While the
patient was septic, he became markedly tachycardiac and
hypotensive and experienced relatively severe demand
ischemia. There were no electrocardiogram changes. The
electrocardiogram did not demonstrate ST elevations, however,
the patient had a maximal troponin of 3.02. Given the
patient's Do-Not-Resuscitate, Do-Not-Intubate status and the
initial instructions of the family to provide comfort care
measures only, with the addition of antibiotics, no further
workup was performed in the hospital. On discharge the
patient was hemodynamically stable and it will be the
decision of the primary care provider and health care proxy
to determine if any additional workup will be provided as an
outpatient.
3. Seizure prophylaxis - The patient was remained on
Dilantin and Tegretol. His Dilantin level was 200 mg p.o.
t.i.d., his Tegretol level was 300 mg p.o. q.d.
4. Pain control - The patient's family expressed that the
patient be treated with aggressive pain control. The patient
was treated with Morphine 1 to 5 mg intravenously q. 4 hours
prn as needed for pain. The patient was comfortable
throughout his hospital course.
CONDITION ON DISCHARGE: The patient has reportedly returned
to his pre-hospital baseline. The patient had a severe
stroke and is aphasic. He has a right-sided hemiplegia and
is not able to contribute to decisions regarding his own
health care. The patient was discharged to a [**Hospital 5735**]
rehabilitation facility for continued management of his
multiple medical problems with discharge home following
completion of his antibiotic course for resolving sepsis.
DISCHARGE STATUS: The patient will be discharged to an
extended care facility.
DISCHARGE DIAGNOSES:
1. Sepsis/shock
2. Fever
3. DIC
4. Hypotension
5. Cerebrovascular accident - management of prior
cerebrovascular accident
6. Coma
7. Non-ST elevation myocardial infarction
8. Seizure prophylaxis
DISCHARGE MEDICATIONS:
Lansoprazole 30 mg p.o. q.d.
Albuterol 1 nebulizer solution, 1 nebulizer q. 6 hours prn as
needed for wheezing
Ipratropium Bromide 1 nebulizer inhaler q. 6 hours prn
Erythromycin 0.5% ophthalmic ointment 0.5 in both eyes q.i.d.
Tylenol 325 to 650 mg p.o. q. 4-6 hours as needed prn for
fever
Carbamazepine 300 mg p.o. t.i.d.
Phenytoin suspension 200 mg p.o. t.i.d.
Morphine Sulfate 1 to 5 mg intravenously q. 4 hours prn as
needed for pain, please start with 1 mg and titrate as needed
for pain relief
Ceftriaxone 1 gm intravenously q. 24 hours times two weeks,
please stop on [**2124-2-3**].
Ampicillin 1 gm intravenously q. 6 hours, please stop on
[**2124-2-3**]
DISCHARGE INSTRUCTIONS:
1. The patient will be discharged to an extended care
facility.
2. The patient will continue to be followed by Dr.
................., his primary care physician for continued
medical management.
3. The patient will continue with [**Hospital6 407**]
services when discharged home from the extended care
facility.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AIY
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2124-1-19**] 19:07
T: [**2124-1-19**] 19:36
JOB#: [**Job Number 54110**]
|
[
"707.0",
"438.20",
"295.90",
"286.6",
"785.52",
"780.39",
"410.71",
"995.92",
"867.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9023, 9227
|
9250, 9916
|
4147, 8450
|
9940, 10479
|
2245, 4129
|
159, 1428
|
1450, 2124
|
2141, 2222
|
8475, 9002
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,340
| 167,200
|
34965
|
Discharge summary
|
report
|
Admission Date: [**2129-3-21**] Discharge Date: [**2129-4-6**]
Date of Birth: [**2048-5-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
TEE [**2129-3-25**]
History of Present Illness:
80 M with MMP brought in by family for increasing confusion for
the past 2 days. Family states patient has been confused past 2
days, asking whether it is day or night and wandering at night
where he has had a few mechanical falls. Of note patient had had
trazodone and welbutrin doses increased in the past couple
weeks. Family states he has had no diarrhea, cough, chest pain,
dyspnea or any other symptoms. He does have a chronic foley in
place for urinary retention which is followed by Urology.
In the ER 98.7, 80, 120/80, 97% ra, WBC 13, Cr 1.6 (1.1), U/A
was + leuk est, nit, many bacteria, no epithelial cells, was
given Levofloxacin and admitted for UTI/delirium. CXR was clear.
CT head unrevealing.
.
ROS: as per HPI
Past Medical History:
-HTN
-MSSA bacteremia/endocarditis- s/p 6 weeks of treatment of IV
Cefzolin completed on [**2128-12-5**]
-C.diff colitis [**11-6**]- completed tx [**2128-12-19**]
-Urinary retention- followed by urology. Recently placed Foley
semi-permanently with worstening retention likely [**1-31**] use of
psych meds.
-Depression x 15 yrs treated most long term with Prozac
-s/p lumbar diskectomy
-b/l cataract removal
-Anemia
.
Surgery HX:
L hip fx repair [**11-6**]
L humeral fx repair [**11-6**]
Bilateral shoulder fractures [**10-6**]
Social History:
Lives with wife and 50 [**Name2 (NI) **] son. Retired machinist. No tobacco use
or alcohol. Family states at baseline he does the crossword
puzzle, is not forgetful. Uses walker in house.
Family History:
NC
Physical Exam:
VS: 99.0, 124/78, 84, 16, 96% room air
GEN: NAD, AOx2, oriented to name, place
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, MM dry
NECK: Supple, no JVD
CV: II/VI SEM heard best at apex, no heaves or thrills
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, foley cath with leg bag in place
EXT: No c/c/e
SKIN: No rash
NEURO: Alert, oriented x 2, CN 2-12 intact. Moves all four
extremities freely, unable to cooperate with full exam.
Pertinent Results:
Admission labs:
[**2129-3-21**] 09:45PM BLOOD WBC-13.2*# RBC-3.31* Hgb-9.4* Hct-29.1*
MCV-88 MCH-28.3 MCHC-32.2 RDW-14.9 Plt Ct-294
[**2129-3-21**] 09:45PM BLOOD PT-14.9* PTT-26.2 INR(PT)-1.3*
[**2129-3-21**] 09:45PM BLOOD Gran Ct-[**Numeric Identifier 79983**]
[**2129-3-21**] 09:45PM BLOOD Glucose-112* UreaN-33* Creat-1.6* Na-135
K-3.7 Cl-99 HCO3-24 AnGap-16
[**2129-3-21**] 09:45PM BLOOD CK(CPK)-48
[**2129-3-21**] 09:45PM BLOOD cTropnT-0.05*
[**2129-3-21**] 09:45PM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1
.
[**2129-3-25**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. A patent
foramen ovale is present with a left-to-right shunt by color
Doppler at rest. Overall left ventricular systolic function is
normal (LVEF>55%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] with normal free wall contractility. There are
complex (>4mm) atheroma in the aortic arch and descending aorta
to 40 cm from the incisors. The aortic valve leaflets are
moderately thickened. Trace aortic regurgitation is seen. There
is mild mitral valve prolapse. There is a large vegetation on
the mitral valve involving both leaflets (predominantly A3/P3)
and measuring 2.3 x 1.0 cm. There is partial flail of the
posterior leaflet. No mitral valve abscess is seen. An
eccentric, anteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. No vegetation/mass is seen on the
tricuspid, pulmonic valve or aortic valve. There is no
pericardial effusion.
IMPRESSION: Large vegetation on the mitral valve with moderate
eccentric mitral regurgitation and partial flail of the
posterior leaflet.
[**3-21**]:
Blood Culture, Routine (Final [**2129-3-25**]):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 0.75 MCG/ML, Sensitivity testing performed
by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2129-3-22**]):
[**3-29**]:
6:53 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECALIS. PRELIMINARY SENSITIVITY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ S
LEVOFLOXACIN---------- R
VANCOMYCIN------------ R
Aerobic Bottle Gram Stain (Final [**2129-3-30**]):
REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) 79984**], PAGER#[**Serial Number **] @ 0637
ON
[**2129-3-30**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Brief Hospital Course:
80 yo M with h/o HTN, depression, several fractures [**10-6**], C
Diff, recent MSSA endocarditis and urinary retention w/ bladder
stones who comes in with AMS, [**1-31**] enterococcus endocarditis.
# [**Name (NI) 79985**] Pt initially had high grade bacteremia with 8/8
bottles from blood cultures in first two hospital days positive
for enterococcus. Proven with veg on MV on [**3-25**] TEE. ID was
consulted. Pt was placed on vanco/gent and PICC line was placed
for antibiotics. On [**3-29**] pt had another blood cx positive for
Enterococus. His sensitivites returned sensitive to
ampicillin/penicillin, and pt had pcn desensitizaiton, which he
tolerated well. Pt was started on Pcn G/Gent combination
therapy. The sensitivities for the new cx on [**3-29**] showeed
resistence to Vancomycin but the patient had already been
changed to Pcn/Gent. The culture from the 31st also returned as
resistant to Gentamycin. So his antiboitic regimen was changed
again to Ampicillin 2g IV q4h, and Strepomycin 650mg IM q24. The
cultures continued to remain negative for the remaining time
during this admission (for 6 days). Pt should get weekly BMP
checked and Gent troughs. If pt's Cr rises a gent Peak should
also be checked. These labs should be faxed over to the Dr.
[**Last Name (STitle) **] in [**Hospital 191**] clinic. The fax number is ([**Telephone/Fax (1) 16691**]. Pt also
had a streptomycin peak and trough drawn prior to discharge and
this should be followed as outpt.
# Mitral Valve failure- Pt has 2+ regirg w/ mild MVP and partial
failure of post leaflet. No abscess seen on echo. Pt still needs
to d/w family whether to pursue surgery. CT [**Doctor First Name **] saw the patient
and first noted that pt's antibiotic course would need to be
finished if any procedure was to be done, but in their opinion
pt did not need surgery. Pt did not have any mitral valve
abscess, new heart failure, nor complete failure of the valve.
So at this point pt does not need surgery. Pt should have a
repeat echo in 6 weeks.
# Altered mental status- Pts altered mental status was thought
to be [**1-31**] infection and several recent changes in his
psychiatric medications. Pts infection was treated as above and
all psychiatric medications were held.
# Depression - pt has severe depression and was on 3
antidepressants when he came. These were held due to his AMS.
After his mental status was back at baseline, pt's mood appeared
very depressed. We spoke to his outpt psychiatrist, who
recommended to start the Wellbutrin at 150mg [**Hospital1 **], and trazedone
as needed for sleep. From speaking ot the daughter pt would
become overstimulated on [**Hospital1 **], and pt was changed to QD. Pt's
mood still appears depressed at discharge and should be
continiued to be followed closely.
# PE- non-occlusive lumbar PE seen inicidentally on CT chest
[**3-23**]. Unable to do CTA for further evaluation [**1-31**] ARF. LENI's
neg [**3-24**]. Pt was started on heparin gtt initially which was
switched to lovenox. At no time was he hemodynamically unstable
or symptomatic from PE. The lovenox was discontinued near the
end of his hospitalizaiton since anticoagulation is relatively
contraindicated in the setting of endocarditis for risk of
septic emboli to the brain becoming hemorrhagic. No septic
emboli were suspected, but as pt had a small non-occlusive PE
the decision was made to discontinue the lovenox.
# ARF/ Urinary retention- Pt likely had post-renal azotemia.
Patient was admitted with Cr 1.6. At discharge, Cr is now 1.3.
Pt's urinary retention is a chronic problem for this patient and
he is followed by Dr. [**Last Name (STitle) 261**] in urology. He was seen by urology
on HD 5 after pt pulled out own foley traumatically with
bleeding. To f/u in outpt urology clinic re urinary retention
and keep in foley for at least another [**12-31**] wks until F/u. Note:
has bladder stone but per urology nothing to do for these. ID ?
if source of infxn. Continuing home tamsulosin. Lasix and
lisinopril were held in house [**1-31**] ARF. Pt was restarted on half
of his dose of lasix 40mg (which was recently increased to 80mg
QD). Pt on discharge had rare urine eos, but it may have been
previous antibiotics he was on, and since his Cr is now stable,
we suspect this will resolve. Pt should have his Cr followed
once per week, until seen by the urologist.
# Incidental lesions found - pt with incidental liver, pancreas
and kidney lesions on CT [**3-23**]. Likely needs f/u
Medications on Admission:
Flomax 0.8 QHS
Lopressor 25mg [**Hospital1 **] (recently increased from daily)
KCL 20 mEq [**Hospital1 **]
Lasix 80 Daily (recently increased from 40 daily and feet
swelling came down)
Oscal 500 [**Hospital1 **]
Vit D Q week
Klonopin 0.5 Daily
Remeron 30mg daily (started during last hospitalization, stopped
[**3-18**])
Wellbutrin 150 [**Hospital1 **] (started [**3-18**])
Trazodone 50 Qhs (started [**3-18**])
Fluoxetine 60 daily (stopped [**2129-2-9**])
Effexor 37.5 daily (started [**2-17**] and stopped [**3-9**])
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
13. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
Sig: One (1) Intravenous Q4H (every 4 hours) for 31 days: 6
weeks will be complete on [**2129-5-3**].
14. Gentamicin Sulfate (PF) 60 mg/6 mL Solution Sig: Sixty (60)
mg Intravenous every twelve (12) hours for 31 days: please
continue until [**2129-5-3**] to complete the 6 week course.
15. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Enterococcus Endocarditis
.
Secondary diagnoses:
Pulmonary embolism
Acute renal failure
Delerium
Urinary retention
Discharge Condition:
Good
Discharge Instructions:
You were admitted with confusion and found to have an infection
of your heart called endocarditis. You were placed on
antibiotics to treat this infection, and are now on the best
antibiotic for your type of infection Penicillin and
Gentamyacin. You will need to continue these antibiotics for a
total of 6 weeks.
.
We made the following changes to your medications:
- Continue Pencillin G 3M units every 4 hours until [**2129-5-3**]
(total of 6 wks)
- Continue Gentamycin 60mg every 12 hours until [**2129-5-3**]
(for a total of 6wks)
- Wellbutrin was restarted for depression
- Trazedone was restarted for sleep
.
Please follow up as below.
.
Please call your doctor or return to the ED if you have any
fever, chills, chest pain, shortness of breath, worstening leg
swelling, nausea, lightheadedness, falls or any other concerning
symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], she will be your new primary
care doctor. [**First Name (Titles) 6**] [**Last Name (Titles) 648**] was made for [**4-14**], at 3pm.
This is at [**Hospital6 733**] at the [**Hospital Ward Name 23**] building on the
[**Location (un) **]. The number is [**Telephone/Fax (1) 250**]
Please follow up with Dr. [**Last Name (STitle) **], the infectious disease doctor,
and [**Last Name (STitle) 648**] could not be made before you were discharged.
Please call [**Telephone/Fax (1) 250**].
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**], Orthopedic surgeon
[**6-14**]@9am at [**Hospital Ward Name 23**] [**Location (un) 551**]
Phone number: [**Telephone/Fax (1) 34025**]
Please follow up with urologist, Dr. [**Last Name (STitle) 33427**] in 2 weeks. [**4-15**] 11:30am, [**Telephone/Fax (1) 277**]
Please follow up with your Psychiatrist in [**2-1**] weeks, an
[**Date Range 648**] was not able to be made. Please call on Monday.
Completed by:[**2129-4-6**]
|
[
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"424.0",
"593.9",
"311",
"790.7",
"421.0",
"V07.1",
"573.8",
"577.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
12404, 12476
|
5825, 10313
|
275, 297
|
12654, 12661
|
2381, 2381
|
13551, 14593
|
1825, 1829
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10883, 12381
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12497, 12497
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10339, 10860
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12685, 13022
|
1844, 2362
|
12565, 12633
|
5177, 5802
|
13051, 13528
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231, 237
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325, 1054
|
2398, 5133
|
12516, 12544
|
1076, 1604
|
1620, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,371
| 180,577
|
1206
|
Discharge summary
|
report
|
Admission Date: [**2160-3-22**] Discharge Date: [**2160-4-19**]
Date of Birth: [**2107-5-31**] Sex: F
Service: MEDICINE
Allergies:
Zofran
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Resp failure & hypotension
Major Surgical or Invasive Procedure:
Intubation/Extubation
Thoracentesis
Breast biopsy
History of Present Illness:
52 yo f with history of DM on insulin and HTN who has been
feeling generally unwell for months. She has been coughing up
sputum and more trouble breathing for the past few months. She
has been having so much trouble breathing that she has been
unable to eat or drink for the past few days to a week; this
prompted her to call 911 this am. One son thinks that she may
have been having intermittent fevers. They were unaware of any
weight loss. The note that she avoids seeing the doctor.
In the ED, she was found to be in respiratory distress and quite
hypoxic. Initial VS were 97.9 94 135/94 24 98% on NRB. She was
found to have a large breast mass and decreased breath sounds on
the right on exam. She eventually required intubation for
hypoxia. The intubation was complicated by the ETT being placed
in R main stem bronchus initially. In the setting of
intubation, she became hypotensive to the 60s. She was given 4L
of IVF and required levofed and Neosyn at one point. Prior to
being transferred she was weaned down to levofed alone. In the
setting of hypotension, she developed STE on EKG, which rapidly
resolved with improvement in BP. Interventional cardiology was
called and evaluated the patient in the ED. They did not
recommend any heparin or cardiac catheritization, but
recommended cycling CE, EKGs and an ECHO if she remains
unstable.
CT torso shows a complex, likely malignant effusion, lung mass
and breast mass; In the [**Last Name (LF) **], [**First Name3 (LF) **] urgent femoral line was placed,
which was not done under completely sterile conditions. In the
ED she was given levofloxacin 500mg IV x1 and CTX 1 gm IV x1 for
presumed PNA. For hyperkalemia she was given Insulin D50,
Calcium chloride. She was also hyponatremic, presumed
hypovolemic hyponatremia, butn not improved with NS boluses in
ED. Her glucose is also elevated to 400s. Her VS prior to
transfer are: 72 117/76 18 100%, A/C 450 x18 peep 5 60%.
Past Medical History:
Diabetes mellitus, type II, insulin dependent
Hypertension
C-section x5
Social History:
Social History: Originally from [**Country 2045**]; most extended family in
[**Country 2045**]. She has one brother in US, lives nearby. She is
married, separated, sons say they don't know her husband. Lives
in [**Location (un) 577**]. Had 5 children, the eldest son is disabled. Worked
as nurses aid up until [**12-11**], when she quit because she had been
feeling ill. Never smoker. No EtOH. No drugs.
Family History:
Family History: Sons do not know extended family history. Not
aware of any FHx of cancer.
Physical Exam:
On ICU admission:
GEN: intubated, sedated.
HEENT: PERRL, anicteric, exopthalmus.
LYMPH: + axillary LAD. no supraclavicular or cervical
lymphadenopathy,
NECK: JVP elevated. no carotid bruits
CHEST: right fungating breast mass 10x5 cm, encasing entire
right breast, with skin nodule 2.5 x 2.5 cm lateral to mass.
RESP: bilat rhonchorous breath sounds
CV: RR, S1 and S2 wnl, no m/r/g
ABD: +b/s, soft, nd, nt, no masses or hepatosplenomegaly
EXT: mild non-pitting pedal edema, skin cool, 2+DP pulses bilat.
no clubbing.
SKIN: no rashes/no jaundice/no splinters
GU: foley in place
NEURO: sedated, withdraws to pain in LE bilat
.
On transfer from ICU to floor [**2160-4-8**]:
Vitals: 99.3 140/90 72 22 99%4L NC
GEN: pleasant, AAOx3
HEENT: PERRL, anicteric
LYMPH: + axillary LAD. no supraclavicular or cervical
lymphadenopathy,
CHEST: right fungating breast mass 10x5 cm, encasing entire
right breast, with skin nodule 2.5 x 2.5 cm lateral to mass.
RESP: bilat rhonchorous breath sounds
CV: RR, S1 and S2 wnl, no m/r/g
ABD: +b/s, soft, nd, nt, no masses or hepatosplenomegaly
EXT: mild non-pitting pedal edema, skin cool, 2+DP pulses bilat.
no clubbing.
SKIN: no rashes/no jaundice/no splinters
NEURO: A & O x 3, CN II - XII intact, difficulty abducting
shoulder past 90degrees
.
On discharge:
Vitals: 97.4 120/70 72 18 97%RA
GEN: pleasant, AAOx3, NAD
HEENT: PERRL, anicteric, MMM
LYMPH: + axillary LAD. no supraclavicular or cervical
lymphadenopathy
CHEST: right fungating breast mass 10x5 cm, encasing entire
right breast, with skin nodule 2.5 x 2.5 cm lateral to mass.
RESP: CTAB, no wheezes or crackles
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: +b/s, soft, nd, minimally tender in mid abdomen, no masses
or hepatosplenomegaly
EXT: [**2-3**]+ non-pitting pedal edema, skin cool, 2+DP pulses bilat.
no clubbing.
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
On admission:
[**2160-3-22**] 03:50AM BLOOD WBC-6.5 RBC-5.84* Hgb-17.6* Hct-50.6*
MCV-87 MCH-30.1 MCHC-34.7 RDW-12.9 Plt Ct-275
[**2160-3-22**] 03:50AM BLOOD Neuts-77.8* Lymphs-13.5* Monos-8.4
Eos-0.3 Baso-0.2
[**2160-3-22**] 03:50AM BLOOD PT-12.8 PTT-26.7 INR(PT)-1.1
[**2160-3-22**] 11:13AM BLOOD Fibrino-530*
[**2160-3-22**] 03:50AM BLOOD Glucose-332* UreaN-28* Creat-0.9 Na-118*
K-6.5* Cl-79* HCO3-27 AnGap-19
[**2160-3-22**] 07:40AM BLOOD ALT-56* AST-40 AlkPhos-87 TotBili-0.5
[**2160-3-22**] 07:40AM BLOOD Lipase-52
[**2160-3-22**] 11:13AM BLOOD CK-MB-23* MB Indx-5.5 cTropnT-0.02*
[**2160-3-22**] 07:40AM BLOOD Albumin-2.9* Calcium-9.6 Phos-5.2* Mg-2.1
[**2160-3-22**] 07:40AM BLOOD Osmolal-276
[**2160-3-22**] 11:13AM BLOOD TSH-1.5
[**2160-3-22**] 11:13AM BLOOD Cortsol-23.5*
[**2160-3-25**] 07:52AM BLOOD Vanco-13.6
[**2160-3-22**] 05:55AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.027
[**2160-3-22**] 05:55AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-MOD
[**2160-3-22**] 05:55AM URINE RBC-0-2 WBC-21-50* Bacteri-MOD Yeast-NONE
Epi-[**7-11**]
[**2160-3-22**] 05:55AM URINE CastGr-0-2
[**2160-3-24**] 09:58AM URINE AmorphX-MOD
[**2160-3-22**] 05:55AM URINE UCG-NEGATIVE
[**2160-3-24**] 11:15AM PLEURAL WBC-450* RBC-220* Polys-14* Lymphs-15*
Monos-0 Macro-12* Other-59*
[**2160-3-24**] 11:15AM PLEURAL TotProt-2.1 Glucose-200 LD(LDH)-147
On discharge:
[**2160-4-19**] 06:50AM BLOOD WBC-4.3 RBC-3.58* Hgb-10.7* Hct-32.3*
MCV-90 MCH-29.8 MCHC-33.1 RDW-16.1* Plt Ct-287
[**2160-4-19**] 06:50AM BLOOD Glucose-198* UreaN-18 Creat-0.7 Na-138
K-4.3 Cl-99 HCO3-32 AnGap-11
[**2160-4-18**] 06:25AM BLOOD ALT-39 AST-20
[**2160-4-19**] 06:50AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.3
Microbiology:
Blood Culture, Routine (Final [**2160-3-28**]): NO GROWTH.
Blood Culture, Routine (Final [**2160-3-29**]): NO GROWTH.
URINE CULTURE (Final [**2160-3-24**]):
GRAM POSITIVE BACTERIA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
URINE CULTURE (Final [**2160-3-23**]): NO GROWTH.
URINE CULTURE (Final [**2160-3-25**]): NO GROWTH.
URINE CULTURE (Final [**2160-4-4**]): YEAST. ~5000/ML.
[**2160-3-22**] 11:53 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2160-3-22**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2160-3-24**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. MODERATE GROWTH.
[**2160-3-24**] 11:29 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2160-3-24**]):
4+ (>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 [**2160-3-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2160-3-30**]): NO GROWTH.
[**2160-4-9**] 12:29 pm PLEURAL FLUID
GRAM STAIN (Final [**2160-4-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2160-4-12**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2160-4-15**]): NO GROWTH.
Pathology: Right breast biopsy
1. Right breast, frozen section, core needle biopsy (A):
Invasive ductal carcinoma.
2. Right breast, permanent, core needle biopsy (B-C): Invasive
ductal carcinoma. High grade ductal carcinoma in situ, scant
foci.
ADDENDUM:
FISH assay for HER-2/neu gene amplification was performed by US
LABS, [**Street Address(2) 7630**], [**Location (un) 7631**], [**Numeric Identifier 7632**]:
Result: NOT AMPLIFIED
Estrogen Receptor: Interpretation: Positive (>1% of tumor cells
positive)
Progesterone Receptor: Interpretation: Positive (>1% of tumor
cells positive)
CXR [**2160-3-22**]:
Right middle and lower lobe consolidation with associated
moderate effusion. Mild interstitial edema.
CT head w/o contrast [**2160-3-22**]:
Multiple areas of small hypodensities in the brain could
represent small
intracranial metastases. An MR may be obtained for further
evaluation.
CT chest/abdomen/pelvis [**2160-3-22**]:
1. Findings consistent with right sided advanced breast cancer
with
metastases to both axillae, lung, bilateral adrenal glands and
possibly liver.
2. Moderately large right pleural effusion is intermediate in
density. A
malignant effusion cannot be excluded.
3. CT findings suggest right heart strain with enlargement of
the right
ventricle with obliteration of the right middle lobe pulmonary
artery. This examination was not intended for evaluation of the
pulmonary arteries. If further evaluation is of clinical
concern, then a dedicated CTPA may be obtained.
4. The ET tube terminates in the right mainstem bronchus and
should be pulled back by 3 cm and a repeat radiograph should be
obtained to document
appropriate positioning.
TTE [**2160-3-25**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. 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.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade. There is at least mild
to moderate pulmonary artery systolic hypertension.
CTA chest [**2160-3-28**]:
1. No pulmonary embolism or evidence for extrinsic pulmonary
artery
compression. The main pulmonary artery; however, is top normal
in size,
suggestive of mild pulmonary arterial hypertension.
2. Progression of pulmonary edema. Decreased right-sided pleural
effusion. The right-sided pigtail catheter tip is in the
pleural space, however, part of the loop of the pigtail is
outside the pleural space as described. Enlarged left pleural
effusion. Anasarca.
3. Progression of right lower, and right middle lobe pneumonia.
4. Rounded pulmonary nodules may be metastatic foci. Wall
thickening of the right main stem bronchus difficult to evaluate
given underlying edema. Both these findings should be
re-evaluated when patient improves to evaluate for potential
metastatic disease to the bronchi and lungs.
5. Stable appearance to the right breast mass, and axillary
metastases.
MRI head [**2160-3-30**]:
1. 7mm focus of enhancement over the right frontal extra-axial
convexity may represent artefactual venous enhancement. Tiny
meningioma or a dural based metastasis is not ruled out. Follow
up is recommended.
2. No evidence of intra-axial metastatic disease.
3. Microangiopathic small vessel disease
KUB [**2160-4-1**]:
IMPRESSION: Non-specific air-filled loops of large bowel. No
definitive
signs of obstruction.
Right shoulder x-ray [**2160-4-7**]:
IMPRESSION: Limited evaluation of the right shoulder
demonstrates no gross
abnormality. If there is concern for metastasis, recommend
further evaluation with MRI.
CXR [**2160-4-17**]:
FINDINGS: As compared to the previous radiograph, the bilateral
pleural
effusions have minimally increased in extent. The subsequent
areas of mild
retrocardiac atelectasis are unchanged. Minimal interstitial
fluid overload. Unchanged moderate cardiomegaly. No other
abnormalities have appeared in the interval.
Pleural fluid [**2160-4-9**]:
NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells.
Pleural fluid [**2160-4-11**]:
ATYPICAL. Rare atypical epithelioid cell.
Pleural fluid [**2160-4-10**]:
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and lymphocytes.
EKG:
[**2159-3-23**] 3:52 - NSR HR 90, RAD with S1, Q3, T3, poor baseline.
1/2mm STE in V3 & V5.
[**2159-3-23**] 7:15 - NSR 92, RAD, STE in V3-V5 and also in inferior
leads.
[**2159-3-23**] 7:23 - NSR 64, RAD resolution of STE in V3 & V5, still
present in V4, and slight elevation in III & ? AVF.
[**2160-3-22**] 11:13: NSR 69, Q wave in V3, V4 with upsloping ST
segment otherwise resolution of ST changes.
Brief Hospital Course:
52 y/o F with history of DM on insulin and HTN who presented
with SOB and developed respiratory failure thought [**3-5**] pleural
effusion and widely metastatic breast malignancy.
# Respiratory failure, hypercarbic: Pt required intubation upon
arrival to ED given hypoxia and tachypnea. Respiratory failure
was most likely [**3-5**] to large effusions and extensive malignant
involvment of lungs. PNA was also a possibility given
leukocytosis at presentation. She was treated empirically with 8
days of cefepime + vancomycin. She had no culture growth. IP was
consulted and 800cc of transudative pleural fluid were drained
from the right chest, fluid cytology was negative for malignant
cells, pleurex catheter was left in place. She was extubated
briefly but then re-intubated for worsening hypercapnea and
increased work of breathing, likely due to increased dead space
and mucus plugging. It was felt that fluid retention was
contributing to the patient's poor repsiratory status and
inability to wean off ventilation. Lasix drip was used to
diurese her and she was eventually transitioned to boluses of
lasix. She was re-extubated and tolerated this well. She had
weakness that led to hypercarbia and severely elevated
bicarbonate, which could have been [**3-5**] contraction alkalosis and
hypoventilation 2/2 pleural effusions. NIV was used to bridge
her during the day. She used a schedule of 2 hours on and 2
hours off NIV, and over 2 days she was able to extend her times
off of NIV so that she only used it at night. Pleurex catheter
was later found to be in subcutaneous space and was removed.
Her improved respiratory status and strength coupled with her
starting Taxol (likely causing HCO3 leak from the kidney),
improved her bicarbonate level. Pleural effusion reaccumulated
in the interim, requiring another pigtail catheter that drained
initially 2L daily. It was pulled when she was draining 400cc
daily. Repeat chest xray showed minimal reaccumulation of
pleural effusion by time of discharge and IP inserted pleurex
catheter on day prior to discharge for further drainage.
Multiple pleural fluid samples were analyzed; they were largely
transudative without malignant cells. Her pleural effusions and
LE edema were attributed largely to CHF and improved with
diuresis. Kidney function remained stable while being diuresed.
Hypercarbia resolved by time of discharge and bicarb levels were
normal. She did not require bipap by time of discharge. She
was discharged on po lasix for further diruesis. She was on
room air and satting in 90s even with ambulation by discharge.
# Metastatic breast cancer: Records from OSH showed that right
breast biopsy showing infiltrating ductal carcinoma with ductal
carcinoma in situ, tumor grade II/III, in 5 of 6 biopsies. She
was found to be estrogen/progesterone receptor positive at that
time. She did not receive follow-up care after this diagnosis.
Biopsies were taken here on [**2160-3-22**] showing invasive ductal
carcinoma, high grade. Additional imaging studies showed
metastases in the lungs, possibly liver, both adrenal glands,
and also possibly in the brain. She was ER/PR positive and
Her-2/neu negative. She was started on taxol on [**2160-4-3**] with
good response. She received her next doses on [**2160-4-10**] and
[**2160-4-17**] and tolerated chemotherapy well. She will follow up
with her new primary oncologist who also followed her during her
hospital course.
# Blood pressure instability: Pt became hyoptensive to systolic
60s following intubation, requiring pressors in the ICU. Cause
not entirely clear, likely pre-load dependent d/t right sided
failure [**3-5**] to malignancy related pulmonary hypertension. Echo
and CTA chest shows mild RV dilation and hypokinesis and mild to
moderate PAH (likely [**3-5**] to malignant infiltration), but no
indication to stent PA.
Her TTE and CTA did not suggest enough RV failure to fully
explain her hypotension. Adrenal insufficiency was ruled out
with normal [**Last Name (un) 104**] stim test. Patient had episodes of bradycardia
followed by hypertension with SBPs in low 200s, thought to be
response to Levophed, so it was DC??????ed in favor neosynephrine.
Midodrine was then started and were able to wean off
neosynephrine. Her blood pressures stabilized, and she was able
to be taken off of the Midodrine as well. Of note, pt does have
history of HTN and was on diovan-HCTZ and diltiazem prior to
admission. However, BP was stable, systolic 110s-120s, after
her transfer from ICU to the floor and prior to discharge. Her
home BP medications, therefore, were discontinued.
# Cardiac ischemia (resolving)/1st degree AV block: On [**3-25**] pt
had episode of rapidly reversing ST elevations in course of 5
mins that were consistent with possibly thrombo-embolic
phenomenon. CEs were negative. Unlikely to be ACS. Unusual to
see STE with demand ischemia, but possible. History and time
course seems most c/w demand. Resolved quickly with tx of
hypotension and hypoxia. On [**3-25**], had episode of chest
discomfort with 4.7sec pause on telemetry. Cardiology fellow was
consulted. Agreed that patient has 1st degree heart block, but
thought the pause was unrelated to chest pain and was result of
PVC causing reset. Aspirin 325mg was continued and she was
started on simvastatin. She had another episode of chest pain
on [**2160-4-14**]. Described the pain as right sided, near her breast
mass, and was tender on palpation of epigastrium towards the
right. EKG showed ST elevation in V2 and nonspecific TWIs; trop
was 0.03 and downtrended to 0.02. She reported no further chest
discomfort for remainder of hospital stay.
# Social issues: There were several social issues complicating
patient's care. Social work and palliative care were very
involved in the case. She is the single mother to five teenage
children. The oldest son is incapacitated and being taken care
of at home by his uncle. She also has two sons in college.
Several family meetings were held to assist the family while
mother was in the hospital, particularly with care of the oldest
son. Also complicating pt's care was mistrust of the healthcare
system. She often refused therapeutic interventions (e.g.
BiPAP), became frustrated at blood draws and other procedures,
and refused discharge to rehab as recommended by PT. After
transfer from ICU to the floor, she gradually became more
trusting of the medical team and with discussion and negotiation
was amenable to appropriate therapeutic interventions. However,
she adamantly refused rehab and was discharged home with VNA
services; documents were also submitted for additional services
including personal care attendant, the ride, and home PT.
Medications on Admission:
Medications at home: (per sons, need to confirm with pharmacy)
Diovan-hydrochlorothiazide 160-12.5mg PO daily
Dilt-XR 240mg PO daily
Multivitamin 1 tab po daily
NPH & Regular insulin 70/30 mix - [**Hospital1 **], dosage unknown
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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas, constipation.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain: Do not drive or operate machinery while on
this medication.
Disp:*30 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Disp:*30 packet* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. metronidazole 1 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
Disp:*1 tube* Refills:*0*
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
right shoulder 12 hr on and 12 hr off.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Sixteen (16) units Subcutaneous twice a day.
Disp:*1 month supply* Refills:*0*
13. Insulin Syringe 1 mL 29 x [**2-3**] Syringe Sig: One (1) syringe
Miscellaneous twice a day.
Disp:*2 box* Refills:*0*
14. Hospital bed
Please give 1 hospital bed
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Metastatic breast cancer
Respiratory failure
Pneumonia
Acute congestive heart failure
Secondary:
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with respiratory failure and found to have fluid in
your lungs. This fluid was removed through several procedures
and your respiratory function improved remarkably. You also
were given a medication to help you remove that fluid through
increased urination. You will continue this medicine at home
until you see your doctor. You will need a repeat chest x-ray
in two weeks to see if the fluid in your lungs has
reaccumulated.
Biopsies of your right breast were consistent with invasive
cancer. Additional scans showed that the cancer had spread to
your lungs, your adrenal glands and possibly your liver.
Chemotherapy was initiated while you were in the hospital and
you tolerated this well. You will continue chemotherapy as
outpatient.
The following changes were made to your medications:
1) STOP diltiazem: please discuss with your primary care
provider when this should be restarted
2) STOP diovan/HCTZ: please discuss with your primary care
provider when this should be restarted
3) CONTINUE your insulin 70/30, twice a day as you were doing
previously according to your blood sugar
4) START lasix 40mg twice a day
5) START oxycodone 2.5mg every 6 hours as needed for pain. Do
not drive or operate machinery while on this medication
6) START docusate 100mg twice a day for constipation
7) START aspirin 325mg daily
8) START simvastatin 40mg daily
9) START simethicone 80mg four times a day as needed for gas
10) START polyethylene glycol 17grams daily as needed for
constipation
11) START metronidazole gel twice a day for your breast. You
will need prior authorization for this medication for your
insurance. Please discuss prior authorization details with your
primary care doctor
12) START lidocaine (700mg/patch) 12 hours daily (take off for
12 hours daily). You will need prior authorization for this
medication for your insurance. Please discuss prior
authorization details with your primary care doctor
13) START senna 8.6mg twice daily as needed for constipation
Followup Instructions:
You have the following appointments scheduled for you:
Department: [**Hospital3 249**]
When: FRIDAY [**2160-4-25**] at 3:50 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 7633**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Dr. [**Last Name (STitle) **] is your new physician in [**Name9 (PRE) 191**] and Dr.[**Last Name (STitle) **] works
closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], [**First Name3 (LF) **] both will be involved in your
care.
Department: Radiology
When:THURSDAY [**2160-5-1**] at 10:00 AM
Walk in appointment for chest x-ray, [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2160-5-1**] at 11:00 AM
With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2160-5-2**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2160-5-2**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2160-4-19**]
|
[
"276.7",
"V58.67",
"799.02",
"233.0",
"486",
"198.7",
"250.00",
"416.8",
"518.81",
"238.4",
"276.3",
"401.9",
"276.1",
"197.0",
"V86.0",
"197.7",
"198.3",
"511.9",
"458.9",
"174.9",
"426.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93",
"38.91",
"96.04",
"96.6",
"85.11",
"34.09",
"34.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
22097, 22155
|
13313, 20041
|
295, 347
|
22309, 22309
|
4843, 4843
|
24575, 26422
|
2884, 2959
|
20321, 22074
|
22176, 22288
|
20067, 20067
|
22492, 24552
|
20088, 20298
|
2974, 4247
|
6274, 13290
|
228, 257
|
375, 2330
|
4857, 6260
|
22324, 22468
|
2352, 2425
|
2457, 2852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,797
| 162,624
|
46613
|
Discharge summary
|
report
|
Admission Date: [**2167-5-5**] Discharge Date: [**2167-5-13**]
Date of Birth: [**2101-9-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Carcinoma of the left lung -> upper lobe
Major Surgical or Invasive Procedure:
- thoracotomy for left upper lobectomy
- rexploration for bleeding
- re-intubation for respiratory decompensation and Pneumonia
History of Present Illness:
The patient a 65-year-old woman with a 40 pack-year smoking
history who quit a number of years ago and was found to have an
intensely PET-positive solitary left upper lobe pulmonary
nodule. Bronchoscopic approach to biopsy was nondiagnostic but
there was no evidence for any disseminated disease. I felt this
was highly likely to represent lung cancer. There was 1 enlarged
enhancing AP window lymph node that was not PET positive. I
recommended that we stage the
mediastinum and if it is node-negative proceed onto definitive
resection as it was presumably early stage lung cancer. She
agreed to proceed.
Past Medical History:
Asthma
breast cancer
chronic sinusitis
Social History:
40 pack-year smoking history who quit a number of years ago
Family History:
non-contrib
Physical Exam:
On discharge:
vitals:
wd, wn, nad
alert and oriented x3, mae
rrr, no m/r/g
lung:
soft, nt, nd, nabs
bilateral extrem warm, no c/c/e
incisions clean, dry, and intact; no erythema or discharge
Pertinent Results:
[**2167-5-11**] 03:00AM BLOOD WBC-9.9 RBC-3.49* Hgb-10.9* Hct-32.2*
MCV-92 MCH-31.2 MCHC-33.8 RDW-13.9 Plt Ct-242
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-5-12**] 10:14 AM
IMPRESSION: PA and lateral chest compared to [**5-11**]:
Postoperative left lower lobe atelectasis and left pleural
thickening extending over the apex of the aortic arch is
unchanged. Also stable following removal of left basal pleural
tube is a small locule of air along the left lower costal
pleural surface and a second small air collection at the left
apex medially, now containing a very small volume of pleural
fluid. Heart size is normal and mediastinal position unchanged.
Right lung grossly clear.
Pathology Examination
SPECIMEN SUBMITTED: LEVEL 5 LYMPH NODE, LEFT UPPER LOBECTOMY,
LEVEL 10 LYMPH NODES, LEVEL 11 LYMPH NODES, L9 LYMPH NODES (5).
Procedure date Tissue received Report Date Diagnosed
by
[**2167-5-5**] [**2167-5-5**] [**2167-5-9**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/nbh
DIAGNOSIS:
I. Level 5 lymph nodes (A):
Nine lymph node(s) with no carcinoma seen (0/9).
II. Left upper lobectomy (B-J):
Poorly differentiated squamous cell carcinoma; see synoptic
report.
Lung Cancer Synopsis
MACROSCOPIC
Specimen Type: Lobectomy.
Laterality: Left.
Tumor Site: Upper lobe.
Tumor Size
Greatest dimension: 1.7 cm. Additional dimensions: 1.5
cm.
MICROSCOPIC
Histologic Type: Squamous cell carcinoma with focal clear cell
change.
Histologic Grade: G3: Poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor 3 cm or less in greatest dimension,
surrounded by lung or visceral pleura, without bronchoscopic
evidence of invasion more proximal than the lobar bronchus (ie,
not in the main bronchus).
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 0.5 cm. Specified
margin: Bronchial resection margin.
Direct extension of tumor: None.
Venous invasion (V): Absent.
Lymphatic Invasion (L): Absent.
Additional Pathologic Findings: Inflammation, Chronic, mild.
Emphysematous change and chronic hemorrhage.
Comments: Immunostains of the tumor are strongly positive for
cytokeratin 7 and TTF-1, and negative for cytokeratin 20,
supporting a pulmonary origin. Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] reviewed slides C,
D and G-I and concurs.
Brief Hospital Course:
Pt. was admitted to the Thoracic Surgery Service after
undergoing a bronchoscopy, thoracotomy, and left upper
lobectomy. An epidural was in place for pain control. The
patient initially tolerated this procedure well and was being
recovered in the PACU without event. However, late evening on
POD 0 the pt. became hypotensive, 6 point hct drop. Pt was given
two fluid boluses - one of normal saline and one of hespan. She
was responsive to the fluid though her systolic blood pressures
were maintained in the 90s for the duration of the night. Her
chest tube output was minimal but more sanguinous than
serosanguinous. A CXR late that evening revealed a large left
opacity possibly consistent w/ a hemothorax. On the morning of
POD 1 pt was taken back to the OR for re-exploration for
bleeding. A large amount of clot was removed and small areas of
generalized oozing were cauterized but no definitive source of
bleeding was isolated. Two chest tubes and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] were placed
at the time of surgery for drainage and maintained to sxn. Pt
was extubated and transferred to the PACU-once recovered pt was
tarnsferred to the floor for ongoing post-op care.
She was maintained on peri op ancef. Chest tubes were placed to
water seal on POD#[**2-27**]. epidural was changed to starigt
bupivicaine and morphine PCA was added to improve pain control
w/ good effect. Pt was able to cough and deep breathe
effectively, chest tube output was minimal and serosang, urine
output was adeq.
CXR revealed a large gastric bubble and dilated loops of bowel
-pt did c/o fullness, was belching, passing flatus and [**Last Name (un) 1815**]
clears.
Later that afternoon of POD#[**2-27**] pt began to desaturate to 90% on
35% face mask. A CXR did reveal mild volume overload and a right
mid-lung infiltrate consistent w/ possible aspiration PNA. Pt
was given lasix w/ rapid and brisk response and IV levaquin. A
CT angio was ordered to r/o PE however, pt resp compromise
worsened and requiring CTA to be post-poned and pt to the
transferred to the SICU. She was intubated for progressive resp
decompensation. Bronch after intub revealed copious secretions
and multiple mucous plugs. Flagyl was added to regimen for ?
aspir PNA. Once resp stabilized on the vent , she proceeded to
CTA which was neg for PE. She remained intub overnoc rec'd
ongoing pul toilet and diuresis. She was extubated the following
day POD#[**3-31**]. Transferred out of the ICU and progressed well w/
post op course. On POD# [**5-1**] chest tubes placed to WS-cxr w/no
PTX, ant CT removed, post-pull CXR: no PTX. POD# [**6-2**] posterior
CT d/c, post-pull CXR: small apical PTX. epidural d/c'd. On PCA
w/ po pain med bridge. [**Last Name (un) 1815**] reg diet. POD# [**7-3**] [**Doctor Last Name **] d/c,
post-pull CXR: no PTX. PCA d/c'd. Pain controlled w/ po pain
med. Bowel function intact. Ambulating w/ O2 sats 92-93% on
roomair. D/c'd to home -declined VNA services.
.
Medications on Admission:
Inhaler prn
Flonase prn
MVI
calcium
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every
8 Hours) as needed for post op pain.
Disp:*30 Capsule(s)* Refills:*0*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q4hrs prn pain
as needed for patient may refuse, please offer q 4: - do not
drive while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
q4hrs prn.
Disp:*60 doses* Refills:*2*
10. nebulizer device
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
- left upper lobectomy w/ re-exploration for post-operative
bleeding.
- pneumonia
Discharge Condition:
good
Discharge Instructions:
- Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pian, shortness of breath, pain swelling or
redness at your incision site.
- You may shower on Thursday. After showering, remove your chest
tube site dressings and cover the areas with clean bandaids
daily until healed. The steri-strips on your incision will fall
off in time.
- Do not drive while you are taking narcotic pain medicine
- take stool softeners every day you take pain medication:
colace, senna, dulcolax, and mild of magnesia are all good
options
- you should eat a regular diet
- you should continue to do your breathing exercises with the
incentive spirometry, coughing, and deep breathing
- you should remain as active as tolerated and gradually
increase your activity level on a daily basis
Followup Instructions:
**It is very important that you call to confirm the following
appointments**
- You have a follow up appointment with Dr. [**Last Name (STitle) **] on Thursday
[**2167-5-21**] at 10am and immediately following DR. [**Last Name (STitle) **] at
10:30am in the [**Hospital Ward Name 23**] clinical center [**Location (un) **]. Please arrive
45 minutes prior to your appointment and report to the [**Location (un) **]
radiology dept for a CXR.
- Provider: [**First Name8 (NamePattern2) 3679**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 95321**]
Date/Time:[**2167-6-11**] 11:00
- Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2167-9-22**] 11:40
- you should make sure you have a post-hospitalization
appointment with your primary care physician as well.
Completed by:[**2167-5-14**]
|
[
"162.3",
"507.0",
"997.3",
"473.9",
"V15.82",
"V10.3",
"493.90",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"33.22",
"96.71",
"96.04",
"34.03",
"96.05",
"32.3"
] |
icd9pcs
|
[
[
[]
]
] |
8099, 8157
|
4029, 7017
|
360, 490
|
8283, 8290
|
1520, 4006
|
9157, 9988
|
1281, 1294
|
7103, 8076
|
8178, 8262
|
7043, 7080
|
8314, 9134
|
1309, 1309
|
1323, 1501
|
280, 322
|
518, 1126
|
1148, 1188
|
1204, 1265
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,158
| 196,851
|
42120
|
Discharge summary
|
report
|
Admission Date: [**2197-9-3**] Discharge Date: [**2197-9-13**]
Date of Birth: [**2115-6-23**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
Transferred from OSH, intubated
Major Surgical or Invasive Procedure:
Tracheostomy/Gastrostomy
History of Present Illness:
This is an 82 (not 72) yo M with
a history of CAD s/p MI [**17**] years prior, HLD, likely HTN and s/p
recent retinal surgery on the left who is transferred from
[**Hospital **] Hospital intubated and sedated for a higher level of
care. His wife provides the history, and she reports that he was
in his USOH until this afternoon around noon. At baseline he is
completely "healthy" and independent for all ADLs. He had been
nauseous for a few days. He was loading some dishes into the
dishwasher and suddenly fell backwards at around 12:30PM. Then
he
walked out to take the trash out and couldn't climb the two
steps
to come back into the house. Later, his wife sat him down
because
his speech became garbled and he couldn't really understand what
his wife was saying. EMS was called because his wife was
concerned for a TIA. He was taken to an OSH, and was noted to be
nauseous and vomiting en route in the ambulance. While at this
OSH, he was noted to be hypertensive. He was given labetalol IV,
fosphenytoin 1g load and zofran and intubated for airway
protection. He had a NCHCT which revealed a left sided basal
ganglia bleed, and was thus transferred to the [**Hospital1 18**] for a
higher
level of care. The wife denies that the patient is being
anticoagulated or ever having been treated for atrial
fibrillation.
Past Medical History:
- HLD
- HTN: wife reports that patient has had a history of having
relatively high blood pressures
- Recent eye surgery on left: Ripple retina procedure? Wife
reports that the patient may be on atropine eye drops
- CAD: s/p MI at age 50
- Tobacco abuse: smoked for 20 years, quit following his MI
Social History:
Negative for heavy alcoholism, current smoking or
illicit drug use.
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: AF, 149/76, HR 80s, 96% on ETT FiO2 40%
General: Intubated, sedated
HEENT: Eyes open at baseline, no obvious oropharyngeal lesions
noted externally
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic Examination (patient is currently receiving small
boluses of propofol/fentanyl for sedation and intubation):
- Eyes closed at baseline. Making some nonpurposeful movements
of
the left extremities, right arm and leg are visibly less active
- Left pupil is 5mm and nonreactive, right is 3-2mm reactive
briskly
- No roving eye movements or gaze deviation or nystagmus noted
- Breathing over the vent
- Positive VORs and corneals bilaterally
- RUE extensor postures to pain, LUE localizes to sternal rub
- RLE extends to painful stimulus, LLE withdraws nicely
- Right toe is upgoing
Physical Exam on Discharge:
vital signs: Tmax 100.7, Tc 99.3, BP 142/70 (114-165/55-86), HR
89 (72-112), RR 21 (17-34), 99% on trach with 40% FiO2
GEN: elderly male lying in bed asleep, NAD
HEENT: trach in place, OP clear
CV: RRR
PULM: central congestion, mild crackles at L base
ABD: soft, NT, ND
EXT: trace, non-pitting edema at ankles bilaterally.
Neuro Exam:
- opens eyes spontaneously
- L pupil large (5mm) and minimally reactive, R pupil reactive
3->2mm
- looks to the left, but not to the R past midline
- tracks to the left, but not to the right
- moves LUE and LLE spontaneously and sometimes purposefully
- very minimally and only occasionally withdraws RUE and RLE to
noxious stim
- toes upgoing bilaterally
Pertinent Results:
Labs on Admission:
[**2197-9-3**] 03:34PM BLOOD WBC-9.6 RBC-3.88* Hgb-13.7* Hct-39.2*
MCV-101* MCH-35.3* MCHC-34.9 RDW-13.5 Plt Ct-220
[**2197-9-3**] 03:34PM BLOOD Neuts-75.1* Lymphs-20.2 Monos-3.6 Eos-0.8
Baso-0.2
[**2197-9-3**] 03:34PM BLOOD PT-11.3 PTT-19.8* INR(PT)-0.9
[**2197-9-3**] 03:34PM BLOOD Glucose-169* UreaN-16 Creat-1.1 Na-138
K-3.9 Cl-99 HCO3-24 AnGap-19
[**2197-9-4**] 03:35AM BLOOD ALT-21 AST-25 LD(LDH)-211 CK(CPK)-75
AlkPhos-53 TotBili-0.5
[**2197-9-3**] 06:31PM BLOOD CK-MB-2 cTropnT-<0.01
[**2197-9-4**] 03:35AM BLOOD CK-MB-1 cTropnT-<0.01
[**2197-9-3**] 06:31PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9
[**2197-9-6**] 02:52AM BLOOD calTIBC-195* VitB12-265 Folate-14.7
Ferritn-432* TRF-150*
[**2197-9-4**] 03:35AM BLOOD %HbA1c-6.2* eAG-131*
[**2197-9-4**] 03:35AM BLOOD Triglyc-132 HDL-56 CHOL/HD-2.8 LDLcalc-77
[**2197-9-3**] 04:09PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-150 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2197-9-3**] 04:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2197-9-3**] 04:09PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Labs on Discharge:
[**2197-9-13**] 04:02AM BLOOD WBC-10.2 RBC-2.64* Hgb-9.2* Hct-26.6*
MCV-101* MCH-34.7* MCHC-34.4 RDW-13.8 Plt Ct-368
[**2197-9-13**] 04:02AM BLOOD Glucose-136* UreaN-25* Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2197-9-13**] 04:02AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.4
Microbiology:
[**2197-9-5**] 2:32 pm SPUTUM Source: Endotracheal.
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2197-9-6**] 3:00 pm BRONCHOALVEOLAR LAVAGE LLL BAL.
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). ~1000/ML. FURTHER WORKUP ON
REQUEST ONLY.
[**2197-9-6**] 3:00 pm SPUTUM
GRAM STAIN (Final [**2197-9-6**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2197-9-8**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
URINE CULTURE (Final [**2197-9-12**]): NO GROWTH.
GRAM STAIN (Final [**2197-9-11**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2197-9-13**]):
SPARSE GROWTH Commensal Respiratory Flora.
EEG [**2197-9-5**]: This telemetry captured no pushbutton
activations. The EEG
record showed a slow and encephalopathic background throughout.
There
were no prominent focal abnormalities, but encephalopathies may
obscure
focal findings. There were no epileptiform features or
electrographic
seizures.
Neuroimaging:
NCHCT ([**2197-9-3**]): 3.5-cm acute left basal ganglia hemorrhage,
with intraventricular extension. Interval increase in size since
the prior study. Mild increase in the edema and rightward shift
of midline structures.
CT C spine ([**2197-9-3**]): No acute cervical spine fracture.
Multilevel degenerative changes of the cervical spine, without
evidence of significant spinal canal stenosis.
NCHCT ([**2197-9-4**]): Unchanged acute left basal ganglia
intraparenchymal hemorrhage with redistribution of blood into
the bilateral occipital horns. No new areas of hemorrhage.
EEG [**2197-9-4**]: IMPRESSION: This telemetry captured no pushbutton
activations. It showed a slow encephalopathic background
throughout. Medications, metabolic disturbances, and infection
are among the most common causes. There were no areas of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features or electrographic
seizurs.
CT HEAD [**2197-9-12**]: IMPRESSION:
1. The left basal ganglia hematoma is slightly decreased in
size, though the associated mass effect is unchanged. No new
hemorrhage.
2. Decreased intraventricular blood. Stable ventricular size.
Brief Hospital Course:
Mr. [**Known lastname **] arrived to the [**Hospital1 18**] intubated and sedated for a higher
level of care for an intraparenchymal bleed into what was
initially reported as the left basal ganglia, later confirmed to
be largely thalamic in nature. On examination in the ED, he was
found to have an atropine-related fixed and dilated left pupil,
a dense right hemiparesis, spontaneous nonpurposeful movements
of the left arm and would not follow commands or open his eyes.
He was admitted to the neuro-ICU for close monitoring and q1hr
neuro checks. His blood pressures have since been controlled
under SBP<160 with PRN hydralazine/labetalol. A repeat NCHCT
performed the following day showed no difference in bleed
volume.
He remained intubated for the next several days. The concern was
that he would not be able to tolerate his secretions and that he
was not following commands, both signs that extubation would be
unsafe. His wife confirmed that he was a full code, but did
communicate his wishes that he would not want to continue life
"if he were a vegetable". In the days following, he started to
develop low grade fevers, an elevated WBC and thick secretions
from his ETT suction. Out of concern for a community acquired
pneumonia ([**1-18**] possible aspiration) he was initiated on IV
Ceftriaxone. His sputum and BAL cultures only grew out GNRs and
respiratory commensal flora. Initiating antibiotic therapy did
reduce his WBC and improve his fevers. His blood pressures
remained under control, especially after the addition of a low
dose of ACE inhibitor.
We had a family meeting on [**2197-9-7**] where we discussed (with
his extended family and wife) that he has a long road to
recovery, and that should be able to survive the various
complications that may occur (e.g., DVTs, infections, etc.), he
may be able to regain a greater degree of consciousness and
appreciate his surroundings. We discussed how his weakness could
improve and he may not be aphasic. We emphasized the long road
to recovery. On [**9-8**], the decision was finally made to
pursue tracheostomy and PEG tube placement in an attempt
expedite his transition out of the ICU and to rehabilitation.
He was continued on ceftriaxone for presumed CAP, but he
continued to spike fevers through this. His sputum Cx initially
grew GNRs, but these cleared. However, his CXR continued to
show a consolidation that was worsening at the LLL base. He was
started on vancomycin and cefepime on [**9-12**] and his WBC and fever
curve trended down. He will need to complete a 14 day course
for presumed VAP, which will stop on [**9-26**]. In addition, on
[**9-12**] he had a head CT done that showed that his bleed was
stable, and so he was started on ASA 81mg QD.
PENDING LABS:
Blood culture [**2197-9-10**]
Sputum culture [**2197-9-13**]
TRANSITIONAL CARE ISSUES:
We have been unable to ascertain who did patient's recent ripple
retina procedure. This will need to be determined, and they
will need to be contact[**Name (NI) **] to determine if patient requires
specific eye drops for his post-surgical recovery. His wife
thought he may have been on atropine, but wasn't sure, and
therefore this wasn't given here. His wife had the medications
at home and should be able to bring them to the rehab facility
on request.
Medications on Admission:
Medications per family (although they are very unsure)
Niacin
Cholesterol medication
aspirin
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
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. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever .
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. 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.
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1,000 mg
Intravenous Q 12H (Every 12 Hours): Day 1 = [**9-12**].
12. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours): Day 1 = [**9-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary: Cerebral hemorrhage
Secondary: HTN, hyperlipidemia, CAD s/p MI
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
NEURO EXAM: L pupil 5mm and minimally reactive ([**1-18**] surgery), R
pupil reacts 3->2mm, opens eyes spont, moves LLE and LUE
spontaneously, and very occ. withdrawas RUE and RLE to noxious
stim.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were seen in the hospital for a bleed in your brain. While
you were here, you were stabilized medically. Your course was
complicated by a pneumonia, for which you were started on
antibiotics. We were not completely sure of what medications
you were on as an outpatient, and your family and friends were
unable to tell us.
We made the following changes to your medications:
1) We STOPPED your NIACIN. Your family was not sure you were on
this, so we did not start it here.
2) We STARTED you on LISINOPRUL 20mg once a day.
3) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day to prevent DVTs
4) We STARTED you on ARTIFICIAL TEARS as needed for dry eyes
5) We STARTED you on CLORHEXIDINE GLUCONATE 15mL twice a day
6) We STARTED you on SENNA twice a day.
7) We STARTED you on DOCUSATE 100mg twice a day.
8) We STARTED you on BISACODYL 10mg once a day.
9) We STARTED you on TYLENOL 650mg every 6 hours as needed for
pain/fever.
10) We STARTED you on ASPIRIN 81mg once a day.
11) We STARTED you on a HEPARIN FLUSH for your PICC. Once you
no longer need your PICC you won't need this medication.
12) We STARTED you on VANCOMYCIN 1,000mg twice a day for a total
of 14 days, to finish on [**9-26**].
13) We STARTED you on CEFEPIME 2 grams every 8 hours for a total
of 14 days to finish on [**9-26**].
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room, or have
your rehab facility transport you to an emergency room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2197-11-13**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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31,482
| 147,928
|
48089
|
Discharge summary
|
report
|
Admission Date: [**2189-11-30**] Discharge Date: [**2189-12-19**]
Date of Birth: [**2135-7-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
L knee pain/swelling
Major Surgical or Invasive Procedure:
Knee surgery (wash out) - twice
PICC line placement
History of Present Illness:
Pt is a 54 yo female with pmhx of childhood polio with resultant
orthopedic complications who has undergone multiple orthopedic
procedures on the lower extremities including a total knee
replacement on the left in [**2183**]. Pt had increasing pain in that
knee. A nuclear medicine WBC scan done in [**Location (un) 620**] in [**Month (only) **]
of [**2188**] revealed increased uptake in several areas and she
elevated ESR at that time. She had plain films done in [**Month (only) 404**]
of [**2189**] suggestive of
hardware loosening and a periosteal reaction. An ultrasound
revealed a popliteal cyst which may be been reactive. She went
on to have a knee aspiration and arthrogram with the fluid being
negative for cells and no growth(Specimens sent to Quest.) A
repeat WBC scan on [**2189-4-10**] revealed extension of the uptake in
the bone marrow extending down to distal femur on the right with
prominent uptake in bilateral lower extremity vasculature. At
that time, the thought was that this represented an aseptic
loosening of the hardware. She was admitted for the tibeal
plateau be removed as was the femoral portion of the prosthesis
but the patellar button was left in place. There was no pus
noted but there was some softening of the bone and significant
loosening of the hardware. Postoperatively, the cultures
ultimately grew Coag negative staph. She was on Kefzol 1 G Q 8
starting on [**12-2**], switched to vancomycin [**12-3**] with reciept of
culture data.
Past Medical History:
History of childhood polio
Definite left total knee replacement in [**2183**].
Cervical fusion with hardware [**8-14**]
Right knee osteoarthritis.
Hypertension
Thyroid disease
L-spine DJD with herniated disk per MRI in [**2185**]
Rosacea
Palmar pustular psoriasis
Social History:
Pt lives at home with her husband and daughter. She denies tob.
She drinks 2 glasses of wine with dinner. No IVDA.
Family History:
Non-contributory
Physical Exam:
[**Hospital Unit Name 153**] Admit:
T: 99.2 P: 94 R: 14 BP: 111/46 O2 96% RA
General: Alert, sleepy, NAD
HEENT: NCAT, anicteric, no injections, Oropharynx without
lesions, MM dry
Neck:Supple, soft without tenderness or lymphadenopathy
Cardiovascular: Regular, S1 S2 only, no murmurs appriciated
Respiratory: Clear bilaterally
Gastrointestinal: Soft, NT, ND
Musculoskeletal:No Joint Swelling, Left Lower extremity in brace
with dressing in place
Skin:No rashes
Neurological:Grossly intact
Pertinent Results:
<b>Admit Labs:</b>
[**2189-11-30**] 02:57PM BLOOD WBC-9.1 RBC-3.37* Hgb-10.7* Hct-32.7*
MCV-97 MCH-31.7 MCHC-32.7 RDW-13.8 Plt Ct-358
[**2189-11-30**] 02:57PM BLOOD Glucose-137* UreaN-13 Creat-0.6 Na-141
K-4.4 Cl-106 HCO3-28 AnGap-11
<br>
<b>Other Labs:</b>
[**2189-12-9**] 10:00AM BLOOD D-Dimer-1781*
[**2189-12-15**] 05:37AM BLOOD ESR-75*
[**2189-12-13**] 06:45AM BLOOD ESR-78*
[**2189-12-3**] 09:40AM BLOOD ESR-71*
[**2189-12-17**] 06:03AM BLOOD Ret Aut-2.1
[**2189-12-8**] 01:11AM BLOOD CK-MB-3 cTropnT-<0.01
[**2189-12-18**] 05:24AM BLOOD Albumin-3.2* Calcium-9.2 Phos-5.2* Mg-2.5
Iron-44
[**2189-12-18**] 05:24AM BLOOD calTIBC-204* VitB12-605 Folate-11.8
Ferritn-435* TRF-157*
[**2189-12-11**] 07:40AM BLOOD VitB12-431 Folate-11.7
[**2189-12-9**] 10:00AM BLOOD calTIBC-156* Hapto-401* Ferritn-599*
TRF-120*
[**2189-12-9**] 05:47AM BLOOD Hapto-376*
[**2189-12-8**] 01:11AM BLOOD Osmolal-277
[**2189-12-11**] 07:40AM BLOOD TSH-5.1*
[**2189-12-15**] 05:37AM BLOOD CRP-127.5*
[**2189-12-3**] 09:40AM BLOOD CRP-267.2*
[**2189-12-16**] 12:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2189-12-12**] 01:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.000*
[**2189-12-16**] 12:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2189-12-12**] 01:50AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2189-12-16**] 12:42PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-RARE
Epi-0-2
[**2189-12-9**] 02:36PM URINE RBC-[**4-13**]* WBC-[**4-13**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2189-12-16**] 12:42PM URINE Eos-NEGATIVE
[**2189-12-12**] 03:00PM URINE Eos-NEGATIVE
[**2189-12-9**] 07:04PM URINE Eos-POSITIVE
[**2189-12-7**] 01:54PM URINE Eos-NEGATIVE
[**2189-12-16**] 12:42PM URINE Hours-RANDOM UreaN-65 Creat-18 Na-77
[**2189-12-9**] 07:04PM URINE Hours-RANDOM
[**2189-12-8**] 11:08AM URINE Hours-RANDOM UreaN-605 Creat-163 Na-<10
[**2189-12-16**] 12:42PM URINE Osmolal-195
[**2189-12-8**] 11:08AM URINE Osmolal-368
<br>
<b>Discharge labs:</b>
[**2189-12-19**] 05:06AM BLOOD WBC-10.1 RBC-3.06* Hgb-9.1* Hct-29.3*
MCV-96 MCH-29.8 MCHC-31.2 RDW-13.4 Plt Ct-692*
[**2189-12-19**] 05:06AM BLOOD Glucose-87 UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-101 HCO3-29 AnGap-15
[**2189-12-19**] 05:06AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.6
<br>
<b>Micro Data:</b>
Blood ([**12-12**] x 2, [**12-9**] x 2, [**12-8**] x 2, [**12-5**] x 2, [**12-2**] x 2) -
negative
Urine ([**12-12**], [**12-9**], [**12-2**]) - negative
Tissue ([**11-30**]) - coag negative staph (oxacillin resistant)
<br>
<b>Studies:</b>
RENAL U.S. [**2189-12-16**] 2:32 PM
FINDINGS: Both kidneys are normal in size measuring
approximately 10 cm in their respective long axes. No mass
lesions are seen, no calculi and no hydronephrosis. The cortical
thickness is within normal limits.
CONCLUSION: Normal renal ultrasound. Renal cortex is normal in
echotexture and thickness.
<br>
CHEST PORT. LINE PLACEMENT [**2189-12-12**] 7:02 AM
FINDINGS: A single AP portable upright view of the chest was
obtained. Cervical fusion hardware is seen. A right PICC line
terminates in the distal superior vena cava. The lungs are
clear. There is no pneumothorax. The cardiac silhouette and
pulmonary vasculature are within normal limits.
IMPRESSION:
1. Right PICC line terminating in the distal superior vena cava.
2. No evidence of acute intrathoracic process.
<br>
CT HEAD W/O CONTRAST [**2189-12-10**] 1:13 PM
FINDINGS: No prior studies are available for comparison.
There are no intracranial hemorrhages or masses. The [**Doctor Last Name 352**]/white
matter differentiation is maintained. The ventricles and
extra-axial CSF spaces are normal.
The visualized orbits are normal. The visualized paranasal
sinuses and mastoid air cells are clear. No suspicious bony
abnormalities are seen.
IMPRESSION: Normal unenhanced head CT.
<br>
Tissue Biopsy ([**11-30**]):
1. Left knee tissue:
Synovial tissue with fibrosis, lymphocytes and histiocytes.
Focal foreign body giant cell reaction.
2. Bone, left knee:
Bone and synovial-like tissue with rare neutrophils.
3. Left knee tissue, #2:
Synovial tissue with focally increased neutrophils as well as
histiocytes and granulomatous inflammation. (See note.)
Foreign body giant cell reaction.
Note: The findings, in conjunction with the tissue culture, are
consistent with infection. GMS and AFB stains are negative for
fungal and mycobacterial organisms, respectively. Foreign
material is present within the "granulomatous" inflammation.
Dr. [**Last Name (STitle) **] has reviewed slide D.
<br>
TTE ([**12-8**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 11-15mmHg. 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. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. There
is abnormal septal motion/position. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved global
biventricular systolic function. Mild pulmonary hypertension.
Mild biatrial enlargment. No pathologic valvular disease.
Brief Hospital Course:
Septic arthritis (prosthetic joint) - staphylococcus (coagulase
negative) - was initially on orthopedic service and went to OR
x2 for wash out. The joint fluid culture as above. ID consulted
and 6 weeks on IV antibiotics recommended. Initially on
Vancomycin, then Levaquin. Being discharged on Daptomycin per
ID recommendation. Weekly labs to be faxed to Dr [**Last Name (STitle) 7443**]. ID
follow up scheduled. The patient will follow up with orthopedic
surgery for removal of sutures.
.
Fever - work up for UTI & pneumonia was negative. the patient
had fevers despite IV vancomycin for staph. U. eos were positive
transiently, so patient was changed to levofloxacin per ID
recommendations due to possibility of AIN. Later changed to
Daptomycin.
.
Delerium - transient and resolved. Some evidence of myoclonus.
Was likely from IV narcotics (on dilaudid PCA). Resolved when
meds were changed. Neuro was consulted, CT head negative and no
acute neurological issues were noted.
.
Hypotension - transient necessitating 2 transfers to ICU,
resolved with PRBC transfusion. Could be from blood loss anemia
from blood loss during surgery. No other evience of bleeding
noted and Blood cultures remained negative. Unlikely that this
was sepsis.
.
Acute renal failure - multifactorial - from ATN from low BP and
AIN from vancomycin. Seen by renal consult service.
Unremarkable renal U/S as above. Decision made to hold off on
using Vancomycin given possibility of AIN. Renal function
improved once patient began taking in more PO fluids.
.
Blood loss anemia - as above. Hematocrit remained stable during
rest of hospital stay.
.
Hypothyroidism - repeat TFTs recommended in 4 weeks.
.
Anticoagulation - was maintained on heparin SC in-house. Was
discharged on Lovenox for 4 weeks.
Medications on Admission:
on hold from her home meds are lisinopril 40 mg qd, toprol xl
100 mg daily, celebrex 200 mg [**Hospital1 **], , lasix 80 mg daily (in
addition to meds on d/c)
Discharge Medications:
1. R Knee Hinged Unloading Brace Sig: As directed as
directed: Use as directed.
Disp:*1 brace* Refills:*0*
2. PICC Line Care Per Protocol Sig: as directed as directed.
Disp:*qs qs* Refills:*0*
3. Daptomycin 500 mg Recon Soln Sig: One (1) bag Intravenous
once a day for 6 weeks.
Disp:*qs bags* Refills:*0*
4. Halobetasol Propionate 0.05 % Ointment Sig: One (1)
application Topical [**Hospital1 **] (2 times a day) as needed for psoriasis.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Metronidazole 1 % Gel Sig: One (1) application Topical [**Hospital1 **]
(2 times a day) as needed for psoriasis.
11. Tretinoin (Emollient) 0.02 % Cream Sig: One (1) application
Topical twice a day as needed for rosacea.
12. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*56 injection* Refills:*0*
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**5-15**]
hours as needed for leg pain.
Disp:*60 Tablet(s)* Refills:*0*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): For constipation.
Disp:*60 Tablet(s)* Refills:*2*
17. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Take while on
Lovenox. [**Month (only) 116**] substitute Prilosec if necessary.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Septic arthritis (prosthetic joint) - staphylococcus (coagulase
negative)
Fever (question of joint-related vs. antibiotic related)
Delerium
Hypotension
Acute renal failure
Blood loss anemia
Hypothyroidism
Discharge Condition:
Afebrile, vital signs stable. Ambulating with crutches. L knee
in brace.
Discharge Instructions:
You will need to continue to take Daptomycin for at least 6
weeks.
.
You will need recheck of thyroid tests in 4 weeks. Discuss this
with your PCP.
.
You will also need Lovenox shots to prevent clots for 4 weeks.
.
You were on Lasix for swelling in your legs. This is being held
because of your kidney function. You should talk to your doctor
about the need for continuing with this.
.
You were also on Toprol XL 150mg and Lisinopril 40mg. These
medications have been held through much of your hospitalization.
You should talk to your doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] these
medications. Until then, you should hold off on [**Last Name (Titles) 9533**]
them.
.
You will also need to discuss with your doctor about whether it
is advisable to continue with your celebrex given your kidney
function.
.
Physical therapy will follow up at home.
Keep your appointments.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2190-1-18**] 9:00. Please call to arrange closer
follow-up in the next 1-2 weeks.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]. Please call to arrange a
follow up appointment.
Orthopedics: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**]: Wednesday [**12-23**] at 9:30 am ([**Street Address(2) **], [**Location (un) **] MA). At that time, you can discuss
removal of the sutures.
|
[
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"E849.9",
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"276.50",
"996.66",
"E937.9",
"E878.1",
"285.1",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.21",
"80.06",
"84.56",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12444, 12515
|
8539, 10319
|
337, 392
|
12764, 12841
|
2877, 3119
|
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|
2334, 2352
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|
12536, 12743
|
10345, 10505
|
12865, 13767
|
4963, 8516
|
2367, 2858
|
277, 299
|
420, 1899
|
1921, 2186
|
2202, 2318
|
3130, 4948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,728
| 136,671
|
50477
|
Discharge summary
|
report
|
Admission Date: [**2140-11-16**] Discharge Date: [**2140-11-24**]
Service: MEDICINE
Allergies:
Ciprofloxacin / Levaquin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Confusion, decreased po intake
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube on the left
History of Present Illness:
Ms. [**Known lastname 105149**] is an 88 year old female with recurrent UTIs,
nephrolithiasis, CAD, AF on coumadin, s/p AVR and CAD who
presented to [**Hospital1 **] [**Location (un) 620**] on [**11-16**] with fatigue and altered mental
status. She was found to have a urinary tract infection as well
as acute on chronic renal failure. She was started on Meropenem
given history of MDR UTIs in past. She also had a CT head which
showed a new subacute right parietal infarct. She was
transferred to [**Hospital1 18**] for further care.
.
Here, renal US showed moderate to severe left hydronephrosis. CT
Abd/pelvis showed a proximal renal stone with perinephric
stranding. Urology was consulted and recommended IR precutaneous
nephrostomy tubes. She received 4units of FFP to reverse INR
prior to procedure. Following the procedure she required 3L NC
and was noted to have an oxygen saturation of 60% on room air.
She was transferred to MICU for closer monitoring.
.
In the MICU, ABG notable for A-a gradient and CXR with bilateral
infiltrates. She was continued on meropenem and vancomycin was
added for empiric PNA coverage. She was quickly weaned from NRB
back to NC and has continued good oxygenation. She was also
briefly hypotensive after receiving IV and PO metoprolol for AF
with RVR. BP responded to fluids. She was also seen by neurology
based on CT findings and had MRI/MRA which showed a small
hemorrhage in the area of the parietal infarct. INR was 1.7 on
admission, ie subtherapeutic INR. Carotid US was done which was
unchanged from 4/[**2139**]. Based on this, neurology felt that
infarct was likely cardioembolic in origin and less likely to be
[**Country **] related. They recommended restarting heparin bridge,
aspirin and aggrenox.
.
Of note, she was recently discharged [**2140-11-13**] for UTI with left
ureteral stent removal [**2140-11-1**] and was treated with IV
Meropenum for 10 days.
.
This AM, patient denies complaints. She continues to be
confused, oriented to person only.
Past Medical History:
1. Opthalmic artery infact [**2-22**] - thought to be secondary to a
high grade rt carotid artery stenosis. Discussed surgery during
admission, but chose medical therapy for treatment.
2. Rheumatic heart disease-Prosthetic AVR-[**2126**]
3. Atrial Fibrillation
4. CAD-[**2126**] LIMA to LAD for 80%lesion, at time of AVR
5. Chronic Kidney Disease Stage IV-baseline creatinine ~2
6. MVA in [**2128**]-residual colostomy
7. MSSA bacteremia/discitis
8. Left heel ulcer
9. Recurrent UTI's
10. History of urosepsis [**6-/2139**]-managed at [**Hospital1 18**]
[**Location (un) **].
11. History of C. difficile colitis
12. Anemia
13. history of Herpes Zoster
Social History:
Patient lives with her son, daughter-in-law, and grandchildren.
At baseline, she uses a walker for ambulation. She has several
visiting home health aids that help with her ADLs. Husband
passed away about 30 years ago.
Quit smoking many years ago. Denies drug use, occasional alcohol
use (wine)at social events a few times a year.
Family History:
Mother died of colon cancer at the age of 62.
Father died of "old age" at the age of 84.
Brother died of testicular cancer at the age of 72.
Her children are all alive and in good health.
Physical Exam:
PHYSICAL EXAMINATION:
VS: Tm: 98.0 Tc: 97.8 BP 11/64 HR 76 RR 18 O2 sat 98 RA
GEN: pleasant, awake, alert, not oriented
HEENT: sclera anicteric, conjunctivae clear, OP dry and without
lesion
NECK: Supple, no JVD
CV: irregularly irregular, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, positive BS, tenderness throughout however, unable to
specific exact location, no gaurding or rebound.
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
On Admission:
[**2140-11-16**] 09:40AM BLOOD WBC-9.2 RBC-3.59* Hgb-11.1* Hct-33.2*
MCV-93 MCH-31.0 MCHC-33.5 RDW-14.8 Plt Ct-230
[**2140-11-16**] 09:40AM BLOOD Neuts-67.9 Lymphs-26.6 Monos-4.1 Eos-1.0
Baso-0.4
[**2140-11-16**] 09:40AM BLOOD PT-21.1* PTT-36.1* INR(PT)-2.0*
[**2140-11-16**] 09:40AM BLOOD Glucose-96 UreaN-41* Creat-2.4* Na-140
K-4.8 Cl-111* HCO3-23 AnGap-11
[**2140-11-16**] 09:40AM BLOOD Calcium-9.7 Phos-3.1 Mg-1.7
.
Imaging:
[**Location (un) 620**] Head CT: per verbal report: Acute R superior parietal
infarct suggestive of MCA lesion. Suggest MRI.
.
[**11-16**] CXR: There has been no radiographic change. The right lung
is particularly hyperinflated suggesting emphysema or chronic
small airways obstruction. No focal pulmonary abnormality is
seen. The patient has had median sternotomy, coronary bypass
grafting and aortic valve replacement. Heart size is normal.
There is no pulmonary vascular engorgement, edema or pleural
effusion.
.
[**11-16**] Renal US: Interval development of moderate-to-severe left
hydronephrosis. No evidence of right hydronephrosis. Prominent
debris or hemorrhage layers dependently within the urinary
bladder.
.
[**11-16**] CT Abd/Pelvis:
1. New obstructing 7-mm calculus within the proximal left ureter
with
resultant moderate hydronephrosis and perinephric stranding.
2. Nonobstructing renal stone within the left renal pelvis.
3. Little change in 2.2 cm left adnexal cyst over two-year
period. Further
evaluation with pelvic ultrasound may be obtained to exclude
low- grade
genitourinary malignancy given postmenaupausal status.
4. Cholelithiasis without acute cholecystitis.
5. Extensive spinal degenerative changes and atherosclerotic
plaque within
the abdominal aorta and major branches.
.
[**11-16**] MR/MRA head:
The right posterior parietal infarction noted on the head CT of
[**2140-11-15**] is again identified and there is a small
amount of
hemorrhage associated with it. The MRA examination demonstrates
no
occlusions, but there is possible narrowing in the inferior
division of the
right middle cerebral artery. No other infarction is detected.
.
[**11-18**]: Echo:
The left atrial volume is markedly increased (>32ml/m2). There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. The
transaortic gradient is normal for this prosthesis. Trace aortic
regurgitation is seen. [The amount of regurgitation present is
normal for this prosthetic aortic valve.] The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is no systolic anterior motion of the mitral
valve leaflets. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension.
IMPRESSION: No left atrial thrombus seen. However, transthoracic
echo is NOT accurate at determining presence or absence of
atrial thrombus. Symmetric LVH with a small cavity and
near-hyperdynamic systolic function. At least moderate mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension. The aortic arch
probably has atheromatous plaque.
.
[**11-18**] Carotid US: Findings as stated above which indicate an
approximately 70% right ICA stenosis, unchanged from the exam of
[**2140-3-14**]. There is
approximately 40% left ICA stenosis, also unchanged. Possibility
of cardiac
disease.
Brief Hospital Course:
Mrs. [**Known lastname 105149**] is an 88-year-old female with a PMH significant for
a recurrent UTIs, recent discharged [**2140-11-13**] for UTI with left
stent removal [**2140-11-1**] and was treated with IV Meropenum for 10
days. She returned with an Per daughter, patient had an 8 day
history of wax-[**Doctor Last Name 688**] confusion, poor po intake, nausea,
vomiting.
.
# Urinary tract infection with hydronephrosis: On arrival to the
ED, patient was noted to be in acute renal failure. Renal US
and CT Abd/Pelvis demonstrated 7 mm obstructing renal calculus
within the proximal left ureter with resultant moderate
hydronephrosis and perinephric stranding. UA significantly
positive. She was started on Meropenem while awaiting culture
results. A left percutaneous nephrostomy tube was placed to
relieve obstruction. Urine culture grew Proteus and Klebsiella.
Urine culture from nephrostomy tube grew proteus and
enterococcus. Both the Klebsiella and Proteus were sensitive to
Meropenem and plan is for 14 day course via PICC line. She
remained afebrile. A repeat urine culture was sent on [**11-23**] prior
to discharge to evaluate for resolution. This should be
followed by the rehab.
.
# Sub-acute CVA: CT without contrast [**First Name8 (NamePattern2) **] [**Location (un) 620**] verbal report R
superior parietal infarct suggestive of MCA lesion. No focal
neuro deficits, some waxing and [**Doctor Last Name 688**] confusion. Patient
history of A Fib and aortic prosthetic valve ([**Last Name (un) 5487**] type), INR
sub-therapeutic 1.7 at [**Location (un) 620**] (here INR 2). Neurology was
consulted and recommended MRI/MRA which demonstrated a small
hemorrhage at CVA site. A repeat CT scan was done which did not
show evidence of bleeding and therefore the recommendation was
to restart heparin, coumadin, ASA and aggrenox which was done on
[**11-18**]. An echo was done which did not show a left atrial
thrombus. Carotid dopplers were unchanged from prior and
therefore neurology felt that CVA was likely cardioembolic
source. Anticoagulation with coumadin was continued.
.
# Respiratory distress: On the evening of nephrostomy tube
placement patient became acutely hypoxic requiring a
non-rebreather. CXR showed volume overload and ABG with large
A-a gradient. The desaturation was attributed to TRALI vs
aspiration PNA. She did have an elevated WBC count and
infiltrates on CXR. She was given 1 dose of vancomycin in
addition to Meropenem she was on for UTI. She was weaned to 3L
the day following the event. An echocardiogram was done which
showed worsening tricuspid regurgitation. She was on Meropenem
as above. At the time of discharge she was oxygenating well on
room air.
.
# Acute renal failure: Creatinine on admission increased to 2.4
from 1.3 likely related to obstruction, infection and perhaps
dehydration. After placement of percutaneous nephrostomy tube,
creatinine improved throughout stay and returned to baseline.
She should follow up with Dr. [**Last Name (STitle) 770**] in 1 week from discharge
from hospital. Interventional radiology is also available if
there are any questions regarding nephrostomy tube,
[**Telephone/Fax (1) 53983**].
.
# Afib, prosthetic valve: The patient's valve was reportedly
placed in [**2128**] per daughter. Coumadin was held initially for IR
procedure and patient was given FFP. Subsequently, patient had
MRI which demonstrated small hemorrhage at CVA so heparin was
held for another day. On repeat head CT no evidence of bleeding
so hpearing restarted on [**11-18**]. On [**11-19**] nephrostomy tube noted to
have increasingly bloody output and so per IR heparin/coumadin
held again. Beta blocker was continued with good rate control.
On [**11-22**] coumadin was held for a supratherapeutic INR, restarted
on 2mg daily on [**11-23**]. She should have daily INR for the next
several days until INR has stabilized.
.
# CAD: Patient was continued on BB and aspirin, aggrenox.
.
# Generalized arthritis pains: Continued on her usual home
regimen of gabapentin for joint related pains/arthritis.
.
# Anemia: At baseline 27-28. Hematocrit dropped slightly over
last several days of hospitalization. Guaiac was negative.
Iron was started. Would recommend every other day monitoring of
hematocrit while at rehab to ensure this is stable.
.
# Depression: Continued on her usual home regimen of sertraline.
Medications on Admission:
Aghgrenox 200/25 [**Hospital1 **]
Coumadin 2mg daily
Lopressor 12.5 [**Hospital1 **]
Zoloft 200 daily
Neurontin 300 q48h
aspirin 325 daily
Simvastatin 20mg
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nwb Inhalation Q2H (every 2 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
8. Meropenem 1 gram Recon Soln Sig: Five Hundred (500) mg
Intravenous Q12H (every 12 hours) for 7 days: day 1 = [**11-16**], to
complete 14 day course on [**11-29**].
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Acute renal failure [**12-19**] obstruction
Urinary tract infection
Subacute parietal infarct
Aspiration pneumonia
Tricuspid regurgitation
Congestive heart failure
Atrial fibrillation on coumadin
Aortic valve replacement - bioprosthetic
Anemia of chronic disease
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted with a urinary tract infection and acute renal
failure. This was felt to be due to blockage from a stone. A
percutaneous nephrostomy tube was placed to help relieve the
blockage. Your kidney function improved following this
intervention. If you have any difficulties with the nephrostomy
tube, please call Dr.[**Name (NI) 825**] office, otherwise you can call
Interventional Radiology at [**Telephone/Fax (1) 53983**].
Your urinary tract infection was treated with Meropenem. You
will need to continue the antibiotics for 14 days total. A PICC
line was placed for administration of antibiotics.
You were also found to have a small stroke. You were seen by
the neurologist in the hospital who felt that it was safe to
restart your coumadin. You are also taking aspirin and
aggrenox.
Your coumadin was held initially for the nephrostomy placement.
When it was restarted, it was noted that you had a
supratherapeutic INR and it was held briefly. While at rehab,
they should be checking your INR daily until it has stabilized.
You were also noted to be anemic. The low red blood cell level
was stable, but this should also be checked at rehab every other
day.
The following changes were made to your medical regimen.
1. You will continue on Meropenem. Day 1 of antibiotics was
[**11-16**]. Your course will be completed on [**11-29**].
If you have any fevers, chills, abdominal pain, chest pain,
shortness of breath or other concerning symptoms please call
your doctor or return to the Emergency Room.
Followup Instructions:
You have the following appointments:
1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2141-1-4**] 11:00
2. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2141-5-8**] 2:00
You should also see Dr. [**Last Name (STitle) 770**] in one week's time for follow
up. His phone number is [**Telephone/Fax (1) 5727**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.07",
"55.03",
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icd9pcs
|
[
[
[]
]
] |
13722, 13864
|
7966, 12369
|
264, 308
|
14171, 14181
|
4104, 4104
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|
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|
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336, 2340
|
4582, 7943
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4118, 4573
|
2362, 3016
|
3032, 3365
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,874
| 113,329
|
212
|
Discharge summary
|
report
|
Admission Date: [**2101-10-25**] Discharge Date: [**2101-10-28**]
Date of Birth: [**2064-10-2**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Floxin / Penicillins
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Xanax, Tylenol & Klonopin Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 yo F with history of depression and suicidal attempt in the
past presented with obtundation. Of note, her prior attempt was
about 15 years ago during which she OD on theophylline,
requiring intubation. She has been feeling more depressed over
the last few months and has been seeing a therapist, on the ECT
waiting list with recent evaluation by Dr. [**Last Name (STitle) 2109**], [**First Name3 (LF) **] her
partner. [**Name (NI) **] reports taking 120 mg of Xanax and 80 mg
Klonopin in the afternoon of [**2101-10-25**] as well as at least [**4-7**]
g of Tylenol daily over the last 2 weeks. She also admitted to
taking 20 mg of Ambien. She says that she was taking the
tylenol intentionally to worsen her liver function. She says
that she decided to do this because she wanted to commit
suicide. She also reports having had 1 glass of wine on the day
of these medication ingestions. She then called one of her
friends afterwards, and her therapist ([**First Name8 (NamePattern2) 2110**] [**Last Name (NamePattern1) **]) was
subsequently involved and called the EMS for patient.
In the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98%
on RA. She arrived with her friend, very lethargic. Per
report, was only responsive to sternal rub and GCS of 8
throughout. Tox screen showed positive benzos and acetaminophen
only. ECG showed sinus tachycardia. UA was negative. CT head
did not show ICH. Her initial Tylenol level was 40. Toxicology
was consulted and recommended NAC for 21 hours until level is
undetectable and LFT stabilizes. She started NAC in the ED and
her repeat level was 29. VS prior to transfer were T95, HR 66,
BP 121/73, RR 22, O2Sat 98% RA.
She was transferred to the ICU for her poor mental status.
While on the floor, appears comfortable, denies any SOB, chest
pain/discomfort, abdominal pain/discomfort, urinary symptoms or
URI symptoms. She does have some throat tightness and
discomfort when swallowing. Her partner reports that patient's
mental status seems to have improved since her initial arrival
to the ED.
Past Medical History:
- Asthma, requiring 1x intubation in late teen (unclear if this
was related to the theophylline)
- GERD with severe esophagitis ([**2098**])
- Insomnia
- Bipolar Type 2, currently severe depression, requiring
hospitalization at [**Doctor First Name **] in the past
- Depression
- Suicidal attempts (last [**1-/2099**] following impulsive suicide
attempt in which she crashed her cars, 2 other ones with OD in
her late teens)
Social History:
Occupation: a nurse mid-wife at [**Name (NI) 2025**] x 10 years
Drugs: Marijuana, last used about 1 week ago
Tobacco: None
Alcohol: occasionally
Married to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 976**] [**Telephone/Fax (1) 2111**], live in [**Location (un) 538**].
Family History:
- mother- depression
- maternal grandmother- EtOH abuse, benzodiazepine abuse
- maternal uncle- bipolar affective d/o
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA
General: lethargic, answers questions appropriately but in
whispers, follows commands, NAD
HEENT: PERRL, EOMi, anicteric, Mucous membrane moist
NECK: no supraclavicular or cervical LAD, no JVD, no carotid
bruits, no stridor
Resp: CTAB with good air movement throughout, no wheeze,
crackles, or rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: soft, ND, mildly tender in the umbilical area, no
hepatosplenomegaly, no guarding.
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
[**2101-10-25**]
- CT head: There is no acute intracranial hemorrhage, acute
large major
vascular territory infarction, discrete masses, mass effect,
brain edema or
shift of normally midline structures. The ventricles and sulci
are normal in size and configuration. The visualized osseous
structures are unremarkable. The visualized paranasal sinuses
are within normal limits. Incidentally noted is a
faintly-calcified likely sebaceous cyst in the left
paramedian frontovertex scalp soft tissues (2:26-27); correlate
with physical examination.
IMPRESSION: No acute intracranial process
[**2101-10-27**] 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8*
MCV-87 MCH-31.2 MCHC-36.0* RDW-13.5 Plt Ct-238
[**2101-10-25**] 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0
MCV-90 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-275
[**2101-10-26**] 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2*
[**2101-10-27**] 06:50AM BLOOD PT-12.4 INR(PT)-1.0
[**2101-10-25**] 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2
Baso-1.0
[**2101-10-27**] 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8
Cl-106 HCO3-26 AnGap-11
[**2101-10-25**] 03:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139
K-3.8 Cl-104 HCO3-26 AnGap-13
[**2101-10-27**] 06:50AM BLOOD ALT-21 AST-13
[**2101-10-26**] 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39
TotBili-0.3
[**2101-10-25**] 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56
TotBili-0.4
[**2101-10-27**] 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
[**2101-10-25**] 03:00PM BLOOD HCG-<5
[**2101-10-25**] 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40*
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2101-10-25**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2101-10-26**] 02:23AM BLOOD Acetmnp-6*
[**2101-10-26**] 07:00PM BLOOD Acetmnp-NEG
Brief Hospital Course:
37 yo F with depression on ECT waiting list and remote history
of suicidal attempts presents with OD of benzodiazepine and
Tylenol
Medicaion Overdose, an attempt to suicide. The patient was
treated supportively for benzodiazepine overdose and did not
require mechanical ventilation. In regards to tylenol toxicity
she required a N acetylcysteine drip for a tylenol level of 40
and normal liver function tests, after stopping the NAC drip her
tylenol level was negative and LFTs remained normal. She was
medically cleared for discharge to a psyhiatric inpatient
facility as of the a.m. of [**2101-10-27**], she is also medically
cleared for ECT. In regards to her bipolar disorder and suicide
attempt psychiatry was consulted and suggested the following
medication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po
daily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn,
and ambien 10mg po qhs prn insomnia.
Asthma. Does not appear to be active currently. prn albuterol /
atrovent nebs.
GERD: continued home omeprazole
Communication/Emergency Contact: partner [**Name (NI) **] [**Name (NI) 976**]
[**Telephone/Fax (1) 2111**]
Medications on Admission:
Meds (at home):
cymbalta 60 mg PO daily
wellbutrin SR 450 mg PO daily
lamictal 350 mg PO daily
ambien 10 mg PO QHS
prilosec 20 mg PO daily and sometimes [**Hospital1 **]
risperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week)
klonopin 1 mg PO prn
was stockpiling xanax, so not taking
Meds (in ICU):
NAC 560 mg/h IV gtt
albuterol nebs prn
Wellbutrin SR 150 mg [**Hospital1 **]
duloxetine 60 mg PO daily
heparin subQ 5000 TID
lamictal 350 mg PO daily
omeprazole 20 mg PO daily
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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Suicide ingestion
Tylenol overdose
Benzodiazepine overdose
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a suicide attempt and
treated to prevent organ damage. You were transferred to an
inpatient psychiatric facility. Please take your medications as
prescribed and make your follow up appointments.
Followup Instructions:
Please follow up with your psychiatrist within 2 weeks of your
discharge from the psychiatric facility.
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of your discharge from the psychiatric facility: [**Last Name (LF) 2113**],[**First Name3 (LF) 2114**] R.
[**Telephone/Fax (1) 2115**]
|
[
"296.89",
"493.90",
"965.4",
"305.20",
"530.81",
"E950.0",
"275.3",
"285.9",
"V45.79",
"969.4",
"275.41",
"E950.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8401, 8471
|
5857, 7004
|
335, 341
|
8610, 8610
|
4040, 4059
|
9021, 9350
|
3209, 3329
|
7539, 8378
|
8492, 8492
|
7030, 7516
|
8761, 8998
|
3344, 4021
|
261, 297
|
369, 2438
|
4068, 5834
|
8511, 8589
|
8625, 8737
|
2460, 2887
|
2903, 3193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,533
| 152,254
|
7737
|
Discharge summary
|
report
|
Admission Date: [**2142-3-11**] Discharge Date: [**2142-3-22**]
Service: MEDICINE
Allergies:
Codeine / Bactrim DS / Clindamycin / Cephalosporins / Vancomycin
/ Aspirin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
nonverbal, somnolent
Major Surgical or Invasive Procedure:
Mechanical Intubation
Central line placement
PICC line placement
NG tube placement
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]y/o lady with CHF, epilepsy, pacemaker,
lower extremity neuropathy, sacral decub ulcer, and frequent
falls who was brought to the ED after she was found to be
nonverbal at her living facility (her baseline is alert oriented
x3). Per her son, felt nauseated yesterday and vomited yesterday
and today. This morning she was reportedly found gurgling and
hypoxic to the 80s on room air, vomited, likely aspirated. Per
son, she felt nauseated and vomited yesterday.
.
In the ED, initial VS were HR 117, BP 73/39, 99%NRB. No room air
sat was recorded but she was reportedly hypoxic including 88%
during intubation. OG tube was placed and she was noted to have
>300cc guaiac (+) coffee grounds. She was started on a Protonix
gtt. She spiked to 100.6 rectal and labs were notable for WBC
24.5 (11% bands), Hct 32.5 (baseline 38), lactate 3.1. Head CT
unremarkable and CT torso showed LLL opacity. Also UA with >182
WBCs and LG leuk. She was given zosyn/daptomycin given mult [**Age over 90 **]
allergies, and received 5L IVF. She was started on Levophen for
pressure support. Prior to MICU transfer, VS were T 98.3, HR 65,
BP 110/40, AC: TV 450, RR 18, PEEP 5, FiO2 40%.
.
On arrival to the MICU, she is intubated and sedated. Notable
MICU events include:
-black finger; vascular came and recommended nitropaste on black
fingers; likely embolic event.
-CXR with persistent opacities on left, layering effusion on
left side, CT cannot rule out osteo in sacral decub
-NG tube placed
-extubated [**3-14**], weaned off pressors on [**3-15**]; currently on shovel
mask
-[**3-16**] spot EEG: moderate to early severe encephalopathy
-UCx positive for proteus being treated with zosyn
-LLL consolidation and h/o aspiration, being treated for
aspiration PNA (staph aureus); linezolid and zosyn given [**3-15**]
drug Rxns
-deep sacral wound, polymicrobial
-pt noted to be more awake on [**3-16**]; baseline
.
On callout to the medical floor, she is extubated but with a
nasal trumpet and shovel mask. She opens her eyes to voice but
is unable to answer questions.
Past Medical History:
-Polyneuropathy, per notes and per family, unknown etiology
-Head injury s/p fall ([**2121**]), was in coma, cerebral hemorrhage
and temporary shunt/R frontal craniotomy at that time, seizure
disorder since - usual seizures are "few minutes of L face
tightening" with immediate return to baseline; occur 1-2x/yr
-CLBP related to lumbar stenosis and degenerative disease,
associated polyradiculopathy by MRI [**4-17**]
-Possible cervical stenosis
-h/o falls [**3-15**] gait disturbance (post-cerebral hemorrhage)
-HTN
-CHF (EF 45-50% in [**2129**] but >55% on TTE in [**2-22**])
-diverticulosis/diverticulitis
-Arthoscopic knee surgery
-Depression
-Constipation
-h/o RLE cellulitis on bactrim and keflex
-chronic leg edema/ rt leg ulcer
Social History:
She has one son who lives in [**Location **]. Her son is very involved
and does the food shopping, running of errands as well as
laundry and other household chores. She was admitted from rehab.
Family History:
Father may have died of an MI and he also had DM. Mother died of
cancer. She is an only child.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.2 HR 94 BP: 118/87 (85-121/50s) 99% 10L shovel
mask with nasal trumpet.
General: elderly woman. Has nasal trumpet and shovel mask. She
opens her eyes to voice but is unable to answer questions. CVL
in R neck.
HEENT: Sclera anicteric, dry MM, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmur
Lungs: Clear to auscultation bilaterally but poor air movement,
no wheezes; expiratory rhonchi throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly; flexiseal in place.
GU: foley in place
Ext: warm, thin, 2+ pulses. Both forearms 2+ edema with bruising
skin changes and are cold.
Neuro: PERRL. Withdraws to pain, intermittently opens eyes,
vocalizing but not talking, can squeeze hand on command.
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc 98.2 118/61 91 20 98% 4L NC
General: elderly woman lying in bed in NAD
HEENT: Sclera anicteric, dry MM, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmur
Lungs: poor air movement throughout, no wheezes; expiratory
rhonchi have improved
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly; flexiseal fell out 2/9am.
GU: foley in place draining clear/yellow urine
Ext: warm, thin, 2+ pulses. Both forearms 2+ edema with bruising
skin changes. 1+ pedal edema, no pretib edema.
Neuro: This AM, pt has eyes open and is answering questions and
saying words; is more intelligible than [**3-20**] but remains
confused. Denies pain. Somewhat following commands to squeeze
hands. Is AAOx1 (name), does not know time or place.
Pertinent Results:
ADMISSION LABS:
[**2142-3-11**] 12:30PM BLOOD WBC-24.7*# RBC-3.46* Hgb-10.1* Hct-32.5*
MCV-94 MCH-29.1 MCHC-30.9* RDW-14.4 Plt Ct-306#
[**2142-3-11**] 12:30PM BLOOD Neuts-81* Bands-11* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-3-11**] 12:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2142-3-11**] 12:30PM BLOOD PT-17.0* PTT-26.2 INR(PT)-1.6*
[**2142-3-11**] 12:30PM BLOOD Glucose-136* UreaN-75* Creat-2.8*# Na-143
K-5.4* Cl-108 HCO3-19* AnGap-21*
[**2142-3-11**] 08:10PM BLOOD CK(CPK)-87
[**2142-3-11**] 12:30PM BLOOD ALT-29 AST-27 TotBili-0.3
[**2142-3-11**] 12:30PM BLOOD Lipase-9
[**2142-3-11**] 12:30PM BLOOD cTropnT-0.13*
[**2142-3-11**] 08:10PM BLOOD CK-MB-5 cTropnT-0.07*
[**2142-3-11**] 12:30PM BLOOD Calcium-9.1 Phos-6.5*# Mg-1.9
[**2142-3-11**] 12:30PM BLOOD Carbamz-2.6*
[**2142-3-11**] 03:19PM BLOOD pO2-346* pCO2-45 pH-7.24* calTCO2-20*
Base XS--7
[**2142-3-11**] 09:57PM BLOOD Type-ART Rates-18/3 Tidal V-450 PEEP-5
FiO2-40 pO2-106* pCO2-39 pH-7.28* calTCO2-19* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2142-3-16**] 11:16AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-42 pH-7.39
calTCO2-26 Base XS-0 Comment-ABG ADDED
[**2142-3-11**] 12:34PM BLOOD Glucose-129* Lactate-3.1* K-5.2*
.
DISCHARGE LABS:
[**2142-3-21**] 05:25AM BLOOD WBC-9.1 RBC-2.57* Hgb-7.7* Hct-24.1*
MCV-94 MCH-29.8 MCHC-31.8 RDW-15.0 Plt Ct-106*
[**2142-3-20**] 06:36AM BLOOD Glucose-110* UreaN-20 Creat-0.6 Na-137
K-4.3 Cl-101 HCO3-30 AnGap-10
[**2142-3-20**] 06:36AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.8
.
MICROBIOLOGY:
.
[**2142-3-19**] 11:11 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2142-3-20**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2142-3-20**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
__________________________________________________________
[**2142-3-16**] 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2142-3-17**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2142-3-17**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
__________________________________________________________
[**2142-3-11**] 8:45 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2142-3-15**]**
GRAM STAIN (Final [**2142-3-12**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2142-3-15**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. OXACILLIN Sensitivity testing performed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
__________________________________________________________
[**2142-3-11**] 7:00 pm SWAB Source: coccyx.
**FINAL REPORT [**2142-3-17**]**
GRAM STAIN (Final [**2142-3-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
WOUND CULTURE (Final [**2142-3-17**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. SPARSE GROWTH.
Sensitivity testing performed by Sensititre.
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. SENSITIVE TO CLINDAMYCIN MIC <= 0.12
MCU/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=2 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2142-3-11**]):
SPECIMEN NOT PROCESSED DUE TO: SPECIMEN NOT TRANSPORTED
ANAEROBICALLY.
PATIENT CREDITED.
__________________________________________________________
[**2142-3-11**] 2:15 pm BLOOD CULTURE #2.
**FINAL REPORT [**2142-3-17**]**
Blood Culture, Routine (Final [**2142-3-17**]): NO GROWTH.
__________________________________________________________
[**2142-3-11**] 12:30 pm BLOOD CULTURE
**FINAL REPORT [**2142-3-17**]**
Blood Culture, Routine (Final [**2142-3-17**]): NO GROWTH.
__________________________________________________________
[**2142-3-11**] 1:25 pm URINE Site: CATHETER
**FINAL REPORT [**2142-3-16**]**
URINE CULTURE (Final [**2142-3-16**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Piperacillin/Tazobactam REQUESTED PER DR [**Last Name (STitle) 28078**]
([**Numeric Identifier 28079**]) [**2142-3-14**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
IMAGING:
-[**2142-3-11**] CT HEAD:
IMPRESSION: No hemorrhage or other acute intracranial process.
Extensive
encephalomalacia and volume loss are stable from [**2141-3-17**].
.
-[**2142-3-11**] CT CHEST, ABD/PELVIS:
IMPRESSION:
1. Consolidation of the left lower lobe, with associated volume
loss, which
could reflect aspiration, pneumonia, or atelectasis. Of note,
volume loss
does appear chronic, making simple atelectasis somewhat less
likely.
2. Linear scarring and atelectasis at the right lung base, which
could
reflect sequelae of chronic aspiration.
3. No acute intraabdominal process to explain sepsis. No free
fluid, free
air, or abscess formation. Fluid-filled bowel loops are
nonspecific but can
be seen with gastroenteritis, though the bowel wall appears
normal with no
thickening or adjacent inflammation.
4. Cholelithiasis, without CT evidence of acute cholecystitis.
5. Sacral decubitus ulcer. Underlying osteomyelitis cannot be
excluded.
6. Diffuse atherosclerosis and extensive thoracolumbar scoliosis
and
spondylosis, little changed from prior studies.
.
-[**2142-3-12**] TTE:
Conclusions
The left atrium is mildly dilated. 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. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is systolic anterior motion of the mitral valve leaflets.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global biventricular systolic function. Minimal aortic valve
stenosis. Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of [**2141-3-21**], the
transaortic valve gradient is minimally higher.
.
-[**2142-3-15**] EEG:
IMPRESSION: Abnormal EEG due to the slow and disorganized
background,
frequent suppressive bursts and bursts of generalized slowing,
and due
to sevearl generalized high voltage sharp waves. These findings
are all
suggestive of a moderately severe encephalopathy affecting both
cortical
and subcortical structures. No focal abnormalities were evident,
but
encephalopathies may obscure focal findings. The sharp waves
were seen
in isolation and not repetitively. There was no evidence of
ongoing
seizures during this recording.
.
[**2142-3-18**] CXR:
IMPRESSION: AP chest compared to [**3-17**].
Right PIC line can be traced as far as the junction of the right
subclavian and jugular veins. Transvenous right atrial and right
ventricular pacer leads are unchanged in their respective
positions. Extensive consolidation in the left lower lobe and
accompanying small-to-moderate pleural effusion have varied in
size, no larger today than on [**3-17**]. Mild-to-moderate
cardiomegaly and a generally enlarged thoracic aorta are also
stable. Borderline edema persists in the right lung.
Nasogastric tube ends in the upper stomach. No pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **]y/o lady with h/o CHF (EF >55% in [**2-22**]),
seizure disorder [**3-15**] complicated head trauma, HTN, sacral decub
who was brought to the ED for lethargy. She was found to be
hypoxic and was intubated and admitted to the MICU for septic
shock. She was called out to the regular medical floor on [**3-16**],
where her mental status slowly improved, although her
respiratory status remained the same. Multiple family meetings
were held, and the decision was made to change her status to no
ICU transfer, DNR/DNI. Her mental status slowly improved but
marked confusion remained; her respiratory status was stable on
the NC, and her PICC line, NGT, and restraints were removed per
the family's wishes.
.
#. Septic shock, resolved: Was likely combined urinary vs.
pulmonary vs. wound sources. Patient initially p/w
leukocytosis, bandemia, fever. Per her son, there were no clear
localizing signs, though due to ongoing issues with sacral
decub, a foley was placed 2 days ago at her rehab. Her UCx
showed proteus. Imaging with LLL consolidation and history of
aspiration suggested aspiration pneumonia vs HCAP, with staph
aureus growing in her sputum. Finally, her sacral wound with
some purulence and foul smell could have been a source as well
(multiple organisms on gram stain). Pt was treated with IVF, was
extubated and weaned off of pressors, and remained HD stable.
As to her [**Month/Day (4) **]: she was initially on Dapto/Zosyn (missing MRSA
lung penetration and ESBL coverage), but was transitioned to
Linezolid and zosyn (d1 = [**3-12**]). Pt had an exfoliative skin rxn
to vanc, keflex, and clinda (unclear which [**Name (NI) **] was the culprit).
She was maintained on a 7 day course of linezolid and zosyn (a
PICC was placed on [**3-17**]). Given that her mental status improved
very slowly, her respiratory status remained tenuous, she began
having more frequent episodes of vtach, and she began stating
that she wished to go home, multiple goals of care discussions
were held with HCP and family. The decision was made for no ICU
transfer, DNR/DNI, but to continue treating her on the floor
with [**Month/Day (4) **]. While finishing her 7day course of PNA treatment and
10day course of complicated UTI treatement, her mental status
slowly improved but marked confusion remained. Her respiratory
status was stable on the NC, and her PICC line, NGT, and
restraints were removed on [**3-21**] per the family's wishes. She
remains a very high aspiration risk, and per her HCP they will
reevaluate whether or not she will eat for comfort at her rehab
facility.
.
#. Respiratory Failure: likely [**3-15**] aspiration. She was hypoxic
on arrival to MICU after witnessed aspiration at rehab, and
imaging suggested LLL infiltrate. She was successfully extubated
on [**3-15**]. Thereafter, she required continuous 10L facemask with
nasal trumpet to maintain oxygenation; trumpet was d/c'd on
2/6pm. She was kept NPO, with NGT for tube feeds; NGT d/c'd on
[**3-21**] (see above). Pt remains very high aspiration risk.
.
#. Encephalopathy/altered mental status: Likely [**3-15**] her
infection and sepsis. Per son, pt's baseline prior to admission
was that she was able to hold conversations and interact
meaningfully with others, but she was admitted lethargic. Per
MICU team, pt's mental status slightly improved after
extubation; she had not rec'd any sedating Rx for >48hr prior to
callout. Pt has h/o seizures s/p complicated head injury in
[**2121**]. On [**3-15**] EEG showed moderate to early severe encephalopathy.
Mental status appeared to be worsening slowly over the hospital
course. We cont tegretol, and cont to monitor mental status; as
of 2/6am, she appeared more alert and was answering some
questions although still appears altered. Her mental status had
appeared to clear after small doses of morphine were
administered, and she may have been in the throes of delirium
[**3-15**] acute illness, hospitalization, and pain likely from sacral
decub. Her mental status has improved such that she can speak
full sentences, occasionally follow commands, and answer
questions, but this fluctuates and she remains disoriented and
confused.
.
#. Anemia: Hct fell to 20.4 on 2/5pm from admission Hct of 32.5,
and was transfused 1U RBC's. She is possibly still losing blood
from the likely [**Doctor First Name 329**]-[**Doctor Last Name **] tear, although her stool was
guaiac neg. Her anemia could also be [**3-15**] linezolid marrow
suppression as all 3 cell lines appear to be decreasing.
Linezolid was d/c'd on 2/6pm.
.
#. Thrombocytopenia: PLT were 112 on [**3-18**], from admission PLT of
306. Also possibly [**3-15**] linezolid marrow suppression; widespread
coagulopathy such as DIC unlikely but smear was unremarkable;
HIT is of intermediate probability (timing, level of PLT drop,
but no obvious thrombosis other than old ecchymoses on skin, and
other causes do exist (linezolid)). Linezolid was d/c'd on
2/6pm.
.
#. UGIB: likely from M-W tear, with history of emesis x2 and
coffee grounds and no prior history of PUD/UGIB. Hct and
hemodynamics stable since admission; did not require
transfusion. She was transitioned IV PPI to PO after MICU
callout; GI signed off as scope was deferred after discussion
with her son.
.
#. [**Last Name (un) **]: Was likely hypovolemic, resolved in MICU.
.
#. Sacral decub ulcer: sacral wound was extant PTA; is about 2cm
deep with and 4-5cm across, with surrounding erythema. Wound
swab showed mixed flora. We cont wet to dry gauze dressings;
instituted wound c/s recommendations as per OMR note.
.
#. Hypernatremia: Resolved. Was considered hypovolemic in nature
in the MICU; trended down to 143 on [**3-16**].
.
#. Black finger: Resolved; this was observed in MICU. Vascular
recommended nitropaste on black fingers; likely embolic event;
finger improved upon MICU callout per MICU team.
.
#. HTN: was not an active issue given recent sepsis. Held home
lasix and carvedilol.
.
TRANSITIONS OF CARE:
.
Sacral ulcer Wound care recs: Cleanse sacral ulcer with wound
cleanser set to "stream". Pat dry, use dry gauze as needed to
remove excess cleanser. Prep periwound tissues with No Sting
Barrier Wipe. Fill ulcer with moistened AMD( antimicrobial
dressing - item # [**Serial Number 28080**]) Kerlix.
Cover with dry gauze, softsorb dressing. Secure with Medipore H
soft cloth tape.
change daily.
.
Per discussion with HCP [**Name (NI) 28075**] [**Name (NI) **], they will reevaluate
whether or not she will eat for comfort at her rehab facility.
He currently plans to have her receive comfort-focused care, and
does not currently intend to have her hospitalized or put in the
ICU if she develops another infection (he will further discuss
this at her rehab facility).
Medications on Admission:
[per list faxed by rehab]
Carvedilol 3.125mg daily
Lasix 20mg daily
Tegretol 200mg daily
Remeron 15mg QHS
Fentanyl 12mcg/hr patch: 1 patch Q72H
Dilaudid 1mg/mL: 1mg PO Q4H PRN
Tylenol 650mg PO Q6H PRN pain/fever
vitamin C 500mg daily
MTV w/minerals 1 tab daily
vitamin D 1000IU daily
Tums daily
Calcium 800 + D3 600mg daily
Bisacodyl 10mg PR daily PRN
Milk of Mag 30mL daily PRN
Discharge Medications:
1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Last Name (STitle) **]: One
(1) mg PO Q4H (every 4 hours) as needed for pain.
3. carbamazepine 200 mg/10 mL Suspension [**Last Name (STitle) **]: Two Hundred (200)
mg PO DAILY (Daily).
4. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2436**] Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
Primary diagnosis:
Septic shock
Secondary Diagnoses:
Urinary tract infection
Pneumonia
Sacral decubitus ulcer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you were
found to be somnolent. You were treated in the intensive care
unit with intravenous fluids and antibiotics, and were intubated
for a short time. You were transferred to the regular medical
floor, where in consultation with your son and family members,
the focus was on transitioning your care to maximal comfort
care. We sincerely wish you all the best at your rehab facility.
The following changes were made to your medications:
NEW:
-Morphine solution as needed for pain
-Miconazole powder for groin
CHANGED: none
STOPPED:
Carvedilol 3.125mg daily
Lasix 20mg daily
Remeron 15mg QHS
Fentanyl 12mcg/hr patch: 1 patch Q72H
Dilaudid 1mg/mL: 1mg PO Q4H PRN
Tylenol 650mg PO Q6H PRN pain/fever
vitamin C 500mg daily
MVI w/minerals 1 tab daily
vitamin D 1000IU daily
Tums daily
Calcium 800 + D3 600mg daily
Bisacodyl 10mg PR daily PRN
Milk of Mag 30mL daily PRN
Followup Instructions:
None
Completed by:[**2142-3-27**]
|
[
"401.9",
"427.1",
"518.81",
"285.9",
"428.0",
"530.7",
"V45.01",
"907.0",
"311",
"482.41",
"345.90",
"287.5",
"459.89",
"E929.3",
"V49.86",
"995.92",
"038.9",
"414.01",
"785.52",
"707.24",
"707.03",
"276.0",
"507.0",
"349.82",
"584.9",
"599.0",
"355.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"00.14",
"38.93",
"38.97",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
23620, 23705
|
15897, 18999
|
303, 388
|
23860, 23860
|
5210, 5210
|
25030, 25066
|
3499, 3596
|
23103, 23597
|
23726, 23726
|
22700, 23080
|
23996, 25007
|
6503, 12411
|
3636, 4393
|
23780, 23839
|
243, 265
|
416, 2512
|
12420, 15874
|
5226, 6487
|
23745, 23759
|
23875, 23972
|
21907, 22674
|
2534, 3271
|
3287, 3483
|
4418, 5191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,348
| 199,971
|
46719
|
Discharge summary
|
report
|
Admission Date: [**2171-12-9**] Discharge Date: [**2171-12-14**]
Date of Birth: [**2119-10-25**] Sex: F
Service: Cardiothoracic
The patient is a postoperative admit prior to admission.
CHIEF COMPLAINT: Shortness of breath and chest heaviness x1
year.
HISTORY OF PRESENT ILLNESS: A 52-year-old woman who has been
followed by her cardiologist over the past 10 years for a
heart murmur. Patient was recommended to have a mitral valve
replacement a few years back, but refused at that time. Her
shortness of breath and chest heaviness had been worsening
progressively since that time, and this has prompted her to
agree to have surgery at this time.
A cardiac catheterization done on [**2171-11-12**] showed no
coronary artery disease, severe mitral regurgitation with
preserved left ventricular function. Cardiac echocardiogram
data from [**2171-6-27**] showed an ejection fraction of
greater than 55%, mitral leaflets that were moderately
thickened, and moderate-to-severe mitral regurgitation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic bronchitis.
3. Sleep apnea.
4. Obesity.
5. Arthritis.
6. Cutaneous lupus.
6. Seborrheic dermatitis.
7. Depression.
PAST SURGICAL HISTORY:
1. Left total hip replacement in [**2165**].
2. Right knee arthroscopy in [**2170**].
3. Total abdominal hysterectomy in [**2159**].
4. Removal of fibroids in [**2159**].
5. Laparoscopic cholecystectomy with gallstone removal in
[**2168**].
MEDICATIONS:
1. Furosemide 20 mg q day.
2. Zestril 20 mg q day.
3. Calor 10 mEq q day.
4. Ferrous sulfate, no dose provided.
5. [**Doctor First Name **] 60 mg q day.
6. Naproxen 375 mg q day.
7. Rhinocort nasal spray q day.
8. Albuterol q day.
ALLERGIES: Sulfa, penicillin, and Flagyl all of which cause
upset stomach and rash.
SOCIAL HISTORY: Denies alcohol use. Denies tobacco use.
Retired nursing assistant. Lives alone in [**Location (un) 669**]. Mother
is alive at 68. She has a history of diabetes and heart
disease. Father died in his 30s of a stroke. Patient also
denies any recreational drug use.
PHYSICAL EXAMINATION: Height 5'9", weight 235 pounds.
Generally: Adult woman in no acute distress appears her
stated age. Skin: No rashes and well hydrated. HEENT:
Pupils are equal, round, and reactive to light with
extraocular movements intact. Normal buccal mucosa, and
normal dentition. Neck is supple, no jugular venous
distention, no lymphadenopathy, and no thyromegaly. Chest
was clear to auscultation bilaterally. Heart regular, rate,
and rhythm, S1, S2 with a 3/6 systolic ejection murmur heard
best on the left sternal border. Abdomen is obese, soft,
nontender, nondistended, normoactive bowel sounds,
well-healed midline scar. No guarding or rebound.
Extremities are warm with no edema, cyanosis. Right calf
tenderness with palpation and left hip scar well-healed. No
varicosities. Neurologic: Cranial nerves II through XII are
grossly intact. No sensory or motor deficits. Pulses:
Femoral 1+ bilaterally, dorsalis pedis 1+ bilaterally,
posterior tibial 2+ bilaterally and radial 2+ bilaterally.
On [**12-8**], the patient was admitted to the operating
room, where she underwent a mitral valve repair. Please see
operating room note for full details. In summary, the
patient had a mitral repair with #26 [**Doctor Last Name 405**] angioplasty
ring. She tolerated the operation well and was transferred
from the operating room to the Cardiothoracic Intensive Care
Unit.
At the time of transfer, the patient had milrinone at 0.25
mcg/kg/min and Neo-Synephrine at 0.3 mcg/kg/min. Patient did
well in the immediate postoperative period. The patient was
reversed. She was weaned from the ventilator and
successfully extubated.
On postoperative day one, the patient was weaned from her
milrinone infusion. On postoperative day two, the patient's
chest tubes were discontinued, and she was transferred to the
floor for continuing postoperative care and cardiac
rehabilitation.
Over the next two days the patient did well on the floor,
increasing her activity level with the assistance of physical
therapy and the nursing staff. On postoperative day four, it
was felt the patient was stable and ready for discharge to
home.
At that time, her physical examination is as follows: Vital
signs: Temperature 100.1, heart rate 83 sinus rhythm, blood
pressure 135/83, respiratory rate 18, and O2 sat is 96% on
room air, weight preoperatively is 102 kg, at discharge 109.7
kg.
LABORATORY DATA: White count 9.9, hematocrit 24.9, platelets
124. Sodium 138, potassium 3.8, chloride 101, CO2 29, BUN
10, creatinine 0.9, glucose 120.
PHYSICAL EXAMINATION: Is alert and oriented times three.
Moves all extremities, follow commands. Breath sounds are
clear to auscultation bilaterally. Cardiovascular: Regular,
rate, and rhythm, sternum is stable. Incisions are open to
air, clean, and dry. Abdomen is soft, nontender, and
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with 1+ pedal edema.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg [**Hospital1 **] x2 weeks.
2. Potassium chloride 20 mEq [**Hospital1 **] x2 weeks.
3. Colace 100 mg [**Hospital1 **].
4. Aspirin 325 mg q day.
5. Ferrous sulfate 325 mg q day.
6. [**Doctor First Name **] 60 mg [**Hospital1 **].
7. Fluticasone inhaler two puffs [**Hospital1 **].
8. Albuterol two puffs q6h prn.
9. Metoprolol 25 mg [**Hospital1 **].
10. Hydromorphone 2-4 mg po q4h prn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation status post mitral valve repair with
a #26 [**Doctor Last Name 405**] ring.
2. Hypertension.
3. Sleep apnea.
4. Arthritis.
5. Depression.
6. Cutaneous lupus.
7. Left total hip replacement.
8. Right knee arthroscopy.
9. Total hysterectomy.
10. Status post laparoscopic cholecystectomy.
Sh[**Last Name (STitle) 14388**]o be discharged to have followup in the [**Hospital 409**] Clinic
in two weeks. Follow up with Dr. [**Last Name (Prefixes) **] in four weeks,
and follow up with her primary care provider [**Last Name (NamePattern4) **] [**2-11**] weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2171-12-13**] 11:47
T: [**2171-12-13**] 11:57
JOB#: [**Job Number 99162**]
|
[
"286.9",
"401.9",
"780.57",
"V43.64",
"424.0",
"710.0",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5509, 6340
|
5052, 5454
|
1212, 1785
|
4653, 5029
|
225, 275
|
304, 1023
|
1045, 1189
|
1802, 2071
|
5479, 5488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,283
| 194,624
|
30370
|
Discharge summary
|
report
|
Admission Date: [**2158-3-30**] Discharge Date: [**2158-4-14**]
Date of Birth: [**2079-7-16**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Sepsis secondary to cholangitis
Major Surgical or Invasive Procedure:
ERCP [**2158-3-30**]
Cardiac Echo TEE [**2158-3-30**]
History of Present Illness:
[**First Name8 (NamePattern2) **] [**Known lastname 4469**] is a 78 yo female transferred from [**Hospital **] hospital
for sepsis secondary to cholangitis. Upon arrival to [**Hospital1 18**], was
hypotensive with a CT showing a CBD stone and a bilirubin of
4.0. She had an open cholecystectomy many years a go. Mrs.
[**Known lastname 4469**] started having abdominal pain in the epigastrium with
radiation to her back 3 days before she presented to [**Hospital **]
Hospital. At [**Hospital **] hospital she was found to have an INR of
3.0 received FFP, underwent a CT scan Head and Torso revealing a
15 mm CBD with and obstructing stone a WBC of
14 with 90% on PMN. She was hypotensive was stared on Levophed,
and was transferred to [**Hospital1 18**].
Past Medical History:
AFib, CRI (Cr 1.2), HTN
Social History:
Pt is a 76 yr old widowed woman. She has one daughter with whom
the pt
resides with pt's son in law and her grand-daughter.
Physical Exam:
102 140 a fib 85/60 20 91% %L
Lungs decreased bilaterally
heart Irregular
ABD very tender Epigastrium
Rectal No blood
Ext no edema
Pertinent Results:
[**2158-3-29**] 10:50PM BLOOD WBC-25.2* RBC-3.69* Hgb-11.7* Hct-33.9*
MCV-92 MCH-31.6 MCHC-34.4 RDW-15.7* Plt Ct-154
[**2158-3-29**] 10:50PM BLOOD Neuts-81* Bands-10* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2158-3-29**] 10:50PM BLOOD PT-20.5* PTT-41.2* INR(PT)-2.0*
[**2158-3-30**] 01:45AM BLOOD Fibrino-280
[**2158-3-29**] 10:50PM BLOOD Glucose-88 UreaN-15 Creat-1.2* Na-143
K-1.6* Cl-102 HCO3-24 AnGap-19
[**2158-3-29**] 10:50PM BLOOD estGFR-Using this
[**2158-3-29**] 10:50PM BLOOD ALT-46* AST-77* CK(CPK)-70 AlkPhos-291*
Amylase-29 TotBili-3.6*
[**2158-3-29**] 10:50PM BLOOD Lipase-13
[**2158-3-29**] 10:50PM BLOOD Albumin-2.7* Calcium-7.3* Phos-0.7*
Mg-1.4*
[**2158-3-31**] 10:10AM BLOOD Cortsol-36.4*
[**2158-3-31**] 06:15AM BLOOD Vanco-23.1*
[**2158-3-30**] 01:48AM BLOOD Type-ART pO2-416* pCO2-27* pH-7.34*
calTCO2-15* Base XS--9
[**2158-3-29**] 11:08PM BLOOD Lactate-6.8* K-2.0*
[**2158-4-12**] 06:55AM BLOOD WBC-11.9* RBC-2.98* Hgb-9.3* Hct-28.4*
MCV-96 MCH-31.3 MCHC-32.7 RDW-18.6* Plt Ct-255
[**2158-4-12**] 06:55AM BLOOD Plt Ct-255
[**2158-4-1**] 01:33AM BLOOD Fibrino-311
[**2158-4-13**] 07:05AM BLOOD Glucose-91 UreaN-17 Creat-1.4* Na-146*
K-3.7 Cl-105 HCO3-31 AnGap-14
[**2158-4-9**] 02:30AM BLOOD ALT-46* AST-35 AlkPhos-382* TotBili-2.2*
[**2158-4-13**] 07:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.5*
Brief Hospital Course:
[**First Name8 (NamePattern2) **] [**Known lastname 4469**] was admitted to surgical ICU under the care of Dr.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]. Anesthesia was called and pt was intubated for
respiratory distress and emergent bedside ERCP. Pt demonstrated
signs of sepsis. FFP was given to reverse her INR and CVL was
placed for vascular access. Flagyl and Unasyn was started for
broad spec coverage. Cardiology was consulted for septic shock.
LVEF around 30% and recommendations were made regarding diuresis
and pressors.
By HD#3, pt still on versed, dobutamine and fentanyl drips,
remained intubated on CMV. Rate and PEEP were reduced. Urine
output by this time greater than 30cc/hr.
HD#4 ([**2158-4-3**]) Pt off of all sedatives. Afebrile and pressors
off. On CPAP/PS ABG's WNL. On trophic TF.
HD#8 Pt extubated overnight. On PO diet by this time. No
antibiotics by this time.
HD#9 Pt tolerated extubation for 24hrs and has been extubated
eversince.
Pt was transferred to surgical floor on HD#11 as pt's condition
has significantly improved. Tolerating POs well and
spontaneously diuresing. Since transfer to surgical floor pt
has had no significant problems/complications. She remains
afebrile, tolerating reg diet and has been working with PT/OT.
Pt is being discharged to rehab in good condition on HD#16 and
is to f/u with cardiology through her primary care doctor and
with surgery. (She is s/p cardioversion during this hospital
admission)
Medications on Admission:
Coumadin, Trazodone, Lactinex, Xanax, Atenolol
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per ISS
Injection ASDIR (AS DIRECTED).
Disp:*qs * Refills:*2*
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: [**1-3**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
8. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
10. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]
Discharge Diagnosis:
ASCENDING CHOLANGITIS 2ND TO STONE IN CBD
Discharge Condition:
good
Discharge Instructions:
Please call your doctor if you have the following symptoms:
-fever greater 101.4f
-vomiting
-worsening abdominal pain
-anyother signs/symptoms you may be concerned about
Followup Instructions:
1. Please call Dr [**Last Name (STitle) **] @[**Telephone/Fax (1) 600**] for a follow up
appointment in 2wks.
2. Please call [**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 72236**]. You will need a
referal to see a cardiologist. (RAPID A-FIB REQUIRING
CARDIOVERSION [**3-30**])
Completed by:[**2158-4-14**]
|
[
"585.9",
"576.1",
"427.31",
"574.51",
"518.82",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"88.72",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5620, 5710
|
2862, 4360
|
303, 361
|
5796, 5803
|
1503, 2839
|
6021, 6354
|
4457, 5597
|
5731, 5775
|
4386, 4434
|
5827, 5998
|
1351, 1484
|
232, 265
|
389, 1146
|
1168, 1193
|
1209, 1336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,394
| 164,187
|
11831
|
Discharge summary
|
report
|
Admission Date: [**2104-1-3**] Discharge Date: [**2104-2-8**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is an 82 year-old male
patient with a one year history of presyncope with recent
increase in symptoms three to four weeks prior to admission.
This has also been accompanied by chest discomfort for
approximately two weeks prior to admission. The patient
underwent cardiac catheterization at an outside hospital on
[**2104-1-3**], which revealed left main coronary artery
disease as well significant three vessel disease. The
patient transferred to [**Hospital1 69**]
on the evening of [**2104-1-3**] with a plan to undergo
coronary artery bypass graft by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
PAST MEDICAL HISTORY: Atrial fibrillation, hypertension,
congestive heart failure, status post right above the knee
amputation, status post repair of an incarcerated umbilical
hernia. The patient is a former cigarette smoker. Denies
alcohol intake. Also, peripheral vascular disease.
MEDICATIONS: Digoxin 0.25 po q.d., Neurontin 300 mg q.d.,
Ziac 1.25 mg b.i.d., aspirin 81 mg po q.d., nitroglycerin
patch and the patient is also on Coumadin for chronic atrial
fibrillation.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs were temperature 97.1.
Pulse 71. Blood pressure 179/76. Respiratory rate 18.
Oxygen saturation 98% on 2 liters per minute nasal cannula.
Physical examination in general, the patient was in no acute
distress. He did have bilateral expiratory wheezes. His
coronary examination was S1 and S2 with a grade 1/6 systolic
ejection murmur. His abdomen was benign. Left leg had a
weak peripheral pulse. Right leg had a well healed above the
knee amputation.
LABORATORY VALUES ON ADMISSION: Revealed a hematocrit 39%,
potassium 4.9, BUN 18, creatinine 0.8. Cardiac
catheterization revealed a normal ejection fraction with left
main and three vessel coronary artery disease.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2104-1-4**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where he underwent
coronary artery bypass graft times three with a left internal
mammary coronary artery to the left anterior descending
coronary artery, saphenous vein to the obtuse marginal and a
saphenous vein to the diagonal. Intraoperatively, the
patient was noted to have a significant calcified aorta.
Postoperatively, the patient was on epinephrine,
neo-synephrine, nitroglycerin and Propofol intravenous drip.
He was transported from the Operating Room to the Cardiac
Surgery Recovery Unit and he was AV paced via his epicardial
pacing wires. Initially postoperatively, the patient went
into atrial fibrillation with a rapid ventricular rate. He
was placed on intravenous Amiodarone at that time.
Over the course of the next 48 hours or so the patient had
somewhat of a metabolic acidosis. He remained in atrial
fibrillation with a ventricular response rate in the 90s. He
ultimately was placed on an intravenous Dobutamine drip,
remained on Propofol for sedation and was also on insulin and
nitroprusside intravenous drips. The patient had lactate
acidosis with a serum lactate in the 4 to 7 range. By
postoperative day two the patient had stabilized. He was
weaned from mechanical ventilator and ultimately extubated.
Early in the day on postoperative day three his lactate had
resolved. He was transferred from the Intensive Care Unit to
the Telemetry floor. However, later that day the patient
exhibited significant respiratory distress evidenced by
hypoxia and tachypnea and was transferred back into the
Intensive Care Unit at that time. Initially he was treated
with BiPAP mask, however, his respiratory status did not
improve and he was intubated in the evening of postoperative
day three and placed on mechanical ventilation.
The next couple of days in the Intensive Care Unit the
patient remained intubated and was sedated on intravenous
Propofol and was placed on low dose Dobutamine at 3 to 5 mics
per kilo per minute. He was given inhaled bronchodilators
through the ventilator circuit. Over the course of the next
few days the patient remained dependent upon mechanical
ventilator. He remained sedated. Every time sedation was
attempted to be decreased the patient got profoundly
tachypneic as well as tachycardic. He had difficulty
ventilating and significant problems oxygenating as well.
For this reason it was felt appropriate to proceed with a
tracheostomy as well as a PEG feeding tube. The patient was
placed on Levofloxacin for tracheobronchitis questionable
pneumonia. The sputum initially grew out gram negative rods,
which turned out to be Moraxella, which was resistant to
Ampicillin Penicillin. Postoperative day five the patient
underwent echocardiogram, which revealed significant left
ventricular hypokinesis as well as tricuspid regurgitation
and mitral regurgitation. The patient was kept on Dobutamine
and full mechanical ventilation, intravenous Dilaudid and
intravenous Propofol for sedation to tolerate the
ventilation. On [**2104-1-10**] the patient underwent
percutaneous tracheostomy as well as PEG placement by Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]. The patient tolerated the procedure
well.
On [**1-10**], the Dobutamine was ultimately weaned off.
Tube feedings were initiated via the PEG and the patient
still required full ventilatory support due to marginal
oxygenation status. The patient was started on low dose
Lopressor on [**1-12**]. The patient also had intermittent
episodes of hypoxia requiring PEEP increased FIO2 on the
ventilator. The patient's chest x-ray over the next couple
of days was consistent with acute respiratory distress
syndrome, which would correlate with this increased oxygen
requirement as well as the need for increased PEEP. The
patient was continued to be tube fed at that time and the
patient had also become febrile with a white blood cell count
in the 20,000 range. He was being treated with Levofloxacin
for the Moraxella pneumonia.
On the [**1-13**] the patient was restarted on
intravenous Dobutamine due to his periods of hypotension and
known left ventricular dysfunction. Over the course of the
next few days the patient began to have increased gastrostomy
tube output necessitating CAT scan of his abdomen and chest
for his distended abdominal examination, increased white
count without clear explanation and in ability to tolerate
his tube feeds. General surgery consult was obtained on the
[**1-13**] due to continued fever spikes, decreasing
level of responsiveness and inability to tolerate tube feeds.
It was the feeling of the General Surgery Service that his
was all a result of his pneumonia process and there was no
obvious intra-abdominal pathology to explain these symptoms
and concerns. The patient underwent bronchoscopy on the [**2104-1-14**], which revealed clear watery secretions and
no purulent drainage.
The patient was ultimately started on hyperalimentation since
he continued to be intolerant of tube feeds into his stomach
via the PEG and remained fully sedated on Fentanyl drip. He
remained in atrial fibrillation with a controlled ventricular
rate, but continued to spike fevers over the course of the
next few days. The patient had some problems with
hyperventilation he was intermittently placed on pressure
support, however, became hypoxic and placed back on assist
control ventilation mode. On the [**1-17**] he again
required higher FIO2 and higher PEEP due to significant
hypoxia with a PO2 in the 60s on full ventilator support.
The patient has been placed on Vancomycin due to staph not
yet speciated at that time and was on Ciprofloxacin at that
time as well for gram negative rods in his sputum.
On postoperative day 16 into 17 he began to have issues with
hypernatremia for which he received free water. He continued
to spike fevers despite being on broad spectrum antibiotic
coverage. He remained ventilator dependent with ARDS and
pneumonia. He was intermittently responsive, however, he
required significant sedation to tolerate his full ventilator
support without bucking the ventilator. Over the course of
the next few days to the next week or so the patient was
placed on Dopamine drip due to hypotension. The patient
continued to not tolerate tube feeds and was maintained on
hyperalimentation. He remained fully sedated to tolerate
complete ventilator support and was making very little
progress weaning from the ventilator. The patient received
intermittent blood transfusion with the hope to get him off
the pressors to help with blood pressure support. His
pressors had been at varying doses over the next few weeks to
maintain adequate mean arterial blood pressure. The patient
continued to have intermittent fevers over the next two weeks
or so and was maintained on hyperalimentation for nutritional
support. He continued to have trouble with abdominal
distention, although not a specific reason for him not
tolerating tube feeds, nor his abdominal distention.
Abdominal CT scan was essentially negative.
The patient underwent a bronchoscopy on [**2104-2-2**] due
to worsening respiratory status and increasing need for
ventilator support, which he had previously been weaned a
little bit in his support. The patient remained sedated,
however, occasional opened his eyes. He had intermittent
periods of hypoxia over the next couple of days. He remained
on Dilaudid and Ativan drips for sedation and Fentanyl patch
for pain control. He was continuing to be treated with
Levofloxacin and Vancomycin for MRSA in his sputum as well as
gram negative for the sputum, which was previously identified
at Moraxella. He also had Enterobacter in his urine. The
patient essentially remained in unchanged status with need
for full ventilator support as well as varying doses of
vasopressors to maintain adequate blood pressure.
On [**2104-2-6**] the patient was on Dobutamine at 7.5 mics
per kilo per minute, he was on neo-synephrine, Dilaudid and
Ativan drip throughout that time. His Dobutamine was
ultimately weaned off without significant change in his blood
pressure. He was placed on Levophed for blood pressure
support and was able to have that weaned somewhat and
ultimately was on 0.5 mics per kilo per minute. The patient
was intermittently given diuretics to maintain adequate urine
output. He was also intermittently transfused packed red
blood cells to help with his blood pressure support. On
[**2104-2-7**] the patient went to the Radiology Department
where he underwent a conversion of his PEG to a PEG
jejunostomy feeding tube. He appeared to tolerate that
procedure well. Over the past few days discussions have
taken place between Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the patient's
family. The family has indicated that it was their wish to
have the patient moved to a facility closer to home, since he
still remained dependent on vasopressors for blood pressure
support, we were unable to have him transferred to a long
term chronic ventilator facility or an acute rehabilitation
facility with ventilator support and this required his
remaining in the Intensive Care Unit.
Dr. [**Last Name (STitle) **] has spoken with Dr. [**Last Name (STitle) 37360**] [**Name (STitle) **] the patient's
primary cardiologist at [**Hospital3 35813**] Center in
[**Location (un) 37361**], [**State 792**]who has agreed to accept this
patient in transfer to [**Hospital3 35813**] Center for definitive
care and continued support in the Intensive Care Unit. The
patient today [**2104-2-8**] is essentially unchanged from
his previous status. He is on decreased ventilator support
from his previous settings. It was felt that it would be
safe to transfer him via ambulance to [**Hospital3 35813**] Center
at this time per the family's request.
CONDITION ON DISCHARGE: Temperature 98.7. Heart rate 89 in
atrial fibrillation. Blood pressure 126/47. Oxygen
saturation is 100%. The patient remains on the ventilator,
SIMV, FIO2 50%, tidal volume is 500, respiratory rate is 20.
His PEEP is 7.5 and his pressure support is 5. Most recent
arterial blood gases 7.36, PCO2 36, PO2 90, bicarb 21, base
excess 94. Most laboratory values revealed a white blood
cell count 13.9000, hematocrit 31, platelet count of 124,000,
sodium 138, potassium 4.0, chloride 108, CO2 20, BUN 68,
creatinine 1.1, glucose 128, calcium 1.2, magnesium 1.8,
phosphate 4.9. Most recent cultures from [**1-29**], coag
negative staph in the blood. Sputum, Enterobacter, [**Female First Name (un) **]
and coag positive staph, MRSA and gram negative rods as well
as yeast. The patient also had Enterobacter in his urine.
Physical examination, the patient remained sedated, intubated
and fully ventilated. Cardiac examination was irregular rate
and rhythm. The patient has coarse breath sounds
bilaterally. His abdomen was soft, nontender. His
extremities are warm with 3+ edema. The patient has a left
subclavian central intravenous line. He also has a right
brachial arteriole line, Foley catheter and a feeding tube.
The patient remains on intravenous Levophed drip at .05 mics
per kilo per minute.
Other medications include intravenous Dilaudid drip at 2.5 mg
per hour, Colace 100 mg b.i.d., Imipenem 500 mg intravenous q
6 hours, Digoxin 0.25 mg per PEG q.d., Flovent two puffs
b.i.d. through the ventilator circuit, Albuterol and Atrovent
inhalers q 2 hours via ventilator circuit around the clock,
Lasix 40 mg intravenous b.i.d., aspirin 325 mg through the G
tube q.d., sliding scale regular insulin coverage for blood
sugar of 130 to 160 equals 2 units, 161 to 200 equals 4
units, 201 to 250 equals 6 units, 251 to 300 equals 8 units,
301 to 350 equals 10 units and 351 to 400 equals 12 units,
subcutaneously greater then 400 to resume on insulin drip.
The patient is on Nystatin powder to effected areas t.i.d.
and prn. He has been receiving varying doses of Coumadin to
keep him on the low therapeutic side with an INR to 1.5 to
2.0. His most recent Coumadin dose is 2.5 mg on [**2104-2-7**].
CONDITION ON DISCHARGE: The patient's condition remains
guarded on full ventilator support, vasopressor support in
the Intensive Care Unit to be transferred to [**Hospital3 35813**]
Center for continued care in the Intensive Care Unit under
the direction of Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2104-2-8**] 11:24
T: [**2104-2-8**] 12:31
JOB#: [**Job Number 37362**]
|
[
"997.1",
"414.01",
"518.5",
"413.9",
"997.3",
"428.0",
"486",
"427.31",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"36.15",
"99.15",
"39.61",
"96.72",
"31.1",
"36.12",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
2008, 11961
|
1303, 1790
|
127, 760
|
1805, 1990
|
783, 1280
|
14228, 14757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,566
| 196,991
|
3660
|
Discharge summary
|
report
|
Admission Date: [**2149-8-22**] Discharge Date: [**2149-8-25**]
Date of Birth: [**2072-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Mr. [**Known lastname 16585**] is a 77 yo man with 3 vessel CAD s/p CABG [**5-7**] and
s/p LAD stenting [**4-7**] who presents with crescendo chest
discomfort over the last week.
.
He had done well since his last stent placement in [**4-7**], with no
need for nitroglycerin until two weeks prior to admission. He
developed chest discomfort with light activity such as climbing
one flight of stairs or carrying packages. The chest discomfort
was sternal in location, sometimes radiating to his bilateral
shoulders, arms, and jaw, [**4-10**] in intensity, and relieved at
first within minutes of one nitroglycerin. It felt like his
prior angina. He had some associated diaphoresis and nausea,
without dyspnea or palpitations. His chest discomfort was not
pleuritic in character nor did it feel like heartburn. His
nitroglycerin requirement increased over the weeek to the point
where he was taking 4 nitroglycerin per episode, leading him to
seek medical attention.
.
In the ED, his vitals were T 97.3, P 52, BP 151/61, RR 16, O2
99% RA. He was given ASA 325mg. He was taken to the cath lab
where he was found to have 80% stenosis of the LAD at D1 origin
with patent proximal LAD stent, and 70% stenosis of the mid RCA.
The procedure was complicated by dissection of the LAD,
necessitating placement of DESx2 to the LAD. His D1 was occluded
post stenting.
.
Upon arrival to the floor, the patient initially complained of
[**5-11**] chest discomfort that improved with lopressor and IV
morphine.
.
Review of systems is positive for prior stroke, claudications,
and night time leg cramps. He denies any history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
cough, black stools or red stools. He denies recent fevers,
chills or rigors. He does have chronic constipation and urinary
frequency. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
syncope or presyncope.
Past Medical History:
Hypertension
Hyperlipidemia
Systolic CHF (EF 45%; [**5-7**])
CAD
--STEMI [**5-7**]
--CABG [**5-7**] (SVG->OM)
--s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] to LMCA/LAD, PTCA of D2 and mid LAD [**4-7**]
[**2138**] CVA
Carotid artery disease, s/p right CEA in [**2144**]
PVD (known bruit over right groin) with claudication
Gout
GERD
Lower back pain s/p L4-5 laminectomy
Nasal fractures, s/p surgical correction
Tonsillectomy
Social History:
100-pack-year history of smoking,and discontinued in [**2136**]. Wife
smokes.
Social beer drinking (about 8-10 beers/week). Married with four
children. Former truck driver.
Family History:
Brother with ??????heart problems??????, died in his 40??????s.
Physical Exam:
CCU exam
VS: T 96.0F P54 BP 113/44 RR 12 O2 100% on 3L NC
General: Pale appearing elderly man lying in bed appearing
somewhat uncomfortable
Neck: Sclera white, conjunctiva pale. MMM. JVP measurement
limited as patient lying flat post-sheath removal. No carotid
bruits appreciated. Carotid upstrokes brisk 2+ bilaterally.
+scar R neck post CEA. No thyromegally.
CV: Regular rate S1 S2 no m/r/g. PMI nondisplaced.
Pulm: Lungs clear bilaterally on anterior exam without rales,
wheezes, or rhonchi
Chest: Midline sternotomy scar, well healed
Abd: Soft, +BS, nontender, no masses or organomegally, +L renal
bruit and R femoral bruit. R and L groin sites bandaged C/D/I
Extrem: Warm and well perfused, no edema, 2+ distal pulses
Neuro: Alert and interactive, moving all extremities
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Decreased hair on lower extremities.
Pertinent Results:
[**2149-8-22**] 10:47AM WBC-5.8 RBC-4.65 HGB-13.4* HCT-39.5* MCV-85
MCH-28.8 MCHC-33.9 RDW-13.9
[**2149-8-22**] 10:47AM PLT COUNT-214
[**2149-8-22**] 10:47AM NEUTS-60.5 LYMPHS-30.6 MONOS-4.9 EOS-3.2
BASOS-0.9
[**2149-8-22**] 10:47AM PT-10.9 PTT-23.2 INR(PT)-0.9
[**2149-8-22**] 10:47AM CK(CPK)-96
[**2149-8-22**] 10:47AM CK-MB-NotDone
[**2149-8-22**] 10:47AM cTropnT-<0.01
[**2149-8-22**] 10:47AM GLUCOSE-100 UREA N-29* CREAT-1.3* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-29 ANION GAP-12
[**8-23**] 8am CK 832, CK-MB 13.9 (Tropn 0.3 [**7-23**] 3am)
.
[**8-22**] CXR
The patient is status post median sternotomy. There is
calcification of the thoracic aorta. There is no focal
consolidation or overt pulmonary edema.
.
[**8-22**] EKG
10am, ED: sinus bradycardia 51bpm, normal axis and intervals,
normal R wave progression, inv T in III, no signs acute ischemia
.
[**8-23**] TTE
.
Brief Hospital Course:
Unstable Angina: He underwent a cardiac cath which was
complicated by a dissection of LAD, now s/p LAD stenting which
in turn was compliated by a block of D1. He was temporarily on
a balloon pump in the cath lab to enhance coronary perfusion.
The balloon removed in the CCU. His ACEI and beta blocker were
titrated up during this hospitalization. He was also continued
on his ASA/plavix/statin.
.
CHF: TTE with severe apical hypokinesis, EF 30%; clinically
euvolemic with no signs of HF. He was treated with betablocker
and ACE.
.
Anemia: On admission with hct 39-->33. Guaiac negative, no
evidence of acute bleed. Hemodynamically stable.
.
Chronic renal insufficiency: With baseline Cr 1.1-1.2. On
discharge with Cr 1.4 in setting of contrast load with cardiac
catheterization. Received post cath IVF with bicarb.
Medications on Admission:
Aspir-81 81 mg--1 tablet(s) by mouth qam
LISINOPRIL 10 mg--1 tablet(s) by mouth once a day
METOPROLOL TARTRATE 50 mg--1 tablet(s) by mouth twice a day
NITROGLYCERIN 0.4 mg prn
OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day
PLAVIX 75 mg--1 tablet(s) by mouth qam
SIMVASTATIN 40 mg--1 tablet(s) by mouth once a day
DIPHENHYDRAMINE HCL 25 mg--1 tablet(s) by mouth at bedtime
QUININE SULFATE 324 mg--1 capsule(s) by mouth hs
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual x3.
8. Benadryl 25 mg Tablet Sig: One (1) Tablet PO qhs prn.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
Unstable Angina
Secondary
Coronary artery disease
Discharge Condition:
Stable
Completed by:[**2149-9-18**]
|
[
"428.0",
"403.90",
"585.9",
"998.2",
"410.71",
"414.01",
"428.20",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"00.66",
"00.47",
"88.56",
"00.40",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7127, 7185
|
5004, 5831
|
326, 351
|
7287, 7325
|
4077, 4981
|
3107, 3172
|
6306, 7104
|
7206, 7266
|
5857, 6283
|
3187, 4058
|
276, 288
|
379, 2404
|
2426, 2900
|
2916, 3091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,338
| 174,316
|
738
|
Discharge summary
|
report
|
Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 86 year old female
who has had recent multiple admissions to the hospital for
shortness of breath who was admitted on [**2140-1-16**], from
rehabilitation with listlessness and a blood pressure in the
low range of 100/60. She also had an oxygen saturation of
88% on two liters. The patient's primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 3357**], assessed the patient and she was sent to [**Hospital1 346**] Emergency Department for evaluation
for congestive heart failure. She had some wheezes on
examination and was given Albuterol and Ipratropium
nebulizers and Lasix 40 mg intravenously. Her blood pressure
on admission to Emergency Department triage was approximately
80/60 which was lowered to 74/23. Dopamine drip was started
for blood pressure support and the patient was admitted to
Intensive Care Unit and given two liters of normal saline.
She was noted to be 88% in room air and got antibiotics for
possible pneumonia. She was placed on an eight liter face
mask and had an arterial blood gases of 7.30 with a pCO2 of
47 and a pO2 of 58. She was in the Intensive Care Unit for
three hospital days and was transferred out to the Medicine
floor after it was determined that she was likely dehydrated
and went into renal failure due to dehydration and possible
over diuresis.
PAST MEDICAL HISTORY:
1. Multi-infarct dementia.
2. Coronary artery disease, status post pacer for complete
heart block.
3. Diabetes mellitus.
4. Depression.
5. Congestive heart failure.
6. Status post radial fracture.
7. Bilateral knee arthroplasty.
MEDICATIONS ON ADMISSION:
1. Colace.
2. Vitamin D.
3. Lipitor 10 mg p.o. once daily.
4. Aspirin 81 mg p.o. once daily.
5. Lopressor 50 mg p.o. twice a day.
6. Imdur 90 mg p.o. once daily.
7. Lisinopril 20 mg p.o. once daily.
8. Ultram 50 mg p.o four times a day.
9. Protonix 40 mg p.o. once daily.
10. Lasix 20 mg p.o. once daily.
11. Zyprexa 10 mg p.o. twice a day.
12. Effexor 75 mg p.o. once daily.
13. Effexor XR 150 mg p.o. q.h.s.
14. Neurontin 300 mg p.o. twice a day.
PHYSICAL EXAMINATION: Upon presentation to Medicine,
temperature is 96.9, blood pressure 103/63, heart rate 86,
respiratory rate 27, oxygen saturation 96% in room air. In
general, she is sitting in bed, bright and alert. Head,
eyes, ears, nose and throat examination reveals moist mucous
membranes with a clear oropharynx. The lungs show slight
crackles at the left base and no audible wheezes.
Cardiovascular reveals a regular rate and rhythm with distant
heart sounds. Abdomen is soft, obese, nontender,
nondistended with positive bowel sounds. Extremities show no
pedal edema.
LABORATORY DATA: Upon presentation to Medicine, white blood
cell count was 9.1, hematocrit 35.6, platelet count 326,000.
Creatinine 1.1, blood urea nitrogen 27, potassium 5.2,
glucose 171.
HOSPITAL COURSE:
1. Dyspnea, hypoxia - She was much improved after getting
fluids in the Intensive Care Unit without any diuresis. It
was determined by chest x-ray that she was dry and had
possible infiltrate and was treated with antibiotics,
Levofloxacin, Flagyl, Vancomycin. The Vancomycin was
discontinued, however, she remained on Levofloxacin and
Flagyl for concern of aspiration pneumonia. Intensive Care
Unit team also felt that the patient had reactive airways and
started steroids p.o. along with continuing nebulizers. She
had a negative infectious workup to date. Of note, she has
not had a history of chronic obstructive pulmonary disease or
asthma in the past. Upon transfer to the Medicine floor, she
was found the next day to be in significant respiratory
distress requiring respirator care and nebulizers. She
seemed to do better after this. Chest x-ray was obtained and
showed progressive heart failure over the past four days in
the hospital. She was given 20 mg intravenous Lasix and had
good urine output and was saturating well. She then became
very lethargic and was given intravenous fluids as it is
noted in the past the patient responds very well to
intravenous fluids, becoming more alert and aware of her
environment. Also of note, the patient had a transthoracic
echocardiogram which showed an ejection fraction of 55% and
E:A ratio of 0.82, however, this did not meet criteria for
diastolic dysfunction. She also had a very poor quality
echocardiogram which limited our evaluation of whether she
has systolic dysfunction in addition to diastolic
dysfunction. A heart failure consultation was obtained by Dr.
[**Last Name (STitle) **] and it was determined that it was difficult to tell
whether she had pure diastolic dysfunction. It was
recommended that the patient start Diltiazem for rate control
without using beta blockers to exacerbate any potential
bronchospasm. The patient did well on Diltiazem and was
continued only on Lisinopril 5 mg p.o. once daily. Her
previous Imdur and Lopressor were discontinued.
2. Hypotension - It was unclear whether the patient was
overmedicated with blood pressure medications upon admission
or was over-diuresed. Her previous hospital stay had
actually cut down her previous Lasix dose so it is unclear
whether this had anything to do with her hypotension.
However, while in house, the patient's blood pressure
remained well without Lopressor or Lisinopril at 20 mg. At
the reduced Lisinopril dose as well as the Diltiazem, the
patient did well. She was restarted on her Lasix 20 mg p.o.
Once daily.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To [**Hospital 5412**] Rehabilitation.
DISCHARGE DIAGNOSES:
1. Multi-infarct dementia.
2. Coronary artery disease, status post pacer for complete
heart block.
3. Diabetes mellitus.
4. Depression.
5. Congestive heart failure.
6. Status post radial fracture.
7. Bilateral knee arthroplasty.
MEDICATIONS ON DISCHARGE:
1. Diltiazem XR 120 mg p.o. once daily, hold for systolic
blood pressure of less than 110.
2. Prednisone 40 mg p.o. twice a day on a taper to decrease
by 10 mg twice a day every two days.
3. Metronidazole 500 mg p.o. three times a day.
4. [**2140-1-23**], is her last day of Levofloxacin 250 mg p.o.
once daily.
5. [**2140-1-23**], is her last day of Acetamodic.
6. Gabapentin 300 mg p.o. twice a day.
7. Phenylfaxene SR 75 mg p.o. once daily.
8. Lisinopril 5 mg p.o. once daily.
9. Ipratropium MDI two puffs inhaled four times a day.
10. Albuterol MDI one to two puffs inhaled q4hours p.r.n.
11. Olanzapine 10 mg p.o. twice a day.
12. Vitamin D 400 units p.o. once daily.
13. Docusate 100 mg p.o. twice a day.
14. Aspirin 81 mg p.o. once daily.
15. Atorvastatin 10 mg p.o. once daily.
FOLLOW-UP PLANS: The patient is to follow-up with her
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**].
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2140-1-23**] 08:39
T: [**2140-1-23**] 09:13
JOB#: [**Job Number 5413**]
|
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icd9cm
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9,808
| 103,248
|
26534
|
Discharge summary
|
report
|
Admission Date: [**2130-2-3**] Discharge Date: [**2130-3-17**]
Date of Birth: [**2072-7-10**] Sex: F
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Paracentesis X 3
Intubation
History of Present Illness:
57-year-old woman w/ h/o HTN, hyperlipidemia, alcoholic
cirrhosis transfered from OSH for worsening renal and liver
function. She stopped drinking four months ago and is scheduled
to have a BDIMC outpt liver transplant evaluation on [**2130-3-16**].
She was admitted from a [**Hospital1 1501**] to AJH on [**2130-1-24**] w/ worsening
ascites, abnormal LFTs including increased ammonia level (61 on
[**1-21**] to 129) and ARF. She was admitted w/ a WBC of 22, Cr of 3.1
(baseline 1.2). Given concern for SBP, she was tapped and 3.5L
fluid were removed but no cultures were sent. She was started on
Unasyn IV but developed desquamation of her soles on [**2-1**] so it
was stopped and steroid cream was used to treat the rash. Renal
consult diagnosed her w/ hepatorenal and started her on
midodrine 10mg po tid and octreotide 100mcg SQ tid. The patient
was retapped [**2-2**] and cultures are pending, gram stain negative,
WBC 280 with 29% neut.. Per OSH transfer note one out of four
bottles BCx grew noncandidal yeast (however micro lab now says
no yeast in cultures) and she was started on caspofungin IV. GI
consult felt she was recovering from severe alcoholic hepatitis
but recommended no specific therapy other than abstinence from
EtOH, diet, and vitamins.
.
During her hospitalization her INR was noted to be rising,
reaching 2.6 on [**2-2**]. Her WBC [**2-3**] was 26.4 (88.5% and 15
bands), an increase from 16 over the past few days. Her renal
function improved gradually w/ creatinine 1.6 today from 3.1.
.
On speaking with her husband, he states there is no way she
could have received alcohol within the last week and that she
has been sober for about 2 months. Besides her family, a couple
of family friends have visited her in the hospital and [**Hospital1 1501**]. She
is currently unable to answer questions. On the floor she was
very agitated, she received 6mg Haldol and was placed in
restraints. An NG tube was placed and labs sent. Based upon
her labs MICU was called to evaluate.
Past Medical History:
1. acute alcoholic cirhhosis, treated at AJH in [**12-23**]
2. hypercholesterolemia
3. HTN
4. chronic hyponatremia
5. depression
6. h/o TAH remotely
7. hemorrhoids seen on sigmoidoscopy
Social History:
Living at [**Hospital1 1501**]. Quit smoking and drinking ~2 months ago.
Previously was drinking [**2-19**] heavy liquor alcoholic beverages per
day. Used to work for children with special needs but now does
not work. Married. Father deceased, mother has dementia. 2
children, one in [**Location (un) 5028**] and one in [**Location (un) 8072**], NH, both well.
Family History:
n/c
Physical Exam:
VS: 98.9, 106/45, 112, 28, 98% on 2L NC
Gen: agitated, trying to get out of bed, responded yes to name
HEENT: MM dry, OP dried blood on palate and lips, anicteric, NG
tube in place
Neck: supple, no meningeal signs by agitated movement
Lungs: Diffuse rhonchi throughout, left greater than right.
CV: tachy, nl S1S2, no friction rub
Abd: hypoactive bowel sounds, soft, nontender, distended, +
ascites
Ext: 3+ pitting edema in LE bilaterally, no c/c, patchy
erythema/desquamation on feet bilaterally
Neuro: agitated, not responding appropriately to commands,
tremulous
.
EKG: sinus tach at 127, nl axis, nl intervals, low voltage,
right atrial abnormality, poor baseline due to agitation
Pertinent Results:
OSH Abd U/S: Ascites throughout abdomen, echogenic liver,
gallbladder sludge
OSH CXR: inspiration poor, minimal atelectasis.
OSH Head CT ([**2129-12-27**]) : mild atrophy, no acute abnormality
.
Brief Hospital Course:
A/P: 57F w/ alcoholic hepatitis, likely hepatorenal syndrome
transferred from OSH w/ worsening liver function, fevers,
agitation. Initially presented with sepsis based upon
tachycardia, elevated lactate, anion gap acidosis, elevated WBC,
and low grade temp. admitted with decreased mental status and
worsening renal function. Patient developed progressive
Respiratory failure, Liver failure, Coagulopathy, Sepsis and
Renal failure. Was admitted to the MICU. Was started on pressors
and was also intubated. Was given multiple units of FFP,
platelets and was put on many other life suportin measures.
However patient progressively deteriorated and ultimately she
was made CMO. She expires on [**2130-3-17**].
Medications on Admission:
Medications at nursing home:
Protonix 40mg po qd
aldactone 50 mg po bid
thiamine 100mg po qd
folate 1mg qd
MVI qd
Anusol [**Hospital1 **]
Protein powder 1 scoop tid
.
Meds on transfer:
albumin 12.5g daily IV
Lasix 40mg IV qd
Caspofungin 35mg IV qd
Levaquin 500mg IV qd (started [**2-3**])
Protonix 40mg po qd
Thiamine 100mg po qd
Folate 1mg po qd
Aldactone 50mg po qam
MVI qd
Mycolog cream ointment
Lactulose 30mL po q12h
Neomycin 500mg po tid
Ativan 0.5 po q6h prn
Triamcinolone ointment
Preparation H cream prn
Oxycodone 5mg po q4h prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver Failure
Renal Failure
Coagulopathy
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Completed by:[**2130-3-31**]
|
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icd9cm
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5212, 5221
|
3886, 4595
|
273, 302
|
5325, 5334
|
3666, 3863
|
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|
5242, 5304
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,516
| 118,316
|
568+569+570+55223
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2123-10-27**] Discharge Date:
Date of Birth: [**2085-3-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has fevers to greater
than 104, likely pneumonia or other pulmonary process
increasing for one month. He reports increased cough,
usually nonproductive, but occasional production of bloody
sputum. In addition, he has some dark stool which he states
is maroon in color in the last few weeks as well as nausea
and vomiting. He states that sometimes he vomits blood.
Reports left upper quadrant pain times one month with eating.
Denies dyspnea or chest pain. He states some pain in his
chest with cough only and that's resolved, mild headache like
a hot plate on his forehead, mild neck pain, positive urinary
frequency and dysuria times weeks. Today, he has had
diarrhea, 30 minutes after meals. He states he has been
depressed, not sleeping and wants to die without active
suicidal ideation.
PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2118**], treated with HAART in [**2122-7-2**],
viral load was 50,000, went to less than 50, but then patient
quit his medications after his rectal abscess. Last CD4
count [**2123-7-2**] was 1, viral load in [**2123-6-1**] was greater
than 500,000.
2. Kaposi's of skin, oral cavity and lung, status post
chemotherapy in [**2119**].
3. ......... of the skin, buttocks in [**2122-4-1**].
4. History of neutropenia exacerbated by Bactrim and
resolved with discontinuation.
5. HSV2 resolved [**2123-6-1**], perianal.
6. History of perianal abscess in [**2122**], status post surgery.
7. Left upper lobe pneumonia in [**2123-7-10**], treated with
levofloxacin and resolved.
8. Recurrent zoster.
9. Pancreatitis.
10. Oral ulcers and [**Female First Name (un) **] esophagitis.
11. Depression.
12. Tinea barba.
SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24
beers most recently until five days ago.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Bactrim intolerance.
MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800
t.i.d. times 30 days, then b.i.d., azithromycin 250 times
five q. week, dapsone 100 q.d., Epivir 150 b.i.d., Indinavir
400 b.i.d., Paxil 20, Prilosec 20, Ritonavir 100 times four
b.i.d., stavudine 40 b.i.d.
REVIEW OF SYSTEMS: No rigors, fevers and chills and sweats
today only. Weight loss 30 pounds in one month. Cough.
Bloody sputum. Very weak, appetite is poor, severe watery
diarrhea ("like peeing"). Left upper quadrant abdominal
pain, nausea and vomiting. Pain at the site of his spinal
tap, insomnia.
PHYSICAL EXAMINATION: Temperature 104.4. Heart rate 110.
Blood pressure 118/68. Respiratory rate 18. In general:
Thin, uncomfortable male with soft voice who looks
chronically but not acutely ill. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light.
Extraocular muscles were intact. Mucous membranes moist.
White patches on cheek and tongue with poor dentition. Neck:
Small lymphadenopathy. Cardiovascular: Loud S1, S2, no
murmurs, tachycardia but regular. Pulmonary clear to
auscultation bilaterally. Abdomen loud bowel sounds, soft,
diffusely tender, maximum left upper quadrant, right upper
quadrant, suprapubic liver edge down 2 cm, 10 cm total of 10,
tender. Extremities: No cyanosis, clubbing or edema. Skin:
Brown macules 1 cm scattered on back, right thigh. Rectal:
Heme positive, perianal abscess with scarring.
Genitourinary: Scars on scrotum, papules with ventral dot
right inguinal consistent with molluscum contagiosum.
Psychiatric: Depressed mood. Neurological: Alert and
oriented times three, normal bulk and tone.
LABORATORIES: White blood cell count 2.3, hematocrit 35.5,
platelets 112,000, MCV 90. Sodium 130, potassium 3.9,
chloride 96, bicarbonate 22, BUN 10, creatinine 0.7, glucose
104. Urinalysis: Ketones 15, protein 100, otherwise
negative. Cerebrospinal fluid: Tube 2 glucose 61, 4 no
cells clear. Head CT negative. Chest x-ray: Left upper
lobe consolidation consistent with pneumonia.
Patient admitted to the Medical Service.
HOSPITAL COURSE: By system:
1. Infectious Disease: The patient was spinal tapped which
was not consistent with meningitis, however, he was treated
empirically with Ceftriaxone and noted to defervesce.
Therefore, Ceftriaxone was continued. Infectious Disease
Service was consulted. PO acyclovir and dapsone were
continued. KUB was obtained which was negative except for a
small amount of pelvic free fluid. Numerous microbiology
studies were sent. The only one which was positive was a
sputum that grew out aspergilloses fumigatus. Blood
cultures, urine cultures were negative. Ova and parasites
was negative. Stool ova and parasites was negative. Stool
culture for yersinia, Campylobacter, E. Coli, vibrio,
cryptococcus, Giardia were all negative. RPR was negative.
Sputum ova and parasites was negative. Toxicology IgG was
negative. Cryptococcus antigen was negative. Sputum for
acid fast bacilli times three were negative, however, patient
was isolated respiratory until this was obtained. The
cerebrospinal fluid from [**10-27**] grew one colony on one
plate of ..... bacterium which was .......this was thought
most likely to be contaminant. Patient was continued on
ceftriaxone as he defervesced and remained afebrile. Also
continued on dapsone and acyclovir, however, his white count
was noted to drop and the acyclovir was decreased and then
stopped. However, after stopping the acyclovir, the patient
noted increase in rectal burning and the acyclovir was
restarted given the patient's history of herpes and the
patient was put on neutropenic precautions. The patient was
not restarted on HAART during this acute period as he had
been off it previously.
On [**10-28**], a chest CT was obtained which showed a 1.8 x
1.5 cm cavitary lesion in the posterior left upper lobe
surrounded by consolidation and ground glass opacity, as well
as scattered emphysema. The patient was started on nystatin
for thrush and over the next couple of days, the diarrhea
seemed to resolve. The Pulmonary Service was consulted and
on [**11-2**], the patient underwent bronchoscopy. BAL grew
aspergillus fumigatus, however, it was negative for PCP, [**Name10 (NameIs) **]
cardia, ova and parasites and acid fast bacilli. Thoracic
Surgery was consulted to assess whether the aspergilloma was
resectable. They felt that he would need at least four to
six weeks of treatment before surgery would be a
consideration. Therefore, amphotericin was started with a
test dose and then at 0.5 mg /kg/IV/q.d. Gastrointestinal
was consulted given continuing abdominal pain without source,
heme positive, and history of skin ........and patient with
elevated eosinophils on his white count differential.
Esophagogastroduodenoscopy was performed on [**11-4**] which
was noted for friability, erythema and congestion in the
antrum consistent with gastritis and abnormal mucosa in the
duodenum, but otherwise normal. Biopsy was taken. The
antrum biopsy showed chronic gastritis with focal intestinal
metaplasia. No active gastritis seen. Duodenal biopsy
showed no diagnostic abnormalities. Patient was continued on
Protonix.
2. Gastrointestinal: As above. Multiple stool studies were
sent and all were negative.
3. Respiratory: Patient found to have aspergillosis and
started on amphotericin.
4. Fluid, electrolytes and nutrition: Patient noted to have
a low sodium on admission of 130 felt consistent with
syndrome of inappropriate diuretic hormone. This resolved
with fluid restriction.
5. Psychiatric: Patient continued on Paxil. It was
discussed with the patient as to whether to have a social
worker or psychiatrist and he declined at that time. On
[**11-9**], patient was noted to start having nausea and
vomiting. After that, he was found later in the morning,
after he had tried to get out of bed, next to formed stool
and he was unable to get up at that time. Head CT was
ordered but before patient was sent for head CT it was noted
that his systolic blood pressure dropped to the 80s. Patient
was bolused with one liter of normal saline. Blood pressure
only responded slightly. Medical Intensive Care Unit Team
was called and was in the room at bedside. Patient was
vomiting and curled on his side. Eyelids were noted to
flutter and subsequently patient noted to become rigid, then
arms came towards chest in tonic-clonic. Patient was
nonresponsive. Ativan 4 mg given and Code Team called.
Patient intubated for airway protection and transferred to
Medical Intensive Care Unit.
In the Medical Intensive Care Unit, patient by system:
1. Neurologic: He was loaded on Dilantin. First lumbar
puncture showed protein of 524. Other cultures and cytology
were negative. He was on acyclovir until HSV, PCR came back
negative from cerebrospinal fluid. MRI was negative.
Patient continued to have occasional gaze deviation and
facial twitching, so, bedside electroencephalogram was
obtained which revealed seizures q. 10 minutes. He was
loaded on phenobarbital. He was still having seizures, so
induced pentobarbital coma. Neurology had been consulted.
Electroencephalogram flat line using pentobarbital for 72
hours. During this time, he developed central diabetes
insipidus, spiked fevers with negative cultures, which was
suspicious for ..........dysregulation. The second lumbar
puncture showed protein of 226. Patient believed to have
meningitic process, especially active in basilar regions
given central diabetes insipidus and neurogenic fevers of
unclear etiology. Question of whether this might be partly
due to HIV encephalopathy.
After three days from [**11-11**] to [**11-14**], pentobarbital
was weaned to off over 24 hours, continuous
electroencephalogram monitoring for 72 hours after started
pentobarbital taper with no signs of epileptic activity on
electroencephalogram. Bedside electroencephalogram was
discontinued and patient was followed clinically. He had
occasional eye twitch and facial myoclonus believed not to be
seizure activity. He was maintained on phenobarbital and
Dilantin, which will be his anti-epileptic coverage for life.
Goal levels are 30 for phenobarbital and 17 for Dilantin.
On the fourth day after pentobarbital was off, patient noted
to have brain stem activity, reactive pupils and corneal
reflexes. By day seven, off pentobarbital. He became awake
and alert, though not interactive over the next two to three
days, he became interactive and vocal after extubation,
although not at baseline mental status. He was able to
follow commands sporadically, although confused often and
quite exhausted. Mental status will be impeded by his high
viral load and his cerebrospinal fluid. Central diabetes
insipidus resolved but he continued to have fevers, but did
not seem to be infectious. At the end of his Intensive Care
Unit stay, he appeared to have ICU psychosis requiring a
sitter and Haldol.
2. Pulmonary: He was intubated for airway protection.
Initially acidotic during seizure that resolved quickly on
assist control while on pentobarbital, and then quickly
weaned to pressure support. He was extubated with ease after
the mental status improved and he had no problems with
oxygenation or ventilation. He spent 11 days on the
ventilator during which time sputum became colonized with E.
Coli not believed to be a pathogen, developed bilateral
effusion from fluid overload that resolved with diuresis.
Bronchoscopy after mucus plug, off right upper lobe with
complete collapse. Plug suctioned at bronchoscopy and right
upper lobe atelectasis resolved completely. Left upper lobe
aspergilloma remained unchanged per chest x-ray. Patient was
maintained on itraconazole as amphotericin had to be stopped
after the seizure.
3. Cardiovascular: In the beginning, patient was initially
septic appearing requiring pressors. The need for pressors
increased during the pentobarbital, on dopamine and
vasopressin after the pentobarbital was discontinued,
pressors easily stopped and patient had good blood pressure,
thereafter, echocardiogram was done while in coma with mildly
depressed left ventricular function. After, out of his coma,
he had no cardiac issues. He initially developed effusions
from fluids he received but auto drive receptor-like episode
resolved with resolution of the effusions.
4. Infectious Disease: Dapsone prophylaxis was continued.
Itraconazole for aspergilloma. Initially patient on
ceftriaxone, Levaquin, Flagyl because he looked like he might
have gram negative rods sepsis, but when cultures were
negative, the Levaquin and Flagyl were discontinued. He was
kept on Ceftriaxone to complete a 24 day course. He was on
acyclovir until HSV PCR was negative, ESBL, E. Coli and
sputum, but no infiltrates, so believed to be a colonizer.
Cultures were always negative even when spiking q.d.
Cultures were drawn q. 24-48 hours so fever thought not to be
infectious. Renal function was good throughout. Central
diabetes insipidus treated with DDAVP and matching out's with
resolution of diabetes insipidus. In fact, DDAVP was stopped
completely because he became hyponatremic and then sodium
became normal. Fluid status and urine osmolarity were
monitored and normal saline or D5 water was given prn.
5. Gastrointestinal: Initial loss of bowel sounds during the
coma with poor motility that improved with Reglan. Patient
was put on TPN during the coma, but after the coma, tolerated
tube feeds. Patient with good bowel movement after the coma.
Patient stable and transferred to floor on [**2123-11-25**].
This will be his hospital course from [**2123-11-25**] to
[**2123-11-30**] by system:
1. Pulmonary: Patient with aspergilloma, continued on
itraconazole. 02 saturations and respiratory rate remained
stable. Patient remained on nasal cannula oxygen.
2. Infectious Disease: Patient continued to spike fevers
every day. Blood cultures and urine cultures were sent.
Blood cultures were always negative or pending as were urine
cultures. Infectious Disease consult Service continued to
follow with the discussion that HAART might be started when
Dilantin was weaned off as the two interacted and could not
be started reliably concomitantly. Another lumbar puncture
was obtained for question of possible neck stiffness and
photophobia. That night, tube four had white blood cells, 8
red blood cells, 21 polys, 2 lymphocytes, 52 monocytes, 47 in
tube 1, 7 white cells, 22 red cells, no polys, 71
lymphocytes, 24 monocytes, protein of 46 and glucose of 67.
That night, he got a dose of Ceftriaxone, however, the next
day with review with Infectious Disease Team, it was felt
that this was not consistent with meningitis, and so,
Ceftriaxone was stopped. Patient was started on Levaquin for
possible coverage of pneumonia as he had some crackles on
exam. The following day, oxacillin was also started but this
was stopped after one day as LFTs were known to elevate. At
this time, no source for fevers were definitely discovered.
Patient with nasogastric tube, no nasal drainage or facial
pain to palpation, however, CT at maxillary facial was
obtained and is pending at this time.
3. Neurology: Neurology Team continued to follow the
patient. Dilantin and phenobarbital levels were monitored.
Patient not noted to have any seizure activity. Patient was
started on Keppra, which will not interact with HAART, and
after several days of this, Dilantin will fully be weaned to
off as Keppra becomes therapeutic.
4. Gastrointestinal: Patient followed by Nutrition and
continued on tube feeds, tolerating well, hold on starting po
until swallow study. On [**12-1**], LFTs were checked and
noted to have risen. ALT at 57, AST at 176, alkaline
phosphatase at 333, therefore, oxacillin was stopped. These
may be due both to oxacillin and Dilantin and will be
followed.
5. Fluid, electrolytes and nutrition: Patient noted to have
drop in his sodium after three water fluid boluses were
increased with his tube feeds. These were held and changed
to normal saline intravenous for fluid and sodium fully
started to rise. Electrolytes were monitored and repleted.
6. Cardiovascular: Patient noted to be tachycardic, felt
secondary to fevers and possibly dehydration, therefore,
normal saline boluses were given as needed.
7. Prophylaxis: Patient was kept on ........and Protonix.
Physical Therapy worked with patient.
Addendum to this dictation will be dictated by new intern,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. This dictation is through [**2123-12-1**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4570**], M.D. [**MD Number(1) 4571**]
Dictated By:[**Last Name (NamePattern1) 4572**]
MEDQUIST36
D: [**2123-12-8**] 19:56
T: [**2123-12-8**] 19:56
JOB#: [**Job Number 4573**]
Admission Date: [**2123-10-27**] Discharge Date:
Date of Birth: [**2085-3-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has fevers to greater
than 104, likely pneumonia or other pulmonary process
increasing for one month. He reports increased cough,
usually nonproductive, but occasional production of bloody
sputum. In addition, he has some dark stool which he states
is maroon in color in the last few weeks as well as nausea
and vomiting. He states that sometimes he vomits blood.
Reports left upper quadrant pain times one month with eating.
Denies dyspnea or chest pain. He states some pain in his
chest with cough only and that's resolved, mild headache like
a hot plate on his forehead, mild neck pain, positive urinary
frequency and dysuria times weeks. Today, he has had
diarrhea, 30 minutes after meals. He states he has been
depressed, not sleeping and wants to die without active
suicidal ideation.
PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2118**], treated with HAART in [**2122-7-2**],
viral load was 50,000, went to less than 50, but then patient
quit his medications after his rectal abscess. Last CD4
count [**2123-7-2**] was 1, viral load in [**2123-6-1**] was greater
than 500,000.
2. Kaposi's of skin, oral cavity and lung, status post
chemotherapy in [**2119**].
3. ......... of the skin, buttocks in [**2122-4-1**].
4. History of neutropenia exacerbated by Bactrim and
resolved with discontinuation.
5. HSV2 resolved [**2123-6-1**], perianal.
6. History of perianal abscess in [**2122**], status post surgery.
7. Left upper lobe pneumonia in [**2123-7-10**], treated with
levofloxacin and resolved.
8. Recurrent zoster.
9. Pancreatitis.
10. Oral ulcers and [**Female First Name (un) **] esophagitis.
11. Depression.
12. Tinea barba.
SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24
beers most recently until five days ago.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Bactrim intolerance.
MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800
t.i.d. times 30 days, then b.i.d., azithromycin 250 times
five q. week, dapsone 100 q.d., Epivir 150 b.i.d., Indinavir
400 b.i.d., Paxil 20, Prilosec 20, Ritonavir 100 times four
b.i.d., stavudine 40 b.i.d.
REVIEW OF SYSTEMS: No rigors, fevers and chills and sweats
today only. Weight loss 30 pounds in one month. Cough.
Bloody sputum. Very weak, appetite is poor, severe watery
diarrhea ("like peeing"). Left upper quadrant abdominal
pain, nausea and vomiting. Pain at the site of his spinal
tap, insomnia.
PHYSICAL EXAMINATION: Temperature 104.4. Heart rate 110.
Blood pressure 118/68. Respiratory rate 18. In general:
Thin, uncomfortable male with soft voice who looks
chronically but not acutely ill. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light.
Extraocular muscles were intact. Mucous membranes moist.
White patches on cheek and tongue with poor dentition. Neck:
Small lymphadenopathy. Cardiovascular: Loud S1, S2, no
murmurs, tachycardia but regular. Pulmonary clear to
auscultation bilaterally. Abdomen loud bowel sounds, soft,
diffusely tender, maximum left upper quadrant, right upper
quadrant, suprapubic liver edge down 2 cm, 10 cm total of 10,
tender. Extremities: No cyanosis, clubbing or edema. Skin:
Brown macules 1 cm scattered on back, right thigh. Rectal:
Heme positive, perianal abscess with scarring.
Genitourinary: Scars on scrotum, papules with ventral dot
right inguinal consistent with molluscum contagiosum.
Psychiatric: Depressed mood. Neurological: Alert and
oriented times three, normal bulk and tone.
LABORATORIES: White blood cell count 2.3, hematocrit 35.5,
platelets 112,000, MCV 90. Sodium 130, potassium 3.9,
chloride 96, bicarbonate 22, BUN 10, creatinine 0.7, glucose
104. Urinalysis: Ketones 15, protein 100, otherwise
negative. Cerebrospinal fluid: Tube 2 glucose 61, 4 no
cells clear. Head CT negative. Chest x-ray: Left upper
lobe consolidation consistent with pneumonia.
Patient admitted to the Medical Service.
HOSPITAL COURSE: By system:
1. Infectious Disease: The patient was spinal tapped which
was not consistent with meningitis, however, he was treated
empirically with Ceftriaxone and noted to defervesce.
Therefore, Ceftriaxone was continued. Infectious Disease
Service was consulted. PO acyclovir and dapsone were
continued. KUB was obtained which was negative except for a
small amount of pelvic free fluid. Numerous microbiology
studies were sent. The only one which was positive was a
sputum that grew out aspergilloses fumigatus. Blood
cultures, urine cultures were negative. Ova and parasites
was negative. Stool ova and parasites was negative. Stool
culture for yersinia, Campylobacter, E. Coli, vibrio,
cryptococcus, Giardia were all negative. RPR was negative.
Sputum ova and parasites was negative. Toxicology IgG was
negative. Cryptococcus antigen was negative. Sputum for
acid fast bacilli times three were negative, however, patient
was isolated respiratory until this was obtained. The
cerebrospinal fluid from [**10-27**] grew one colony on one
plate of ..... bacterium which was .......this was thought
most likely to be contaminant. Patient was continued on
ceftriaxone as he defervesced and remained afebrile. Also
continued on dapsone and acyclovir, however, his white count
was noted to drop and the acyclovir was decreased and then
stopped. However, after stopping the acyclovir, the patient
noted increase in rectal burning and the acyclovir was
restarted given the patient's history of herpes and the
patient was put on neutropenic precautions. The patient was
not restarted on HAART during this acute period as he had
been off it previously.
On [**10-28**], a chest CT was obtained which showed a 1.8 x
1.5 cm cavitary lesion in the posterior left upper lobe
surrounded by consolidation and ground glass opacity, as well
as scattered emphysema. The patient was started on nystatin
for thrush and over the next couple of days, the diarrhea
seemed to resolve. The Pulmonary Service was consulted and
on [**11-2**], the patient underwent bronchoscopy. BAL grew
aspergillus fumigatus, however, it was negative for PCP, [**Name10 (NameIs) **]
cardia, ova and parasites and acid fast bacilli. Thoracic
Surgery was consulted to assess whether the aspergilloma was
resectable. They felt that he would need at least four to
six weeks of treatment before surgery would be a
consideration. Therefore, amphotericin was started with a
test dose and then at 0.5 mg /kg/IV/q.d. Gastrointestinal
was consulted given continuing abdominal pain without source,
heme positive, and history of skin ........and patient with
elevated eosinophils on his white count differential.
Esophagogastroduodenoscopy was performed on [**11-4**] which
was noted for friability, erythema and congestion in the
antrum consistent with gastritis and abnormal mucosa in the
duodenum, but otherwise normal. Biopsy was taken. The
antrum biopsy showed chronic gastritis with focal intestinal
metaplasia. No active gastritis seen. Duodenal biopsy
showed no diagnostic abnormalities. Patient was continued on
Protonix.
2. Gastrointestinal: As above. Multiple stool studies were
sent and all were negative.
3. Respiratory: Patient found to have aspergillosis and
started on amphotericin.
4. Fluid, electrolytes and nutrition: Patient noted to have
a low sodium on admission of 130 felt consistent with
syndrome of inappropriate diuretic hormone. This resolved
with fluid restriction.
5. Psychiatric: Patient continued on Paxil. It was
discussed with the patient as to whether to have a social
worker or psychiatrist and he declined at that time. On
[**11-9**], patient was noted to start having nausea and
vomiting. After that, he was found later in the morning,
after he had tried to get out of bed, next to formed stool
and he was unable to get up at that time. Head CT was
ordered but before patient was sent for head CT it was noted
that his systolic blood pressure dropped to the 80s. Patient
was bolused with one liter of normal saline. Blood pressure
only responded slightly. Medical Intensive Care Unit Team
was called and was in the room at bedside. Patient was
vomiting and curled on his side. Eyelids were noted to
flutter and subsequently patient noted to become rigid, then
arms came towards chest in tonic-clonic. Patient was
nonresponsive. Ativan 4 mg given and Code Team called.
Patient intubated for airway protection and transferred to
Medical Intensive Care Unit.
In the Medical Intensive Care Unit, patient by system:
1. Neurologic: He was loaded on Dilantin. First lumbar
puncture showed protein of 524. Other cultures and cytology
were negative. He was on acyclovir until HSV, PCR came back
negative from cerebrospinal fluid. MRI was negative.
Patient continued to have occasional gaze deviation and
facial twitching, so, bedside electroencephalogram was
obtained which revealed seizures q. 10 minutes. He was
loaded on phenobarbital. He was still having seizures, so
induced pentobarbital coma. Neurology had been consulted.
Electroencephalogram flat line using pentobarbital for 72
hours. During this time, he developed central diabetes
insipidus, spiked fevers with negative cultures, which was
suspicious for ..........dysregulation. The second lumbar
puncture showed protein of 226. Patient believed to have
meningitic process, especially active in basilar regions
given central diabetes insipidus and neurogenic fevers of
unclear etiology. Question of whether this might be partly
due to HIV encephalopathy.
After three days from [**11-11**] to [**11-14**], pentobarbital
was weaned to off over 24 hours, continuous
electroencephalogram monitoring for 72 hours after started
pentobarbital taper with no signs of epileptic activity on
electroencephalogram. Bedside electroencephalogram was
discontinued and patient was followed clinically. He had
occasional eye twitch and facial myoclonus believed not to be
seizure activity. He was maintained on phenobarbital and
Dilantin, which will be his anti-epileptic coverage for life.
Goal levels are 30 for phenobarbital and 17 for Dilantin.
On the fourth day after pentobarbital was off, patient noted
to have brain stem activity, reactive pupils and corneal
reflexes. By day seven, off pentobarbital. He became awake
and alert, though not interactive over the next two to three
days, he became interactive and vocal after extubation,
although not at baseline mental status. He was able to
follow commands sporadically, although confused often and
quite exhausted. Mental status will be impeded by his high
viral load and his cerebrospinal fluid. Central diabetes
insipidus resolved but he continued to have fevers, but did
not seem to be infectious. At the end of his Intensive Care
Unit stay, he appeared to have ICU psychosis requiring a
sitter and Haldol.
2. Pulmonary: He was intubated for airway protection.
Initially acidotic during seizure that resolved quickly on
assist control while on pentobarbital, and then quickly
weaned to pressure support. He was extubated with ease after
the mental status improved and he had no problems with
oxygenation or ventilation. He spent 11 days on the
ventilator during which time sputum became colonized with E.
Coli not believed to be a pathogen, developed bilateral
effusion from fluid overload that resolved with diuresis.
Bronchoscopy after mucus plug, off right upper lobe with
complete collapse. Plug suctioned at bronchoscopy and right
upper lobe atelectasis resolved completely. Left upper lobe
aspergilloma remained unchanged per chest x-ray. Patient was
maintained on itraconazole as amphotericin had to be stopped
after the seizure.
3. Cardiovascular: In the beginning, patient was initially
septic appearing requiring pressors. The need for pressors
increased during the pentobarbital, on dopamine and
vasopressin after the pentobarbital was discontinued,
pressors easily stopped and patient had good blood pressure,
thereafter, echocardiogram was done while in coma with mildly
depressed left ventricular function. After, out of his coma,
he had no cardiac issues. He initially developed effusions
from fluids he received but auto drive receptor-like episode
resolved with resolution of the effusions.
4. Infectious Disease: Dapsone prophylaxis was continued.
Itraconazole for aspergilloma. Initially patient on
ceftriaxone, Levaquin, Flagyl because he looked like he might
have gram negative rods sepsis, but when cultures were
negative, the Levaquin and Flagyl were discontinued. He was
kept on Ceftriaxone to complete a 24 day course. He was on
acyclovir until HSV PCR was negative, ESBL, E. Coli and
sputum, but no infiltrates, so believed to be a colonizer.
Cultures were always negative even when spiking q.d.
Cultures were drawn q. 24-48 hours so fever thought not to be
infectious. Renal function was good throughout. Central
diabetes insipidus treated with DDAVP and matching out's with
resolution of diabetes insipidus. In fact, DDAVP was stopped
completely because he became hyponatremic and then sodium
became normal. Fluid status and urine osmolarity were
monitored and normal saline or D5 water was given prn.
5. Gastrointestinal: Initial loss of bowel sounds during the
coma with poor motility that improved with Reglan. Patient
was put on TPN during the coma, but after the coma, tolerated
tube feeds. Patient with good bowel movement after the coma.
Patient stable and transferred to floor on [**2123-11-25**].
This will be his hospital course from [**2123-11-25**] to
[**2123-11-30**] by system:
1. Pulmonary: Patient with aspergilloma, continued on
itraconazole. 02 saturations and respiratory rate remained
stable. Patient remained on nasal cannula oxygen.
2. Infectious Disease: Patient continued to spike fevers
every day. Blood cultures and urine cultures were sent.
Blood cultures were always negative or pending as were urine
cultures. Infectious Disease consult Service continued to
follow with the discussion that HAART might be started when
Dilantin was weaned off as the two interacted and could not
be started reliably concomitantly. Another lumbar puncture
was obtained for question of possible neck stiffness and
photophobia. That night, tube four had white blood cells, 8
red blood cells, 21 polys, 2 lymphocytes, 52 monocytes, 47 in
tube 1, 7 white cells, 22 red cells, no polys, 71
lymphocytes, 24 monocytes, protein of 46 and glucose of 67.
That night, he got a dose of Ceftriaxone, however, the next
day with review with Infectious Disease Team, it was felt
that this was not consistent with meningitis, and so,
Ceftriaxone was stopped. Patient was started on Levaquin for
possible coverage of pneumonia as he had some crackles on
exam. The following day, oxacillin was also started but this
was stopped after one day as LFTs were known to elevate. At
this time, no source for fevers were definitely discovered.
Patient with nasogastric tube, no nasal drainage or facial
pain to palpation, however, CT at maxillary facial was
obtained and is pending at this time.
3. Neurology: Neurology Team continued to follow the
patient. Dilantin and phenobarbital levels were monitored.
Patient not noted to have any seizure activity. Patient was
started on Keppra, which will not interact with HAART, and
after several days of this, Dilantin will fully be weaned to
off as Keppra becomes therapeutic.
4. Gastrointestinal: Patient followed by Nutrition and
continued on tube feeds, tolerating well, hold on starting po
until swallow study. On [**12-1**], LFTs were checked and
noted to have risen. ALT at 57, AST at 176, alkaline
phosphatase at 333, therefore, oxacillin was stopped. These
may be due both to oxacillin and Dilantin and will be
followed.
5. Fluid, electrolytes and nutrition: Patient noted to have
drop in his sodium after three water fluid boluses were
increased with his tube feeds. These were held and changed
to normal saline intravenous for fluid and sodium fully
started to rise. Electrolytes were monitored and repleted.
6. Cardiovascular: Patient noted to be tachycardic, felt
secondary to fevers and possibly dehydration, therefore,
normal saline boluses were given as needed.
7. Prophylaxis: Patient was kept on ........and Protonix.
Physical Therapy worked with patient.
Addendum to this dictation will be dictated by new intern,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. This dictation is through [**2123-12-1**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4570**], M.D. [**MD Number(1) 4571**]
Dictated By:[**Last Name (NamePattern1) 4572**]
MEDQUIST36
D: [**2123-12-8**] 19:56
T: [**2123-12-8**] 19:56
JOB#: [**Job Number 4573**]
Admission Date: [**2123-12-31**] Discharge Date: [**2124-1-10**]
Date of Birth: [**2085-3-7**] Sex: M
Service: Medicine
ADDENDUM: The patient is a 38 year old [**Country 4574**] male with
AIDS, left upper lobe aspergilloma and lower extremity
paraparesis, who was originally admitted on [**2123-10-26**] with fever and cough. He was subsequently found to have
an left upper lobe aspergilloma which was initially treated
with amphotericin, which led to the patient having seizures.
He was then placed in a phenobarbital coma, which slowly
resolved and was started on itraconazole therapy. Please
refer to the dictation summary dictated on [**2124-1-5**],
dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
1. Neurologic: On [**2123-12-29**], the patient began
complaining of dizziness. He did not describe a room
spinning sensation. He felt like his head was falling to the
side, but no particular side, consistently. He did not
complain of new numbness, weakness or tingling. He did not
complain of dysphagia, dysarthria, hearing changes, sense of
fullness in the ear or headache. He had no focal deficits on
examination.
The patient was started on Meclizine and initially showed
improvement on that. Approximately one week after the
Meclizine was started, the patient was changed to a lower
dose of Meclizine. After that change, the patient began
experiencing dizziness again. Subsequently, neurology was
consulted on hospital day number 75. Neurology felt that the
patient's dizziness was likely multi-factorial. The cause
was believed to be vestibular peripheral superimposed axial
and lower extremity weakness with prolonged immobility.
Additionally, multiple medications that the patient was
taking have been associated with dizziness, including the
patient's seizure medications. Neurology recommended
checking a phenobarbital level. On [**2124-1-9**], the
level was 23, which was in the therapeutic range. Neurology
also recommended considering a magnetic resonance imaging
scan if the patient's dizziness did not resolve or worsened.
Additionally, they recommended discontinuing Reglan if the
patient's symptoms did not resolve and the Reglan was not
deemed necessary. The patient did not have any further
seizures during this hospitalization.
2. Infectious disease: The issue of reverse transcript ACE
inhibitors was revisited within the last two weeks. The case
was discussed with infectious disease, who have been
following the case. At this time, they recommended holding
on adding reverse transcript ACE inhibitors. The patient's
amylase level on [**2124-1-7**] was 306. When the amylase
level returns to normal, the infectious disease service will
revisit the issue of reverse transcript ACE inhibitors.
The patient was started on protease inhibitors on [**2123-12-26**]. According to fetal distress, the patient may stay
on double protease inhibitor therapy for up to three months
before resistance occurs. The plan is to revisit the issue
of reverse transcript ACE inhibitors once the patient's
amylase level is within normal limits.
On hospital day number 73, the patient developed a 1 to 2 cm
ulcer at the perineum. It was mildly tender to palpation.
The patient was started on acyclovir. This also was presumed
to be due to herpes simplex virus type II.
3. Physical therapy and occupational therapy: The patient
continued to improve over the course of the hospitalization.
On discharge, the patient was able to ambulate approximately
200 feet with a standard walker. The patient's lower
extremity strength was continuing to improve each day. The
patient was also able to climb several stairs.
DISPOSITION: The patient will need to follow up with the
Infectious Disease Clinic in two to three weeks after
discharge (telephone number [**Telephone/Fax (1) 457**]).
DISCHARGE MEDICATIONS:
Acyclovir 800 mg p.o.t.i.d.
Amprenavir 450 mg p.o.b.i.d.
Azithromycin 1.2 gm p.o.q. Wednesday.
Desitin applied to affect area p.r.n.
Colace 100 mg p.o.b.i.d.
Ibuprofen 600 mg p.o.t.i.d.
Itraconazole 200 mg p.o.q.d.
Lansoprazole 30 mg p.o.q.d.
Levetiracetam 500 mg p.o.b.i.d.
Lidocaine jelly 2% applied to affected area.
Meclizine 25 mg p.o.b.i.d.
Metoclopramide 5 mg p.o.q.i.d.
Multivitamins one p.o.q.d.
Neutra-Phos one p.o.q.d.
Phenobarbital 90 mg p.o.b.i.d.
Ritonavir 100 mg p.o.b.i.d.
Sodium chloride nasal spray b.i.d.
Bactrim DS one p.o.q.d.
Tobramycin one drop applied to each eye q.i.d.
CONDITION AT DISCHARGE: Excellent.
DISCHARGE STATUS: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4570**], M.D. [**MD Number(1) 4571**]
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2124-1-9**] 15:30
T: [**2124-1-9**] 15:29
JOB#: [**Job Number 4576**]
Name: [**Known lastname 526**], [**First Name3 (LF) 126**] Unit No: [**Numeric Identifier 527**]
Admission Date: [**2123-12-2**] Discharge Date: [**2123-12-30**]
Date of Birth: [**2085-3-7**] Sex: M
Service:
ADDENDUM: Briefly, Mr. [**Known lastname **] is a 38-year-old [**Country 528**] man
with acquired immunodeficiency syndrome, left upper lobe
aspergilloma, and lower extremity paraparesis, admitted on
[**2123-10-26**] with fever and cough. Subsequently he was
found to have left upper lobe aspergilloma which was
initially treated with amphotericin which led to the patient
having seizures, and was then placed in pentobarbital coma
which slowly resolved, and was started on itraconazole
therapy. Please refer to the dictation summary dated
[**2123-10-27**] (dictated by Dr. [**First Name8 (NamePattern2) 529**] [**Last Name (NamePattern1) 530**]).
On [**2123-12-2**], Mr. [**Known lastname **] was spiking temperatures to
102 every night, tachycardic in the 120s, alert and oriented
times one. He was in the midst of a 10-day course of
Levaquin for presumed pneumonia and was on day 22 of
itraconazole. He anti-seizure regimen was Keppra 500 mg p.o.
b.i.d. and phenobarbital 90 mg p.o. b.i.d.
Hospital course, at this point for the month of [**Last Name (LF) 531**],
[**First Name3 (LF) **] be summarized by system.
1. INFECTIOUS DISEASE: Mr. [**Known lastname **] [**Last Name (Titles) 532**] throughout the
first days of [**Month (only) 531**]. Culture data was repeatedly
negative. He finished a 10-day course of Levaquin on
[**12-7**]. On [**12-7**] he was also started on highly
active antiretroviral therapy consisting of Kaletra, D4T, and
ddI. This was based on his human immunodeficiency virus
genotype which was resistant to all NNRTIs, susceptible to
NRTI and PI. Although, at that point Infectious Disease
consultation suspected resistance to AZT and 3TC. Following
the stopping of Dilantin on approximately [**12-5**] or
[**12-6**], the patient defervesced and remained afebrile for
the remainder of the month. There was no further positive
culture data. On [**12-6**] his Dapsone was held secondary
to potential myelosuppression.
On [**12-13**] he was noted to have a chemical pancreatitis,
and at this point his highly active antiretroviral therapy
was stopped. His amylase and lipase were followed for
approximately two weeks, and they slowly fell, and in
conjunction with the Infectious Disease consultation team he
was started on amprenavir and ritonavir on [**2123-12-26**].
The patient tolerated these without adverse side effects.
Also during this month, he was started on Bactrim,
Pneumocystis carinii pneumonia and toxo prophylaxis and
azithromycin 1250 q. week for Mycobacterium
avium-intracellulare prophylaxis. He tolerated these
medications without myelosuppression or other undo side
effects.
Itraconazole therapy was transitioned to p.o. during this
month; however, he remained on suppressive itraconazole
therapy. Consultation with Cardiothoracic Surgery and
Infectious Disease consultation team felt that the patient's
best chance for any meaningful recovery involved improvement
in functional status before proceeding with resection of the
left upper lobe aspergilloma.
Also during this month, his cerebrospinal fluid VDRL was sent
to the state laboratory. Results were not back at the time
of this dictation.
2. FLUIDS/ELECTROLYTES/NUTRITION: Mr. [**Known lastname **] was on tube
feeds at the beginning of the month, and there was concern
for safe swallowing. He complained repeatedly about the pain
in his nose. During this month, as his mental status
improved we were able to obtain a swallowing study which
showed safe swallowing ability, and he was transitioned to
full p.o. intake with excellent appetite.
3. NEUROLOGY: The patient was seen by the inpatient
Neurology consultation service who felt him to have his lower
extremity paraparesis and weakness was due likely to an upper
motor neuron lesion as based on electromyogram findings. His
lack of reflexes was presumed secondary to peripheral
neuropathy as a result of the human immunodeficiency virus.
He was seen by Dr. [**Last Name (STitle) 533**] in his [**Hospital6 534**]
clinic who felt that he likely had a human immunodeficiency
virus related pyomyositis and was recommended to start on
highly active antiretroviral therapy as soon as possible,
which was done as his pancreatic enzymes came under control.
4. PHYSICAL THERAPY AND OCCUPATIONAL THERAPY: Mr. [**Known lastname **],
at the beginning of the month, had been bed ridden, and by
the end of the month due to aggressive physical and
occupational therapy he was able to walk approximately 20
feet with a 1-person assist, a walker, and a chair behind him
for support.
5. DISPOSITION: Due to Mr. [**Known lastname 535**] lack of health
insurance there was no rehabilitation option for him, and
therefore he remained in [**Hospital1 536**]
for physical rehabilitation as he was not safe at home. At
the time of this dictation, he remained as an inpatient. His
disposition dependent on improvement of functional status.
MEDICATIONS ON DISCHARGE: (His medications at the time of
this dictation were)
1. Itraconazole 200 mg p.o. q.d. ([**12-30**], day 50)
2. Bactrim-DS 1 p.o. q.d.
3. Azithromycin 1250 mg p.o. q. week
4. Amprenavir 450 mg p.o. q.d.
5. Ritonavir 100 mg p.o. b.i.d.
6. Ibuprofen 600 mg p.o. t.i.d.
7. Prevacid 30 mg p.o. q.d.
8. Keppra 500 mg p.o. b.i.d.
9. Phenobarbital 90 mg p.o. b.i.d.
10. Meclizine 12.5 mg p.o. t.i.d.
11. Normal saline bolus 500 cc q.d.
12. Boost shakes t.i.d.
Dictated By:[**Last Name (NamePattern1) 537**]
MEDQUIST36
D: [**2123-12-31**] 01:02
T: [**2124-1-5**] 15:12
JOB#: [**Job Number 538**]
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|
21234, 37919
|
19730, 21216
|
38563, 44014
|
19419, 19707
|
17160, 18084
|
18106, 18942
|
18959, 19042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,258
| 189,646
|
19631
|
Discharge summary
|
report
|
Admission Date: [**2160-5-2**] Discharge Date: [**2160-5-15**]
Date of Birth: [**2106-8-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy on [**2160-5-3**]
Chest tube placement on right side [**2160-5-3**] secondary to right
pneumothorax
History of Present Illness:
53 yo female with a hx of AML s/p alloBMT from SD, HTN,
hyperlipidemia admitted for increasing shorteness of breath and
infiltrate on chest CT. Pt seen on [**4-28**] complaining of
increasing dry cough and shortness of breath despite a 12 day
course of azithromycin. It was felt that her cough was possibly
due to her chronic GVHD so her prednisone was increased from 20
to 30mg. She denied any fever or chills, SOB at rest, chest
pain, tightness, PND, orthopnea or LE edema. Shortness of breath
has been very slowly progressing over the past 2-3 months but
much worse over the past week. She reports wheeze which was
improved with her inhalers. She also had a chest CT on [**4-28**]
which showed left lower lobe infiltrate. Her dyspnea on exertion
continued over the week and after being seen in clinic today
with tachypnea decision was made for admission for further
workup.
Past Medical History:
- AML. Primary Oncologist is Dr. [**First Name (STitle) 1557**]. Diagnosed [**12-18**]
M2. Initially diagnosed secondary to whooshing sound and
ear pain with white count of 3.68 with 28% blasts, crit of
25 and 18,000 platelets. Initially admitted to [**Hospital1 1774**] and
then to [**Hospital1 69**]. Received
7+3 induction, prolonged hospital course with neutropenia,
fever neutropenia with Imipenem, Vancomycin, Ambazone with
negative culture workup. Also received HIDAC consolidation
- s/p Allo BMT for AML (brother was donor) [**4-16**] with ongoing
graft versus host disease involving her eyes and mouth.
- Anxiety
- h/o C-section
- HTN
- Hypercholesterolemia
Social History:
Married, worked as a financial analyst. Lives with husband,
oldest daughter and a dog. Smoked < 1pk/wk for 20yrs and quit
10 yrs ago but husband is a heavy smoker. Denies EtOH use.
Family History:
2 Aunts with breast cancer, father 76 with hx of CAD, mohter age
71 with DM and CAD, uncle with [**Name (NI) 1932**]
Brief Hospital Course:
Shortness of breath-Infiltrate on chest CT was thought to
represent CAP although pt at risk for PCP and fungal PNA with
chronic immunosuppression. It was less likely viral in origin
with focal infiltrate. Nasal aspirate for RSV, influenza, and
paraflu were negative. Pt had bronchoscopy on [**2160-5-3**] which
revealed nl airways and sent for PCP, [**Name10 (NameIs) **] viral panel, AFB,
bacterial and fungal GS and Cx as well as legionella Ag screen
although develped rt sided pneumothorax post procedure. Chest
tube was placed by CT [**Doctor First Name **] but she cont to have an air leak so
Heimlich valve was placed on [**5-11**]. SOB was not acute in nature
and no effusion seen on chest CT so CHF and PE were unlikely
although we obtained TTE which was normal. We initially started
her on levofloxacin to cover CAP and added vancomycin when GPC
seen on BAL but these were stopped on [**5-9**] since she was never
febrile and CXR's showed no infiltrate. We cont her on Px dose
bactrim since PCP DFA on bronchoscopy was negative. There was
thought to be a component of GVHD to her SOB with possible
bronchiolitis obliterans but we tapered her prednisone to 15mg
[**Hospital1 **]. There also appeared to be some airway inflammatory
component with wheezing so we cont on outpt inhalers with
addition of nebs. We treated her cough symptomatically with
robitussin with codeine and humified air. Aspergillis grew from
BAL and voriconazole was started. Chest tube removed [**5-14**].
Dyspnea improved by time of discharge.
.
GVHD-Pt eye symptoms appeared worse per her report, although
unilateral nature suggested acute injury. We cont on outpt dose
mycofenolate and prednisone as above.
We cont artificial tears and outpatient vigamox and lotemax eye
drops, with tacrolimus lip balm.
.
HTN-Pt was hypertensive on admission so we changed carvedilol to
procardia XL with good response. Pt then became tachycardic of
unclear etiology although she is mildly hypoxic with known lung
disease and pain associated with chest tube. ECG revealed sinus
tach with TSH normal and will consider CTA as part of
tachycardia workup.
.
Aniety-Cont on outpt celexa and ativan prn
.
HSV-Pt has no oral lesions at this time but will cont famvir for
px
.
Medications on Admission:
1. Bactrim DS three times a week, Monday, Wednesday, and
Friday.
2. CellCept [**Pager number **] mg t.i.d.
3. Coreg 6.25 mg p.o. daily.
4. Diflucan 200 p.o. daily.
5. Famvir 500 mg p.o. daily.
6. Prednisone 30 mg p.o. daily.
7. Protonix 40 mg daily.
8. Ativan one milligram p.o. daily p.r.n.
9. Celexa ten milligrams p.o. daily.
10. Vigamox ophthalmic suspension one drop left eye t.i.d.
11. Azithromycin 250mg qd
12. Robitussin with codeine
13. Flovent and Combivent
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
4. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO qd ().
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
9. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
Sig: 2.5 ml PO TID (3 times a day).
10. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed).
14. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
15. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
16. Tacrolimus 0.03 % Ointment Sig: One (1) Topical [**Hospital1 **] ().
17. Lotemax 0.5 % Drops, Suspension Sig: One (1) Ophthalmic
once/day ().
18. Moxifloxacin HCl 0.5 % Drops Sig: One (1) Ophthalmic once
a day ().
19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
20. Dexamethasone 1 mg/mL Drops Sig: Five (5) ml PO Q6H (every 6
hours) as needed for mouth care.
Disp:*50 ml* Refills:*0*
21. oxygen
1-5 liters NC continuous, keep O2sat > 90%
O2sat is 88% on room air
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
PRIMARY:
--pneumothorax
--pneumonia (likely aspergillus)
--graft versus host disease
Bronchiolitis obliterans
SECONDARY:
--hypertension
--anxiety
Discharge Condition:
O2sat 88% on RA, mid 90%s on 1L NC
Discharge Instructions:
--take all medications as prescribed
--follow-up on all appointments
--seek immediate medical attention if experiencing fever,
chills, shortness of breath, chest pain.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) 1557**] Division of Hematology/Oncology
[**Location (un) 830**], [**Hospital Ward Name 23**] 9 [**Location (un) 86**], [**Numeric Identifier 718**] Phone:
[**Telephone/Fax (1) **]
.
You will be called by pulmonary medicine for an appointment to
be scheduled the week of [**4-17**] through [**4-24**]. They should
evaluate you to determine the length of voriconazole treatment
(started
|
[
"512.1",
"205.00",
"510.0",
"516.8",
"401.9",
"710.2",
"564.00",
"484.6",
"117.3",
"996.85",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7285, 7346
|
2429, 4668
|
335, 449
|
7539, 7576
|
7792, 8223
|
2288, 2406
|
5196, 7262
|
7367, 7518
|
4694, 5173
|
7600, 7769
|
275, 297
|
477, 1356
|
1378, 2073
|
2089, 2272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,340
| 113,624
|
2428
|
Discharge summary
|
report
|
Admission Date: [**2112-8-9**] Discharge Date: [**2112-8-25**]
Date of Birth: [**2066-11-3**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 45-year-old
gentleman who is status post inferior wall MI on [**2112-7-1**].
At that time, he underwent a PTCA stent to his RCA. At the
time of his cardiac catheterization, it was noted that he had
multiple LAD and LCX lesions. It was elected to discharge
the patient to home and have the patient come back to the
Cardiac Catheterization Laboratory at a later date for
treatment of those lesions. The patient was admitted on
[**2112-8-9**] for repeat cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Type 2 diabetes, now insulin-dependent.
4. Coronary artery disease, status post myocardial
infarction.
5. Status post kidney surgery, type unknown, as a child.
ALLERGIES: Penicillin.
PREOPERATIVE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Enteric coated aspirin 325 mg p.o. q.d.
3. Zestril 5 mg p.o. q.d.
4. Lipitor 20 mg p.o. q.d.
5. Lopressor 100 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
7. NPH insulin 18 units subcutaneously b.i.d.
8. Humalog sliding scale.
PREOPERATIVE LABORATORY DATA: Significant for a hematocrit
of 40.7, potassium 4.5, BUN 18, creatinine 0.9.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2112-8-9**] where he was started
on an Integrelin infusion and given a heparin bolus. During
the cardiac catheterization, an attempted PCI of the LAD was
undertaken. During the PCI, the patient began to develop
chest pain and ST segment elevations. There was no flow
through the LAD and no improvement in the flow with
vasodilators. Due to the patient's continued chest pain, an
intra-aortic balloon pump was inserted in the Cardiac
Catheterization Laboratory and the patient was taken
emergently to the Operating Room by Dr. [**Last Name (STitle) **] for coronary
artery bypass.
In the Operating Room, the patient underwent a CABG times
three with SVG to LAD, SVG to diagonal, and SVG to OM. Due
to the patient's coagulation status preoperatively with the
patient being on Plavix and Integrelin, the patient had a
large amount of chest tube output in the Operating Room and
postoperatively. The patient was transferred to the
Intensive Care Unit on a large amount of pressors due to a
low blood pressure.
In the Intensive Care Unit, the patient had approximately 2
liters of chest tube drainage in the first hour in the
Intensive Care Unit. The patient was quickly taken back to
the Operating Room. In the Operating Room, there were found
only small areas of bleeding which were repaired. The
patient's coagulopathy was corrected and the patient was
again transferred back to the Intensive Care Unit on
epinephrine and Amiodarone in stable condition. Please see
the operative note for further details.
On the evening of postoperative day number one, the patient
required large amounts of blood products. The patient
continued on his intra-aortic balloon pump. It was elected
to keep the patient intubated on the night of postoperative
day number one. The patient's chest tube output was
considerably decreased. The patient was moderately hypoxic.
The chest x-ray showed volume overload.
By postoperative day number two, the patient's coagulopathy
had been corrected and he was hemodynamically stable. The
intra-aortic balloon pump was removed without complications.
The patient required large amounts of diuresis over the next
several days for the patient's oxygenation and enable the
patient to wean on the ventilator.
On postoperative day number three, it was noted that the
patient had a large right-sided pleural effusion. A right
pleural chest tube was inserted with 1,500 cc of old dark
blood and improvement in the patient's chest x-ray. After
the chest tube was inserted, the patient began complaining of
the sensation of shortness of breath and became tachypneic.
A repeat chest x-ray was performed which showed no
pneumothorax, no effusion; however, the patient's
endotracheal tube was noted to be high. This was advanced.
However, the patient continued to remain anxious. The
patient's oxygenation improved with sedation.
By postoperative day number four, the patient had been weaned
off of his pressors and was started on a low-dose beta
blocker. The patient was noted to have a dropping platelet
count. A heparin antibody test was sent which was
subsequently negative. The patient had been started on
Plavix as he still had a stent to his RCA. It was
recommended by Dr. [**Last Name (STitle) **] that the patient be transfused
platelets and given Plavix as the concern for keeping the
stent patent.
On the evening of postoperative day number four, the patient
began draining large amounts of bloody fluid from his sternal
incision which was thought to be a liquefying hematoma. On
postoperative day number five, the patient continued to have
a large amount of drainage and Dr. [**Last Name (STitle) **] decided to return
the patient to the Operating Room for tightening of the
sternal wires as he thought the drainage was due to a sternal
dehiscence. The patient tolerated this procedure well and
returned to the Intensive Care Unit and remained intubated
throughout.
On the evening of postoperative day number five, the patient
was weaned and extubated from mechanical ventilation and
required vigorous chest PT to maintain oxygen saturation, had
a moderate productive cough. It was also noted on the
evening of postoperative day number five that the patient had
icteric sclerae. A bilirubin was sent which was noted to be
elevated at 6.8.
A right upper quadrant ultrasound was obtained on
postoperative day number eight which showed evidence of
increased echogenicity consistent with fatty infiltration of
the liver. No focal liver lesions. No evidence of
intrahepatic or extrahepatic biliary ductal dilatation,
common bile duct normal in size, unremarkable gallbladder
without stones. Limited view of the pancreas due to
overlying bowel gas.
The patient continued on IV vancomycin prophylactically for
the multiple reoperations and the sternal drainage. The
patient was transferred from the Intensive Care Unit to the
floor on postoperative day number seven. The patient was
again noted to have a moderate amount of serosanguinous
drainage from the sternal incision as well as a moderate
amount of drainage from his right lower extremity vein
harvest site.
On postoperative day number nine, Dr. [**Last Name (STitle) **] evaluated the
patient and applied Dermabond to the sternal incision;
however, on postoperative day number ten, the patient
continued to drain serosanguinous fluid from his incisions.
It was decided by Dr. [**Last Name (STitle) **] that the patient would return to
the Operating Room for sternal rewiring. At this time, the
patient had begun complaining of nausea and abdominal pain.
The patient was noted to have elevated amylase and lipase.
The patient was changed to clear liquids and made n.p.o. for
the Operating Room.
The patient's Operating Room was delayed due to scheduling.
On the evening of postoperative day number nine, the
patient's sternal drainage became very minimal so it was
elected to delay surgery. With the patient becoming n.p.o.,
the patient's amylase and lipase were decreased. The patient
continued to be n.p.o. and subsequently his nausea and left
upper quadrant pain subsided. His amylase and lipase
continued to decrease. His sternal incision drainage
decreased to nothing. The patient continued on his
vancomycin.
On postoperative day number 14, the patient's amylase and
lipase had decreased sufficiently. The patient had tolerated
clear liquids. The patient was started on a regular diet.
On the night of postoperative day number 14, after one meal,
the patient had again elevated amylase and lipase. The
patient was switched to a low-fat diet and the patient's
amylase and lipase continued to trend down. The patient's
sternal drainage had stopped and by postoperative day number
16, the patient was cleared for discharge to home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post emergent coronary artery bypass graft.
3. Status post reoperation for bleeding.
4. Postoperative sternal drainage.
5. Status post sternal rewire for sternal dehiscence.
6. Postoperative pancreatitis.
7. Insulin-dependent diabetes mellitus.
CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus
rhythm, blood pressure 106/60, respiratory rate 14, room air
oxygen saturation 96%. The patient was awake, alert,
oriented times three, ambulating independently with a
nonfocal neurological examination. The heart revealed a
regular rate and rhythm without rub or murmur. The lungs
were clear bilaterally. The abdomen was with positive bowel
sounds, soft, nontender, nondistended. He was tolerating a
low-fat diet. He had no nausea or vomiting. He was having
regular bowel movements. The sternal incision showed peeling
Dermabond. No drainage. No erythema. The sternum was
stable. The right lower extremity showed resolving
ecchymosis with a small amount of serosanguinous drainage
from the medial knee and a small amount of resolving erythema
at the distal incision right above the ankle.
LABORATORY/RADIOLOGIC DATA: White blood cell count 7.7,
hematocrit 40, platelet count 279,000. Sodium 135, potassium
4.4, chloride 98, bicarbonate 26, BUN 22, creatinine 1.0,
glucose 120. AST 64, ALT 93, alkaline phosphatase 129,
amylase 168, lipase 247, total bilirubin 2.1.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Lipitor 20 mg p.o. q.d.
7. Combivent MDI two puffs q. six hours p.r.n.
8. Levofloxacin 500 mg p.o. q.d. times two weeks.
9. Lasix 20 mg p.o. b.i.d. times seven days.
10. Potassium chloride 20 mEq p.o. b.i.d. times seven days.
11. Guaifenesin elixir 10 cc p.o. q. six hours p.r.n.
12. NPH insulin 18 units subcutaneously b.i.d.
13. Humalog sliding scale per the patient to maintain a blood
sugar of 120 or less.
DISPOSITION: The patient is to be discharged to home in
stable condition.
FOLLOW-UP: The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12491**], in one week for recheck of his
amylase and lipase. The patient was instructed to call Dr.[**Name (NI) 12492**] office immediately if he has any abdominal
pain,nausea, or any drainage from his sternal or leg
incisions. The patient is to follow-up with Dr. [**Last Name (STitle) 911**] in two
to three weeks. The patient is to follow-up with Dr. [**Last Name (STitle) **]
in three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2112-8-25**] 02:48
T: [**2112-8-25**] 16:57
JOB#: [**Job Number 12493**]
|
[
"577.0",
"996.72",
"441.01",
"511.9",
"996.09",
"414.01",
"E879.0",
"411.1",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"34.03",
"36.13",
"88.56",
"36.01",
"99.20",
"97.44",
"37.61",
"39.61",
"34.04",
"37.23",
"36.06",
"34.79"
] |
icd9pcs
|
[
[
[]
]
] |
9646, 11142
|
8193, 8484
|
1345, 8172
|
955, 1327
|
699, 929
|
8509, 9623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,996
| 171,949
|
25256
|
Discharge summary
|
report
|
Admission Date: [**2157-9-13**] Discharge Date: [**2157-9-30**]
Service: CARDIOTHORACIC
Allergies:
Prednisone / Benadryl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2157-9-23**] Four vessel coronary artery bypass grafting(left
internal mammary to left anterior descending, vein graft to
ramus, vein graft to diagonal, vein graft to right coronary
artery). Mitral valve replacement utilizing 27 millimeter
[**Last Name (un) 3843**] [**Doctor Last Name **] pericardial valve.
History of Present Illness:
This is a 85 year old male who was recently admitted to
[**Hospital1 **] with chest pain. He ruled in for an MI at that time.
Workup revealed multivessel coronary artery disease. He was
subsequently transferred to the [**Hospital1 18**] for operative care.
His past medical history is significant for known mitral valve
prolapse with moderate to severe mitral regurgitation. An
echocardiogram in [**2155-7-8**] was notable for MVP with severe
mitral regurgitation, trace tricuspid regurgitation and an LVEF
of 65%.
Past Medical History:
Mitral valve prolapse with severe mitral regurgitation,
Hypertension, Hyperlipidemia, Chronic renal insufficiency,
History of deep vein thrombosis(right lower extremity), History
of bladder cancer, History of rectal cancer - s/p ileocolonic
loop colostomy
Social History:
Quit tobacco in [**2106**]. Denies ETOH.
Family History:
Denies premature coronary disease.
Physical Exam:
Vitals: BP 134/78, P 58, R 16, SAT 99% on 2L
General: Elderly male in no acute distress
HEENT: Oropharynx benign
Neck: Supple, no JVD, no carotid bruits
Chest: Lungs clear bilaterally
Heart: RRR, normal s1s2, [**3-13**] holosystolic murmur noted
Abd: Soft, nontender, nondistended, normoactive bowel sounds
Ext: mild RLE swelling noted, no pitting edema
Pulses: 2+ femoral, 2+ radial, decreased PT and DP
Neuro: nonfocal
Pertinent Results:
[**2157-9-29**] 04:39AM BLOOD WBC-8.6 RBC-3.11* Hgb-9.7* Hct-28.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-15.1 Plt Ct-82*
[**2157-9-29**] 04:39AM BLOOD Glucose-95 UreaN-69* Creat-2.6* Na-137
K-3.7 Cl-105 HCO3-22 AnGap-14
[**2157-9-29**] 04:39AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.6
[**2157-9-26**] 08:30AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
Brief Hospital Course:
Mr. [**Known lastname 63229**] was admitted and underwent extensive preoperative
evaluation. A carotid ultrasound showed only minimal plaques in
the internal carotid arteries while a lower extremity ultrasound
confirmed chronic DVT in right lower extremity. An
echocardiogram revealed mitral valve prolapse with 3+ mitral
regurgitatiion. His overall left ventricular systolic function
was normal. The dental service was consulted and recommended
several tooth extractions prior to operative intervention. This
took place on [**2157-9-20**] without incident. He otherwise remained
relatively stable on intravenous Heparin. He complained on
intermittent angina which was relieved with sublingual Nitro.
Cardiac enzymes remained flat and no EKG changes were noted. His
preoperative course was otherwise uneventful and he was
eventually cleared for surgery.
On [**2157-9-23**], Dr. [**Last Name (STitle) **] performed a mitral valve replacement(27
mm CE pericardial valve) and four vessel coronary artery bypass
grafting. Surgery was uneventful. After the operation, he was
brought to the CSRU. He remained sedated and intubated for
several days with a prolonged pressor requirement. His renal
function concomitantly declined, initially requiring Natricor to
improve diuresis. He quickly transitioned to intravenous Lasix.
A routine chest x-ray was notable for a small right apical
pneumothorax for which a new chest tube was inserted. Over
several days, he slowly weaned from inotropic support. He was
eventually extubated on POD#3 and awoke neurologically intact.
All chest tubes were eventually removed without futher
complication. His platelet count dropped as low as 64K on POD#4.
An HIT assay was checked, returning negative. His hemodynamics
eventually stablized with gradual improvement in urine output.
On postoperative day five, he transferred to the SDU. A brief
period of paroxysymal atrial fibrillation was noted. He
otherwise remained mostly in a normal sinus rhythm with first
degree AV block. K and Mg levels were monitored closely and
repleted per protocol. The remainder of his post-operative
course was unremarkable. He was discharged to rehab on post-op
day #7 in stable condition.
Medications on Admission:
Zestril 5 qd, Lipitor 10 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, Cipro 250 qd
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**], TCU
Discharge Diagnosis:
Mitral valve prolapse with severe mitral regurgitation,
Hypertension, Hyperlipidemia, Chronic renal insufficiency,
History of deep vein thrombosis(right lower extremity), History
of bladder cancer s/p urostomy, History of rectal cancer - s/p
ileocolonic loop colostomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No lotions, creams or ointments to
incisions. No lifting more than 10 lbs for 10 weeks. No driving
for one month. Monitor for signs of wound infection.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Local cardiologist in 2 weeks
Local PCP [**Last Name (NamePattern4) **] 2 weeks
|
[
"782.1",
"424.0",
"V44.6",
"V10.51",
"521.00",
"V10.06",
"599.7",
"453.8",
"512.1",
"427.31",
"511.9",
"410.71",
"593.9",
"V44.3",
"414.01",
"287.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"00.17",
"96.71",
"36.13",
"36.15",
"39.61",
"23.09",
"35.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5516, 5589
|
2313, 4514
|
246, 559
|
5902, 5909
|
1949, 2290
|
6139, 6263
|
1457, 1493
|
4656, 5493
|
5610, 5881
|
4540, 4633
|
5933, 6116
|
1508, 1930
|
196, 208
|
587, 1104
|
1126, 1383
|
1399, 1441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,315
| 163,157
|
3764
|
Discharge summary
|
report
|
Admission Date: [**2187-9-5**] Discharge Date: [**2187-9-9**]
Date of Birth: [**2123-7-19**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Carotid artery occlusion.
Major Surgical or Invasive Procedure:
Stent placement in left ICA by CREST protocol.
History of Present Illness:
64 year old man with CAD s/p CABG [**2172**], DM2 with neuropathy,
CRI, PVD, with asymptomatic left carotid artery stenosis
(occlusion: 80-99%). Here for elective carotid stent placement.
A left sided bruit was auscultated by the pt's PCP, f/u doppler
showed moderate stenosis with a peak fluid velocity of 260cm/s.
Pt's prior cardiovascular surgery make him a poor candidate for
carotid endarterectomy, hence stent placement approach.
Past Medical History:
Diabetes x 14y with +neuropathy. Hypercholesterolemia. HTN. CRI.
PVD. 3vCABG in [**2172**] with LIMA->LAD, SVG->OM (occluded [**2180**]),
SVG->PDA.
Social History:
SocHx: Owns plumbing company. Married with 3 children. Remote
tobacco history. No EtOH. No IVDA.
Family History:
FamHx: Mother had a stroke around age 60, died around age 80.
Physical Exam:
Unremarkable at discharge, unchanged from admission.
Pertinent Results:
Carotid US ([**2187-8-9**]) - L:80-99% occ, R:less than 40% occ.
Cardiac cath ([**8-/2180**]) - Occluded SVG->OM, sys fxn and EF wnl.
Brief Hospital Course:
Patient received placement of a left ICA stent. During the
procedure, a small embolus was noted, and the patient had an
episode of aphasia which lasted for 10 minutes and then resolved
spontaneously. There were no further neurological events or
sequelae. The patient's neuological exam remained normal and
non-focal throughout the remainder of the admission. Removal of
the sheath from the right femoral access was accomplished
without complications.
Medications on Admission:
Acetylcysteine 20% 600 mg PO BID
Metoprolol 50 mg PO BID
Amlodipine 5 mg PO QD
Hydrochlorothiazide 25 mg PO QD
Furosemide 20 mg PO QD
Metformin 1000 mg PO BID
Repaglinide 1 mg PO TIDAC
Valsartan 80 mg PO QD
Clopidogrel Bisulfate 75 mg PO QD
Zolpidem Tartrate 5-10 mg PO HS:PRN
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN fever, pain
Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN
indigestion
Aspirin 325 mg PO QD
Discharge Medications:
1. Repaglinide 1 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times
a day (before meals)).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Metformin HCl 500 mg Tablet Sustained Release 24HR Sig: Two
(2) Tablet Sustained Release 24HR PO BID (2 times a day).
5. MED CHANGES
Stop Taking
Norvasc
Lopressor
Hydrochlorthiazide
Diovan
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Follow Up
Please follow up w/ Dr. [**First Name (STitle) **] on Wed [**9-12**] on 4thg floor of [**Hospital Ward Name 121**]
Building for Blood Pressure Check
[**First Name11 (Name Pattern1) 487**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Telephone/Fax (1) 7236**]
8. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic four times
a day.
Disp:*6 tubes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid Vasucalr Disease
CAD
DM
CRI
Hyperlipiedmia
PVD
Discharge Condition:
good
Discharge Instructions:
If you have any neurological symptoms like weakness/change in
vision/numbness -call Dr. [**Last Name (STitle) **] (neurologist) [**Telephone/Fax (1) 2574**]
Followup Instructions:
Please schedule a follow up appointment with Dr. [**Last Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 7394**] in [**3-29**] weeks after discharge from the
hospital.
Please follow up w/ Dr. [**First Name (STitle) **] on Wed [**9-12**] on [**Location (un) **] of [**Hospital Ward Name 121**]
Building for Blood Pressure Check [**First Name11 (Name Pattern1) 487**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 16930**]
Completed by:[**2187-9-12**]
|
[
"250.60",
"435.8",
"997.2",
"433.10",
"458.29",
"414.00",
"V45.82",
"357.2",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3387, 3393
|
1468, 1920
|
340, 388
|
3492, 3498
|
1309, 1445
|
3704, 4200
|
1157, 1221
|
2454, 3364
|
3414, 3471
|
1946, 2431
|
3522, 3681
|
1236, 1290
|
275, 302
|
416, 855
|
877, 1026
|
1042, 1141
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,544
| 147,931
|
16983
|
Discharge summary
|
report
|
Admission Date: [**2161-12-7**] Discharge Date: [**2162-1-18**]
Service: MEDICINE
Allergies:
Ceftriaxone Sodium / Cefotaxime / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy
PEG tube placement
Central venous lines
Arterial lines
Thoracentesis of right lung (three times)
PICC placement
Bronchoscopy
History of Present Illness:
[**Age over 90 **] y/o F w/hx of flash pulm edema, PVD, CAD who developed DOE a
week ago, then developed a nonproductive cough and some
orthopnea. CXR done at the NH revealed bibasilar infiltrates
and she was placed on Bactrim. Sputum cx was + for MRSA. She
failed to improve on this regimen and continued to require
supplmental O2 and so was transferred to [**Hospital1 18**] for further
management.
*
She was initially thought to have a pneumonia, and was begun on
vanc/levo/flagyl (given possibility of nosocomial infxn). Her
CHF medications were held, as her creatinine had bumped and the
team felt she was dry. Later that night, on the floor, she
became tachypneic and appeared to be in some degree of
respiratory distress. Her oxygen saturation decreased from 94%
on 4L to 93% on 10L. She received nebs and lasix 40 iv x1, with
100 cc UOP.
Past Medical History:
CAD s/p bare metal stent to OM1 [**7-5**]
gallstone pancreatitis
cholecystitis
s/p percutaneous cholecystostomy tube
h/o CVA
anemia
CRI
hemorrhoids
AF
junctional arrhythymias
htn
h/o pna
s/p PEG tube placement feeds d/c [**2161-6-25**]
tracheostomy
s/p bilateral thoracentesis
s/p hip replacement
necrotic right foot
CHF, hx of diastolic dysfxn
R foot dry gangrene s/p AKA [**9-4**]
Social History:
Lives with son (healthcare proxy) in [**Hospital1 **], but has been in
rehab for many months.
Family History:
non contributory
Physical Exam:
T: 99.6 P: 66 BP: 180/63 R: 20 O2 sat 96% on 10L
Gen: elderly female, in mod resp distress, alert and oriented
x3, intermittently yelling during exam.
Neck: JVD to angle of jaw at 75 degrees
Lungs: using accessory muscles, decreased breath sounds R>L ([**2-1**]
way up bilaterally)
CV: irreg irreg, no m/r/g
Abd: mildly distended, nontender, +bs.
Ext: s/p R AKA, no edema on left, warm and well-perfused. 2+
distal pulses.
Pertinent Results:
Echo [**2161-7-14**] [**Hospital3 **]:
Mild biatrial enlargement. Concentric LV hypertrophy. LVEF 50%
with inferoposterior wall hypokinesis. Mild to moderate AI. mild
MR, mild TR. new segmental wall motion abnormality since prior
study in [**2161-4-2**]. Pulmonary pressures have increased to 50-55
mmHg
.
Admission Labs:
.
[**2161-12-7**] 07:37AM PT-13.8* PTT-28.7 INR(PT)-1.3
[**2161-12-7**] 07:37AM WBC-8.5 RBC-3.02* HGB-9.2* HCT-27.3* MCV-91
MCH-30.4 MCHC-33.6 RDW-16.2*
[**2161-12-7**] 07:37AM MAGNESIUM-2.7*
[**2161-12-7**] 07:37AM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-176 ALK
PHOS-101 AMYLASE-27 TOT BILI-0.2
[**2161-12-7**] 07:37AM GLUCOSE-133* UREA N-83* CREAT-3.4*#
SODIUM-135 POTASSIUM-6.2* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-24*
[**2161-12-7**] 08:07AM LACTATE-2.4* K+-6.1*
[**2161-12-7**] 12:05PM proBNP-[**Numeric Identifier 47785**]*
[**2161-12-7**] 07:33PM TYPE-ART PO2-74* PCO2-44 PH-7.31* TOTAL
CO2-23 BASE XS--4 INTUBATED-NOT INTUBA
[**2161-12-7**] 11:18PM LACTATE-3.4*
[**2161-12-7**] Pro BNP [**Numeric Identifier 47785**], Cardiac Enzymes: Troponin: .08 CK-MB: 4
.
ECG [**2161-12-7**]: rate 63, afib, nl axis, nl intervals, TWI in 1
(new), avL (old), ST elevation 0.5 mm V2-4 (old)
.
Radiology:
CHEST (PORTABLE AP) [**2161-12-7**]
Bilateral pleural effusions. No evidence of acute congestive
heart failure.
.
RENAL U.S. [**2161-12-10**]
Right Cortical Atrophy
.
DUPLEX DOP ABD/PEL LIMITED [**2161-12-16**]
The findings of unilateral small kidney with abnormal waveforms
are suggestive of renal artery stenosis on the right side. The
left kidney appears essentially normal.
.
ABDOMINAL A-GRAM [**2161-12-18**]
Aortography demonstrated heavily calcified irregular aorta.
There was high-grade ostial stenosis of the left renal artery
with marked calcification at the origin. There was a moderate
stenosis of the right renal artery approximately 2 cm from the
origin. The origin of the right renal artery could not be
delineated. Right kidney was reduced in size. Left kidney
demonstrated normal size and perfusion. Selective renal
arteriogram was not performed.
.
CT HEAD W/O CONTRAST [**2162-1-5**]
Area of subacute infarction suspected within the right occipital
lobe
Microbiology:
Date 6 Specimen Tests Ordered By
[**2162-1-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
{CLOSTRIDIUM DIFFICILE} INPATIENT
[**2162-1-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, ENTEROBACTER CLOACAE}; FUNGAL CULTURE-PRELIMINARY
{YEAST} INPATIENT
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
.
[**2162-1-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +} INPATIENT
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2162-1-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {ENTEROCOCCUS FAECALIS} INPATIENT
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
CHLORAMPHENICOL------- 32 R
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
PENICILLIN------------ 4 S
VANCOMYCIN------------ =>32 R
.
[**2162-1-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2161-12-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +, YEAST} INPATIENT
[**2161-12-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +} INPATIENT
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2161-12-16**] URINE URINE CULTURE-FINAL {YEAST, ENTEROCOCCUS SP.}
INPATIENT
[**2161-12-15**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP., 2ND
ISOLATE} INPATIENT
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
CHLORAMPHENICOL------- 32 R
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- <=16 S
VANCOMYCIN------------ =>32 R
.
[**2162-1-16**] 11:12 am BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2162-1-16**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2162-1-18**]):
~1000/ML OROPHARYNGEAL FLORA.
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
YEAST. ~1000/ML.
GRAM NEGATIVE ROD #2. ~[**2156**]/ML.
FURTHER WORKUP ON REQUEST ONLY Isolates are considered
potential
pathogens in amounts >=10,000 cfu/ml.
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
.
Discharge Labs:
.
CBC: 8.9 > 8.3/27.0 < 240
.
Chem 7:
143 / 103 / 54
--------------------< 97
3.9 / 30 / 0.9
.
Ca: 8.2 Mg: 2.3 P: 3.1
.
PT: 20.2 PTT: 37.1 INR: 2.9
Brief Hospital Course:
#. Respiratory Distress
Patient was admitted to the MICU in moderate respiratory
distress with accessory muscle use, tachypnea, and audible
wheezing. The etiology of the patient's respiratory distress was
not initially clear although thought most likely to represent
decompensated CHF given patient's history of flash pulmonary
edeam and recent cessation of cardiac meds on admission. It was
noted additionally upon transfer that the patient had a chest
film performed at her nursing facility which revealed bibasilar
infiltrates and sputum cultures which were positive for MRSA.
Failing Bactrim therapy the patient was transferred to [**Hospital1 18**] and
was initially started on Vancomycin, Levofloxacin, and Flagyl
for potential nosocomial pneumonia. Upon transfer to the MICU,
given the patient had sputum cultures positive for MRSA at the
NH, the patient's therapy was tailored to Vancomycin only, dosed
by levels with intentions to broaden coverage for gram negatives
if the patient spikes a new temp, develops new consolidation or
infiltrate or fails Vanco therapy. Repeat sputum cultures have
not been obtained to date as the patient has not been able to
expectorate any samples. The patient has remained afebrile but
has developed a leukocytosis since admission, as high as 19.3
with 3% bands, now trending downward. With regards to her
cardiac disease the patient is known by recent echocardiography
as well as cardiac cath to have arelatively preserved EF (50%)
with moderate diastolic dysfunction and possible restrictive
cardiomyopathy. The patient was restarted initially on isordil
and Hydralazine for preload and afterload reduction as well as
Amlodipine for additional blood pressure control. Losartan has
continued to be held as it is the most likely [**Doctor Last Name 360**] contributing
to patient's ARF. The patient has since been transitioned to
isordil, Hydralazine and metoprolol for additional rate control
in setting of atrial tachycardia (see below) as well as history
of CAD with intentions to maximize beta blockade and titrating
Hydral and isordil as needed for additional BP control. The
patient has been undergoing diuresis as well with net negative
fluid balance since admission to the MICU. The patient
additionally on transfer was noted to have bilateral pleural
effusions with a large right sided effusion, likely secondary to
decompensated CHF. Given the size of the effusion and the
patient's respiratory distress on admission, the decision was
made to perform a right thoracentesis to drain the effusion and
reduce any mechanical disadvantage secondary to the effusion.
The patient underwent a successful thoracentesis with drainage
of 600cc of fluid. Chemistry and microanalysis revealed the
effusion to be non-purulent, therefore less concerning for a
parapneumonic effusion. By light's criteria the protein level in
the effusion was > 3 and therefore possible consistent with an
exudate. However, as the LDH was not elevated it was thought
that the effusion was more likely a pseudoexudate in the setting
of diuresis and chronic CHF. With treatment as above, the
patient initially had decreased\oxygen requirements titrating
down from 6L facemask on admission to 2-3L NC currently, not
requiring non-invasive ventilation during her admission. Given
her apparent improvement, the patient was transferred to the
floor but returned to the MICU shortly for repeat hypoxia,
respiratory distress and was managed effectively with
non-invasive mask ventilation with bi-PAP. The patient was
stable over a couple of days with regards to her respiratory
status, although she did not significantly improve. The patient
was noted to have reaccumulation of her right pleural effusion.
Given this, facial skin brakedown from the bi-PAP mask and
anticipation of upcoming procedures, the patient was
semi-electively intubated. The patient then underwent repeat
thoracentesis, again conistent with a sterile uncomplicated
transudate.
She continued to require ventillatory support and had a
tracheostomy tube placed on [**2161-12-30**]. She was repeatedly weaned
down to lower levels of pressure support, but was repeatedly
returned to prior levels secondary to tachypnea. She had the
right pleural effusion tapped again and was found again to be a
transudate. Her vent settings at discharge were PS 10, PEEP 5
with tidal volumes ~300 on 40% FiO2.
*
#. Rhythym - The patient on admission carried a diagnosis of
afib with history of junctional arrythymias. On admission to the
MICU, the patient appeared to be in a junctional rhythym. After
admission to the MICU the patient developed an atrial arrythymia
that appeared most consistent with afib/aflutter with occasional
pauses and junctional escape beats. The patient developed this
tachycardia in the setting of diuresis of 2L of fluid, although
it is unknown if there is any relationship between the
development of this rhythym and any of the treatments to date.
The patient was noted to have associated hypertension rather
than hypotension during these episodes and the patient did not
develop any respiratory decompensation. The patient was given
5mg lopressor and was noted to develop some sinus pauses with
junctional escape, although pauses were less than 3 seconds and
the patient was asymptomatic. EP was consulted and recommended
that there was no indication for pacing currently, but
recommended optimizing rate control with beta blockade with
titration of other meds for blood pressure control after beta
blockade was first maximized. The patient was therefore started
on metoprolol 25mg po bid with plans to tirate up as tolerated
and has additionally been receiving hydralazine and isordil for
improved blood pressure control. EP remarked that there was no
indication for amiodarone and further remarked that as her
pulmonary status improved, it would be expected that her atrial
irritability also should improve. It was additionally suggested
that anticoagulation should be considered given her atrial
arrythmia. Currently, the patient is receiving SC Heparin tid
but whether or not to anticoagulate indefinitely will need to be
addressed. Over the course of her hospital stay, the patient was
noted to have occasional bradycardia with some pauses and
junctional escapes, all concerning for sick sinus. The patient's
cardiac regimen with regards to her arryhtmyia as well as
hypertension/diastolic dysfunction was adjusted to metoprolol
6.25mg mg PO q8hr for rate control as well as hydralazine PO and
clonidine patch for afterload reduction as well as a nitrate
drip for preload reduction with intention to transition back to
PO isordil after stabilization.
She had intermittant episodes of atrial fibrillation, often
during periods of large fluid shifts, which were responsive to
IV lopressor. Additionally, she had episodes of
bradycardia/junctional rhythms to the 30's during which she was
hemodynamically stable. She was put back on metoprolol 12.5mg
with three times a day dosing with good effect.
.
#. Hypertension: The patient's outpatient regimen for BP control
includes isordil, amlodipine, hydralazine, and losartan. As
described above, the patient's losartan has been held in the
setting of ARF and the patient's regimen has been changed to
metoprolol, isordil and hydralazine for the indications above.
Of note, given the patient's resistant hypertension requiring
many agents as well as potential ARF in setting of Losartan it
was suggested that the patient may have renal vascular disease
driving her hypertension. Indeed the patient had a renal
ultraosund with doppler which demonstrated right renal artery
stenosis. The patient underwent angiography by IR which
demonstrated high grade stenosis of the left renal artery but
with normal perfusion and moderate stenosis of the right renal
artery which previously had been demonstrated to be atrophic
with flow studies indicative of significant stenosis. Because
over the course of her stay the patient developed renal failure,
likely secondary to episodes of moderate hypotension as well as
contrast nephropathy from above studies, the patient was allowed
to maintain relative hypertension with systolics in the 140 to
160 range to encourage renal perfusion. Her BP was controlled
with hydralyzine and isordil at discharge.
.
#. ARF: On admission the patient was noted to have a Creatinine
of 3.4 which is a bump from her baseline (most recent baseline
1.2 in [**2161-7-31**]). Over the course of her MICU stay the
patient's creatinine has been decreasing by holding her losartan
and allowing higher perfusion pressures. All medications have
been renally dosed as appropriate. The patient had a UA/Used
that was bland and not consistent with infection. The patient
has been undergoing effective diuresis for her CHF as above, and
her creatinine continues to decrease even in the setting of
diuresis.
Her renal function improved over the stay, with good urine
output at SBP 140-160. She was found to have Renal Artery
Stenosis which was too diffuse to intervene. Creatinine
returned to baseline prior to discharge.
*
#. CAD: The patient has known CAD with bare metal stent
placement in [**Month (only) **] to OM #1. On admission the patient had a
troponin of .08, but a normal CK-MB which likely represented
mild demand ischemia in the setting of pulmonary edema with ARF.
The patient was continued on her outpatient regimen of
atorvastatin and plavix. Her son [**Name (NI) 382**] was asked why the patient
was not additionally on aspirin and team was told because of
history of epistaxis. Metoprolol was restarted at lower doses
given more frequently given her history of eposodes of severe
bradycardia. Aspirin was restarted given history of recent
stenting.
*
#. Hypothyroidism - the patient was continued on her outpatient
regimen of levothyroxine
.
#. Psych - The patient throughout her MICU stay has been noted
to have waxing and [**Doctor Last Name 688**] mental status and mild paranoia
consistent with delerium. The patient has been receiving Zyprexa
PRN at night with decent effect. The patient has a room with
windows to provide normal circadian rhythym, attempts have been
made to orient the patient often to where she is, and treatment
has been ongoing towards the underlying medical conditions that
may additionally been exacerbating her delerium. Her agitation
improved with treatment of her infections.
.
# CVA: She was found to have a subacute right occipital infarct,
found on head CT after unresponsiveness while being weaned off
of sedation after her tracheostomy. Sge was started on ASA.
.
# Ventilator Associated PNA: she was treated for MRSA VAP with
vanco. Bronchoalveolar lavage results from [**1-16**] showed
enterobacter cloacae, see sensitivities in results section.
Patient is currently afebrile, no elevation in WBC, no change in
sputum. Not thought to be a true pathogen given negative gram
stain, likely colonization, but if patient develops a fever and
signs/symptoms for pneumonia, would start empiric treatment for
enterobacter based on these sensitivities.
.
# Enteroccocal Bacteremia: she was treated with ampicillin for
blood cultures (1 of 4 bottles) growing ampicillin sensitive
encterococcus feacales.
.
# Pancreatic Mass: Seen on CT scans of abdomen on [**1-5**] and
[**1-11**]. Ddx included malingancy vs. fat vs. cyst. Patient has
history of pancreatitis in [**2161-1-31**] making pancreatic cyst
the most likely the etiology. Would pursue further imaging as
an outpatient after patient is more stable.
.
# C. Diff: she developed C Diff infection which was treated with
Flagyl and Vancomycin. She completed course of flagyl and is
currently on Day [**10-14**] of PO vancomycin.
.
#. CHF: She has a h/o Diastolic dysfunction. Echo showed
moderate AR with preserved EF >55%. She did require diuresis
with lasix throughout her stay and responded well to 80 mg IV,
which was further enhanced with the administration of metolazone
thirty minutes beforehand. She was discharged on daily laisx
and mitolazone for goal of continued diuresis. These diuretics
should be reevaluated daily as to whether the patient requires
diuresis for that day.
.
#. Anemia: Work up consistent with ACD and iron deficiency
.
#. Ppx: She was anticoagulated with coumadin, PPI, Bowel regimen
*
#. FEN - She had a PEG placed on [**2161-12-18**] and received tube
feeds through the PEG.
.
#. Code: Full
.
#. Communication with son [**Name (NI) **] [**Name (NI) 487**] [**Telephone/Fax (1) 47781**] (consent
for admission received on [**2161-12-8**])
.
Microbiology results pending at discharge:
[**1-15**] sputum cx - rare growth of GNR, ID and sensitivities
pending
[**1-14**] and [**1-15**] blood cx - NGTD, awaiting final report
Medications on Admission:
Losartan 12.5 mg daily
Isordil 40 mg po tid
Hydralazine 50 mg po 4x/day
Norvasc 10 mg po daily
Furosemide 40 mg po daily
Levothyroxine 88 mcg po daily
Atorvastatin 10 mg po daily
Clopidogrel 75 mg po daily
Senna
Bisacodyl prn
Milk of Magnesia prn
Gabapentin 100mg po bid
Acetaminophen 650 mg po q6h
Omeprazole 20 mg po daily
Lidocaine 5% patch daily (12 hrs on/12 hrs off) to R stump
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) PO DAILY (Daily).
5. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Senna 8.8 mg/5 mL Syrup Sig: Five (5) cc PO BID (2 times a
day) as needed.
8. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
10. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: Today is day [**10-14**].
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day) as needed.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Give 30 minutes prior to lasix.
16. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily): After metolazone.
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed
by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN post blood draw + infusion.
18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
Goal INR [**3-5**].
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for HR<50.
20. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q1H (every
hour) as needed for agitation/pain/comfort.
21. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Last day [**1-21**].
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
23. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous
at bedtime.
24. Insulin Sliding Scale
Q4H Please use Humalog
Glucose Insulin Dose
0-50 mg/dL 4 oz. Juice
51-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 5 Units
201-240 mg/dL 8 Units
241-280 mg/dL 11 Units
281-320 mg/dL 14 Units
321-360 mg/dL 17 Units
361-400 mg/dL 20 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Pleural effusions
Hypoxic Respiratory failure s/p tracheostomy
PEG placement
Atrial fibrillation
Acute renal failure with Chronic renal insufficiency
Bilateral renal artery stenosis
Coronary artery disease
Congestive heart failure
Iron deficiency anemia
Hypothyroidism
Ventilator associated pneumonia
Clostridium dificile colitis
Candiduria
Right occipital subacute CVA
Pancreatic mass
Peripheral vascular disease
Discharge Condition:
Afebrile, stable on ventilator with tracheostomy.
Discharge Instructions:
Discharge to acute care vent facility
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
See discharge worksheet for further instructions.
Followup Instructions:
Patient will require ventilator weaning facility.
She will require follow up of her INR given coumadin for Afib.
She will require monitoring of her fluid status given CHF. Her
diuretics should be reevaluated daily as to need for that day.
Goal is to diurese off pleural effusions.
Follow up results of pending microbiology data (please see end
of hospital course)
Completed by:[**2162-2-16**]
|
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"482.41",
"244.9",
"427.31",
"428.31",
"440.1",
"584.9",
"790.7",
"440.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"31.1",
"33.24",
"38.93",
"96.04",
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icd9pcs
|
[
[
[]
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23885, 23956
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|
276, 427
|
24414, 24466
|
2327, 2634
|
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1845, 1863
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23977, 24393
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20984, 21369
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24490, 24685
|
8067, 8220
|
1878, 2308
|
20820, 20958
|
3406, 8051
|
217, 238
|
455, 1310
|
2650, 3389
|
1332, 1717
|
1733, 1829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,548
| 167,593
|
6403+6404+6405+55752
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2125-6-27**] Discharge Date: [**2125-7-20**]
Date of Birth: [**2071-7-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
woman status post renal transplant on Coumadin status post
cerebrovascular accident, who developed right shoulder pain
four days ago. She first noted right arm pain followed by
right upper extremity weakness. Earlier on the day of
admission she developed rapidly progressive quadriplegia. An
MRI scan at [**Hospital **] Hospital demonstrated a right
dorsolateral epidural mass at the C3-C4 level with severe
cord compression consistent with epidural hematoma. The
patient was transferred to the [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY: 1. Thyroid cancer status post
thyroidectomy in [**2099**]. 2. Chronic renal failure status post
renal transplants in [**2097**] and [**2116**]. 3. Aortic stenosis. 4.
Transient ischemic attacks. 5. Osteoporosis. 6. Asthma. 7.
The patient was born without a vagina or uterus and had
reconstructive surgery done as an infant.
HOSPITAL COURSE: On arrival to [**Hospital1 188**] the patient was essentially quadriplegic with a
flicker of movement, [**12-24**] in the left toes, 1-2/5 on the left
biceps, triceps, [**12-24**] on the left grip, no sensation in the
arms or legs, minimal preserved sensation at the T2 to T3
dermatome. No rectal tone, no deep tendon reflexes.
The patient was intubated and sedated and brought emergently
to the operating room for evacuation of this epidural
hematoma at the C3-C4 level. She tolerated the procedure
well. Post procedure the patient was awake, alert, following
commands. She had no movement on the right side, 4+ in the
left IP, 4+ in the AT, 4- in the [**Last Name (un) 938**], and 4+ in the
gastrocnemius. In the upper extremities she was 4+ in the
deltoids, 4- in the biceps, 4- in the triceps on the left
side and on the right side she was 1 in the biceps, 0 in the
triceps. Her sensation was intact to the neck. She remained
intubated. She was followed by the renal service for her
renal transplant and chronic renal failure.
On postoperative day two her motor strength had improved on
the left side. She was 4+/5 in the IP, [**4-23**] in the
quadriceps, [**4-23**] in the AT, 4- in the [**Last Name (un) 938**], and [**4-23**] in the
gastrocnemius on the left side. On the right side she was
[**12-24**] in the IP and that was the only movement she had. Her
toes were downgoing. Her biceps were 4- on the left, 4 in
the triceps and [**4-23**] in the grasp. On the right side she had
slight rotation of the right upper extremity inward. Her
ventilator was weaned. She had a central line and Swan-Ganz
catheter placed on [**2125-6-29**]. The patient developed mild
acute tubular necrosis. Despite good urine output her
creatinine rose to 3.2. Her normal range is 2.5 to 3. The
patient was on cefazolin 1 gram IV q. 8 hours postoperative
and she was being given Lasix on a b.i.d. basis to keep her
urine output at an adequate level. She maintained 30 cc per
hour of urine output. On [**2125-7-3**] she was bronchoscoped.
This showed no occlusion of her endotracheal tube. On
[**2125-7-3**] the patient was extubated. She began having
difficulty with shortness of breath and dropping her
saturations. She was placed on BiPAP for a short time with
slight improvement but then needed to be reintubated. She
did drop her saturations and her blood pressure during
intubation and became asystolic. She required a short time
of very gentle chest compressions. She was given a 250
normal saline IV bolus and improved. Her heart rate came
back to normal with no further treatment necessary. The
patient was awake and following commands, neurologically
unchanged after intubation. Bronchoscopy on [**2125-7-3**] showed
just thick mucus on the left side.
Her motor strength on [**2125-7-5**] continued to improve with a 2
in the IP on the right side and a 1 in the gastrocnemius.
Otherwise her motor strength was 5 in the gastrocnemius, 4 in
the biceps, 4 in the triceps, 5 in the IP, and 4+ in the AT
on the left side. It was difficult to wean from the
ventilator secondary to severe AS and 2+ MR regurgitation
with high PA pressures and mucous plugging. Therefore, the
patient was trached.
Hematology-oncology service was consulted regarding
thrombocytopenia and positive antiplatelet antibody. The
patient was treated with IVIG dosed 1 gram per kg q. day for
two days for the ITP. On [**2125-7-7**] hematology-oncology
suggested continuing the IVIG for four days for her ITP. Her
subcutaneous heparin was held until her platelet count was
over 100,000. Her platelet count on [**2125-7-7**] was 88, white
count 6.5, hematocrit 29.5, sodium 139, K 4.2, chloride 102,
CO2 29, BUN 97, creatinine came down to 2.7. Her mild case
of acute tubular necrosis resolved.
Her motor strength in her extremities continued to be stable
with just a flicker of movement in the right lower extremity.
She was able to bend her right knee up slightly and rotate;
her right arm inwardly rotated minimally. She continued to
be followed by hematology-oncology and the renal service.
The patient did spike a temperature periodically. She was
treated with levofloxacin for 10 days for E. coli in her
sputum. On [**2125-7-13**] the patient had tracheostomy placement.
On [**2125-7-19**] the patient had PEG placement. Her neurologic
status remained stable with greatly improved strength on the
left side, [**4-23**] basically in all muscle groups of the lower
extremities with just a 4+ gastrocnemius. Her grasp was 5+,
biceps 4+, triceps 4-. On the right side she had a 2 IP, a 3
quadriceps, and a 2 deltoid, otherwise she was 0/5.
Her laboratory studies as of [**2125-7-20**] are a white count of
7.0, hematocrit 29, platelet count 105, PT 13.2, PTT 33, INR
1.2, sodium 147, K 5.8, 115/25, 108/2.6, and 87. She had a
grasp of [**4-23**] on the left, 0/5 on the right. IPs were [**1-24**] on
the right, [**4-23**] on the left. She remains neurologically
stable. She was afebrile. Her blood pressures are ranging
from 107-124/40s-50s. Her saturations are 95% and she is
still on the ventilator but trached.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1327**] in two weeks
in his office. Her staples have been removed.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg n.g. q. day.
2. Celexa 20 mg n.g. q. day.
3. Ferrous sulfate 325 p.o. q. day.
4. Heparin 5,000 units subcutaneous q. 12 hours.
5. Calcitonin 2,000 IU q. day.
6. Albuterol 1-2 puffs i.h. q. 6 hours.
7. Cyclosporine 75 mg n.g. q. 12 hours.
8. Atorvastatin 10 mg q. day.
9. Levothyroxine 100 mcg n.g. q. day.
10. Epogen 10,000 units subcutaneous two times a week, Monday
and Thursday.
11. Colace 100 mg p.o. b.i.d.
12. Prednisone 5 mg q. day.
13. Lasix 80 mg n.g. q. day.
14. Percocet elixir 5-10 cc q. 4 hours.
15. Lorazepam 0.5 to 1 IV q. 4 hours p.r.n.
16. Tylenol 325 q. 6 hours.
17. Dulcolax 10 p.r. q. day p.r.n.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2125-7-20**] 09:44
T: [**2125-7-20**] 10:05
JOB#: [**Job Number 24681**]
Admission Date: [**2125-6-27**] Discharge Date: [**2125-7-20**]
Date of Birth: [**2071-7-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53 year-old
woman with multiple medical problems who noted right neck and
shoulder pain on [**2125-6-18**]. She went to an outside Emergency
Room and was treated with non-steroidal anti-inflammatory
drugs and sent home. The night before admission she had a
gradually onset of right arm weakness. She went to an
outside hospital again and evaluated by neurology and
admitted and had an MRI scan, which showed a mass lesion
consistent with a hematoma inferior level of C3 C4 with cord
compression. The patient then developed rapid progressive of
right sided weakness and then progressive left sided
weakness. She was transferred emergently to [**Hospital1 346**] for treatment. On arrival she was
basically quadriplegic on arrival with left toes that were 1
to 2 out of 5, biceps and triceps were 1 out of 5, left grip
no sensation in the arms or legs. Minimal preserved
sensation in the T2 to T3 dermatome. No rectal tone. No
deep tendon reflexes.
HOSPITAL COURSE: The patient was admitted to the
Neurological Intensive Care Unit and taken emergently to the
Operating Room for urgent evacuation of the epidural
hematoma. She was started on Solu-Medrol protocol. The
risks and benefits of her surgery were discussed with her
husband. The patient's prognosis for neurologic recovery is
extremely grave, but the family would like to proceed with
surgery. The patient underwent the procedure on [**2125-6-27**]
without intraoperative complications. Postoperatively, the
patient was intubated. She was awake. She had no movement
at all in the right side of her body upper or lower
extremity. On the left side she had a 4+ IP, 4+ AT, 4- [**Last Name (un) 938**]
and 4+ gastroc. She had minimal rotation of the right leg.
Her sensation was intact to the neck.
PAST MEDICAL HISTORY: Thyroid cancer in [**2099**]. She is
hyperparathyroid. Peripheral vascular disease, osteoporosis,
end stage renal disease status post renal transplant in [**2097**]
and [**2116**], congenital anomalies. The patient was born without
a vagina or uterus and had severe ureteral reflux, which she
underwent surgery for as an infant. She also has chronic
renal insufficiency with renal transplant in [**2097**] and [**2116**].
Congestive heart failure, transient ischemic attacks, asthma,
thyroidectomy.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2125-7-20**] 09:23
T: [**2125-7-20**] 09:38
JOB#: [**Job Number 24682**]
Admission Date: [**2125-6-27**] Discharge Date: [**2125-7-31**]
Date of Birth: [**2071-7-15**] Sex: F
Service: MEDICAL INTENSIVE CARE UNIT GREEN TEAM
HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old female,
who was eventually admitted on [**6-27**], who presented with
quadriplegia, which was rapidly progressive starting from
[**2125-6-18**]. She went to an Emergency Department to an
outside hospital, where she was evaluated by Neurology
consult, and MRI demonstrated a mass lesion/hematoma versus
infection in the C3-C4 epidural space. Patient was
coagulopathic at this time, which was with a PT of 23.9, INR
of 4.74, which was corrected with fresh-frozen plasma at the
outside hospital. Patient was sent by Med Flight to [**Hospital1 1444**] for emergent Neurosurgery.
PAST MEDICAL HISTORY:
1.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2125-7-30**] 11:02
T: [**2125-7-30**] 11:03
JOB#: [**Job Number 24683**]
Name: [**Known lastname 1793**], [**Known firstname 4193**] Unit No: [**Numeric Identifier 4194**]
Admission Date: [**2125-6-27**] Discharge Date: [**2125-7-30**]
Date of Birth: [**2071-7-15**] Sex: F
Service: MICU GREEN
ADDENDUM: Addendum to dictation of [**2125-7-20**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 54-year-old
woman with a history of end-stage renal disease, status post
renal transplant in [**2116**], aortic stenosis, TIAs on Coumadin,
who presented with four days of right shoulder pain after
falling, followed by rapidly progressive quadriplegia on [**2125-6-27**]. MRI at an outside hospital revealed a right
dorsolateral epidural hematoma at the C3-4 level. The
patient was intubated and transferred to [**Hospital1 8**] where she
underwent neurosurgical evacuation of the hematoma. The
patient was admitted to the SICU under the neurosurgical
team. Full notes by the neurosurgical team for her hospital
course from admission to [**2125-7-20**] has already been
dictated.
Post surgery, the patient's left side strength has increased
but her right-sided strength continues to be limited with
little or no strength. Sensation has been intact throughout
her hospital course. The patient was briefly extubated on
[**2125-7-3**] but reintubated again after 02 saturations
decreased with shortness of breath and BIPAP was not
effective. During this reintubation, the patient also had
decreased blood pressure and became asystolic requiring chest
compressions for a short time but improved without other
medication use. Otherwise, cardiac wise has been fully
stable since then. She underwent tracheostomy on [**2125-7-13**] and a PEG feeding tube placement on [**2125-7-19**]. She
has also been treated for fever and E. coli in her sputum
with ten days of levofloxacin. The patient was also
diagnosed during this admission with chronic idiopathic
thrombocytopenia, status post IV Ig treatments in the
hospital.
She was transferred on [**2125-7-23**] to the Medical
Intensive Care Unit team due to a hematocrit drop from 29 to
25 and failure to wean.
ALLERGIES: Tetracycline, sulfa.
MEDICATIONS IN THE SICU:
1. Prednisone 5 once a day.
2. Calcium gluconate p.r.n.
3. Hydralazine p.r.n.
4. Bisacodyl p.r.n.
5. Colace.
6. Zofran.
7. Epogen.
8. Synthroid 100 micrograms.
9. Atorvostatin 10.
10. Cyclosporin 75 q. 12.
11. Albuterol q. six hours.
12. Calcitonin nasal.
13. Subcutaneous heparin.
14. Iron.
15. Citalopram.
16. Tylenol q. six hours.
17. Ativan p.r.n.
18. Lansoprazole 30.
19. Percocet p.r.n.
20. Metoprolol p.r.n.
21. Promethazine p.r.n.
21. Norepinephrine drip.
22. Lasix 80.
PAST MEDICAL HISTORY:
1. End-stage renal disease, status post renal transplant
eight years ago and in [**2097**]. The end-stage renal disease was
thought to be secondary to renal hypoplasia.
2. Thyroid cancer.
3. Aortic stenosis.
4. TIAs, on Coumadin.
5. Osteoporosis.
6. Asthma.
7. Born without a vagina or uterus, status post surgical
reconstruction.
8. Hyperparathyroidism.
SOCIAL HISTORY: Lives with husband, previously fully
functional, independent in activities of daily living, a
housewife.
PHYSICAL EXAMINATION ON ADMISSION: Ventilator: SIMV 60%
oxygen, 400 tidal volume, 10 PEEP, and 10 of pressure
support. Vital signs: Heart rate 74, blood pressure 136/62,
02 saturation 100% on the ventilator, respiratory rate 20,
temperature 97.9. General: The patient was a white female
lying in bed on the ventilator in no apparent distress.
HEENT: Trach in place, oropharynx clear. The mucous
membranes were somewhat dry. Skin: Erythematous left arm,
multiple healed/healing ulcers in the right arm and left
knee. Heart: S1, S2, regular rate and rhythm, systolic
murmur. Lungs: Clear to auscultation anteriorly, loud upper
airway sounds. Abdomen: Soft, mildly tender in the right
upper quadrant, nondistended, normoactive bowel sounds.
Extremities: There were 1+ pulses in the lower extremities,
2+ pulses in the upper extremities, 2+ edema in the bilateral
lower extremities, left arm with an AV fistula. Neurologic:
Alert and oriented times three, communicates with sign
language and pointing to alphabet, 3/5 strength in the left
upper and lower extremity, 0/5 strength in the right upper
extremity, 1/5 strength in the right lower extremity.
LABORATORY/RADIOLOGIC DATA: The laboratories upon transfer
revealed a white blood count of 3.4, hematocrit 25.5, down
from 29.2, platelets 174,000, MCV 98, INR 1.2. Chemistries:
Sodium 144, potassium 4.4, chloride 118, bicarbonate 20, BUN
10, creatinine 2.4, glucose 106, calcium 9.3, phosphate 3.4,
magnesium 1.8. The most recent ABGs were 7.32, 39, 144.
Most recent echocardiogram on [**2125-6-28**] right ventricular
a LVEF greater than 55%, mild symmetric LVH, severe AV
stenosis, 2+ mitral regurgitation, 2+ tricuspid
regurgitation, moderate pulmonary artery hypertension.
Chest x-ray: Mild diffuse interstitial markings, right base
aeration has improved from previously, marked congenital
abnormalities with small lung volumes.
CT of the abdomen on [**2125-7-15**] revealed no cholecystitis,
possible cholelithiasis.
TSH 25.
HOSPITAL COURSE: [**Hospital 4195**] hospital course between [**2125-7-23**] and discharge.
1. FAILURE TO WEAN OFF THE VENTILATOR/RESPIRATORY DISTRESS:
Likely due to congenital abnormalities of the patient's lung
and chest wall, pulmonary edema, neuromuscular weakness,
deconditioning, recent pneumonia. The patient's respiratory
status was stable throughout her stay in the MICU. She was
started on Combivent nebulizers for her underlying lung
disease. The patient was maintained on a ventilator in SMV
mode and the patient had continued to have up to 12
spontaneous breaths per minute. The patient underwent
bronchoscopy on [**2125-7-26**] which showed dynamic collapse
of the airways, diffusely erythematous and edematous airways,
friable mucosa, occasional granulation tissue, especially on
the right lower lobe and left lower lobe, secretions in the
lower lobes were nonpurulent. Gram's stain showed 2+
leukocytes, and 2+ oropharyngeal organisms. Bronchoalveolar
lavage showed E. coli sparse growth resistant to ampicillin,
otherwise sensitive.
CT of the chest on [**2125-7-25**] showed bilateral pleural
effusions with basilar collapse/consolidation, anasarca.
Ultrasound of the abdomen and diaphragm revealed that
bilateral diaphragm was functioning normally with no loss of
motor function. The patient also with some mild pulmonary
edema on chest x-rays and continued to be diuresed with Lasix
and Zaroxolyn.
Plan was to transfer to rehabilitation where the patient will
eventually be weaned from her ventilator after significant
respiratory therapy and respiratory rehabilitation has been
completed.
2. NEUROLOGICAL DEFICITS: The patient continues to have
right upper and lower extremity weakness which has slowly
improved on a daily basis since her surgery. The patient has
received physical therapy here on a daily basis with good
result. The patient is to follow-up on an outpatient basis
with the Neurosurgical Service here.
3. RENAL FUNCTION: Status post renal transplant in [**2116**].
Creatinine decreased from 2.4 at transfer to 2.1 which is her
baseline. The patient's cyclosporin dose was increased from
75 b.i.d. to 100 b.i.d. as her cyclosporin was
subtherapeutic. Renal ultrasound of her transplant showed
that it was functioning well with no pathological process.
4. AORTIC STENOSIS: 2+ tricuspid regurgitation, 2+ mitral
regurgitation, history of atrial fibrillation and TIAs,
CHF/anasarca. The patient continued on Lasix and Zaroxolyn.
The patient was briefly placed on Natrecor as recent
literature has shown that this can improve fluid status for
patients with aortic stenosis. This was later discontinued
as the patient was adequately diuresed just on Lasix and
supplemented by Zaroxolyn p.r.n. Anticoagulation for the
patient's history of atrial fibrillation and TIAs was held
given the recent epidural hematoma. Recommend following up
with Dr. [**Last Name (STitle) **] of Neurosurgery at [**Hospital1 8**] for when to restart
anticoagulation.
Cardiology consulted and does recommend restarting
anticoagulation when neurosurgically cleared.
5. HYPOTHYROIDISM: The patient's TSH was increased to 25
and free T4 was low and her Synthroid was increased from 100
micrograms per day to 125 micrograms per day.
6. ANEMIA: The patient was initially with a hematocrit drop
on the first day of her transfer to the MICU. The patient
underwent blood transfusion of 2 units and since then her
hematocrits have been entirely stable in the low 30 range.
The patient is on Epogen three times per week. The patient's
B12 and folate were within normal limits. The patient's iron
was slightly low at 23 on [**2125-7-23**] but had been normal
on [**2125-7-5**] at 52. The patient was briefly continued on
iron supplements but this was discontinued after she received
2 units of packed red blood cells with effectively gives the
patient iron. Recommend rechecking iron in a few months to
assure that she is not iron-deficient.
7. ACCESS: The patient has a PICC line that was placed in
mid [**Month (only) 1176**], functioning very well.
8. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
tolerating tube feeds well through her PEG. The patient was
with increased calcium and on Calcitonin, unknown etiology.
9. PERIPHERAL ACCESS: The patient was maintained on
subcutaneous heparin as well as a proton pump inhibitor
throughout her hospital stay for DVT and GI prophylaxis.
10. CODE: Full.
11. COMMUNICATION: With the patient and her husband.
DISPOSITION: Rescreening by rehabilitation scheduled for
[**2125-7-30**].
DISCHARGE STATUS: Stable on ventilator.
DISCHARGE DIAGNOSIS:
1. C3-4 epidural hematoma, status post neurosurgical
evacuation.
2. Respiratory failure, acute.
3. Acidosis.
4. Pneumonia, aspiration.
5. Paralysis.
6. Anemia.
7. Hypothyroidism.
DISCHARGE MEDICATIONS:
1. Prednisone 5 mg p.o. q.d.
2. Bisacodyl 10 mg p.r. b.i.d. p.r.n.
3. Colace 100 mg p.o. b.i.d.
4. Ondansetron 4 mg IV q. six p.r.n.
5. Atorvostatin 10 mg q.d.
6. Calcitonin 200 intranasal q.d.
7. Citalopram hydrobromide 20 mg q.d.
8. Ativan 0.5 to 1 IV q. four hours p.r.n.
9. Lansoprazole 30 mg q.d.
10. Promethazine 6.25 to 25 mg IV q. six p.r.n. nausea.
11. Tylenol 325-650 mg p.o. q. four to six hours p.r.n.
fever.
12. Combivent inhalers q. six hours.
13. Heparin subcutaneously q. eight hours.
14. Epoetin 10,000 units three times per week, Monday,
Wednesday, and Friday.
15. Levothyroxine sodium 125 micrograms NG q.d.
16. Lasix 40 IV b.i.d.
17. Ipratropium bromide nebulizer q. six hours p.r.n.
18. Albuterol nebulizer q. six hours p.r.n.
19. Cyclosporin 100 p.o. q. 12.
20. Metolazone 2.5 mg p.o. q.d. given 30 minutes before the
a.m. Lasix dose, starting on [**2125-7-28**] for one week.
FOLLOW-UP PLANS: The patient is to be transferred to a
rehabilitation facility for further weaning from the
ventilator and respiratory rehabilitation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Name8 (MD) 4196**]
MEDQUIST36
D: [**2125-7-30**] 11:32
T: [**2125-7-30**] 11:45
JOB#: [**Job Number 4197**]
|
[
"344.00",
"507.0",
"585",
"952.9",
"518.81",
"428.0",
"599.0",
"287.3",
"574.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"00.13",
"51.22",
"31.1",
"33.23",
"96.6",
"33.22",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
21222, 22131
|
21012, 21199
|
16377, 20991
|
6284, 6403
|
22149, 22541
|
10275, 10879
|
14388, 16359
|
13864, 14229
|
14246, 14373
|
6263, 6272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,789
| 136,954
|
24697+57429
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-10-22**] Discharge Date: [**2122-11-11**]
Date of Birth: [**2045-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal pain, back pain, weakness, LE numbness, transfer for
cath to [**Hospital1 18**]
Major Surgical or Invasive Procedure:
Cardiac catheterization
Right colectomy
Pacemaker placement
History of Present Illness:
Briefly, this pt is a 77M with a history of NIDDM, HTN, who
presented to [**Hospital1 1474**] on [**10-19**] with the complaint of low back
pain, weakness/numbness in the legs, abdominal pain, and
constipation. The patient reports that he has had LBP for
several years, although it has gotten much worse in the last few
days. Pt endores a 40 lb weight loss over the past several
years, although he has not been trying to lose weight. The
patient also endorses dark/black stools, but reports no bloody
stools. The patient had not been taking any medications, and had
not seen his PCP in several years.
.
The patient was found to be profoundly anemic at the outside
hospital with a hematocrit of 23, potassium was 6.7. A CT scan
of the abdomen showed a 5-6cm area of very thickened colon with
luminal narrowing with several small adjacent lymph nodes. An
EKG was done which showed ST depressions in the precordial
leads. Tr was slightly elevated, CK-MB was flat. While it was
likely that the ST-T changes occurred in the setting of his
profound anemia with likely demand ischemia, the patient was
transferred to [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
1. NIDDM, not on meds
2. Low back pain
Social History:
lives alone, has lots of stairs at home, falls often. Drinks at
least [**3-6**] drinks per day. Smoked heavily until 20 years ago. No
illicits.
Family History:
Noncontributory
Physical Exam:
On Admission
GEN: thin disheveled man in NAD. Comfortable, lying in bed.
HEENT: anicteric, pink conjunctivae. PERRLA, EOMI, OP clear,
MMM, poor dentition.
NECK: supple. No LAD, JVD not assessed as lying flat.
COR: very distant heart sounds. No distinct murmur appreciated
CHEST: anterior exam reveals faint crackles in dependent fields.
ABD: soft, NT, ND. NABS. No masses or HSM appreciated
EXT: w/wp. No edema. DP pulses dopplerable
NEURO: AA&Ox3. CN II-XII intact. Sensory exam reveals decreased
sensation over great toe bilaterally. [**Last Name (un) 938**] strength decreased
symmetrically 4-/5. Dorsiflexion 4+/5 bilaterally.
Plantarflexion [**5-7**] bilaterally. Hip flexion not assessed as
patient lying flat after cath.
Pertinent Results:
[**2122-11-10**] 01:20PM BLOOD WBC-11.7* RBC-4.72 Hgb-12.4* Hct-37.9*
MCV-80* MCH-26.3* MCHC-32.8 RDW-16.5* Plt Ct-637*
[**2122-11-9**] 05:02AM BLOOD WBC-7.8 RBC-4.02* Hgb-10.9* Hct-32.9*
MCV-82 MCH-27.0 MCHC-33.0 RDW-16.6* Plt Ct-543*
[**2122-11-8**] 04:55AM BLOOD WBC-7.9 RBC-3.96* Hgb-10.8* Hct-32.6*
MCV-82 MCH-27.3 MCHC-33.1 RDW-16.4* Plt Ct-520*
[**2122-11-7**] 05:30AM BLOOD WBC-7.7 RBC-4.10* Hgb-11.0* Hct-33.3*
MCV-81* MCH-26.7* MCHC-33.0 RDW-16.4* Plt Ct-455*
[**2122-10-23**] 06:35AM BLOOD WBC-12.8* RBC-3.95* Hgb-10.2* Hct-31.3*
MCV-79* MCH-25.8* MCHC-32.6 RDW-16.4* Plt Ct-506*
[**2122-10-22**] 10:08PM BLOOD WBC-14.2* RBC-3.98* Hgb-10.3* Hct-31.6*
MCV-79* MCH-25.9* MCHC-32.6 RDW-16.3* Plt Ct-488*
[**2122-10-22**] 12:30PM BLOOD WBC-12.0* RBC-4.06* Hgb-10.3* Hct-32.6*
MCV-80* MCH-25.4* MCHC-31.7 RDW-16.4* Plt Ct-521*
[**2122-11-3**] 07:20AM BLOOD WBC-7.9 RBC-4.44*# Hgb-11.7*# Hct-35.0*
MCV-79* MCH-26.4* MCHC-33.5 RDW-16.0* Plt Ct-415
[**2122-11-2**] 10:00PM BLOOD Hct-35.0*
[**2122-11-2**] 11:30AM BLOOD Hct-32.2*
[**2122-11-2**] 06:35AM BLOOD WBC-8.2 RBC-3.38* Hgb-8.8* Hct-26.5*
MCV-78* MCH-26.0* MCHC-33.2 RDW-16.0* Plt Ct-392
[**2122-11-1**] 08:00AM BLOOD WBC-6.7 RBC-3.75* Hgb-9.8* Hct-29.9*
MCV-80* MCH-26.2* MCHC-32.9 RDW-16.3* Plt Ct-393
[**2122-10-30**] 02:06AM BLOOD WBC-8.7 RBC-3.84* Hgb-10.0* Hct-30.9*
MCV-80* MCH-25.9* MCHC-32.3 RDW-16.3* Plt Ct-458*
[**2122-10-29**] 06:10AM BLOOD WBC-11.2* RBC-4.24* Hgb-10.8* Hct-33.8*
MCV-80* MCH-25.5* MCHC-32.0 RDW-16.2* Plt Ct-507*
[**2122-11-10**] 01:20PM BLOOD PT-13.0 INR(PT)-1.1
[**2122-11-5**] 02:32AM BLOOD PT-14.1* PTT-34.2 INR(PT)-1.3
[**2122-11-3**] 07:20AM BLOOD PT-13.3 PTT-31.0 INR(PT)-1.2
[**2122-11-2**] 06:35AM BLOOD PT-14.0* PTT-41.2* INR(PT)-1.3
[**2122-11-1**] 08:00AM BLOOD PT-14.0* PTT-33.5 INR(PT)-1.3
[**2122-10-31**] 06:18AM BLOOD PT-13.5* PTT-33.9 INR(PT)-1.2
[**2122-10-25**] 05:41AM BLOOD PT-13.8* PTT-29.4 INR(PT)-1.3
[**2122-10-22**] 12:30PM BLOOD PT-14.7* PTT-30.0 INR(PT)-1.5
[**2122-11-10**] 01:20PM BLOOD Glucose-123* UreaN-6 Na-139 K-4.5 Cl-103
HCO3-28 AnGap-13
[**2122-11-9**] 05:02AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-138 K-4.0
Cl-104 HCO3-26 AnGap-12
[**2122-11-8**] 04:55AM BLOOD Glucose-100 UreaN-5* Creat-0.7 Na-138
K-4.4 Cl-103 HCO3-24 AnGap-15
[**2122-11-7**] 05:30AM BLOOD Glucose-138* UreaN-6 Creat-0.6 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
[**2122-11-6**] 06:35AM BLOOD Glucose-192* UreaN-9 Creat-0.8 Na-136
K-4.5 Cl-103 HCO3-25 AnGap-13
[**2122-11-5**] 02:32AM BLOOD Glucose-81 UreaN-8 Creat-0.8 Na-137 K-4.4
Cl-104 HCO3-21* AnGap-16
[**2122-10-25**] 05:10PM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-136
K-4.4 Cl-101 HCO3-21* AnGap-18
[**2122-10-25**] 05:41AM BLOOD Glucose-108* UreaN-15 Creat-1.0 Na-140
K-4.3 Cl-101 HCO3-26 AnGap-17
[**2122-10-24**] 05:58AM BLOOD Glucose-148* UreaN-17 Creat-1.1 Na-139
K-4.1 Cl-104 HCO3-24 AnGap-15
[**2122-10-23**] 06:35AM BLOOD Glucose-172* UreaN-18 Creat-0.9 Na-140
K-4.2 Cl-103 HCO3-21* AnGap-20
[**2122-10-22**] 12:30PM BLOOD Glucose-156* UreaN-22* Creat-1.0 Na-142
K-4.1 Cl-107 HCO3-24 AnGap-15
[**2122-11-4**] 08:21AM BLOOD CK(CPK)-57
[**2122-11-3**] 04:21PM BLOOD CK(CPK)-46
[**2122-10-26**] 05:30AM BLOOD TotBili-1.1
[**2122-10-25**] 05:41AM BLOOD ALT-18 AST-17 LD(LDH)-258* AlkPhos-92
TotBili-1.2
[**2122-10-24**] 05:58AM BLOOD CK(CPK)-50
[**2122-10-23**] 06:35AM BLOOD ALT-33 AST-16 LD(LDH)-231 AlkPhos-96
TotBili-1.9*
[**2122-10-22**] 12:30PM BLOOD ALT-45* AST-27 AlkPhos-99 TotBili-1.9*
[**2122-11-4**] 08:21AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2122-11-3**] 11:52PM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2122-11-3**] 04:21PM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2122-11-9**] 05:02AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.8
[**2122-11-8**] 04:55AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.8
[**2122-11-6**] 06:35AM BLOOD Calcium-7.5* Phos-2.5* Mg-2.0
[**2122-11-5**] 02:32AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9
[**2122-10-25**] 05:10PM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0
[**2122-11-5**] 02:54AM BLOOD Type-ART pO2-81* pCO2-41 pH-7.36
calHCO3-24 Base XS--1
[**2122-11-4**] 06:12AM BLOOD Type-ART pO2-123* pCO2-40 pH-7.36
calHCO3-24 Base XS--2
[**2122-11-3**] 03:26PM BLOOD Type-ART pO2-361* pCO2-31* pH-7.44
calHCO3-22 Base XS--1
[**2122-10-22**] 12:40PM BLOOD Type-ART O2 Flow-2 pO2-79* pCO2-37
pH-7.42 calHCO3-25 Base XS-0 Comment-NC
[**2122-10-22**] 12:16PM BLOOD Type-ART pO2-68* pCO2-37 pH-7.41
calHCO3-24 Base XS-0
[**2122-11-3**] 03:26PM BLOOD Glucose-133* Lactate-1.5 Na-136 K-3.9
Cl-109
[**2122-11-5**] 02:54AM BLOOD freeCa-1.21
Brief Hospital Course:
After transfer pt underwent cardiac cath. Found severe 3 vessel
disease - no intervention undertaken. EF was 20-30%. Decision
was made to have colectomy to avoid further blood loss. ECG
showed wenkebach heart block. Pacemaker was placed on [**10-29**]
without complications for block. Swan was placed in cath lab on
[**10-29**] and pt was tx to CCU for obs afterwards. O/N he had temp
to 101.4. Started on Levo/Flag/vanc. Surgery was postponed.
Swan was pulled and he was sent back to the med service. AM
[**2122-11-3**] he had swan put in and then underwent R colectomy w/o
complications. Went to ICU post op for monitoring. He was
given fluids post-op did well, diet was advanced as tol, pain
was well controlled. On [**11-10**] he had a perm pacemaker put in by
EP He had a BM on [**2122-11-11**] and had his foley cath removed. EP
adjusted pacemaker as needed throughout visit. He was in good
condition for d/c to rehab on [**2122-11-11**].
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Medications
Insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Colon Mass
Coronary artery disease
Non insulin dependent diabetes
Hypertension
Discharge Condition:
Good
Discharge Instructions:
If you have fever >101, severe pain, persistent diarrhea or
vomiting, blood or discharge draining from wound, or anything
that causes you concern, please call or return.
Follow-up with heme-onc
Follow-up with Dr. [**First Name (STitle) **]
Followup Instructions:
Call Dr. [**First Name (STitle) **] for an appointment ([**Telephone/Fax (1) 3618**]
Call hematology and oncology for an appointment ([**Telephone/Fax (1) 14703**]
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2207**]
Date/Time:[**2122-11-23**] 2:00
Name: [**Known lastname 11249**],[**Known firstname **] J Unit No: [**Numeric Identifier 11250**]
Admission Date: [**2122-10-22**] Discharge Date: [**2122-11-11**]
Date of Birth: [**2045-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2800**]
Addendum:
He was unable to void s/p d/cing foley and he was sent to rehab
with a foley in place.
Brief Hospital Course:
He was unable to void s/p d/cing foley and he was sent to rehab
with a foley in place.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**]
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2122-11-11**]
|
[
"416.0",
"412",
"250.00",
"427.89",
"693.0",
"428.40",
"153.6",
"426.13",
"401.9",
"V17.3",
"414.01",
"780.6",
"285.9",
"V15.82",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.71",
"37.21",
"37.23",
"99.04",
"45.93",
"37.81",
"88.56",
"38.93",
"89.64",
"37.87",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
10605, 10857
|
10494, 10582
|
405, 467
|
9318, 9325
|
2677, 7174
|
9613, 10471
|
1895, 1912
|
8214, 9084
|
9217, 9297
|
8185, 8191
|
9349, 9590
|
1927, 2658
|
276, 367
|
495, 1655
|
1677, 1718
|
1734, 1879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,953
| 133,774
|
4703
|
Discharge summary
|
report
|
Admission Date: [**2143-7-7**] Discharge Date: [**2143-7-9**]
Date of Birth: [**2069-9-2**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / lisinopril / Nifedipine / Cephalexin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 73 year old male w/ PMH of HTN, Asthma,
paroxysmal atrial fibrillation on warfarin, severe atopic
dermatitis, hypercholesterolemia, CKI, anemia who comes in today
with increase pain on his right flank area and 10 poin Hct drop
within the last 4 days on the setting of INR of 8.2 this week.
Pt was last admitted in early [**Month (only) **] for herpes zoster and acute
on chronic renal failure and he was found to have normocytic
anemia with + SPEP/ - UPEP. He had a 2nd admission in [**Month (only) **] for
acute on chronic renal failure which was thought to be related
to hypovolemia. His Hct was 23./Hgb 8.2 from Hct of upper 20s a
few days before. He was
also transfused with 2 units PRBCs which he responded well. He
had heme eval and had a bone marrow biopsy on [**2143-5-24**] which
reported mild erythroid dyspoiesis suggesting the possibility of
an early evolving MDS. Cytogenetics and FISH for MDS were
negative. He states that since his last hospitalization he has
continued to feel fatigued and saw his hematologist this week on
Tues. On that day, he had blood work which showed a Hct of
29.9/10.1 on [**7-2**]. He states that he lifted a heavy gallon of
water with his right hand and he reached over a barrel earlier
in the week. He then developed right lower back pain which
progressed to right flank pain. His INR was checked on Friday
which was 8.1. His coumadin was held since then. Today he states
that the pain on his right flank was unberrable and he came to
the ED for eval.
In the ED his vitals were 98.1 112 122/81 18 95% RA. He had CT
of his abd which showed right retroparitoneal hemorrhage
involving the right psoas muscle along with a 4.4 x 3.6 cm focal
hematoma adjacent in the right lower quadrant. His labs were
notable for Hct of 20.2 (from 29 earlier in the week)with
repeat of 19.2. Plalets of 305, WBC 12.3 (N:79.4 L:9.6 M:6.7
E:3.8 Bas:0.5), PT 48.8/INR 5.2/PTT: 43.4, creatine is stable
at 1.9. He was given 10mg of Vit K, 2 units of FFP and was
typed and crossed. He was also given 4mg of morphine for pain
with some effect. His EKG- A-fib with RVR in the 110s, but no
other significant change. Surgery was consulted and recommended
close monitoring with medicine admission.
.
On arrival to the floor, patient is pale. He appears well in
NAD. His HR is tachy at 120s-130s, he complains of pain on the
right flank area.
.
ROS: As per HPI, he had some nausea related to pain, no
vomiting, no bloody stools or melena. He has complain of
constipation and occ straining. No changes in his bladder
pattern, no hematuria. + fatigue, but no fever, no chills, no
SOB, no chest pain, no DOE, no orthopnea. No dizziness.
Past Medical History:
--HTN
--Asthma
--Atrial fibrillation, on warfarin
--Atopic dermatitis
--Hypercholesterolemia
--Chronic kidney disease (creatine from 1.4-2.3 in the last 2
months)
--s/p UGI bleed in [**2130**] from two gastric ulcers, H. pylori neg
--hx of colonic adenomas on colonoscopy in [**2133**]
--s/p appendectomy
--Normocytic anemia- recent BM bx on [**5-24**] which showed mild
erythroid dyspoiesis suggesting the possibility of an early
evolving MDS. Cytogenetics and FISH for MDS were negative.
--Herpes Zoster on upper back in [**2143-5-8**]
-- gout
Social History:
Originally from [**Country 19828**]; came to USA in the [**2091**]. Married. Lives
with his wife. Three adult daughters. [**Name (NI) 1403**] as a physicist for
radiation oncology at [**Hospital1 112**]/[**Company 2860**]. Previously employed by [**Hospital1 18**]. He
drinks occ (no ETOH recently), no smoking. No drugs.
Family History:
Mother died of complications of childbirth. Father died in his
90s from complications of an aortic aneurysm. Brother died of
cancer of unknown primary. Son died 10 years ago by drowning
during a caving expedition. Three daughters are alive and well.
Multiple family members have eczema.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: =98.5, 127, 164/81, 15, 100% on RA
GENERAL: Well-appearing, pale male in NAD, comfortable,
appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear.
NECK: Supple, no JVD.
HEART: tachycardic, 2/6 SEM radiating to axilla.
LUNGS: CTA bilat, wheeziing on upper airway
ABDOMEN: Soft/NT/ND, tender over right lower quad and right
flank area, no area of induration noted. Echymosis on right
flank. No rebound/guarding.
EXTREMITIES: WWP, no c/c/e.
SKIN: Diffuse erythema secondary to atopic dermatitis.
NEURO: Awake, A&Ox3
PE EXAM ON DISCHARGE:
PHYSICAL EXAM ON ADMISSION:
VS: T=96.2, 87, 130/74, 18, 97% on RA
GENERAL: Well-appearing, in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: Irreg, 2/6 SEM radiating to axilla.
LUNGS: CTA bilat
ABDOMEN: Soft/NT/ND, no area of induration noted. Echymosis on
right flank. No rebound/guarding.
EXTREMITIES: WWP, no c/c/e.
SKIN: Diffuse erythema secondary to atopic dermatitis.
NEURO: Awake, A&Ox3
Pertinent Results:
Admission labs:
[**2143-7-7**] 11:30AM BLOOD WBC-12.7* RBC-2.08*# Hgb-6.8*# Hct-20.2*#
MCV-97 MCH-32.6* MCHC-33.6 RDW-17.4* Plt Ct-305
[**2143-7-7**] 11:50AM BLOOD WBC-12.3* RBC-1.98* Hgb-6.4* Hct-19.2*
MCV-97 MCH-32.4* MCHC-33.4 RDW-16.9* Plt Ct-302
[**2143-7-7**] 07:57PM BLOOD Hct-19.8*
[**2143-7-8**] 12:20AM BLOOD WBC-10.0 RBC-2.89*# Hgb-9.1*# Hct-26.6*#
MCV-92 MCH-31.6 MCHC-34.4 RDW-16.5* Plt Ct-215
[**2143-7-8**] 04:29AM BLOOD WBC-11.1* RBC-2.95* Hgb-9.2* Hct-27.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-16.8* Plt Ct-220
[**2143-7-7**] 11:30AM BLOOD Neuts-79.8* Lymphs-9.5* Monos-6.0
Eos-4.2* Baso-0.5
[**2143-7-7**] 12:37PM BLOOD PT-48.8* PTT-43.4* INR(PT)-5.2*
[**2143-7-7**] 11:30AM BLOOD Glucose-135* UreaN-51* Creat-1.9* Na-137
K-5.0 Cl-103 HCO3-21* AnGap-18
[**2143-7-8**] 04:29AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.6
DISCHARGE LABS:
[**2143-7-9**] 04:52AM BLOOD WBC-8.7 RBC-3.03* Hgb-9.5* Hct-28.2*
MCV-93 MCH-31.3 MCHC-33.7 RDW-17.4* Plt Ct-228
[**2143-7-9**] 04:52AM BLOOD PT-12.9 PTT-26.2 INR(PT)-1.1
[**2143-7-9**] 04:52AM BLOOD Glucose-145* UreaN-33* Creat-1.1 Na-139
K-4.5 Cl-107 HCO3-23 AnGap-14
[**2143-7-9**] 04:52AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.6
IMAGING:
CT ABD AND PELVIS WITHOUT CONTRAST.
IMPRESSION:
Retroperitoneal hemorrhage involving the right psoas muscle
tracking from the level of kidneys all the way down to the
pelvis in the right lower quadrant. there is additionally an
adjacent 4.4 x 3.6 cm focal hematoma. Evaluation for active
extravasation is not possible due to lack of intravenous
contrast.
Brief Hospital Course:
A/P: This is a 73 yo male w/ pmh signficant for HTN, normocytic
anemia w/ BM bx on [**5-24**], A-fib on coumadin with
supratherapeutic INR of 8 this week who presents with right
flank pain and 10 point Hct drop who is found to have
retro-peritoneal bleed and is HD stable.
.
ACTIVE ISSUES:
# Retroperitoneal bleed: Patient presented with flank pain and
acute drop in hematocrit and was found to have large
retroperitoneal bleed. This was in the setting of a
supratherapeutic INR of 8 this week. Patient also had a bone
marrow biopsy 1.5 months however it did not appear to be
related. This incident may have been related by reaching over a
barrel and picking up heavy water gallon. Patient received a
total of 4 units of pRBCs and 2 units of FFP as well as 10mg of
vitamin K. Serial hematocrits remained stable. Patient's pain
slowly improved. Given hemodynamic stability and stable Hct,
patient was discharged directly from the ICU with close PCP and
cardiology follow up. Patient to have hct rechecked 1-2 days
after discharge and follow up with [**Hospital 191**] [**Hospital 1944**] clinic.
Anticoagulation was held prior to discharge.
.
# A-fib with RVR: Patient initially presented with HRs in 130s
which was thought to be [**1-9**] volume depletion and pain. With
blood/fluid resuscitation and pain control, HRs trended to 100s
and after reinstitution of beta blocker, patient HRs were within
normal limits. No changes were made to beta blockade. Patient to
follow up with cardiology prior to restarting anticoagulation.
Dr. [**Last Name (STitle) **] (patient's cardiologist) was made aware prior to
discharge via E-mail.
.
INACTIVE ISSUES:
# Dermatitis
# Asthma
# Gout
.
TRANSITIONAL ISSUES:
- Active Issues: Trend Hct and address anticoagulation
- Pending: None
- Code Status: Full
Medications on Admission:
-ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
[**12-9**] puff four times a day as needed for asthma
-BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply each day to
affected areas.. After 20 days, do not use this cream for 10
days. daily as needed for rash
-CLOBETASOL - 0.05 % Ointment - apply daily for 2 to 4 weeks
then
daily for 2 weeks per month as needed
-CLOBETASOL [CLOBEX] - 0.05 % Shampoo - for use on scalp for 2
weeks daily as needed for red, irritated scalp
-FLUTICASONE [FLOVENT HFA] - (Not Taking as Prescribed: using
once a day) - 110 mcg/Actuation Aerosol - 1 puffs twice a day
-HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth at
bedtime
as needed for itching. [**Month (only) 116**] be sedating.
-METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet Extended
Release
24 hr - 1 Tablet(s) by mouth daily
-OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**12-9**] Tablet(s) by
mouth three times a day as needed for pain. Take with stool
softener.
-SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
-TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply daily for 2 to 4
weeks
-TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - Use to eczema 1-2
times a day as needed. Avoid face, groin, axillae.
-WARFARIN - 2 mg Tablet - --- Tablet(s) by mouth up to 3 tablets
daily take as directed by [**Hospital3 **]
-CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider)
-
1,000 unit Capsule - 1 Capsule(s) by mouth once a day
-MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-9**] Inhalation four times a day as needed for shortness of
breath or wheezing.
2. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for itching.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours: You should not drive or do anything
that requires alertness.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. clobetasol 0.05 % Cream Sig: One (1) application Topical
once a day: apply daily for 2 weeks.
9. Outpatient Lab Work
Please have blood work done on [**7-10**] prior to seeing your doctor
on Thurs.
- CBC
- BMP
- PT/INR, PTT
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Retroperitoneal bleeding
- A-fib with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. [**Known lastname 19829**],
It was a pleasure taking care of you. You were admitted to [**Hospital1 **] for right groin and low back pain. You were
found to have a retroperitoneal bleed (bleeding into one of the
muscles in your back) in the setting of having very high INR
(coumadin levels). Your anticoagulation was stopped and you were
given vitamin K to try to reverse the coumadin effects. You were
also given 4 units of blood and 2 bags of plasma. You were
evaluated by surgery and you did not required to have surgery.
Your blood counts remained stable which gives an indication that
your bleeding has stopped. However it is extremely important
that you have close follow-up and repeat blood work on Thurs.
We have made the following changes to your medications:
-STOPPED COUMADIN(WARFARIN)- please discuss with your
cardiologist and your primary care doctor when this should be
restarted.
Followup Instructions:
Please call Dr[**Name (NI) 1565**] office if you do not hear from them
by the end of the week. You will need to have a follow-up
appointment within the next 1-2 weeks.
Department: [**Hospital3 249**]
When: Thursday [**7-11**] at 1:50 PM With: DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST
[**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.**
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2143-7-11**]
|
[
"V58.61",
"285.21",
"285.9",
"286.9",
"272.0",
"493.90",
"403.90",
"584.9",
"585.9",
"459.0",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11244, 11250
|
6907, 7182
|
325, 332
|
11347, 11347
|
5346, 5346
|
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|
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|
11498, 12249
|
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|
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|
8624, 8699
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|
8555, 8586
|
5362, 6169
|
4884, 5327
|
11362, 11474
|
3054, 3602
|
3618, 3942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,025
| 102,840
|
27155
|
Discharge summary
|
report
|
Admission Date: [**2110-12-12**] Discharge Date: [**2110-12-22**]
Date of Birth: [**2045-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64yoM s/p OP CABGx4 on [**11-20**] discharged to rehab on [**12-11**].
Returned to Emergency prior to scheduled dialysis complaining of
shortness of breath. While in the emergency room the patient was
found to be anemic with a Hct of 20. He was admitted to the
cardiac surgery ICU and transfused with several units of PRBC's.
Additionally a GI bleed workup was initiated including a consult
to the GI service. His Hct increased appropriately to the packed
cells and a source for his bleeding was never identified. His
stools remained guiac negative throughout the hospitalization.
Past Medical History:
Coronary artery disease
s/p off pump cabg x4
[**2110-4-9**] - BMS (Driver) to OM1
[**2110-7-24**] - 95% in-stent thrombosis of OM1, tx with 2 DES (Xience)
in the proximal OM1 extending to the circumflex with no residual
stenosis; distal L Cx occluded
- per cath report, left main without significant disease
- LAD with 30-40% plaque after large septal branch
- known RCA occlusion with collateral flow
Dyslipidemia
ESRD on HD M/W/F
COPD
s/p CVA L MCA [**3-16**]
s/p CVA R MCA [**3-18**]
secondary hyperparathyroidism
Social History:
-Tobacco history: + [**12-12**] ppd
-ETOH: none recently, but + history
-Illicit drugs: pt denies
Family History:
No hx of CAD, MI, DM per daughter.
Physical Exam:
Discharge
VS T 98.4 BP 109/61 HR 76SR RR 20 O2sat 93%-RA Wt 102.7K
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR, sternum stable. Incision CDI
Pulm diminished bilat @ bases
Abdm soft, NT/+BS
Ext warm, extensive scar tissue bilat. Old wound left knee, with
some necrotic and fibrinous tissue. Small amount of
sero-purulent drainage.
Pertinent Results:
[**2110-12-12**] 11:35PM PLT COUNT-281
[**2110-12-12**] 11:35PM PT-16.1* PTT-28.2 INR(PT)-1.4*
[**2110-12-12**] 07:50PM GLUCOSE-93 UREA N-22* CREAT-3.2*# SODIUM-148*
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-38* ANION GAP-11
[**2110-12-12**] 07:50PM CK(CPK)-54
[**2110-12-12**] 07:50PM cTropnT-0.12*
[**2110-12-12**] 07:50PM WBC-9.8 RBC-2.26* HGB-6.9* HCT-20.2* MCV-89
MCH-30.5 MCHC-34.1 RDW-17.2*
[**2110-12-22**] 08:20AM BLOOD WBC-6.6 RBC-3.27* Hgb-9.8* Hct-29.8*
MCV-91 MCH-30.1 MCHC-33.0 RDW-16.4* Plt Ct-257
[**2110-12-22**] 08:20AM BLOOD Plt Ct-257
[**2110-12-15**] 03:10AM BLOOD PT-16.5* PTT-29.7 INR(PT)-1.5*
[**2110-12-22**] 08:20AM BLOOD Glucose-82 UreaN-33* Creat-7.5*# Na-139
K-4.6 Cl-102 HCO3-29 AnGap-13
[**2110-12-13**] 08:19PM BLOOD Hapto-147
[**2110-12-16**] 10:09AM BLOOD PTH-1008*
[**2110-12-22**] 08:20AM BLOOD Vanco-20.1*
[**2110-12-12**] 8:00 pm BLOOD CULTURE #2/FEMORAL.
**FINAL REPORT [**2110-12-20**]**
Blood Culture, Routine (Final [**2110-12-20**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
2ND MORPHOLOGY FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2408**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). FINAL
SENSITIVITIES.
Sensitivity testing performed by Sensititre.
ERYTHROMYCIN = Resistant AT >4 MCG/ML.
GENTAMICIN = Resistant AT 16 MCG/ML.
Penicillin = Resistant AT 8 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CORYNEBACTERIUM SPECIES (DI
| | |
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R R
GENTAMICIN------------ =>16 R 8 I R
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN G---------- =>0.5 R =>0.5 R R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S <=1 S
VANCOMYCIN------------ 2 S 2 S <=1 S
Aerobic Bottle Gram Stain (Final [**2110-12-13**]):
REPORTED BY PHONE TO [**Doctor First Name **] OVERLAND @ 7PM [**2110-12-13**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2110-12-14**]):
GRAM POSITIVE COCCI IN CLUSTERS.
=
=
=
=
=
=
=
=
=
=
=
================================================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 66637**] M 64 [**2045-12-30**]
Radiology Report CHEST (PA & LAT) Study Date of [**2110-12-21**] 9:34 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2110-12-21**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 66639**]
Reason: eval for pleural effusions
Final Report
HISTORY: Status post CABG. Evaluate pleural effusions.
CHEST, TWO VIEWS.
A right IJ central line is present, tip over mid SVC. No
pneumothorax is
detected.
The patient is status post sternotomy. There is mild prominence
of the
cardiomediastinal silhouette, unchanged compared with [**2110-12-16**].
There is a
small left effusion and patchy increased retrocardiac density,
essentially
unchanged. There is minimal pleural thickening along the right
chest wall and blunting of the right costophrenic angle. This is
more apparent on today's exam, but not clearly changed. No CHF.
Probable background hyperinflation.
IMPRESSION: Small bilateral pleural effusions, unchanged on the
left and
probably unchanged on the right, though thelatter is better seen
on today's examination.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: [**First Name8 (NamePattern2) **] [**2110-12-21**] 3:53 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 66640**]TTE (Complete)
Done [**2110-12-15**] at 3:28:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-12-30**]
Age (years): 64 M Hgt (in): 70
BP (mm Hg): 88/49 Wgt (lb): 190
HR (bpm): 73 BSA (m2): 2.04 m2
Indication: R/o Endocarditis , s/p CABG.
ICD-9 Codes: 424.90, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2110-12-15**] at 15:28 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W004-0:57 Machine: Vivid [**6-17**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 87 ml/beat
Left Ventricle - Cardiac Output: 6.38 L/min
Left Ventricle - Cardiac Index: 3.13 >= 2.0 L/min/M2
Aorta - Sinus Level: *4.2 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 206 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2110-11-10**].
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderate regional LV systolic dysfunction. Trabeculated LV apex.
Estimated cardiac index is normal (>=2.5L/min/m2). No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the distal half of the septum and anterior
walls and distal inferior wall. The apex is akinetic and mildly
aneurysmal. No definite thrombus is identified (cannot exclude
due to suboptimal views). . The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated at
the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) 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 [**2110-11-10**],
left ventricular systolic function is slightly improved and the
estimated pulmonary artery systolic pressure is reduced.
CLINICAL IMPLICATIONS:
Based on [**2108**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2110-12-15**] 17:54
[**Known lastname **],[**Known firstname **] [**Medical Record Number 66637**] M 64 [**2045-12-30**]
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2110-12-13**]
10:29 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2110-12-13**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O
CONTRAST Clip # [**Clip Number (Radiology) 66641**]
Reason: source of bleeding**with and without contrast
[**Hospital 93**] MEDICAL CONDITION:
64 year old man acute anemia
REASON FOR THIS EXAMINATION:
source of bleeding**with and without contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CT TORSO WITHOUT INTRAVENOUS CONTRAST
INDICATION: 64-year-old man with acute anemia, evaluate for
source of
bleeding.
COMPARISON: [**2110-12-9**] and [**2110-11-12**].
TECHNIQUE: MDCT axial images of the torso were obtained without
administration of oral or intravenous contrast. Coronal and
sagittal
reformatted images were obtained.
CT CHEST WITHOUT INTRAVENOUS CONTRAST: Bilateral large pleural
effusions are present, the left is slightly increased in size,
when compared with the prior study. The density values of the
effusions are still low to suggest presence of a hemorrhage.
There is adjacent compression atelectasis bilaterally. Again
note is made of aortic arch calcifications. The ascending aorta
measures approximately 4.2 cm maximum dimension. There is a
small amount of pericardial fluid. No significant mediastinal,
hilar or axillary lymphadenopathy is noted.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Re-demonstrated is a
small
diaphragmatic node, measuring now 8 mm in the short axis
diameter.
Low attenuation splenic collection measures 8.9 x 7.1 cm, better
imaged than on the prior study.
There is cholelithiasis, no evidence of acute cholecystitis. The
kidneys are atrophic. Non-contrast evaluation of the pancreas,
adrenal glands, abdominal loops of large and small bowel is
unremarkable. There are dense vascular calcifications. There is
no free air and no free fluid in the abdomen.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The prostate contains
coarse central calcifications. The seminal vesicles, rectum,
sigmoid colon are unremarkable. There is no free pelvic fluid,
no pathologically enlarged pelvic or inguinal lymph nodes. There
is no evidence of retroperitoneal hematoma.
Soft tissues demonstrates diffuse stranding, compatible with
total body edema.
BONE WINDOWS: Demonstrate multilevel degenerative changes, there
is
heterogeneous appearance of the osseous structures, compatible
with renal
osteodystrophy. Remote fracture of the left inferior and
superior pubic rami are again seen.
IMPRESSION:
1. 9 cm splenic collection, not entirely characterized in the
absence of IV contrast, could represent a subacute hematoma,
infected collection cannot be excluded.
2. Low attenuation bilateral left greater than right effusions
with
compression atelectasis. The density values of the effusions
argue against
hemorrhage, however this could be confirmed with thoracentesis.
3. Dilated ascending aorta, extensive vascular and coronary
artery
calcifications and right common iliac artery aneurysm measuring
18 mm.
4. Cholelithiasis, no evidence of acute cholecystitis.
The study and the report were reviewed by the staff
radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: MON [**2110-12-15**] 12:48 PM
Brief Hospital Course:
Mr [**Known lastname 7518**] was admitted the the cardiac surgery service and
transfused with several units of packed red blood cells. He had
a gasteroenterolgy and general surgery consult, they did not
feel there was any indication to scope the patient at this time
as he was guiac negative and his hematocrit rose predictably and
remained stable.
The patient also had blood cultures checked, it was positive for
Cornybacterium and he was started on a 2 week course of
Vancomycin. All lines were changed.
He was also relatively hypotensive with a SBP that frequently
was in the 85-95 range despite being off all antihypertensives.
He was started on Midodrine and his systolic blood pressure rose
and remined stable in the 100-110 range.
On hospital day 11 it was decided he was stable and ready for
transfer to rehabilitation.
Medications on Admission:
Epo
Plavix
ASA
Simvastatin
protonix
albuterol
Atrovent
Percocet Cinacalet
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous HD PROTOCOL (HD Protochol) for 5 days: thru [**12-27**].
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 4400 (4400) units
Injection Q HD.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 64102**]
Discharge Diagnosis:
CAD s/p OP CABG X4([**11-20**]), ESRD(HD), ^cholesterol, Secondary
hyperparathyroidism, COPD, CVA, s/p GI bleed
Discharge Condition:
stable
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr [**Last Name (STitle) 7772**] in [**1-13**] weeks
Dr [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **] in [**1-13**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-12-22**]
|
[
"588.81",
"428.22",
"578.9",
"584.9",
"272.4",
"V12.54",
"511.9",
"790.7",
"041.19",
"707.22",
"032.9",
"V45.81",
"496",
"285.1",
"428.0",
"289.59",
"707.03",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.04",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
17365, 17437
|
15147, 15976
|
343, 350
|
17593, 17602
|
2040, 9938
|
17804, 18074
|
1634, 1670
|
16100, 17342
|
12105, 12134
|
17458, 17572
|
16002, 16077
|
17626, 17781
|
9982, 11179
|
1685, 2021
|
11202, 12065
|
284, 305
|
12166, 15124
|
378, 960
|
982, 1500
|
1516, 1618
|
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