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14,087
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10557
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Discharge summary
|
report
|
Admission Date: [**2198-11-6**] Discharge Date: [**2198-11-16**]
Date of Birth: [**2152-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Intubation, paracentesis
History of Present Illness:
46 year old spanish speaking man with hx. alcoholism who
presents to the ED today complaining of constant, sharp, upper
abdominal pain radiating to his back. In the ED, was found to
be in afib with rvr (HR 156) with BP 79/69. He was given 4
litres of NS and started on a diltiazem drip with HR down to
approx 110.
His abdomen became markedly distended with fluids, and he
underwent a diagnostic and therapuetic tap for 1.5 litres of
fluid: Neg. for SBP. With abdominal distension, he developed
progressive respiratory distress, and was intubated, with versed
and fentanyl sedation. He was given Vancomycin, Levofloxacin,
and Flagyl emperically. He had an OG placed with return of
coffee-grounds. He was also noted to have guaiac positive
stools. Liver and GI were consulted. He was sent to CT for
scan of abdomen en route to SICU/ MICU Green team. Surgery was
additionally consulted for evaluation for Abdominal Compartment
Syndrome.
Past Medical History:
-h/o alcohol withdrawal seizures
-biceps tendonitis and tendinosis and anterior instability of
left shoulder with recent arthroscopic debridement type 1 slap
tear left shoulder and open modified Bankart repair left
shoulder on [**2197-5-4**]
Social History:
Works as a machinist. Significant history of alcohol abuse with
a history of withdrawal seizures. Pt states he drinks [**1-1**] pint
of Bacardi Rum per day. Per family, he does not use IV drugs or
illicit substances. He does use cigarettes.
Family History:
non-contributory
Physical Exam:
96.7 122 [**Last Name (un) **] 126/70 12 99% on 50% FiO2
NAD
Alert, responding to questions, not on sedation
No JVD
[**Last Name (un) **] [**Last Name (un) **] no MRG
Diminished BS at bilateral bases
Abdomen distended, dull, NT, BS+
1+ edema bilaterally
No rash
OGT draining dark, sanguinous material
2 PIV
Foley
Pertinent Results:
[**2198-11-5**] 10:45PM PT-18.4* PTT-42.0* INR(PT)-1.7*
[**2198-11-5**] 10:45PM PLT COUNT-110*#
[**2198-11-5**] 10:45PM ANISOCYT-1+ MACROCYT-3+
[**2198-11-5**] 10:45PM NEUTS-74.2* LYMPHS-20.2 MONOS-4.6 EOS-0.7
BASOS-0.2
[**2198-11-5**] 10:45PM AMMONIA-46
[**2198-11-5**] 10:45PM ALBUMIN-2.7*
[**2198-11-5**] 10:45PM LIPASE-80*
[**2198-11-6**] 12:10AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2198-11-6**] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-4* PH-7.0 LEUK-TR
[**2198-11-6**] 12:10AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2198-11-6**] 12:10AM URINE GR HOLD-HOLD
[**2198-11-6**] 12:10AM URINE HOURS-RANDOM
[**2198-11-6**] 12:43AM LACTATE-4.1*
[**2198-11-6**] 01:20AM ASCITES WBC-18* RBC-6600* POLYS-29* LYMPHS-36*
MONOS-26* MESOTHELI-8* MACROPHAG-1*
[**2198-11-6**] 02:10AM PLT SMR-LOW PLT COUNT-95*
[**2198-11-6**] 02:10AM NEUTS-83.5* BANDS-0 LYMPHS-12.6* MONOS-2.9
EOS-0.6 BASOS-0.4
[**2198-11-6**] 02:10AM WBC-9.9 RBC-2.93* HGB-10.9* HCT-32.8*
MCV-112* MCH-37.3* MCHC-33.3 RDW-15.8*
[**2198-11-6**] 02:19AM LACTATE-4.0*
[**2198-11-6**] 04:30AM PT-19.6* PTT-44.8* INR(PT)-1.9*
[**2198-11-6**] 04:30AM WBC-9.4 RBC-2.89* HGB-10.6* HCT-31.7*
MCV-110* MCH-36.7* MCHC-33.5 RDW-15.6*
[**2198-11-6**] 04:30AM ASA-NEG ETHANOL-129* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2198-11-6**] 04:30AM CALCIUM-6.2* PHOSPHATE-2.9# MAGNESIUM-1.6
[**2198-11-6**] 04:30AM ALT(SGPT)-64* AST(SGOT)-208* ALK PHOS-181*
TOT BILI-6.9*
[**2198-11-6**] 04:30AM GLUCOSE-93 UREA N-7 CREAT-0.7 SODIUM-134
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-22 ANION GAP-17
[**2198-11-6**] 05:10AM LACTATE-3.2*
[**2198-11-6**] 05:10AM TYPE-ART PO2-97 PCO2-35 PH-7.44 TOTAL CO2-25
BASE XS-0
[**2198-11-6**] 01:22PM CALCIUM-7.5* PHOSPHATE-2.6* MAGNESIUM-2.6
[**2198-11-6**] 01:22PM POTASSIUM-3.7
[**2198-11-6**] 02:37PM HCT-30.6*
[**2198-11-6**] 06:32PM ASCITES TOT PROT-1.3 AMYLASE-26
Smooth POSITIVE TITER 1:160
ANCA-NEGATIVE
[**2198-11-9**] 04:45AM 1 2
1 POSITIVE
2 NEGATIVE
REVIEWED BY DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
IMMUNOLOGY [**Doctor First Name **] Titer
[**2198-11-9**] 04:45AM POSITIVE 1:801
1 1:80
PATTERN-SPECKLED
LIVER OR GALLBLADDER US (SINGL Clip # [**Clip Number (Radiology) 34745**]
Reason: eval for obstruction and please also [**Clip Number (Radiology) **] for
paracentesis
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with ETOH cirrhosis and ascites. now w/
pancreatic enzyme
elevation and abd pain
REASON FOR THIS EXAMINATION:
eval for obstruction and please also [**Hospital **] for paracentesis
Final Report
ABDOMINAL ULTRASOUND
INDICATION: 46-year-old man with ETOH cirrhosis and ascites,
now with
pancreatic enzyme elevation, abdominal pain, evaluate for
obstruction. Please
also [**Hospital **] for paracentesis.
ABDOMINAL ULTRASOUND: Comparison is made to prior examination
dated [**2198-11-7**].
Again noted is a coarse echogenic liver. No focal lesions are
seen. The
gallbladder is filled with sludge, however the gallbladder is
not dilated.
There is a small amount of ascites surrounding the liver. A
small-to-moderate
amount is seen in the left lower quadrant as well. The common
bile duct is
not dilated measuring 6 mm.
IMPRESSION:
1. Coarse echogenic liver consistent with cirrhosis. No focal
liver lesions
are identified.
2. Gallbladder filled with sludge.
2. Small-to-moderate amount of ascites.
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: WED [**2198-11-14**] 10:01 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 354**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA7A [**2198-11-13**]
CT ABD W&W/O C; CT PELVIS W&W/O C Clip # [**Clip Number (Radiology) 34746**]
Reason: please r/o nephrolithiasis, also evaluate pancreas as
enzyme
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with EtOH cirrhosis now w/ intermittant CVA
tendernesss
radiating to his groin. UA w/ blood
REASON FOR THIS EXAMINATION:
please r/o nephrolithiasis, also evaluate pancreas as enzymes
tripled over past
4 days
CONTRAINDICATIONS for IV CONTRAST:
None.
Preliminary Report
HISTORY: 46-year-old man with alcoholic cirrhosis with CVA
tenderness
radiating to his groin. Evaluate for nephrolithiasis and also
evaluate
pancreas for elevated enzymes.
TECHNIQUE: Multidetector contiguous axial images of the abdomen
and pelvis
were obtained both prior to and following the administration of
intravenous
contrast with reformatted images in the coronal and sagittal
planes.
Comparison was made to a prior study of [**2198-11-6**].
CT ABDOMEN: Images through the lung bases demonstrates a small
left-sided
pleural effusion, which has decreased compared to the study of
one week prior.
Previously seen lower lobe consolidations are predominantly
resolved on the
right, but are decreased and present on the left. Calcified
granuloma is seen
at the left lung base as well as a calcified left hilar node is
again noted.
Again noted is a diffusely low attenuation liver consistent with
fatty
infiltration. The vasculature of the liver is patent. Again
noted is a
distended gallbladder with sludge unchanged. The pancreas is
normal in
appearance and enhances uniformly. The spleen, adrenal glands,
left kidney,
and stomach are grossly normal. The aorta and mesenteric
vessels remain
patent.
There is a large amount of ascites; however, it is slightly
decreased compared
to the study of one week ago.
Within the lower pole of the right kidney, there is a 3 mm
nonobstructing
stone seen. The loops of small bowel are mildly dilated and
edematous, no
transition point is seen. In the mid ileum, there is focal area
of narrowing
of the ileum (image 65), which is likely secondary to
peristalsis.
Multiple mesenteric lymph nodes measuring up to 6 mm in short
axis diameter
remain unchanged. Small retroperitoneal lymph nodes measuring
up to 6-7 mm in
diameter (aortocaval and left paraaortic) are noted. There is
anasarca.
CT PELVIS: The distal ureters, bladder are normal in
appearance. The sigmoid
colon is collapsed. There is no free air in the abdomen or
pelvis.
BONE WINDOWS: No suspicious lytic or blastic lesions.
Findings were discussed by telephone with Dr. [**Last Name (STitle) **]. Matloff on
[**2198-11-13**].
IMPRESSION:
1. Small 3 mm nonobstructing stone in the lower pole of the
right kidney. No
hydroureter or hydronephrosis on either side.
2. Normal appearance of the pancreas with normal enhancement.
3. Mildly dilated small bowel loops with edema and mildly
edematous right
colon. No transition point seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
1. Atrial fibrillation - apparently was clinically unstable on
presentation to the ED - with diltiazem had suboptiamal rate
control. Dilt gtt increased in the unit to 15/hr and pt.
digoxin loaded with rate control and subsequent conversion to
NSR. After converting to NSR, the digoxin and diltiazem was
D/C'ed, and a low dose of lopressor was begun. The patient
remained in sinus rhythm throughout the rest of his admission.
.
2. Respiratory failure: Likely d/t accumulation of crystaloid in
the abdominal compartment with aggressive IVF in the setting of
hypotension and concern for sepsis. Appeared very comfotable on
admission to the ICU - extubated without complication the next
morning. The patient did not have any more respiratory distress
during the coarse of his admission.
.
3. Abdominal pain - CT and U/S of abdomen neg. Pain resolved
spontaneously. On the sixth day of his admission, the patient
experienced some diffuse abdominal pain that was worst in the
epigastrum, and radiated up to the chest and lower in the
abdomen bilaterally. An EKG was done, which showed no
significant change from prior EKG. The patient was given
Mylanta, which dramatically improved his pain. He continued to
have intermittent abdominal pain, with some diffuse back pain in
the context of a low-grade fever. Due to concern for an occult
infection, repeat CT and US were done, which agian showed no
evidence of cholecystitis or pancreatitis. On CT, a R-sided,
non-obstructing kidney stone was found. By the time these
studies were completed, the patient's abdominal pain had
resolved.
#Low Grade fevers: On the eighth day of his admission, the
patient began having low grade fevers. Since the patient had
also been having some abdominal pain CT and US were done (see
above). Given thise negative findings, along with a suspiscious
UA (few bacteria, nitrite positive), and the fact that a foley
had been in place for a week, a UTI was suspected. A 7 day
course of ciprofloxacin 250mg [**Hospital1 **] was initiated.
.
4. ? Sepsis - no evidence for this, pt. does not have a white
count, no fever, lactate elevation likely due to liver
dysfunction alone, and hypotension was in the setting of AFib
with RVR. Had GPC in initial urine cx., but corresponding UA
wihtout pyuria.
.
5. GIB - OGT draining coffee grounds of small volume. Guaiac
positive. HCT stable, liver following. The patient got an EGD
on the second day of his admission, which showed esophagitis and
linear ulcerations in the esophagus, but no varicies. The
ulcerations could account for the guiac + stools. Per liver
recs, the patient was started on Carafate, and an oral ppi. His
HCT improved over the course of his admission. During his
admission, the patient was tested for H. Pylori, which was
positive. Treatment was initiated with a 10 day course of
amoxicillin, Clarithromycin, in addition to his protonix. He
will continue this 10 day regimen upon discharge.
.
6. Ascites/ liver disease: Fatty liver on CT. Large amount of
ascites. INR is 1.7. Tapped for 1.5 litres in the ED, neg for
SBP. Liver then recommended starting the patient on
spironolactone and lasix, which was done. Over the following
days, the patient's ascitic fluid decreased based on physical
exam. He was given extra lasix IV to increase his urine output,
which was low. On the 6th day of his admission, the patient
began to make more urine, without supplemental lasix. At this
time, the patient's creatinine level began to normalize (1.2 to
0.9).
He did have some low grade fevers for three (see above) days
prior to discharge. Due to risk of SBP, a repeat paracentesis
was done, which showed no evidence of SBP. He is scheduled to
follow up with the liver team as an outpatient.
#Thrombocytopenia: Upon admission, the patient's platelet count
was decreased (85). This is likely due to the patient's liver
disease. During the admission, the platelet count did improve
(to 116).
# FEN: The patient was given a regular diet. By the 6th day of
his admission, he began taking in good PO's.
#PPx: Due to the patient's liver disease, his INR was elevated
and did not require DVT prophylaxis with Heparin.
#Disposition/follow up: The patient is scheduled to see his PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] on Monday, [**11-19**]. In addition, he is
scheduled for follow up with the liver team and Dr. [**Last Name (STitle) **].
Medications on Admission:
Percocet prn.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 8 days.
Disp:*24 Capsule(s)* Refills:*0*
6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 8 days.
Disp:*32 Tablet(s)* Refills:*0*
7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis of the liver
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**Doctor First Name **] h??????gado
Discharge Condition:
Upon discharge, the patient was hemodynamically stable and
afebrile. He was discharged in stable condition.
Sobre [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 34747**], el paciente fue establo de hemodynamically y
afebrile. El fue descargado en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 34748**]??????n fija.
Discharge Instructions:
Please weigh yourself each morning. If your weight is increased
by 5 lbs or more, [**Name8 (MD) 138**] MD
Please take all medications as directed:
Spironolactone 2 pills once a day
Lasix 1 pill once a day
Ciprofloxacin 1 pill twice a day for 5 days
Amoxocillin 1 pill every 8 hours for 8 days
Clarithromycin 2 pills twice a day for 8 days
Pantoprazole 1 pill once a day
Sucralfate 1 pill twice a day
P??????selo por favor [**Last Name (un) 33424**] ma??????[**Doctor First Name **]. Si [**Doctor First Name **] peso es aumentado por 5 lbs
o m??????s, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 34749**] MD
Tome por favor todas medicinas como dirigido:
Spironolactone 2 p??????ldoras una vez un d??????a
Lasix 1 p??????[**Last Name (Prefixes) **] una vez un d??????a
Ciprofloxacin 1 p??????[**Last Name (Prefixes) **] por 5 [**Last Name (un) **]
Amoxocillin dos veces [**Doctor Last Name **] d??????a 1 p??????[**First Name9 (NamePattern2) **] [**Last Name (un) 33424**] 8 horas por 8 d??????as
Clarithromycin 2 p??????ldoras dos veces [**Doctor Last Name **] d??????a por 8 d??????as
Pantoprazole 1 p??????[**Doctor Last Name **] una vez un d??????a
Sucralfate 1 p??????[**Doctor Last Name **] dos veces [**Doctor Last Name **] d??????a
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**]. You have an
appointment scheduled for Monday, [**11-19**] at 3:40 PM.
[**Telephone/Fax (1) 1792**]
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2199-1-29**] 8:30
Siga por favor con [**Doctor First Name **] fenciclidina, DR. [**Last Name (STitle) 1789**]. Usted tiene cita
planificado para el lunes, 20 de noviembre a las 3:40 [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 34750**]. [**Telephone/Fax (1) 1792**]
El proveedor: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2199-1-29**] 8:30
Completed by:[**2198-12-7**]
|
[
"518.81",
"530.19",
"599.0",
"578.9",
"303.90",
"571.2",
"571.1",
"427.31",
"428.0",
"276.1",
"291.81",
"789.5",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.71",
"45.13",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14589, 14595
|
9240, 13403
|
330, 356
|
14758, 15091
|
2240, 4699
|
16391, 17154
|
1869, 1887
|
13705, 14566
|
6243, 6354
|
14616, 14737
|
13667, 13682
|
15115, 16368
|
1902, 2221
|
13414, 13641
|
276, 292
|
6383, 9217
|
384, 1329
|
1351, 1594
|
1610, 1853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,226
| 168,546
|
33999
|
Discharge summary
|
report
|
Admission Date: [**2193-9-23**] Discharge Date: [**2193-9-26**]
Date of Birth: [**2116-12-21**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Ataxia, Diplopia, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 76 year old right handed woman with a history
of atrial fibrillation not on Coumadin due to noncompliance,
history of prior stroke in left PCA and right MCA territories,
hypertension, hypercholesterolemia, and CHF who presents with
dysarthria, dysphagia, vertical diplopia, feeling imbalanced,
left arm/leg weakness, and vomiting. The history is obtained
from her daughter, who also provided [**Name (NI) 8003**] interpretation.
The patient's daughter was with her from 9:00-11:30 am today,
when her daughter dropped her off at her house at 11:30 am. The
patient may have been slightly more tired than usual, but no
other deficits were noticed. EMS was called to the patient's
house at 5:00 pm (when she presumably activated her emergency
button), and they found her crawling on the floor, "couldn't
move", dysarthric, and started vomiting. She was initially taken
to [**Hospital1 **] [**Location (un) 620**], where her bp on admission was 111/98 but peaked
at 205/85. Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] staff, found her to have left pronator
drift, left arm ataxia, and dysarthria. Her NIHSS was 3 at that
time. Head CT showed hypodensities in the left PCA, right
superior MCA, and putamen territories consistent with old
infarcts. Labs showed WBC 11.2. She was given Zofran 4 mg IV x2
and Phenergan 12.5 mg IV x2 for nausea/vomiting. Given the
clinical concern for a new cerebellar infarct, she was
transferred to [**Hospital1 18**].
Her daughter first saw her at [**Hospital1 18**], where she found her to be
mumbling with dysarthria. She reportedly knows what she wants to
say, but it was not coming out correctly. She complained of
vertical diplopia, dysarthria, and dysphagia. She feels like she
is swaying from side to side, but denies vertigo. She feels as
though her left arm and leg are weak, and she reports numbness
described as pins and needles in her left leg. She has a right
frontal headache, but is confused and unable to rate it on a
scale from [**12-1**]. She currently denies nausea. Per her daughter
(who is translating), she is not always making sense when
answering questions. She has denied fevers.
CTA head/neck and CTP were attempted in the [**Hospital1 18**] ED; however,
the patient could not tolerate this due to a mix of anxiety and
orthopnea.
Past Medical History:
CAD s/p MI [**2182**]
Atrial fibrillation, not on Coumadin since [**8-29**] given
noncompliance/didn't like PT checks
h/o stroke [**2177**] (her daughter and the patient do not know what
her symptoms were), based on head CT has old left PCA and right
superor MCA infarcts
CHF, EF 55-60% in [**12-31**]
Hypertension
Hypercholesterolemia
Pulmonary hypertension
Asthma
Allergic rhinitis
GERD
Social History:
The patient lives alone in senior housing, but
lives 2 blocks away from her daughter. She moved here from
[**Male First Name (un) 36290**] 2 years ago.
HABITS:
She has never smoked, does not drink EtOH, or
use illicit drugs.
Family History:
There is family history of hypertension and
asthma.
Physical Exam:
ON ADMISSION:
VS: temp 97.4, bp 185/89, HR 70, RR 18, SaO2 100% on 4L
Genl: Awake, alert, NAD, actively wretching
HEENT: Sclerae anicteric, no conjunctival injection
CV: Irregularly irregular heart rate, Nl S1, S2, no murmurs,
rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, appears acutely ill. Oriented to
person, says place is [**Location (un) 620**], says date is [**2190**]-[**2191**]. Says age
is 78. Speech is fluent with normal repetition; naming intact to
all stroke scale objects. + dysarthria.
Cranial Nerves: Pupils equally round and reactive to light, 1.5
to 1 mm bilaterally. Extraocular movements intact bilaterally
without nystagmus. Sensation intact V1-V3. Flat left NLF. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal tone in the bilateral UE, increased tone in the
bilateral LE. No observed myoclonus, asterixis, or tremor.
Curling of the left fingers on pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 5 5 5 5 5 3 5 5 5 5 5
L 5 5 5 5 5 5 3 5 5 5 5 5
Sensation: Intact to light touch in the bilateral UE and LE.
Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps.
0
and symmetric in knees and ankles. Toes upgoing bilaterally.
Coordination: Dysmetria with left finger-nose-finger, normal on
the right. Unable to perform heel-knee-shin due to bilateral IP
weakness.
Gait: Unsteady, falling to right.
Pertinent Results:
Admission Labs:
WBC-13.0* RBC-4.42 HGB-12.9 HCT-40.1 MCV-91 MCH-29.2 MCHC-32.2
RDW-13.7
GLUCOSE-130* UREA N-26* CREAT-0.8 SODIUM-147* POTASSIUM-4.0
CHLORIDE-111* TOTAL CO2-28 ANION GAP-12
CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-2.1
CK-MB-NotDone cTropnT-<0.01 CK(CPK)-85
.
URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
.
IMAGING:
.
CT Head without Contrast ([**2193-9-23**]):
FINDINGS: Hypodensity is redemonstrated in a leftPCA
distribution as well as at the right MCA and also in the
putamen, consistent with encephalomalacia from previous
infarction. No evidence of new vascular territorial infarction,
intracranial hemorrhage, edema, or mass effect. The ventricles
and sulci are normal in size and configuration. Trace
calcifications are present bilaterally at the basal ganglia. The
included paranasal sinuses and mastoid air cells are
unremarkable.
.
IMPRESSION: Encephalomalacia as a sequela of remote infarction,
unchanged
from the comparison study done earlier on the same day.
.
CT/A Head, Neck ([**2193-9-24**]):
IMPRESSION:
1. Encephalomalacia as a sequela of remote infarction (left PCA,
right MCA, and putamen distribution regions), overall unchanged
when compared to prior studies.
2. Aortic arch calcification. Overall no stenosis or aneurysm
formation.
3. Small punctate calcifications at the bifurcation of carotid
arteries
without significant stenosis, otherwise unremarkable
intracranial and cervical
vessels.
.
Chest X-ray ([**2193-9-23**]):
IMPRESSION:
1. Suboptimal study due to patient motion, particularly in the
right
mid-to-lower lung fields. Because of this, an ill-defined
opacity is seen,
and right base consolidation/atelectasis and small effusion
cannot be
excluded.
2. Cardiomegaly.
.
Transthoracic Echocardiogram:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No obvious atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers (however, all images suboptimal). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%). The right ventricular
cavity is dilated with normal free wall contractility. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). 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. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
IMPRESSION: Suboptimal image quality. No obvious intracardiac
shunt (but cannot be excluded with certainty on the basis of
this study); mild aortic stenosis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 76 year-old right-handed woman with a past
medical history including
hypertension, hyperlipidemia, CHF with diastolic dysfunction,
atrial fibrillation (not on Coumadin since [**8-29**] due to
noncompliance), and left PCA and right MCA strokes who initially
presented to [**Hospital1 **]-[**Location (un) 620**] with imbalance, dysarthria, dysphagia,
vomiting, and diplopia. A non-contrast CT of the head
demonstrated no acute findings. The patient was given zofran
and phenergan for nausea before transfer to the [**Hospital1 18**] for
further evaluation and care. She was admitted to the stroke
service from [**2193-9-23**] to [**2193-9-26**].
.
1. NEURO/CVS
On transfer to [**Hospital1 18**], a repeat head CT was performed. The study
demonstrated signs of the remote infarctions without evidence of
acute change. 24 hours after the onset of her symptoms, a CTA of
the head and neck was obtained, which demonstrated still no
evidence of new infarction nor significant vessel stenosis.
Although MRI was ordered, the patient was unable to tolerate the
study secondary to anxiety and orthopnea. In the setting of her
risk factors and presenting symptoms, there was considerable
concern for a posterior circulation stroke. Accordingly, a
heparin drip with a goal PTT of 50-70 was initated. Aspirin was
held.
.
To maximize cerebral blood flow, outpatient antihypertensives
were held but were estarted the day prior to discharge with
stable BPs. Lasix was continued in the context of CHF.
Simvastatin was continued at the outpatient dose; fasting lipid
panel showed good levels, with total cholesterol of 139, HDL of
48, LDL of 71, and triglycerides of 100.
.
To evaluate for the role of cardioembolic disease, a
transthoracic echocardiogram was performed. The study showed
[**Hospital1 **]-atrial enlargement, EF of 70%, trace AS, moderate TR, but no
specific cardioembolic source (no PFO/ASD, vegetations, or
thrombus).
.
Importantly, lengthy discussions were held with her, her family,
and her primary care, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **], regarding her use of
Coumadin. Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] detailed the extensive efforts he has gone
through on two prior occasions to keep her safely on Coumadin,
but both times she was unable to reliably take the dose he
prescribed and routinely missed appointments to have her PT/INR
checked. Nonetheless, with her multiple prior strokes, she is at
very high risk of a devastating cardioembolic stroke, and so it
was agreed among all parties that a third attempt will be made.
The hope is that with repeated education of the patient and her
family, better compliance will be achieved.
.
2. ENDO
Insulin sliding scale was initiated with a goal of
normoglycemia.
.
3. ABD/GI
In the setting of dysphagia, a speech and swallow evaluation was
obtained prior to starting an oral diet. She was cleared for a
regular diet with thin liquids. Zofran was provided to
alleviate nausea, which had resolved on discharge.
.
4. ID
She had an isolated temperature of 101F on the night of [**9-24**]
with no source found. U/A showed many bacteria but 0 WBC, with
negative LE and nitrites. She had no further fevers.
.
5. CODE
Full
.
6. HCP
[**Name (NI) **] [**Name (NI) 5749**] (daughter) [**Telephone/Fax (1) 78492**]
Medications on Admission:
Aspirin 81 mg a day
Atenolol 75 mg daily (she was recently decreased to 75 mg from
100 mg daily but may be taking 100 mg instead)
Lisinopril 40 mg daily
Simvastatin 40 mg qhs
Lasix 40 mg daily
Fluticasone 50 mcg 2 puffs daily
Advair 250 mcg-50 mcg 1 puff [**Hospital1 **]
Proair prn
.
Allergies: NKDA
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezes, SOB.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Seven Hundred (700) Units/hr Intravenous ASDIR (AS
DIRECTED): Goal PTT 50-70. Discontinue when INR > 2.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
1. TIA
Secondary:
1. Atrial fibrillation
2. Prior stroke
3. Diastolic Heart Failure
Discharge Condition:
Medically stable. Neurologic exam notable for nystagmus on left
lateral gaze, mild weakness of the left deltoid, pronator drift
of the right UE, dysmetria of the left arm, and unsteady gait.
Discharge Instructions:
You were admitted with difficulty walking and slurred speech.
This may have been a TIA, as no evidence of stroke was seen on
serial head CTs. This may have been related to your atrial
fibrillation, and therefore, after discussion with you, your
family, and your primary care doctor, we have decided to start
you on Coumadin again. This will significantly reduce your risk
of stroke, but it is crucial that you take it exactly as
directed and that you have your blood level (your INR) checked
whenever Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] tells you to. No other medication changes
have been made. Please take all medications as directed and keep
all follow-up appointments.
.
If you have new weakness on one side, facial droop, imbalance,
difficulty with coordination, or any other sudden neurologic
symptom, please call 911. If you have questions about your prior
stroke, you may call Dr. [**First Name (STitle) **] (number below). For questions
about your Coumadin, please call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] (number below).
Followup Instructions:
1. NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time: [**2193-11-11**] 2:00
.
2. Please call [**Telephone/Fax (1) 3070**] on discharge from rehab to schedule
a follow-up appointment with your PRIMARY CARE Provider: [**First Name11 (Name Pattern1) 20**]
[**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2193-9-26**]
|
[
"401.9",
"416.8",
"412",
"435.9",
"428.30",
"414.01",
"272.0",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12714, 12859
|
8029, 11369
|
344, 350
|
12997, 13190
|
5094, 5094
|
14308, 14866
|
3366, 3420
|
11721, 12691
|
12880, 12976
|
11395, 11698
|
13214, 14285
|
3435, 3435
|
278, 306
|
378, 2694
|
4088, 5075
|
5110, 8006
|
3449, 3785
|
3824, 4072
|
3809, 3809
|
2716, 3107
|
3123, 3350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,108
| 185,966
|
31489
|
Discharge summary
|
report
|
Admission Date: [**2163-7-17**] Discharge Date: [**2163-7-22**]
Date of Birth: [**2142-4-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Assault (found down)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21 yo male who was found down on his porch by neighbors, s/p ?
assault. He was transported to an area hopsital where found to
have multiple skull fractures,
pneumocephalus, and a left sided subdural hematoma. He was
intubated and sedated prior to transfer to [**Hospital1 18**] because of
increased agitiation.
Past Medical History:
Infantile/juvenile stroke w/ residual facial droop on left
Attention deficit disorder
"Knee surgery"
Social History:
Fisherman who lives with his father
Family History:
Noncontributory
Pertinent Results:
[**2163-7-17**] 04:00PM GLUCOSE-105 UREA N-10 CREAT-1.2 SODIUM-150*
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-25 ANION GAP-14
[**2163-7-17**] 04:00PM ALT(SGPT)-26 AST(SGOT)-39 ALK PHOS-74
AMYLASE-83 TOT BILI-0.9
[**2163-7-17**] 04:00PM WBC-8.2 RBC-4.50* HGB-13.3* HCT-36.8* MCV-82
MCH-29.5 MCHC-36.1* RDW-14.3
[**2163-7-17**] 04:00PM PLT COUNT-176
[**2163-7-17**] 04:00PM PT-13.1 PTT-26.1 INR(PT)-1.1
[**2163-7-18**]
CT HEAD W/O CONTRAST
Again seen is a subdural hematoma along the left frontoparietal
convexity. Additionally, again seen and unchanged are a left
frontal intraparenchymal hemorrhage and a small temporal
intraparenchymal hemorrhage. Also, again seen is increased
density within the sulci of the left frontal lobe in high vertex
position consistent with subarachnoid hemorrhage. Again seen is
a focal bubble of air overlying the frontal lobe on the left in
the high vertex position consistent with pneumocephalus. There
is diffuse low attenuation within the left frontal lobe.
Additionally, again seen is an approximately 4-mm midline shift
toward the right. There is no evidence of intraventricular
hemorrhage.
Again seen are multiple skull fractures, and please refer to the
report of [**2163-7-17**] for further description. Also, again seen
is air-fluid level in the bilateral maxillary sinuses, left
greater than right. Additionally, the left sphenoid air cell is
completely opacified, as before. Fluid is again seen within the
left maxillary air cell. Additionally, again seen is soft tissue
hematoma overlying the left frontal and left preseptal as well
as the right temporal-occipital area. In the interim, there has
been placement of skin staples overlying the superior scalp and
overlying the frontal bone.
IMPRESSION: No significant change as compared with the earlier
study dated [**2163-7-17**]. Please see above for further description
of findings and prior report of [**2163-7-17**] regarding description
of multiple skull fractures.
CT C-SPINE W/O CONTRAST [**2163-7-18**]
IMPRESSION:
1. No evidence of fracture or abnormal alignment within the
cervical spine.
2. Subtle area of increased density posterior to the C5
vertebral body on the left with extension to neural foramen.
This may represent artifact, but other etiology including
hemorrhage or focal disc protrusion cannot entirely be excluded
since CT is not able to provide intraspinal detail comparable to
MRI.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery, Plastics,
Ophthalmology and Neurology were all consulted. His injures were
nonoperative. he was loaded with Dilantin and continued on this
therapy to receive a total of 8 days. There were no reported or
observed seizure activity. He underwent serial head CT scans
which were stable. He will follow up with Dr. [**Last Name (STitle) 23813**] in
[**4-15**] weeks for repeat imaging of his head.
His skull/facial fractures were evaluated by Plastics and
Ophthalmology; these injuries were nonoperative as well. He was
started on Clindamycin for prophylaxis of the skull fractures
and Erythromycin eye ointment for his right eye. No globe
entrapment, rupture or compartment syndrome was noted.
Behavioral Neurology was consulted given his traumatic brain
injury. It was recommended to continue Dilantin for 8 days;
regulate sleep/wake cycle and repeat head CT prior to discharge
to assess extent of brain contusion.
Social work and the Center for Violence Prevention and Recovery
were consulted due to the circumstances surrounding his
injuries.
Medications on Admission:
None
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) appl Ophthalmic QID
(4 times a day) for 2 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO Q 8H (Every 8 Hours) for 3 days.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p ? Assault vs. Fall
Multiple skull fractures left parietal bone
Orbital wall fractures
Subdural hematoma
Left frontal lobe intraparnechymal hematoma
Pneumocephalus
Discharge Condition:
Stable
Discharge Instructions:
Continue with Dilantin for another 3 days and then discontinue.
Followup Instructions:
Follow up in [**4-15**] weeks with Dr. [**Last Name (STitle) 23813**], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Follow up in [**Hospital 3595**] Clinic with Dr. [**First Name (STitle) **] in 2 weeks, call
[**Telephone/Fax (1) 5343**] for an appointment.
Completed by:[**2163-7-22**]
|
[
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"317",
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icd9cm
|
[
[
[]
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[
"96.71",
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|
[
[
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5202, 5272
|
3352, 4451
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339, 346
|
5483, 5492
|
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880, 897
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5516, 5581
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274, 301
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374, 687
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709, 811
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827, 864
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,044
| 110,709
|
1467
|
Discharge summary
|
report
|
Admission Date: [**2135-5-27**] Discharge Date: [**2135-6-8**]
Date of Birth: [**2075-12-27**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Transfer from outside hospital for
evaluation and pericardiocentesis.
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
female with a recent diagnosis of nonischemic cardiomyopathy
with an EF of [**10-12**]% who was in her usual state of health
until [**2135-3-29**] when she presented to an outside hospital
with chest pain. She was ruled out for a myocardial infarct
at that time; however, developed shortness of breath and
bilateral pleural effusions, at which time she was
transferred to another outside hospital where cardiac
catheterization showed clean coronary arteries but increased
right-sided pressures. A transthoracic echocardiogram was
performed and showed an EF of [**10-17**]% and was transferred to
[**Hospital1 18**] CCU on a dobutamine drip for a heart transplant and
evaluation for her cardiac transplant here. She had a PA
catheter placed and was found to have a CVP of 9, PA pressure
of 42/22, cardiac output 4.5, and index of 2.5. She was
weaned from a dobutamine drip without any changes in her PA
catheter numbers. She was maintained on fluid restriction,
started on digoxin and Coumadin for her low EF.
The previous admission culminated and the feeling that she
did not need a cardiac transplant at that time. She was,
therefore, discharged to home with follow-up with Dr. [**Last Name (STitle) **].
She was admitted to [**Hospital 6691**] Hospital on [**2135-5-24**] for
fevers to 103-104, chills and rigors. She had reported 5/10
chest pain since admission to [**Hospital 6691**] Hospital. A
transthoracic echocardiogram was performed to evaluate for
endocarditis due to her persistent fevers and revealed a very
large pericardial effusion. Her blood pressure dropped to
84/53 and her oxygen saturations decreased to 88% on room air
and, therefore, she was transferred to [**Hospital1 18**] for
pericardiocentesis.
She describes her chest pain as "pressure" which was
nonradiating and not associated with food or shortness of
breath. It started spontaneously when she was at the outside
hospital and was worse with inspiration and unrelieved by
sublingual nitrogens. Also, during her outside hospital
course, she was started on antibiotics; however, she did not
defervesce with her fevers in the 101-103 range. Blood
cultures and urine cultures were performed and all found to
be negative. A CT of the chest was performed which showed
mediastinal lymphadenopathy, bilateral small pleural
effusions and a 1 by 3 cm infiltrate in the right middle lobe
which did not have an appearance of pneumonia.
She had the transthoracic echocardiogram which is as
described above which noted a 1.5 cm circumferential effusion
with some RA collapse but no RV collapse. Her EF was
calculated at 10-15%.
PAST MEDICAL HISTORY:
1. Cardiomyopathy, nonischemic, diagnosed in [**2135-3-29**]
with an EF 10-15%.
2. Status post CVA times two, last one occurring
approximately three years ago without any residual symptoms.
3. Hyperlipidemia.
4. History of alcohol abuse.
5. Cardiac catheterization on [**2135-4-6**] at outside hospital
showing clean coronary arteries, increased right-sided
pressure with RA pressure of 18, pulmonary capillary wedge
pressure 23-29, cardiac output 2.3 and index 1.37.
6. Hypothyroidism.
7. Anxiety.
8. Gout.
9. Transthoracic echocardiogram on [**2135-4-11**] at [**Hospital1 18**] showed
EF 10-15%, left ventricular hypokinesis, anterior septal
akinesis, small pericardial effusion.
ALLERGIES: The patient has an allergy to Bactrim.
MEDICATIONS ON TRANSFER: (Same as her home medications.)
1. Paxil 25 mg p.o. q.d.
2. Synthroid 88 mg p.o. q.d.
3. Allopurinol 300 mg p.o. q.d.
4. Digoxin 125 p.o. q.d.
5. Lasix 10 p.o. q.d.
6. Toprol XL 25 mg p.o. q.d.
7. Lisinopril p.o. q.d.
8. Coumadin 2.5 mg p.o. q.d.
9. Aspirin.
10. Mevacor 10 mg p.o. q.d.
SOCIAL HISTORY: The patient is a retired secretary, lives
with her husband who is very supportive and involved in her
care. Alcohol: She previously drank greater than five
glasses of wine per day but has had no alcohol since [**2135-3-29**]. She denied any current or remote history of tobacco
use.
FAMILY HISTORY: Mother died of a myocardial infarct at age
57. Maternal uncles all died of myocardial infarct. Her
cousin had idiopathic cardiomyopathy.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs:
Temperature 102.8, blood pressure 97/60 with inspiration
98/58, heart rate 118, respiratory rate 18, oxygen saturation
96% on 2 liters nasal cannula. General: The patient was in
no apparent distress. She was anxious and mildly
dishevelled. HEENT: Poor dentition. The extraocular
muscles were intact. The pupils were equal, round, and
reactive. The oropharynx was clear. Neck: Supple. No
lymphadenopathy. Increased jugular venous pulsation to the
angle of the mandible. Chest: Lungs were clear to
auscultation bilaterally except for decreased breath sounds
at the bilateral bases. Cardiovascular: Tachycardiac but
regular with muffled heart sounds. Abdomen: Soft, diffuse
mild tenderness to palpation. Normoactive bowel sounds.
Extremities: No lower extremity edema. There were no
[**Last Name (un) 1003**] lesions or Osler's nodes appreciated. Neurologic:
She was alert and oriented times three. Cranial nerves II
through XII were intact. Motor was [**5-2**], symmetric upper and
lower extremities.
LABORATORY/RADIOLOGIC DATA: White count 13.1 with normal
differential and no bandemia, hemoglobin 12.3, hematocrit
36.1, MCV 98, platelets 336,000. PT 15.8, PTT 29.5, INR 1.6.
ESR 116. Sodium 133, potassium 4.4, chloride 96, bicarbonate
24, BUN 12, creatinine 1.1, AST 13, ALT 6, LDH 198, alkaline
phosphatase 112, amylase 70, total bilirubin 0.5, total
protein 6.9, albumin 3.1, calcium 9.6, phosphorus 4.1,
magnesium 1.9. TSH 6.5, [**Doctor First Name **] negative, rheumatoid factor
negative. CRP 10.88, significantly elevated. SPEP and UPEP
negative. C3 and C4 levels were both within normal limits.
Digoxin 1.6 and normal. Blood cultures: No growth times
five sets.
EKG on admission showed sinus tachycardia at a rate of 104,
normal axis, normal intervals with nonspecific ST-T wave
abnormalities in V4-V6.
IMPRESSION: This is a 59-year-old female with a history of
nonischemic cardiomyopathy with an EF of [**10-12**]%,
hypertension, history of alcohol abuse who was transferred
from an outside hospital after being admitted for a three day
history of spiking temperatures, chills, and rigors, found to
have a large pericardial effusion. The patient was
transferred to [**Hospital1 18**] for evaluation of pericardial effusion
and possible pericardiocentesis.
HOSPITAL COURSE: 1. PERICARDIAL EFFUSION: Upon transfer
from the outside hospital, the patient was taken directly to
the Cardiac Catheterization Holding Area where she was found
to be hemodynamically stable. A transthoracic echocardiogram
was performed while in the Cardiac Catheterization Holding
Area which was found to show no echocardiographic evidence of
tamponade with anterior portions of pericardial fluid
loculated an echodense. The remainder of the pericardial
fluid is echolucent. The effusion was moderate in size. Her
blood pressure was checked and she was found to have no
evidence of pulsus paradoxus.
As she was stable at that point, the decision was made not to
proceed with pericardiocentesis and monitor the patient with
medical management.
She remained hemodynamically stable for the first three days
of her hospitalization with heart rate ranging from 90s to
low 110s with occasional tachycardia in the 130s to 140s.
Her blood pressure was in the 90-110/40-60 range which was
near her baseline. Her oxygenation remained well at 95% on
room air. On [**2135-5-30**], hospital day number three, she was
taken to the Cardiac Catheterization Laboratory and had a
right heart catheterization performed which showed cardiac
output of 4.5, cardiac index 2.5, PA pressure of 44/27, and
no evidence of equalization of pressures. The pulse was
measured in the Catheterization Laboratory to be 7 mmHg.
Therefore, it was felt that conservative management of the
effusion was appropriate at that time.
The following day, the patient became hypotensive with
systolic blood pressures in the 60s and was started on
dopamine on the floor. After initiation of 5 micrograms per
kilogram per minute of dopamine, her blood pressure increased
to approximately 85-90 and she was transferred to the Cardiac
Care Unit.
While in the CCU, a transthoracic echocardiogram was
performed which showed early unchanged pericardial effusion
which was moderate in size, measuring less than 1 cm inferior
to the left ventricle, 1-1.5 cm lateral to the left
ventricle, less than 0.5 cm around the LV apex and anterior
to the right ventricle and greater than 2 cm anterior to the
right atrium. The asymmetric nature of the effusion again
suggested loculation.
She was weaned off dopamine in the Cardiac Intensive Care
Unit after a Swan-Ganz catheter was placed. The Swan-Ganz
catheter measured her wedge pressure to be 20, RA pressure of
17, and SVR 730 with an elevated cardiac output of 7.4. This
was slightly different from numbers during right heart
catheterization the day before. She was off dopamine
approximately 12 hours of initiation with stable systolic
blood pressures in the 100-120 range.
She was transferred back to the Cardiology Floor in stable
condition on [**2135-6-2**] after a two day stay in the Intensive
Care Unit. On [**2135-6-3**], a CT-guided pericardiocentesis was
performed by Radiology, at which time 15 cc of fluid was
removed. Analysis of this fluid showed a total protein of
5.2 and an LDH of 648. There were 0 red blood cells and
3,100 white blood cells which showed 90% neutrophilic
predominance. Judging by the analysis of the pericardial
fluid, it appeared to be exudative in nature and cytology was
sent. Cytology showed no evidence of malignant cells. AFB
stain was performed on fluid as well as Gram's stain culture,
fungal culture, all were found to be negative.
The etiology of the pericardial effusion still remains
unclear at the time of this dictation. However, it is
suspected to be a viral pericarditis/myocarditis; however,
the [**Location (un) **], Adenovirus, Histoplasmosis serologies were all
pending at the time of this dictation. Her Lyme serology was
negative. A Mycoplasma IgM and IgG were both negative as
well.
On [**2135-6-4**], twenty-four hours after pericardiocentesis, a
repeat transthoracic echocardiogram was performed which
showed resolution of the pericardial effusion with stable EF
of less than 20%. She remained hemodynamically stable after
transfer out of the Cardiac Intensive Care Unit.
2. NONISCHEMIC CARDIOMYOPATHY: As described in the history
of the present illness, the patient was diagnosed with
nonischemic cardiomyopathy in [**2135-3-29**], approximately
two months prior to current admission. She was evaluated for
a cardiac transplant at that point and was found not to need
one at the current time. She has been managed with diuresis
at home and just prior to current admission had been doing
excellent. Cardiac enzymes were cycled during this
hospitalization and were negative times three sets. She had
some chest discomfort during this hospitalization which was
thought secondary to her large effusion rather than ischemia
given her normal coronary arteries per cardiac
catheterization two months prior.
Once hemodynamically stable, she was diuresed with 10 mg p.o.
Lasix with 10 mg IV Lasix p.r.n. For the three days prior to
discharge, she was felt to be volume overloaded and was run
negative with a decrease in her weight of approximately 2
kilograms. At the time of discharge, she was felt to be
mildly volume overloaded but back to her baseline. Her
oxygen saturations were 95% on room air and decreased to
90-91% with ambulation.
3. NSVT: While on the Cardiac Floor, she was seen by
Electrophysiology initially for evaluation for pacemaker
placement who felt that it was not necessary at this time.
They were reconsulted after she had two episodes of NSVT of
15 and 16 beats. She was asymptomatic and denied any
palpitations, lightheadedness or shortness of breath during
these episodes. Her digoxin level, TSH and chemistry panel
were checked following these episodes and were found to be
within normal limits except for mildly elevated TSH given her
hypothyroidism. She was started on Amiodarone 400 mg p.o.
b.i.d. for which she will complete three weeks of therapy and
then switched to 400 mg p.o. q.d. She is being sent out of
the hospital on a Holter monitor given her initiation of
Amiodarone. LFTs were checked prior to initiation of therapy
an were found to be within normal limits. She will follow-up
with Dr. [**Last Name (STitle) **] and possibly Electrophysiology once stable on a
dose of 400 mg q.d. of Amiodarone.
4. INFECTIOUS DISEASE: The patient had spiking temperatures
through the first three to four days of hospitalization to as
high as 102.8. She had blood cultures performed on five
different occasions and were found to all be no growth. A
urine culture was performed when a Foley was placed in the
Intensive Care Unit and was shown to be contaminated. As she
was asymptomatic from a genitourinary point of view, it was
not felt that her urine culture was the source of her spiking
fevers. The Infectious Disease team was consulted while she
was in the Intensive Care Unit given her Swan numbers of
increased cardiac output to 7.3 and a decreased SVR to around
700 for evaluation of infectious etiology of her pericardial
effusion and hemodynamic instability. She was not felt to be
septic and the Infectious Disease Team recommended viral
serologies for evaluation of the pericardial effusion. She
was found to have a negative IgG and IgM for Mycoplasma and a
negative Lyme titer as well. Urine Histoplasma antigen was
checked as well as [**Location (un) **] A and B and Adenovirus which is
pending at the time of this dictation.
As described above, once pericardiocentesis was performed,
pericardial fluid was Gram's stain negative, culture
negative, and AFB negative. Therefore, the leading theory
for the patient's pericardial effusion was from a viral
infection that had not been identified at this time.
With the exception of one fever to 100.0 on [**2135-6-3**], five
days prior to discharge. The patient remained afebrile for
the remainder of the hospitalization.
5. PULMONARY: During evaluation for fever of unknown origin,
she had a CT scan of her torso which showed enlarged right
tracheal lymph node measuring 1.8 by 2.1 cm and multiple
other prominent right paratracheal lymph nodes as well as
multiple subcentimeter prominent lymph nodes in the
perivascular space and the aorticopulmonary window. The
Pulmonary Team was consulted on possible mediastinoscopy and
biopsy of the larger right tracheal lymph node to evaluate
for lymphoma as an etiology of her pericardial effusion. It
was the feeling of the pulmonary team as well as the
congestive heart failure team that the lymph nodes were
secondary to congestive heart failure and a biopsy was not
indicated at this time. She will follow-up with a repeat
chest CT approximately two to three weeks after discharge for
regression of lymph nodes. If they are still present at that
time, she will follow-up with the Pulmonary Team, Dr. [**Last Name (STitle) **],
who will perform mediastinoscopy plus biopsy of lymph nodes.
She was also noted to have bilateral pleural effusions, right
greater than left and given her spiking fevers and unclear
etiology of pericardial effusion she was taken to the
Interventional Pulmonary Laboratory for possible
ultrasound-guided thoracentesis. Under ultrasound
evaluation, she was found to have less than 1 cm of pleural
fluid and, therefore, it was not felt that a thoracentesis
was indicated. She did not have the procedure performed and
it was felt that her effusions would regress with appropriate
diuresis.
7. RHEUMATOLOGY: In evaluation of her pericardial
effusions, an ESR was checked and was found to be 116 and on
repeat was 115. CRP was also checked and found to be
significantly elevated at 10.88. Through workup of systemic
rheumatologic disease as a cause of her effusion, she had [**First Name8 (NamePattern2) **]
[**Doctor First Name **] and RF checked which were both found to be negative.
Compliment levels were checked and also found to be negative.
A CH50 and an ACE level are pending at this time to evaluate
for sarcoidosis.
The Rheumatology Team was consulted and did not feel given
her clinical history and supportive laboratory tests that she
had any evidence of systemic rheumatologic disease.
Her gout remained well controlled on Allopurinol 300 mg q.d.
8. ENDOCRINOLOGY: TSH was checked and found to be elevated
on two separate occasions and, therefore, her Synthroid dose
was increased from 88 micrograms to 100 micrograms q.d. The
increase in her Synthroid dose also showed positive effects
on blood pressure and heart rate.
9. RIGHT SHOULDER PAIN: After pericardiocentesis, the
patient complained of right shoulder pain which was evaluated
by upper extremity ultrasound as this was the location of her
central venous catheter while in the Intensive Care Unit.
This was found to be negative for deep venous thrombosis. A
chest x-ray was performed as well and she had no evidence of
elevated hemidiaphragm, ruling out phrenic nerve injury as
the etiology of the pain. The pain resolved spontaneously
and it was felt that it was most likely positional given her
extended period of lying in a decubitus position while in
Radiology to have the effusion drained.
10. HEMATOLOGY: She was found to have anemia of chronic
disease by iron studies. Her crit remained stable throughout
the hospitalization and she was given 2 units of FFP for an
elevated INR. The increased INR was likely secondary to her
Coumadin which she was taking as an outpatient but was not
continued during the hospitalization. She was not sent out
on Coumadin as her only indication was for
cardiomyopathy/decreased EF and CVA times two. Instead, she
was placed on Aggrenox for CVA prevention and Coumadin will
not be continued.
DISPOSITION: The patient was evaluated by Physical Therapy
the day before discharge. It was found that she was safe for
discharge to home. She had minor desaturation with
ambulation, otherwise, did excellent.
DISCHARGE DIAGNOSIS:
1. Pericardial effusion, status post CT-guided drainage,
etiology unclear, however, suspect viral source.
2. Pleural effusions, likely secondary to congestive heart
failure.
3. History of nonischemic cardiomyopathy with ejection
fraction 10-14%.
4. Mediastinal lymphadenopathy.
5. Nonsustained ventricular tachycardia, recently started on
Amiodarone.
6. Hypotension, status post transient dopamine infusion and
Cardiac Intensive Care Unit admission.
7. Transient febrile illness of unclear etiology.
8. Hyperlipidemia.
9. Hyperthyroidism.
10. History of alcohol abuse.
11. Anxiety.
12. Gout.
DISCHARGE MEDICATIONS:
1. Paxil 20 mg p.o. q.d.
2. Digoxin 0.125 mg p.o. q.d.
3. Synthroid 100 micrograms p.o. q.d.
4. Allopurinol 300 mg p.o. q.d.
5. Lasix 10 mg p.o. q.d.
6. Toprol XL 25 mg p.o. q.a.m.
7. Lisinopril 2.5 mg p.o. q.h.s.
8. Aggrenox one tablet p.o. b.i.d.
9. Amiodarone 400 mg p.o. b.i.d. until [**2135-6-19**] and then 400
mg p.o. q.d. until instructed to change dose by cardiologist.
10. Mevacor 10 mg p.o. q.d.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], in approximately one to two weeks after
discharge.
2. She will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2135-7-5**].
3. She will have a follow-up CT scan in two weeks for which
she will call for a specific appointment time.
4. She is being sent out on the [**Doctor Last Name **] of Hearts Monitor with
instructions provided prior to discharge.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2135-6-8**] 10:39
T: [**2135-6-11**] 11:36
JOB#: [**Job Number 8702**]
|
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icd9cm
|
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[
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icd9pcs
|
[
[
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4333, 6827
|
19305, 19722
|
18680, 19282
|
6845, 18659
|
19746, 20582
|
175, 2922
|
3715, 4012
|
2944, 3689
|
4029, 4316
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,500
| 173,518
|
52288
|
Discharge summary
|
report
|
Admission Date: [**2149-6-23**] Discharge Date: [**2149-6-27**]
Date of Birth: [**2066-10-17**] Sex: F
Service: SURGERY
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
[**2149-6-23**]
Exploratory laparotomy, lysis of adhesions, small
bowel resection, enteroenterostomy, washout
History of Present Illness:
82-year-old
woman who presented with a day history of abdominal pain with
nausea and vomiting. Unable to tolerate POs. No fevers,
chills. Last BM 2d ago per family. Patient with poor responses
to questioning at this point but family has not heard/smelled
any flatus. She had elevated white blood cell count to 20,000.
CT scan shows a small bowel obstruction with internal hernia.
Consent was reviewed and signed for laparotomy.
Past Medical History:
1. Coronary artery disease, status post ST elevation MI with
subsequent placement of bare-metal stents to the LAD in [**Month (only) 956**]
[**2147**].
2. Remote history of non-Hodgkin's lymphoma treated with MOPP
chemotherapy and mantle radiation.
3. Mitral valve prolapse.
4. Diabetes mellitus.
5. Hypertension.
6. SVT.
7. Osteoporosis.
8. GI bleed in [**2098**].
9. Bladder cancer metastatic to [**Year (4 digits) 500**], undergoing
chemotherapy
Past Surgical History:
- s/p cholecystectomy
- s/p appendectomy
- stomach ulcers: status post surgery in [**2135**]
- incisional hernia repair at the gallbladder sight
- partial thyroidectomy due to injury after mantle radiation
- vein stripping on the left lower extremity
Social History:
-Tobacco history: never
-ETOH: rare
-Illicit drugs: denies
-lives with husband and has two daughters that live near by who
have been very helpful and present for the patient
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Her father
died age [**Age over 90 **], her mother died in her 90s with a PPM (unknown
reason why she got it)
- son died in 20's of NH lymphoma
- mother had a pacemaker in place, died at 92.
Physical Exam:
114 107/74 14 100
Elderly female, appears uncomfortable, minimally responding to
questioning
Tachycardic
Lungs clear b/l.
Abdomen soft, diffusely TTP, greatest TTP at Rt abd, focal
rebound, +tympany, no guarding
No LE edema
Pertinent Results:
[**2149-6-23**] 02:00PM BLOOD WBC-20.1*# RBC-3.45* Hgb-10.4* Hct-31.8*
MCV-92 MCH-30.2 MCHC-32.8 RDW-16.7* Plt Ct-517*
[**2149-6-23**] 02:00PM BLOOD Neuts-92.4* Lymphs-4.1* Monos-3.1 Eos-0.2
Baso-0.2
[**2149-6-23**] 02:00PM BLOOD PT-14.9* PTT-27.8 INR(PT)-1.3*
[**2149-6-23**] 02:00PM BLOOD Glucose-145* UreaN-32* Creat-1.2* Na-138
K-5.4* Cl-104 HCO3-17* AnGap-22*
[**2149-6-23**] 02:00PM BLOOD cTropnT-0.07*
CT Abd/Pelvis [**2149-6-23**]:
1. Findings concerning for ischemic small bowel in the right
lower quadrant secondary to an internal hernia. Recommended
urgent surgical consult.
2. New bilateral pleural effusions and bibasilar atelectasis,
right > left.
3. New segment IV liver lesion, concerning for metastatic
disease. Extensive nodal and osseous metastatic disease, grossly
stable.
Brief Hospital Course:
The patient is an 82-year-old woman who presented with a 2 day
history of abdominal pain with nausea and vomiting. She had an
elevated white blood cell count to 20,000 and a CT scan that
showed a small bowel obstruction with internal hernia. Risks
and benefits of surgery were reviewed with the patient who was
minimally responsive at this point but also with her family.
She and her family wished to proceed with the operation knowing
of the poor prognosis and signed for laparotomy.
She was taken immediately to the operating room where an
exploratory laparotomy was performed revealing a large segment
of ischemic small bowel caused by a dense adhesive band in the
right lower quadrant likely present from her prior appendectomy.
A small bowel resection was performed with primary anastamosis.
The patient tolerated the procedure well and was extubated
postoperatively. She remained hemodynamically stable
postoperatively and was transferred to the ICU for postoperative
care. Over the course of postop day#0 through 2 she remained
NPO with an NGT on IV fluid. Her alertness and mental status
improved daily. She was well pain controlled.
On POD#3 her respiratory status declined and she was noted to
have an increased work of breathing and was noted to have
opacification of the right lung on CXR. Her family wished her
to be DNR/DNI after the immediate perioperative period but
agreed to bronchoscopy to help to clear a presumed mucus plug.
On bronchoscopy it was noted there was a large mucus plug and
that an ecotrin aspirin (which the patient had never received
postoperatively) was in her right mainstem bronchus. This was
removed by interventionary pulmonology. Her CXR improved
post-bronchoscopy and the patient transiently improved but
declined again. In discussion with the family, it was decided
not to bronch the patient again if necessary and to attempt only
non-invasive positive pressure ventilation. She was first tried
on CPAP and then later on BiPAP, with ever worsening acidemia
and hypercarbia. The patient's family asked to have a priest
administer last rites and then decided to remove the BiPAP mask
and make the patient CMO. The patient passed shortly thereafter
at 3:00 AM on [**2149-6-27**].
Medications on Admission:
LACTULOSE - 10 gram/15 mL Solution - 15-30 mL(s) by mouth daily
as needed for constipation
LEVOTHYROXINE [SYNTHROID] - 137 mcg Tablet - 1 (One) Tablet(s)
by
mouth once a day brand name only,no substitutions.Medically
necessary
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for sleep
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
MORPHINE - 15 mg Tablet - 1 Tablet(s) by mouth as needed every 4
or 5 hours for pain
OMEPRAZOLE - 10 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth once a day
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
as needed for nausea
OXYCODONE - 10 mg Tablet Sustained Release 12 hr - 1 Tablet(s)
by
mouth three times a day
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth once a day
BISACODYL [DUCODYL] - (Prescribed by Other [****] daily
while on narcotics) - Dosage uncertain
DOCUSATE SODIUM [STOOL SOFTENER] - (Prescribed by Other
[**Provider Number 37206**] every Am & PM) - Dosage uncertain
IBUPROFEN - 200 mg Tablet - two Tablet(s) by mouth three times a
day
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
small bowel ischemia
respiratory failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
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"518.5",
"188.9",
"424.0",
"202.80",
"414.01",
"276.2",
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icd9cm
|
[
[
[]
]
] |
[
"45.62",
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"33.22",
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icd9pcs
|
[
[
[]
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6770, 6779
|
3202, 5438
|
280, 391
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6863, 6872
|
2383, 3179
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6742, 6747
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6800, 6842
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6896, 6901
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1356, 1609
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2138, 2364
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232, 242
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419, 856
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878, 1333
|
1625, 1801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,497
| 134,599
|
29272
|
Discharge summary
|
report
|
Admission Date: [**2175-1-8**] Discharge Date: [**2175-1-24**]
Date of Birth: [**2148-2-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
RLE Pain
Major Surgical or Invasive Procedure:
.
s/p IVC filter placement
s/p L3 biopsy
s/p Liver biopsy
.
History of Present Illness:
.
HPI (per floor/MICU notes, confirmed w/pt):
Briefly, 26 y/o F, flew from [**Country **] [**1-7**] for medical care,
who presents with severe hip pain, low back pain and 4 weeks of
urinary incontinence and fevers since [**2172**], although increasing
in frequency over the past few weeks. Also with occasional night
sweats, denies weight changes or change in appetite,
+intermittent nausea. Recent progression of urinary
incontinence, also associated with sensation changes in RLE. She
notes that for the past month she has been unable to feel when
she is having a bowel movement.
.
She denies known exposure to TB.
.
In ED, performed pan-spine MRI, which demonstrated collapse of
the superior and inferior endplates at L3, along with mild
enhancing epidural soft tissue changes posterior to the
vertebral body. In the right sacrum, there was a large area of
signal abnormality with adjacent soft tissue mass from S1 to S3
level, extending to the right iliacus muscle and ilium. There
also appeared to a thrombus in the IVC. CXR also suggested
bilateral lower lobe pulmonary nodules. She was also found to
have elevated LFTs, with ALT 48, AST 57, Alk phos 548, GGT 248,
tbili 0.8. She was admitted to the floor for further work-up.
.
Past Medical History:
-R ovarian cyst-She affirms increasing abdominal girth [**2168**],
feeling increased bloating, presented to the ED found to have a
right ovarian cyst, was resected.
- [**2155**] (7yrs old) hospitalized for 6 months for fever/cough,
weakness, unclear source of infection, did require blood
transfusions.
- Gyn- no menstrual periods for the past year
Social History:
Social History: Had ovary removed secondary to cyst at 19 years
old -
denies any history of ovarian cancer. Lives with her sister
and brother. Recently relocated from [**Country 3587**] - speaks Creole
and Portugese. 2 live time sexual partners, denies stds, denies
etoh, ivdu, smoking
Family History:
1 sister age 27, with question of R leg mass resected 4 yrs ago
Denies other cancer history
Physical Exam:
VS: Temp: 96.7 BP:98/54 HR: 89 RR:18 100 O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, 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, epigastric mass ~2 inch diameter, firm,
nontender, no hepatomegaly detectable, ? splenomegaly, lower abd
well healed scar
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact.
LLE [**3-20**], RLE [**5-20**],
Sensation decreased to light touch, RLE
Toes Down going in R leg, upgoing in L leg
Pertinent Results:
.
EKG: Q-waves, ST depressions and TWI in III. LAD, tachycardic,
normal intervals.
.
Micro: urine cx [**1-7**] with burkholderia cepacia
.
Imaging:
.
Pan-spine MRI:
CERVICAL SPINE:
IMPRESSION: No significant abnormalities on MRI of the cervical
spine.
THORACIC SPINE:
IMPRESSION: No significant abnormalities on MRI of the thoracic
spine. No evidence of disc herniation, bony metastasis or
epidural abscess. 1.2-cm nodular opacity in the right lower
lung.
LUMBAR SPINE:
IMPRESSION: The signal changes and associated soft tissue
extension at L3 level and within the sacrum are suggestive of
metastatic disease. The central post-gadolinium low signal seen
within the sacral mass appears to be due to central necrosis
within a tumor than an area of abscess. Probable thrombus within
the inferior vena cava. Further evaluation with abdominal and
pelvic CT recommended.
.
CT Torso:
IMPRESSION:
1. Massive aggressive tumor involving the entire left and mid
scarum, right iliac bone, L3 and symphysis pubis which most
likely represent metastatic spread.
2. Marked involvement of the liver by large masses most likely
due to metastatic spread of unknown primary. For precise
evaluation of spinal involvement please review the MRI from
[**2175-1-8**]
3. Multiple pulmonary metastases.
4. Dermoid cyst, most likely in left ovary
.
Chest CTA:
IMPRESSION:
1. Bilateral massive central pulmonary embolism as described
above, involving right main, right ascending and descending,
left descending and their branches.
2. Multiple pulmonary nodules in lower lobes, representing
metastasis as seen on the prior study.
3. Partially visualized heterogeneous masses in the liver
representing metastasis as seen on the prior CT scan. For
complete assessment of the abdomen and pelvis, please refer to
the official report of CT study performed a day earlier.
.
TTE:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). The right ventricular cavity is moderately dilated.
Right ventricular systolic function is normal. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Right ventricular cavity enlargement with preserved
systolic function. Moderate pulmonary artery systolic
hypertension.
.
LENIs:
GRAYSCALE AND DOPPLER ULTRASOUND OF THE BILATERAL LOWER
EXTREMITIES: Normal flow, compressibility, and augmentations are
seen in bilateral common femoral, superficial femoral, and
popliteal veins. There is no evidence of DVT.
IMPRESSION: No evidence of DVT.
.
MRV [**1-9**]: 1. Focal inferior vena caval thrombus at the L2
level. The thrombus appears to be bland, superior in location
to the tumor-infiltrated L3 vertebral body.
2. Multiple masses consistent with the patient's history of
metastatic disease.
3. Splenomegaly
.
MRI brain:
1. There is no definite evidence of intracranial metastatic
disease.
2. Prominent pituitary gland with possible microadenoma.
Attention to this area should be paid on follow-up study.
2. Heterogeneous bone marrow signal within the partially imaged
cervical spine. This finding may be related to underlying
anemia versus an infiltrative process.
.
[**2175-1-20**] Repeat CT scan, Abd/Pelvis w/contrast:
1. Thrombus in the IVC 8 cm below the tip of a suprarenal IVC
filter,
unchanged. 2. No interval change in appearance of innumerable
soft tissue and bony metastatic lesions from prior exam dated
[**2175-1-8**]. 3. New left lung base wedge-shaped opacity most
consistent with infarction
given the prior history of a left lower lobe pulmonary embolism.
.
Brief Hospital Course:
.
A/P: 26 y/o F, from [**Country 3587**], with h/o ovarian cyst/mass 6
years ago presenting with hip and back pain, decreased ability
to ambulate and urinary incontince, found to have widely
metastatic disease of unclear primary and bilateral PEs with
residual IVC thrombus, s/p IVC filter placement [**1-10**].
.
# Initial hospital course: On the floor, Ms. [**Known lastname 13983**] [**Last Name (Titles) 1834**] a
torso CT, which confirmed the presence of soft-tissue density
masses, the largest in the left lingula, measuring 7.2cm x
6.5cm. There was also local septal thickening in the subpleural
posterior portion of the left lower lobe which could represent
focal lymphangitic spread. There was a 1.2cm hypoechoic nodule
in the thyroid. There was no mediastinal, axillary, or hilar
adenopathy, and no bony lesions in the chest.
Abdominal cuts demonstrated multiple large heterogeneous masses
involving the entire left hepatic lobe up to 6.5 cm in the most
distal portion of the lobe and 6 x 7 cm in the more medial and
lower portions with marked enlargement of the entire left lobe,
depressing the transverse colon and stomach downward and
backward. There was retroperitoneal LAD up to 3 x 1.8 cm. There
was no evidence of bowel obstruction, and kidneys, adrenals, and
pancreas were unremarkable. Pelvis cuts demonstrated a L 7cm x
6.5cm ovarian lesion consistent with a dermoid cyst. Images also
confirmed the presence of a 9.5 x 7 x 10 cm heterogeneous mass
involving the right and mid portion of the sacrum, the proximal
portion of the iliac bone with complete destruction of the
above-mentioned bones and invading the spinal canal at the level
of the sacrum as well as the spinal nerve foramina. In addition,
there was partial destruction of the vertebral body of L3 with
soft tissue mass entering into the spinal canal with mild
compression. A round area of low density of 1.7 cm in diameter
is in the right iliac muscle, series 3 image 87, most likely
representing part of the aggressive tumor. There was a lytic
lesion of the right part of the symphysis pubis with erosion of
the cortex, periosteal reaction and soft tissue component.
.
The morning of admission, Ms. [**Known lastname 13983**] became tachycardic, with
ECG showing evidence of right heart strain. A stat chest CTA was
obtained, which demonstrated massive bilateral central pulmonary
embolism. There was a large clot in the right main pulmonary
artery, proximally occluding at least 50% of the lumen, distally
completely occluding the lumen extending to right ascending and
descending arteries, which continues down to the right middle
and lower lobe branches. There was also a total occluding clot
in the left descending artery and its branches. She was started
on heparin drip, and a stat TTE was obtained, which demonstrated
intact RV systolic function, with moderately elevated PA
pressures, and no evidence of clot-in-transit. LENIs showed no
evidence of clot. She was sent to the MICU for further
management.
.
# MICU Course: In the MICU, she had an MRI of head which ruled
out brain mets and she was begun on a heparin gtt. She had an
MRV which demonstrated residual clot in the IVC as well as the
left iliac vein. On [**1-10**], she went to IR and had an infrarenal
IVC filter placed, and also had a biopsy of her sacral lesion by
IR. The next morning (day of transfer to floor) she was
switched from heparin to lovenox, given that it was difficult to
get her therapeutic on the heparin. Her neuro exam remained
stable throughout her MICU course. She was transferred back to
the floor for further management after she was monitored and
treated for PE in the MICU.
.
# Sacral mass w/widely metastatic disease: Concerning for
neoplastic disease. Pathology obtained from the sacral lesion
showed only necrotic material. The patient then had an
IR-guided biopsy of a lesion lesion. The pathology from the
liver core showed poorly differentiated cells. It was
impossible to make a diagnosis based on the tissue morphology
along and special staining was sent to help determine what type
of primary. The differential included primary ovarian (hx of
ovarian "cyst" removed 6 years ago and dermoid noted in left
ovary on CT scan) vs yolk sac (given elevated AFP) vs lymphoma
vs hepatoma (has active hep B) vs osteosarcoma vs breast. A
breast exam was performed and the patient was found to have
fibrocystic breasts but no fixed masses or lumps, and no
discharge from either breast. The patient was seen by
neurosurgery who felt the sacral lesion was inoperable. There
was concern for cord compression but the patient's neuro exam
was carefully monitored and remained stable (patient continued
to have urinary incontinence and unchanged slight lower
extremity weakness ([**5-20**] LLE but normal strength 4/5 RLE)). The
patient may require pelvic reconstruction in the future.
Heme/onc also followed the patient and recommended starting
steroids for concern of cord compression. The patient was seen
by radiation oncology and was simulated for XRT but not treated
as her neuro exam remained stable. Her pain remained under
adequate control with PRN oxycodone. Upon discharge, pathology
results were still pending. The patient will be followed up by
her primary care doctor and an outpatient oncology appointment
will be scheduled for her by the oncology consult service
pending results of her pathology to initiate treatment.
.
# PE/IVC clot: The patient was switched from a heparin gtt to
Lovenox after it was difficult to get the patient therapeutic on
a heparin gtt. She remained hemodynamically stable and was on
RA. There was no evidence of RV collapse on TTE. She is s/p
IVC filter placement by RIJ approach [**1-10**]. The patient had a
repeat CT scan during her hospital course to reevaluate her IVC
filter and her IVC clot. The IVC clot was found to be distal to
the IVC filter. Upon discharge, she was started on a Lovenox
bridge to Coumadin. She will be followed up by her PCP for an
INR check on the day after discharge.
.
#Hepatitis B: The patient was found to have labs consistent with
chronic hepatitis B. Her LFTs showed a mildly elevated AST
(45), elevated GGT, and elevated AP (400) c/w metastatic bone
and liver dx. Bilirubin was normal and the patient showed no
evidence of acute cholestasis during this admission.
.
# Elevated platelet count: Patient was admitted with extreme
thrombocytosis given prior values >1000. Her platlet could was
thought to be most likely reactive thrombocytosis [**2-17**]
malignancy. Her platlet count trended down to 700s-800s.
.
# ?UTI: Patient was found to have a mildly positive UA, and
urine cx with Burkholderia cepacia. She was treated with 3 days
of Bactrim.
.
# Low HCT: There are no prior Hct for a baseline Hct. Fe studies
are most c/w AOCD. Haptoglobin is not depressed. Her hematocrit
remained stable.
.
# FEN: Regular diet
.
Medications on Admission:
oxycodone
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*1*
3. Enoxaparin 40 mg/0.4 mL Syringe Sig: 40 mg Subcutaneous Q12H
(every 12 hours): Please continue Lovenox until your INR is
between 2.0-3.0. You will need to see your primary care doctor
for INR checks (see appointments).
Disp:*14 * Refills:*0*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Please get your INR checked on [**1-25**] at your primary care
doctor's office.
Disp:*30 Tablet(s)* Refills:*0*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
.
Primary:
1) Widely metastatic disease (sacral mass, pulmonary nodules,
masses in liver)
2) pulmonary emboli - severe
3) dermoid cyst in left ovary
4) microcytic anemia
5) thrombocytosis
6) pseudomonal UTI
.
Secondary:
1) Chronic HBV infection
.
Discharge Condition:
Good
Discharge Instructions:
.
1- Please take all medications as prescribed. You were started
on the following new medications:
- Lovenox injections and Coumadin to protect you from further
clots. You will see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**],
[**1-25**], for an INR check. If you INR is between 2.0-3.0, you may
stop the Lovenox injections and continue only the Coumadin.
- Dexamethasone for possible cord compression from the tumor in
your sacrum
- Oxycodone as needed for back pain.
.
2- Please seek medical attention immediately if you experience
worsening lower extremity weakness, decreased sensation in your
lower extremities, decreased ability to walk, or inability to
have a bowel movement or urinate.
.
Followup Instructions:
.
Please followup with your primary care doctor, Dr. [**First Name8 (NamePattern2) 6**] [**Name (STitle) **]. You
will need to see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**], [**1-25**] at 2pm at [**Hospital1 **] Clinic. You will need
to have your INR checked during that visit on [**Hospital1 20212**].
.
[**Location **] is located at:
[**Hospital1 **].
[**Location (un) 686**], [**Numeric Identifier 12201**]
Phone: [**Telephone/Fax (1) 7976**]
.
You will be contact[**Name (NI) **] by the oncology department for a followup
visit. If you do not hear from them within 2 weeks, please
contact Ms. [**Name13 (STitle) **] at [**0-0-**] or call the hospital at
[**Telephone/Fax (1) 2756**] and have the heme/onc fellow, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 5565**],
page [**Numeric Identifier **].
.
Completed by:[**2175-1-24**]
|
[
"220",
"198.5",
"197.7",
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"199.1",
"415.19",
"197.0",
"238.71",
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icd9cm
|
[
[
[]
]
] |
[
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"38.93",
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icd9pcs
|
[
[
[]
]
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14897, 14903
|
7096, 7421
|
323, 385
|
15194, 15201
|
3149, 7073
|
15986, 16876
|
2346, 2439
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14924, 15173
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14026, 14037
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7438, 14000
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15225, 15963
|
2454, 3130
|
275, 285
|
413, 1650
|
1672, 2022
|
2055, 2330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,787
| 147,029
|
9267
|
Discharge summary
|
report
|
Admission Date: [**2122-12-18**] Discharge Date: [**2123-1-4**]
Date of Birth: [**2044-4-18**] Sex: M
Service: MEDICINE
Allergies:
Calcium / Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal tube placement ([**2122-12-18**])
G-tube exchange by Interventional Radiology
History of Present Illness:
78 yo male with history of HTN, DMII, CKD, CVA ([**2101**], [**2121**]) with
residual deficits, presents from nursing home with respiratory
distress. Patient had very labored breathing, inhaling and
expiring forceably, and gurgling. He was intubated in the
emergency department. CXR showed elevated right hemidiaphragm
with possible consolidation in the right middle lobe.
.
Patient had received vecuronium during intubation process but
for a long time following that, was nonresponsive, not
responding to pain. He had an episode of SBP transiently
dropping to 70s shortly following intubation, but otherwise has
had BP in the 160s. He received vancomycin and zosyn and 2 L of
IVF in the ED. Patient sent for head CT, CTA chest, CT
abd/pelvis prior to transfer to the MICU. Vital signs prior to
transfer to the MICU were: 97.8, 178/109, 114, 16, 100% on
ventilator.
.
On arrival to the MICU, patient is opening his eyes, moving all
his extremities weakly.
.
Review of systems:
Unable to be obtained
Past Medical History:
multiple strokes: 1)old remote left frontal stroke in [**2101**] that
per NH notes purportedly left him with R-hemi and dysarthria
(per son, able to think of words he wants to say and makes
grammatically intact sentences, but is often unintelligible)
2)[**4-13**](MRI [**2122-4-6**] showing acute infarcts in the R medial
temporal lobe, R basal ganglia, and high signal in the petrous
portion of the R-ICA thought to be 2/2stenosis/occlusion started
on asa/plavix, thought to be too sig
a fall risk for anticoagulation
DM2 (last HgbA1C [**2-11**] was 6.6)
CRI (baseline Cre ~1.6)
HTN
gout
GERD
Social History:
Prior to recent stroke, lived at home with wife now at rehab.
Remote history of alcohol and smoking cigarettes (quit 1 year
ago.)
Family History:
NC
Physical Exam:
General: chronically ill appearing male, intubated, sedated
HEENT: pupils reactive, no JVD, neck supple
CV: S1S2, RRR, no m/r/g
Chest: crackles diffusely, no wheezing
Abd: PEG tube in place, hernia at PEG insertion site, soft, ND,
NT, +BS
Ext: no e/c/c, 2+ peripheral pulses
Neuro: unable to follow commands, but there is a language
barrier
.
Pertinent Results:
Admission Labs
[**2122-12-18**] 01:00AM BLOOD WBC-20.5*# RBC-3.89* Hgb-12.7*# Hct-36.5*
MCV-94 MCH-32.6* MCHC-34.7 RDW-12.1 Plt Ct-430
[**2122-12-18**] 01:00AM BLOOD Neuts-92* Bands-1 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2122-12-18**] 01:00AM BLOOD PT-12.2 PTT-27.1 INR(PT)-1.0
[**2122-12-18**] 01:00AM BLOOD Glucose-273* UreaN-31* Creat-1.3* Na-138
K-4.3 Cl-104 HCO3-21* AnGap-17
[**2122-12-18**] 01:00AM BLOOD ALT-60* AST-51* AlkPhos-106 TotBili-0.5
[**2122-12-18**] 01:00AM BLOOD cTropnT-0.06*
[**2122-12-18**] 06:32AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2122-12-18**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-12-18**] 12:25AM BLOOD Glucose-295* Lactate-1.2 Na-135 K-4.6
Cl-105 calHCO3-22
.
Pertinent Labs
[**2122-12-18**] 06:32AM BLOOD WBC-15.0* RBC-3.78* Hgb-13.5* Hct-35.9*
MCV-95 MCH-35.7* MCHC-37.6* RDW-12.3 Plt Ct-401
[**2122-12-19**] 04:38AM BLOOD Neuts-86* Bands-8* Lymphs-3* Monos-1*
Eos-0 Baso-1 Atyps-1* Metas-0 Myelos-0
[**2122-12-19**] 04:38AM BLOOD Glucose-219* UreaN-36* Creat-1.8* Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
[**2122-12-24**] 03:33AM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-142
K-3.6 Cl-108 HCO3-26 AnGap-12
[**2122-12-19**] 04:38AM BLOOD ALT-35 AST-41* LD(LDH)-395* AlkPhos-81
TotBili-0.3
[**2122-12-18**] 01:00AM BLOOD cTropnT-0.06*
[**2122-12-18**] 06:32AM BLOOD CK-MB-7 cTropnT-0.33*
[**2122-12-18**] 05:00PM BLOOD CK-MB-3 cTropnT-0.26*
[**2122-12-21**] 05:41AM BLOOD CK-MB-2 cTropnT-0.08*
[**2122-12-21**] 05:41AM BLOOD Vanco-17.5
[**2122-12-19**] 04:38PM BLOOD Lactate-1.1
.
Microbiology
Blood culture ([**2122-12-18**]) x 2 - No growth
Urine culture ([**2122-12-18**]) - STAPHYLOCOCCUS, COAGULASE NEGATIVE.
10,000-100,000 ORGANISMS/ML..
.
GRAM STAIN (Final [**2122-12-18**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): PLEOMORPHIC GRAM NEGATIVE
ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2122-12-20**]):
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
.
C. diff ([**2122-12-22**], [**2122-12-23**]) -ve x 2
.
Pertinent Reports
KUB ([**2123-1-1**])
1. No evidence of bowel obstruction or ileus
2. Stable appearance of previously visualized left kidney
inferior pole
calculus.
.
PICC ([**2122-12-29**])
In comparison with the study of [**12-26**], there has been placement
of a
left subclavian PICC line that extends to the lower SVC or
possibly cavoatrial junction. The opacification at the right
base is slightly more prominent. In the appropriate clinical
setting, the possibility of developing consolidation should be
considered. Some indistinctness of pulmonary vessels raises the
possibility of some elevation in pulmonary venous pressure.
.
G-TUBE PLACEMENT ([**2122-12-25**])
Successful exchange of an old G tube for a new 20 French MIC
G-tube, ready for use.
.
CT HEAD ([**2122-12-22**])
1. Old left MCA infarct and old right ACA-MCA watershed infarct.
2. No evidence of an acute intracranial abnormality.
.
CXR ([**2122-12-17**])
1. ET tube 5 cm above carina; endogastric tube side port below
GE junction.
2. Elevated right hemidiaphragm with underlying atelectasis
and/or pleural effusion.
.
CXR ([**2122-12-18**]): Interval improvement in right middle and right
lower lobe atelectasis has been demonstrated with focal
consolidations currently better appreciated in the right lower
lobe. There is new consolidation in the right upper lobe that
given its rapid development is most likely representing a focus
of aspiration. Neoplastic origin would be significantly less
likely given its rapid development. The left lung is clear.
.
ECHO ([**2122-12-22**])
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
basal and mid-inferolateral akinesis. The remaining segments
contract normally (LVEF = 45%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2119-3-9**],
regional wall motion abnormalities are new. Mitral regurgitation
is slightly more prominent.
.
CT HEAD ([**2122-12-18**])
1. No acute intracranial process.
2. Remote left MCA infarct.
3. Right cerebral watershed infarct, secondary to ICA occlusion.
4. Chronic involutional changes.
.
CTA chest/abd ([**2122-12-18**])
1. Collapse of the apical segment of the right upper lobe, the
right middle lobe, and the basilar segments of the right lower
lobe. Endobronchial soft tissue density is appreciated, which
does not appear to be enhancing and may represent mucus
plugging. Correlate with bronchoscopy as obstructive mass is not
excluded.
2. 1-cm nonobstructive stone in the left kidney.
3. No acute intra-abdominal process.
4. There is a 9 mm nodule within the right lobe of the thyroid,
requires no followup.
.
EKG: sinus tachy at 109 bpm, nl axis, nl intervals, inferior Q
waves, nonspecific lateral ST changes
.
TTE ([**2122-12-22**]): The left atrium and right atrium are normal in
cavity size. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with basal and mid-inferolateral akinesis. The
remaining segments contract normally (LVEF = 45%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
.
CT head without contrast ([**2122-12-22**]):
1. Old left MCA infarct and old right ACA-MCA watershed infarct.
2. No evidence of an acute intracranial abnormality.
Brief Hospital Course:
78 year old male with hypertension, type 2 diabetes mellitus,
chronic kidney disease, cerebrovascular disease with residual
deficits admitted from nursing home with respirator distress.
.
#. Respiratory failure - Given persistent fever and
leukocytosis, likely bacterial pneumonia with hemophilus
influenza noted on sputum culture. Treated with four days of
vancomycin/cefepime/levaquin which was switched to unasyn on day
5, 6 and 7 and then switched to augmentin for three more days.
Blood and urine cultures were negative (coag negative staph in
urine culture is likely contaminant). Legionella was negative.
Urine toxicology was negative. CT abdomen/pelvis/head with no
pathology. Extubated on [**2122-12-23**] and weaned to nasal canula
over the next day.
.
After transfer to the medicine floor, the patient became again
febrile with repeat leukocytosis. Concern was that augmentin
was not being properly absorbed, and given that the pt was
unable to get medications through the G-tube given the need for
IR guided replacement, we restarted the pt on unasyn. Unasyn
was continued for a period of 11 days total. Of note, also on
ddx of fever was C-diff, especially with recent antibiotic
usage. A C-diff assay was sent which was positive (see below).
Over time, the pt was able to be weaned to RA. After ~ 2 weeks,
the pt again began to spike fevers with a leukocytosis. A
repeat CXR showed possible infiltrate in LLLF. Thought was that
aspiration pneumonitis vs. pneumonia could have been
contributing. IV flagyl (which had been started for c-diff) was
kept on for possible aspiration PNA. IV flagyl was stopped on
[**2123-1-2**] as pt was then afebrile without leukocytosis. Pt did
not have any new O2 requirement or increase secretions.
.
# C-diff: Pt noted to spike a fever upon transfer to the
medicine floor with a new leukocytosis of 23. Notably had been
on unasyn, so C-diff sent which was positive. IV flagyl was
started at first, however once pt spiked a fever again after 1
week (with mild leukocytosis), and distended abdomen, PO vanc
was started and KUB showed nondistended loops of bowel. He was
to continue this medication for 2 weeks since last abx dose
other than PO vanc (stating [**2123-1-2**]), ending [**1-15**].
#. Sinus tachycardia: Pt noted to be tachycardic upon arrival to
the medical floor to the 110s. As he was febrile, this was
treated with APAP and his tachycardia improved to the 100s. As
the pt was wet on exam, we held off on IVF boluses, and the
thought was that the tachycardia was more likely responsive to
the fever the pt was having, or possibly [**1-6**] anemia (see below).
Of note, the pt's BPs were stable throughout the episodes of
tachycardia. An EKG was done which confirmed sinus tach. The
pt denied pain throughout these episodes. Once the fever was
adequately treated, the tachycardia improved.
.
# Anemia/Hct Drop: In the setting of aggressive IVF boluses in
the MICU, the Hct drop seen during Mr. [**Known lastname **] hospital stay was
thought most likely [**1-6**] dilution. That said, we sent labs to
test for the pt's iron indices which were c/w ACD. The patient
was also guaiac'ed which was positive. Thought was that anemia
may also be contributing to sinus tach, and in the setting of
demand ischemia, may also benefit from transfusion in that
regard. Hct continued to drop to 22, so transfusion of 1 unit
pRBC was done. A GI c/s was called out of concern that there
was an upper GI bleed (melena noted). Endoscopy was done which
showed that the site of G-tube switch had some stigmata of
recent bleed, but no active bleeding. Aside from the
pantoprazole IV 40 BID that was started (and then transitioned
lansoprazole PO), we also started 1 gram sucralfate as per GI
c/s recommendations. He will continue this for 7 days
post-discharge. He will continue lasoprazole 30 [**Hospital1 **]
indefinitely. After this episode, Hct was trended daily and
stayed stable ~ 30.
.
#. Elevated troponin: Likely demand ischemia in the setting of
hypotension upon presentation. No EKG changes noted. Cardiac
enzymes peaked at 0.33. Continued on aspirin, plavix, statin
and metoprolol. Transthoracic echocardiogram showed LVEF of 45%
and no regional wall motion abnormality.
.
#. Cerebrovascular disease - status post two strokes in [**2101**] and
[**2121**]. He has residual right hemiplegia and dysarthria. Not on
warfarin given history of GI bleed and fall risk. Only on
plavix at nursing home which was held on day 1 but restarted on
day 2. Plavix was again held in the setting of GI bleed,
however restarted after stable Hct. CT head did not show any
acute intracranial process. At baseline, has 3+ motor RUE, 1+
motor LUE, can wiggle toes on R foot, not on left.
.
#. Hypertension: Held on admission due to hypotenion in the
setting of his pneumonia. Restarted
hydrochlorothiazide-triamterene on [**2122-12-24**] while continuing
metoprolol 50 mg po TID.
.
# Eosinophilia: Pt noted to have eosinophilia after 2 weeks.
Thought was that unasyn likely cause of eosinophilia (abs
eosinophil count remained <1000).
.
#. Diabetes mellitus: Last HbA1c on [**2-/2122**] was 6.6%. Sugars
well controlled on insulin sliding scale.
.
# GERD: Continued on pantoprazole IV qdaily while intubated and
changed to po once extubated. Unfortunately, pt had episode of
UGI bleed. As such, pantoprazole was started IV BID. This was
changed to PO at the time of discharge.
.
# Depression: Continued on citalopram.
.
# Nutrition - His PEG was leaking with tube feeds.
Interventional radiology was consulted on [**2122-12-24**] to replace
his PEG tube so his tube feeds can be restarted. This was
completed on [**2122-12-25**] in the IR suite. A nutrition c/s was
called for assistance with TF recommendations.
.
# Goals of Care: Multiple discussion with his son and wife, HCP
were held over the course of his ICU stay. He will be DNR but ok
to intubate for respiratory distress. A family meeting was then
held on [**2122-12-30**], and they again decided for DNR ok to intubate,
but further conversations will be held as they also understand
the poor prognosis. Hospice services were offered and the
family said they would speak with us once they had made a firm
decision.
Medications on Admission:
citalopram 20 mg daily (liquid)
MVI 1 tab daily (elixir)
triamterene-HCTZ 37.5/25 mg daily
simvastatin 40 mg daily
tamsulosin 0.4 mg daily
omeprazole 40 mg [**Hospital1 **]
ferrous sulfate 300 mg [**Hospital1 **] (elixir)
trazodone 25 mg daily prn agitation
regular insulin sliding scale
glyburide 1.5 mg [**Hospital1 **]
vitamin C 500 mg [**Hospital1 **]
acetaminophen 1000 mg q8h
metoprolol 50 mg TID
pureed, nectar thick liquids
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Pneumonia and respiratory failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
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27,077
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48399
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Discharge summary
|
report
|
Admission Date: [**2128-8-8**] Discharge Date: [**2128-8-24**]
Date of Birth: [**2080-2-22**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Codeine / Latex
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Altered mental status and respitatory distress
Major Surgical or Invasive Procedure:
R femoral line placement
Bilateral thoracentesis
History of Present Illness:
48 y/o male chronic ill with systolic CHF (EF 15-20%), HTN, CAD,
ESRD on HD, MSSA osteomyelitis with paraspinal abscess on
nafcillin living at MACU of [**Hospital 100**] Rehab who presents with
lethargy *2 days of worsening somnulence/responsiveness. [**Hospital 100**]
Rehab and family noted nausea [**8-7**]. [**2128-8-8**] patient noted to have
temp 101.4 with question of aspiration as patient vomited *2.
Also noted intermittently having shortness of breath which was
worse this am. CXR per [**Hospital 100**] rehab showed increasing right
pleural effusion and worsening congestive heart failure. The
patient was transferred from [**Hospital 100**] rehab due to worsening
shortness of breath and worsening AMS.
.
In ED temp:99.8 HR:105 BP:83/49 RR20 high 93% on 3LNC. Patient
in ED unable to answer questions, but did localize to pain.
Patient was intubated for airway protection as patient was
snoring respirations/ gagging on tongue. CXR bilateral pleural
effusions worse from prior.
Started levophed BP 108/88, HR 95, access left EJ by EMS, PICC
-double lumen. Patient given in ED levaquin/cefepime/
vancomycin. Patient admitted to MICU due to intubation,
congestive heart failure, and leukocytosis.
.
Patient unable to give history.
Past Medical History:
Past medical:
Depression
ESRD of unknown etiology: s/p HD fistula RUE, on HD [**Hospital 12075**]
HTN
CAD with positive stress test [**5-8**]
Restless leg syndrome
Psoriasis
Anemia [**3-6**] esrd
Hypothyroid
MSSA bacteremia [**3-12**] (unclear if fully treated as patient
missing HD sessions so may also have missed taking Abx)
h/o abdominal fluid collection drained s/p anterior spinal
fusion
<br> Past surgical:
L2-L4 anterior and posterior fusion [**5-11**] s/p MVA [**2-10**] and for
paraspinal abscess
Social History:
Smokes [**2-4**] ppd, cut down from 1 ppd. Denies alcohol use. Denies
illicit drug use. Resides with mother and brother in [**Name (NI) 745**]
(before hospitalizations). This hospitalization, came from
[**Hospital1 100**] home MACU
Family History:
Father died of MI in 60's; mother alive and well 77; 8 siblings,
one of whom has HTN, one who has a cerebral aneurysm; he has no
children.
Physical Exam:
Vitals: T:100.8 BP: 103/71 P: 99 RR:20 AC 70% 10/5 O2Sat: 95%
Gen: alert, non verbal, in mild distress
HEENT: Clear OP, MMM, dry skin around mouth.
NECK: Supple, No LAD, JVP to neck
CV: RR, NL rate. NL S1, S2. No murmurs, rubs. S4+
LUNGS: crackles/rales throughout lung fields.
ABD: distended, mildly tender throughout, no rebound/guarding. +
BS.
EXT: gross 3+ whole body anasarca. 2+ DP pulses BL
SKIN: Stage II pressure ulcer on buttock, dehised back wound
from spinal surgery healing by secondary intention oozing serous
fluid
NEURO: opens eyes on command, unable to squeeze hands on
command, but moving all extremities.
Pertinent Results:
[**2128-8-12**] 02:42AM BLOOD WBC-10.6 RBC-2.95* Hgb-9.3* Hct-30.0*
MCV-102* MCH-31.3 MCHC-30.9* RDW-21.6* Plt Ct-447*
[**2128-8-11**] 03:27AM BLOOD WBC-9.3 RBC-2.82* Hgb-8.9* Hct-28.6*
MCV-101* MCH-31.6 MCHC-31.2 RDW-22.6* Plt Ct-453*
[**2128-8-10**] 04:35AM BLOOD WBC-12.8* RBC-3.05* Hgb-9.7* Hct-30.5*
MCV-100* MCH-31.8 MCHC-31.8 RDW-22.9* Plt Ct-533*
[**2128-8-9**] 03:35PM BLOOD Hct-32.8*
[**2128-8-9**] 04:22AM BLOOD WBC-19.8* RBC-3.48* Hgb-11.0* Hct-35.2*
MCV-101* MCH-31.6 MCHC-31.3 RDW-22.2* Plt Ct-573*
[**2128-8-8**] 03:42PM BLOOD WBC-18.1* RBC-3.28* Hgb-10.5* Hct-33.7*
MCV-103* MCH-32.0 MCHC-31.1 RDW-22.7* Plt Ct-537*
[**2128-8-8**] 11:15AM BLOOD WBC-14.5*# RBC-3.08* Hgb-9.6* Hct-32.2*
MCV-105* MCH-31.1 MCHC-29.7* RDW-22.0* Plt Ct-424#
[**2128-8-8**] 03:42PM BLOOD Neuts-76* Bands-7* Lymphs-4* Monos-12*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2128-8-8**] 11:15AM BLOOD Neuts-78* Bands-1 Lymphs-10* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2128-8-11**] 03:27AM BLOOD PT-19.8* PTT-38.5* INR(PT)-1.8*
[**2128-8-10**] 04:35AM BLOOD PT-20.9* PTT-40.5* INR(PT)-2.0*
[**2128-8-9**] 04:22AM BLOOD PT-19.2* PTT-38.9* INR(PT)-1.8*
[**2128-8-8**] 03:42PM BLOOD PT-17.7* PTT-36.4* INR(PT)-1.6*
[**2128-8-8**] 11:15AM BLOOD PT-18.7* PTT-150* INR(PT)-1.7*
[**2128-8-12**] 02:42AM BLOOD Glucose-106* UreaN-27* Creat-1.9* Na-145
K-3.7 Cl-110* HCO3-27 AnGap-12
[**2128-8-11**] 03:27AM BLOOD Glucose-101 UreaN-40* Creat-2.4* Na-145
K-3.6 Cl-110* HCO3-26 AnGap-13
[**2128-8-10**] 04:35AM BLOOD Glucose-93 UreaN-35* Creat-2.1* Na-146*
K-3.7 Cl-108 HCO3-26 AnGap-16
[**2128-8-9**] 04:22AM BLOOD Glucose-67* UreaN-56* Creat-2.8* Na-141
K-4.2 Cl-104 HCO3-22 AnGap-19
[**2128-8-8**] 03:42PM BLOOD Glucose-101 UreaN-53* Creat-2.6* Na-139
K-4.1 Cl-102 HCO3-24 AnGap-17
[**2128-8-8**] 11:15AM BLOOD Glucose-82 UreaN-48* Creat-2.3* Na-143
K-3.8 Cl-110* HCO3-24 AnGap-13
[**2128-8-10**] 04:35AM BLOOD ALT-7 AST-16 Amylase-31
[**2128-8-9**] 04:22AM BLOOD ALT-8 AST-21 CK(CPK)-39 AlkPhos-82
TotBili-0.6
[**2128-8-8**] 03:42PM BLOOD ALT-10 AST-18 CK(CPK)-50 AlkPhos-82
Amylase-42 TotBili-0.5
[**2128-8-11**] 06:10AM BLOOD cTropnT-0.48*
[**2128-8-9**] 04:22AM BLOOD CK-MB-NotDone cTropnT-0.51*
[**2128-8-8**] 03:42PM BLOOD CK-MB-NotDone cTropnT-0.48*
[**2128-8-8**] 11:15AM BLOOD cTropnT-0.4*
[**2128-8-12**] 02:42AM BLOOD Phos-3.8 Mg-1.8
[**2128-8-11**] 03:27AM BLOOD Phos-5.1* Mg-1.9
[**2128-8-10**] 04:35AM BLOOD Albumin-2.1* Calcium-8.2* Phos-4.4#
Mg-1.9
[**2128-8-9**] 06:23PM BLOOD Mg-2.1
[**2128-8-9**] 04:22AM BLOOD Phos-6.0* Mg-2.2
[**2128-8-8**] 03:42PM BLOOD Albumin-2.3* Calcium-8.4 Phos-6.1* Mg-2.2
[**2128-8-8**] 11:15AM BLOOD Calcium-7.4* Phos-6.4*# Mg-2.1
[**2128-8-11**] 06:10AM BLOOD Vanco-18.1
[**2128-8-9**] 05:12PM BLOOD Vanco-5.7*
[**2128-8-12**] 02:58AM BLOOD Type-ART Temp-37.6 Rates-16/3 Tidal V-500
PEEP-8 FiO2-40 pO2-114* pCO2-41 pH-7.44 calTCO2-29 Base XS-3
-ASSIST/CON Intubat-INTUBATED
[**2128-8-11**] 11:05AM BLOOD Type-ART Temp-35.6 Rates-16/1 Tidal V-500
PEEP-8 FiO2-50 pO2-174* pCO2-37 pH-7.43 calTCO2-25 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2128-8-10**] 07:07PM BLOOD Type-ART Temp-36.9 Rates-16/ Tidal V-500
PEEP-8 FiO2-50 pO2-148* pCO2-38 pH-7.43 calTCO2-26 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2128-8-10**] 05:46AM BLOOD Type-ART Temp-37.0 Tidal V-550 PEEP-10
FiO2-50 pO2-123* pCO2-35 pH-7.49* calTCO2-27 Base XS-4
-ASSIST/CON Intubat-INTUBATED
[**2128-8-9**] 03:46PM BLOOD Type-ART Temp-37.2 Rates-20/ Tidal V-550
PEEP-10 FiO2-60 pO2-139* pCO2-38 pH-7.46* calTCO2-28 Base XS-3
[**2128-8-9**] 09:09AM BLOOD Type-ART Temp-37.2 Rates-20/ Tidal V-550
PEEP-10 FiO2-60 pO2-127* pCO2-31* pH-7.43 calTCO2-21 Base XS--2
-ASSIST/CON Intubat-INTUBATED
ECHO [**2128-8-10**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is severe global left ventricular hypokinesis (LVEF = 20
%). The right ventricular cavity is moderately dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonic valve leaflets are thickened with
restricted leaflet motion or systolic doming. No pulmonic
stenosis is appreciated. Significant pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2128-5-18**],
the right ventricle now appears dilated and hypokinetic. The
other findings are similar.
CT ABD/PELVIS [**2128-8-9**]: 1. Limited study demonstrates diffuse and
extensive anasarca, ascites. 2. Large bilateral pleural
effusions, with associated atelectasis. 3. Interval decrease in
left-sided retroperitoneal fluid collection, without visible
internal loculations or gas. No definite focal, circumscribed
fluid collection separate from this to suggest abscess. 4. No
gross bony destruction to suggest osteomyelitis. 5. Possible
decubitus ulcer.
Brief Hospital Course:
OVERALL SUMMARY OF STAY:
<br> Mr. [**Known lastname **] presented to [**Hospital1 18**] on [**8-8**] with altered mental
status, hypotension, and respiratory failure as well as fever
and leukocytosis. He was grossly fluid overloaded at
presentation with whole-body anasarca and large bilateral
pleural effusions. The source of his infection was not clear as
he had multiple possible sources for infection including
previous MSSA paraspinous abscess, a PICC line which had been in
place for several weeks, a known intraabdominal fluid collection
and recent diarrheal illness. However, scans did not reveal any
paraspinous abscess, blood cultures from the PICC were negative,
C. diff labs were negative, and scans showed that the abdominal
fluid collection had decreased in size; therefore the source of
the infection was not clear though it resolved rather quickly
after hospitalization and antibiotics.
He was treated with vancomycin/cefipime(changed to
ceftazidime)and briefly needed to be on pressors for
hypotension. He was intubated from presentation until [**8-14**] and
did well after extubation without significant further
respiratory distress. His fever and leukocytosis resolved with
antibiotics. He received dialysis by HD, CVVH with UF, then HD
again and this greatly improved his anasarca; he also received
bilateral thoracentesis which were transudative. After
extubation he did well from a respiratory and hemodynamic
standpoint. He was in the MICU until [**8-19**] at which point he was
stable and discharged to the floor. On the floor, pt has been
stable and tolerating HD [**Month/Year (2) 12075**] well. Pt will finish 14 day course
of Vancomycin and Ceftazidime on [**2128-8-23**] just prior to discharge
to rehab.
<br> HOSPITAL COURSE BY PROBLEM:
<br> Respiratory failure: Patient presented with decreased
breathing and was intubated from [**8-8**] until [**8-14**]. The most
likely etiology of his respiratory failure was thought to be
both his septic picture and infection at presentation
(fever/leukocytosis) as well as his acute on chronic heart
failure (baseline L heart failure with new R heart failure at
presentation) leading to fluid overload and pulmonary edema.
His significant pleural effusions at presentation which likely
contributed heavily to his respiratory difficulty. As he was
diuresed and dialyzed, fluid status improved and his respiratory
status also improved. He was extubated on [**8-14**] and did well
from a respiratory standpoint; he was weaned to NC by [**8-16**]. He
had a brief episode of desaturation to high 80's while on HD on
[**8-18**] and was given non-rebreather and came back to 100%; was
then able to be weaned back to NC. Lower extremity US were
performed to assess for DVT [**2128-8-19**] and these results were
negative. On floor, pt was weaned to RA and was discharged with
O2 sat 92% on RA.
<br> Fever and leukocytosis: Patient presented febrile and with
high WBC count as well as hypotension, c/w a septic picture.
There were multiple possible sources for infection including his
old PICC line, his known paraspinal abscess, his history of
recent intraabdominal fluid collection, and recent diarrhea. He
came to the hospital on nafcillin and this was switched to
vancomycin given the possibility that he had MRSA not covered by
previous outpatient regimen. He was also started on
ciprofloxacin and zosyn given the possibility of anaerobic
infection [**3-6**] abdominal source; this was changed to vancomycin
and cefipime per ID recs. Flagyl was started given the
possibility of C. diff or other gut flora as evidenced by his
diarrhea; this was D/C when 3X C. diff were negative. The
patient was kept on a 2-week of vancomycin and cefipime
(cefipime switched to ceftazidime on [**8-16**]). Cultures obtained
from the HD catheter and the PICC were negative. A femoral
arterial line was placed on [**8-9**] and central line placement was
attempted on [**8-9**], however this placement was not successful.
Because of this, his PICC was left in place until he was
hemodynamically stable. Femoral A-line was pulled on [**8-16**] and
PICC was pulled on [**8-17**]. MRI of T and C spine was obtained per
ortho to search for any other possible areas of spinal
osteomyelitis, and though MRIs were not ideal because of
movement artifact, they showed no new paraspinous abscess or
fluid collection. CTs of the T and L spine also showed no
paraspinous abscess or fluid collection. Overall after his
initial presentation with fever and leukocytosis, his WBC
trended downward and he had no significant fevers. He completed
a 14 day course of ceftazidime and vancomycin on [**2128-8-23**].
<br> Pleural effusions: Patient has a history of pleural
effusions but CXR read at presentation showed worsened effusions
compared to prior. He had daily CXRs to monitor and was
dialyzed as BP tolerated. Though he did not spike further fevers
and WBC were stable, his pleural effusions persisted throughout
his MICU stay despite HD and ultrafiltration. On [**8-13**] the
possibility of therapeutic bilateral thoracentesis was
considered with the patient and his family. R thoracentesis on
[**8-13**] was traumatic and appeared exudative with eosinophilia. L
thoracentesis on [**8-14**] was non-traumatic and transudative; it was
thought that the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] showed false values due to ?tap
technique and possible old blood in R pleura. Gram stain and
culture of both the R and L pleural fluid was negative. The
most likely etiology of the effusions was still thought to be
volume overload (confirmed by physical exam and CXR as well as
the second [**Female First Name (un) 576**] results).
<br> Cardiomyopathy/Acute on Chronic Systolic Heart Failure:
Patient had a known EF of 15-20% (based on echo [**2128-5-18**]) at
presentation, and a BNP was >70,000. There was no prior BNP for
comparison. He also had a troponin of 0.48 at presentation
which increased slightly to 0.51 on [**8-9**]. These were thought to
be primarily due to demand ischemia given his probable
infection. There were no concerning EKG changes. Troponins
were measured and trended down (repeat troponin on [**8-11**] was
0.48). He had an echo on [**8-10**] which showed new RV dilation and
hypokinesis not seen on the [**2128-5-18**] Echo, as well as other
findings consistent with his [**2128-5-18**] echo including mild left
atrial enlargement, mild symmetric LVH, severe LV hypokinesis
and an EF ~20% as well as mild MR, significant pulmonic
regurgitation and trivial pericardial effusion. This new R
heart failure could be either a result of his known L heart
systolic failure or the result of new R heart strain. CTA was
performed to rule out PE and this showed no evidence of PE but
did confirm large bilateral pleural effusions. Fluid was
removed as BP tolerated during his [**Month/Day/Year 12075**] hemodialysis. Patient
was started on captopril 6.25 TID on [**8-13**] for further management
of heart failure (rather than metoprolol because he was still
hypotensive at this point). He had a history of HTN at home
treated with 50mg metoprolol TID. His metoprolol was restarted
at 12.5mg TID on [**8-16**] when pressures came back up. Since his
pressure and heart rate were still high on [**8-17**], this was
increased to 25mg TID and he remained on this for the rest of
his hospital stay.
<br> ESRD on HD: Patient was very volume overloaded at
presentation, and extremely edematous. This was thought to be
the likely source of his respiratory compromise. He was
maintained on [**Month/Year (2) 12075**] hemodialysis. After receiving HD on [**8-9**] and
[**8-11**] the renal team felt that ultrafiltration would be useful to
take more fluid off in the setting of his hypotension on HD but
his persistent fluid-overloaded state. He was placed on CVVH
from [**Date range (1) 93564**] and this was successful at removing large
quantities of fluid. Patient appeared much less anasarcic after
CVVH. This was switched to HD with ultrafiltration on [**8-18**] (his
regular [**Month/Year (2) 12075**] schedule) since his pressures had stabilized and his
clinical exam had improved.
<br> Tachycardia: Patient was persistently in sinus tachycardia
to the 110s-120s during the latter part of his MICU stay. This
was thought to be due to heart failure placing him on the
descending limb of the Starling curve so that his fluid overload
put strain on his heart and cardiac output was low, leading to
tachycardia. He also was anemic which could have contributed.
He had a history of hypothyroidism treated with synthroid and
TSH was checked for the possibility that renal failure and fluid
shifts led to increased levels of synthroid causing a
hyperthyroid picture; however TSH was slightly elevated c/w mild
hypothyroidism. His tachycardia persisted but at lower levels
(low 100s)on [**7-28**].
<br> Altered Mental Status: Paient presented with decreased
mentation from his baseline. It was thought that his altered
mental status was primarily [**3-6**] infection given his leukocytosis
and fever. He did also have a known history of hypoglycemia in
the setting of being hospitalized. A glucose at presentation
was 59 and he was given [**2-4**] amp D50 with an improvement in
mental status. Finger sticks were normal through the rest of
his hospital stay, and infection was treated as per above.
Patient's mental status improved significantly after extubation
and weaning of sedation.
<br> Paraspinal Abscess: Patient presented with known paraspinal
abscess. Initial plan when this abscess was discovered was to
have an 8-week course of nafcillin. he had initially been on
rifampin as well, but this was stopped on [**2128-7-8**] given his
worsening LFTs. At the time of admission, patient was put on
the antibiotic regimen described above, i.e. switched from
nafcillin to vancomycin given signs of infection (fever and
leukocytosis) in the setting of already being on nafcillin.
Leukocytosis and fevers improved as per above.
<br> Diarrhea: Patient had a history of loose stools at a
previous admission which were attributed to his bowel regimen
and his low albumin. At the time of this admission, he was
cultured for C. diff X3 and all cultures were negative. He was
started on flagyl at the time of initial admission, and this was
continued until [**8-11**] when the 3rd C. diff culture returned
negative. His home loperamide was held.
<br> Decubitus ulcer on buttocks: Patient had state II decub
ulcers on buttocks and a healing wound from recent spinal
surgery. He had flexiseal dressings placed to protect, and
wound care consult saw him.
<br> Anemia: Thought to be likely [**3-6**] his ESRD. Iron studies
were repeated and he received epogen at HD. He did have a Hct
drop on [**8-17**] from 29.9 to 26.0 and repeat Hcts during the next
few days showed Hct persistently low in the 24-26 range. Iron
studies were repeated and showed low iron and high TIBC c/w iron
deficiency anemia. On [**8-21**], pt had Hct 20.9 and was given 1
unit PRBCs with rise in HCt to 24.2. HCT is 25.3 at time of
discharge.
<br> Pain: Patient was on methadone as a home regimen. This was
decreased at presentation to 5mg TID given his altered mental
status. He did complain of abdominal pain during his stay, and
amylase and lipase were checked on [**8-10**]; these were normal. Per
previous records this abdominal pain has been a longstanding
issue. Patient was culture for C. diff as per above. By [**8-11**]
the patient was no longer complaining of abdominal pain.
<br> HTN: patient has a history of HTN was on home metoprolol.
This was held in the setting of his septic picture with hypoTN
requiring pressors, and he was monitored for reflex tachycardia.
Levophed was started at admission and was able to be weaned and
turned off by [**8-10**]. Captopril was started on [**8-13**] as per above
(for his cardiac failure rather than for hyperTN as he was still
hypotensive at this point). His home metoprolol was restarted
on [**8-16**] and titrated up as tolerated because his pressures had
slowly increased to the 120s and he was tachycardic to the
100s-110s. He remained slightly tachycardic for the rest of his
stay but his pressures were in the normal range and he was not
hypertensive.
<br> CAD with positive stress test [**5-8**]: Patient was maintained
on ASA 325mg daily, plan was to restart metoprolol when his BP
would tolerate. Echo was repeated as per above. Captopril and
metoprolol started as per above.
<br> Restless leg syndrome: Patient's home mirtazipine was held
given his altered mental status at presentation.
<br> Psoriasis: treated with sarna lotion PRN
<br> Hypothyroid: Patient's home synthroid was increased to 62.5
mcg from 50 this hospital stay after TSH slightly elevated at
5.4 (ULN 4.2) with a free T4 of 0.8. Pt's TSH should be
rechecked in [**7-11**] wks to ensure appropriate dosing.
<br> FEN: Patient was kept NPO until [**8-10**] at which point his tube
feeds were restarted per nutrition recommendations. Lytes were
repleted PRN. He was started back on a PO diet on [**8-16**] and
advanced as tolerated per speech and swallow recs (no gag reflex
on initial assessment, but was able to be advanced with no signs
of choking).
<br> PPX: Heparin SC, bowel regimen
<br> Code: FULL CODE. This was readdressed and confirmed at a
family meeting on [**8-17**].
Medications on Admission:
(per [**Hospital 100**] rehab record)
Antibiotics started on last admission
Ciprofloxacin 500mg daily PO/via tube day 1 [**2128-6-12**]
Nafcillin 2gm q4hr day 1 [**2128-6-12**]
.
Metoprolol Tartate 50 mg q6hr
Mirtazapine 15 mg QHS
Methadone 10 mg TID (per medical record)
Loperamide 2mg [**Hospital1 **]
Pantoprazole 40 mg [**Hospital1 **]
Levothyroxine 50 mcg daily
Gabapentin 300 mg QHS
Amylase/lipase/protease Creon 20, 3 capsules TID
Lactobacillus 2 tab TID
Lanthanum carbonate 500 mg [**Hospital1 **] (0800, 2200)-phos binder
Vitamin B complex 1 tab daily
Heparin SC 5000 BID
Tylenol 650 mg q6hr prn
Zofran 4mg q8hr prn
Betamethasone 0.1% lotion to perineum, buttocks [**Hospital1 **]
Zinc Oxide 20% ointment apply daily
Discharge Medications:
1. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
7. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. Betamethasone Valerate 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for buttocks, perineum.
9. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin infxn.
16. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed.
17. Lactobacillus Acidophilus Tablet Sig: Two (2) Tablet PO
three times a day.
18. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis:
Sepsis from probable line infection
Secondary Diagnoses:
Respiratory Failure
Pleural Effusions
ESRD on HD
Acute on Chronic systolic CHF
Anemia
Depression
Hypothyroidism
Discharge Condition:
Stable- 92% O2 sat on room air
Discharge Instructions:
You were admitted with low blood pressure and and respiratory
failure after you got an infection in your blood stream. Here,
you were treated for 14 days with antibiotics for this
infection. Now, you are being transferred back to a nursing
home. You will continue to get dialysis there on your normal
Mon, Wed, Fri schedule.
Please call your doctor or return to the ED if you get chest
pain, shortness of breath, increasing abdominal pain, dizziness,
or any other concerning symptoms.
Followup Instructions:
Infectious disease:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2128-9-3**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2128-9-15**] 9:30
Orthopedics:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2128-10-7**] 11:00
Completed by:[**2128-8-24**]
|
[
"E879.1",
"428.23",
"730.18",
"038.9",
"333.94",
"785.52",
"696.1",
"403.91",
"585.6",
"518.81",
"E879.8",
"789.59",
"999.31",
"414.8",
"305.1",
"244.9",
"995.92",
"285.21",
"458.21",
"348.31",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.72",
"96.6",
"38.93",
"38.91",
"86.05",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
24309, 24384
|
8401, 10150
|
335, 385
|
24616, 24649
|
3256, 8378
|
25186, 25753
|
2456, 2596
|
22612, 24286
|
24405, 24405
|
21861, 22589
|
24673, 25163
|
2611, 3237
|
24481, 24595
|
249, 297
|
10178, 17327
|
413, 1657
|
24424, 24460
|
17342, 21835
|
1679, 2190
|
2206, 2440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
781
| 163,526
|
21689+57252
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-9-21**] Discharge Date: [**2117-11-27**]
Date of Birth: [**2041-8-18**] Sex: F
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
abdominal sepsis
Major Surgical or Invasive Procedure:
right femoral CVL placement [**9-21**]
diagnostic paracentesis [**9-22**]
exploratory laparotomy [**9-22**]
right brachial arterial line placement [**9-22**]
History of Present Illness:
76F s/p tissue AVR & PFO closure [**8-17**], c/b DVT on coumadin as
well as respiratory failure requiring tracheostomy & PEG
placement, who presented from [**Hospital **] rehab on [**9-21**] with
fevers, abdominal pain, mental status changes & marked
hypotension requiring pressor treatment in the ED. She was
previously admitted on [**9-10**] with mild abdominal pain, when she
was noted to have free abdominal air. However, she was managed
conservatively & was tolerating tube feeds prior to discharge on
[**9-16**].
Past Medical History:
PVD
hypertension
COPD
stage III lung ca, s/p chemo/XRT 7 yrs ago
CAD
atrial fibrillation
severe aortic stenosis
patent foramen ovale
1+ mitral regurgitation
hypercholesterolemia
h/o L subclavian vein DVT [**9-15**] (on coumadin)
s/p tissue AVR, PFO closure [**2117-8-17**]
s/p open tracheostomy
s/p PEG placement
s/p left CEA
s/p pacemaker insertion
s/p thoracentesis & pericardial window for malignant effusions
s/p total abdom hysterectomy
h/o MRSA infection
Social History:
Quit cigs [**2091**] (30 pk yrs)
Drinks 2 glasses of wine daily
Lives with her husband
Family History:
noncontributory
Physical Exam:
98.8 81 (AV paced) 90/59 (on dopamine gtt) 90% (on vent)
Alert, +trach
RRR, no JVD
CTA bilat
Chest site CDI
Tense abdomen with guarding, no rebound
PEG site w/o surrounding cellulitis
Guaiac negative
Mottled extremities, nonpalpable femoral pulses with faint
doppler signals
Diffuse ecchymotic patches
L antecub port site CDI
Pertinent Results:
[**2117-9-21**] 07:57PM BLOOD WBC-7.1 RBC-3.83* Hgb-11.3* Hct-34.0*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.0 Plt Ct-382
[**2117-9-21**] 07:57PM BLOOD Neuts-55 Bands-26* Lymphs-7* Monos-7
Eos-3 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2117-9-21**] 07:57PM BLOOD PT-42.5* PTT-99.4* INR(PT)-11.9
[**2117-9-21**] 07:57PM BLOOD Glucose-74 UreaN-48* Creat-1.5* Na-128*
K-6.1* Cl-94* HCO3-23 AnGap-17
[**2117-9-21**] 07:57PM BLOOD ALT-39 AST-58* AlkPhos-178* TotBili-1.2
Amylase-73 Lipase-35 CK(CPK)-35, cTropnT-0.55*
[**2117-9-21**] 08:06PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2117-9-21**] 08:06PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-MOD
[**2117-9-21**] 08:06PM URINE RBC-[**12-26**]* WBC-[**12-26**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**2117-9-22**] 09:34AM ASCITES TotPro-3.5 Glucose-1 LD(LDH)-436
Amylase-178 TotBili-0.9
[**2117-9-22**] 09:34AM ASCITES WBC-6600* RBC-4000* Polys-96* Lymphs-0
Monos-3* Eos-1*
[**2117-9-22**] 05:00PM BLOOD Cortsol-75.4*
CULTURES
[**2117-9-21**] 8:08 pm BLOOD CULTURE # 2.
**FINAL REPORT [**2117-9-27**]**
AEROBIC BOTTLE (Final [**2117-9-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name **] AT 1620 [**9-22**]..
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..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- 1 S
PENICILLIN------------ 4 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2117-9-27**]): NO GROWTH.
[**2117-9-22**] 1:31 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2117-9-28**]**
AEROBIC BOTTLE (Final [**2117-9-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2117-9-26**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 05:39AM ON [**2117-9-24**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
[**9-22**] ABDOMINAL OR SWAB
GRAM STAIN (Final [**2117-9-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2117-9-26**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
PROBABLE ENTEROCOCCUS. SPARSE GROWTH.
LACTOBACILLUS SPECIES. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2117-9-26**]): NO ANAEROBES ISOLATED.
ECHOS
[**9-21**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The gradient was not
assessed and the leaflets are not well seen. No aortic
regurgitation is seen. The mitral valve leaflets and supporting
structures are thickened. At least 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. There is mild
pulmonary artery systolic hypertension. The pulmonic valve
leaflets are thickened. There is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with low
normal systolic function. At least moderate mitral
regurgitation. Pulmonary artery systolic hypertension.
[**9-30**]: Repeated echo (unchanged, except for only MILD mitral
regurgitation)
RADIOLOGY
[**9-21**] CT ABDOMEN: Interval development of worsened pulmonary
opacities, most pronounced in the right base. This appearance is
concerning for aspiration, with note of reflux of oral contrast
into the esophagus. Interval development of a large amount of
ascites throughout the abdomen with decrease in the previously
seen free fluid. This may reflect underlying sepsis, CHF or low
albumin state, particularly given the associated anasarca and
edematous changes in the bowel as noted above.
[**9-22**] US: Successful paracentesis. Approximately 400 cc of clear
yellow
fluid were recovered & sent for culture.
[**9-30**] CT abdomen: 1. No evidence of intra-abdominal abscess. 2.
Few tubular gas-filled structures within the left liver lobe. It
is unclear whether these represent air within the portal venous
or biliary system. There is no air within the mesenteric
vessels, or loops of intra-abdominal large or small bowel. 3.
Slight interval increase in right lower lobe consolidation,
concerning for worsening aspiration. 4. Slight interval increase
in bilateral pleural effusions, left greater than right. 5.
Significant interval decrease in the amount of intra-abdominal
ascites. Subcutaneous edema persists.
Brief Hospital Course:
[**9-21**]: Presented to ED in septic shock. After CVL placed,
negative echo & abdominal CT showing new ascites, she was
admitted to the SICU for resuscitation and reversal of her
supratherapeutic INR.
[**9-22**]: Diagnostic paracentesis showed serous inflammatory ascitic
fluid, and the patient was taken for ex lap & abdominal washout.
A diffuse inflammatory process awas encountered, but no frank
infectious collections were seen. The previously gastrostomy
tube was removed & the gastrotomy site was oversewn.
She remained in SICU postop, and was weaned off pressors &
ventilatory support. Her extended SICU course is summarized
below according an organ systems.
NEURO: Her pain was controlled with small doses of morphine &
her agitation was controlled with ativan & seroquel.
CV: Echocardiograms showed good cardiac function, with mild
mitral regurgitation. Initially she required pressors to
maintain her blood pressure, but she has been hemodynamically
stable for some time.
RESP: She was maintained on assist control ventilation & at
discharge was on with fiO2 0.4 & PEEP [**6-13**]. Each day, she
tolerated about 4 hours of CPAP with PSV towards the end of her
admission.
FEN/GI: Abdominal pain gradually improved after surgery.
Initial fluid avidity resolved after surgery & she was diuresed
down to her baseline weight of 55kg. Was fed with impact via
nasogastric dobhoff tube. Hypernatremia treated with free water
boluses. Patient had an GI bleed from a hemorrhoid which caused
us to stop anticoagulation for L subclavian DVT.
HEME: INR was reversed with vitamin K & FFP prior to [**9-22**]
paracentesis. Prior to discharge, she was re-anticoagulated
with lovenox & coumadin for her L subclavian DVT.
Anticoagulation was stopped due to GI bleed.
ID: treated x 2 weeks with vanc/ceftaz/flagyl for her
peritonitis. Poor creatinine clearance required small dose of
vanco (500qd). h/o MRSA infection. VRE negative. C diff
negative.Prior to D/C patient was kept on Gent/Zosyn for
Pseudomonas in urine and blood.
ENDO: blood glucose maintained less than 130 with RISS. Despite
low BP, she had an appropriate cortisol response.
Patient has a R port-a-cath
DISPO: being discharged to vent rehab.
HCP: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 57036**]
Medications on Admission:
flovent
digoxin 125'
lasix 20'
KCL
amiodarone 100'
prevacid
lipitor 20'
ezetimibe 10'
combivent
asa 81
reglan
vanco
coumadin
tylenol prn
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Venlafaxine 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Glutamine 10 g Packet Sig: One (1) Packet PO BID (2 times a
day).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
8. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day): alternate 0.0625 with 0.125 every other day.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours).
16. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
17. Morphine 2 mg/mL Syringe Sig: [**2-7**] Injection Q6H (every 6
hours) as needed.
18. Gentamicin in NaCl (Iso-osm) 120 mg/100 mL Piggyback Sig:
One (1) Intravenous Q48H (every 48 hours).
19. Furosemide 10 mg/mL Solution Sig: Two (2) Injection [**Hospital1 **] (2
times a day).
20. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): sliding scale printed out.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
s/p exploratory laparotomy for abdominal washout for chemical
peritonitis
s/p aortic valve replacement/PFO repair
tracheostomy
PVD
hypertension
COPD
stage III lung ca, s/p chemo/XRT 7 yrs ago
CAD
atrial fibrillation
severe aortic stenosis
patent foramen ovale
1+ mitral regurgitation
hypercholesterolemia
h/o L subclavian vein DVT [**9-15**] (on coumadin)
s/p tissue AVR, PFO closure [**2117-8-17**]
s/p open tracheostomy
s/p PEG placement
s/p left CEA
s/p pacemaker insertion
s/p thoracentesis & pericardial window for malignant effusions
s/p total abdom hysterectomy
h/o MRSA infection
Discharge Condition:
stable
Followup Instructions:
f/u Dr. [**Last Name (STitle) **] 2 weeks
Name: [**Known lastname 5160**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 10616**]
Admission Date: [**2117-9-21**] Discharge Date: [**2117-11-27**]
Date of Birth: [**2041-8-18**] Sex: F
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 203**]
Addendum:
It was decided that since the patient received 2 weeks of
pseudomonas double coverage, that the antibiotics would be
discontinued.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Venlafaxine 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Glutamine 10 g Packet Sig: One (1) Packet PO BID (2 times a
day).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
8. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day): alternate 0.0625 with 0.125 every other day.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
17. Morphine 2 mg/mL Syringe Sig: [**2-7**] Injection Q6H (every 6
hours) as needed.
19. Furosemide 10 mg/mL Solution Sig: Two (2) Injection [**Hospital1 **] (2
times a day).
20. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): sliding scale printed out.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**0-0-0**]
|
[
"286.9",
"428.0",
"707.07",
"280.0",
"038.9",
"707.05",
"536.42",
"455.8",
"V42.2",
"995.92",
"V53.31",
"584.9",
"453.8",
"V55.0",
"567.89",
"276.0",
"496",
"785.52",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"44.62",
"45.24",
"45.13",
"54.91",
"96.72",
"54.12",
"38.91",
"45.23",
"00.17",
"38.93",
"99.15",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15598, 15792
|
8437, 10733
|
287, 446
|
13414, 13422
|
1986, 8414
|
13445, 13966
|
1600, 1617
|
13989, 15575
|
12804, 13393
|
10759, 10897
|
1632, 1967
|
231, 249
|
474, 996
|
1018, 1480
|
1496, 1584
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,353
| 143,876
|
52581
|
Discharge summary
|
report
|
Admission Date: [**2166-7-22**] Discharge Date: [**2166-7-29**]
Date of Birth: [**2101-6-19**] Sex: M
Service: MEDICINE
Allergies:
Benadryl / Morphine / Ativan / Compazine / Dilaudid
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Fever and mental status changes
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
65 year old man with a past medical history significant for CAD,
CHF, ESRD on dialysis, COPD, and hypothyroidism who presents
with fever and mental status changes. Patient is a poor
historian and was unable to relay much of story and patient's
wife was not available, so history gleaned from ED records. On
the day of admission, patient was noted by family to have
altered mental status and was unable to answer questions
appropriately. On review, patient states that he has had a
productive cough over the past several days and that "[he]
didn't feel right". After driving down the sidewalk today,
patient was brought to the ED by family.
In the ED, patient was febrile to 104, HR 80, BP 130/60, RR 20,
and oxygen saturation was 96% on room air. White count was 16.1.
Venous blood gas revealed 7.37/53/66. He received levofloxacin,
vancomycin, and flagyl. CT head was negative for intracranial
hemorrhage. CT abdomen and pelvis pending. Lumbar puncture
negative for infection.
Past Medical History:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula.
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral [**Year (4 digits) 1106**] disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
cardiology who notes he was previously on coumadin.
Social History:
Lives in [**Location 686**] with wife, has older children
tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH. +Hx of
narcotic abuse.
Family History:
Non contributory
Physical Exam:
98.2, 101/50, 60, 20, 97
Gen: Middle-aged man in wheelchair in NAD
HEENT: Mild conjunctival pallor. No icterus. Moist mucous
membranes
NECK: Supple. No cervical or supraclavicular lymphadenopathy
could be appreciated.
CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs
or [**Last Name (un) 549**] appreciated.
LUNGS: Decreased breath sounds in lower lung fields,
bilaterally. No wheezes, crackles, or rhonci appreciated.
ABD: Soft. Nontender, +BS. left inguinal hernia
[**Last Name (un) **]: Warm and well perfused upper extremities. Right AV fistula
in place. Lower extremities with hyperpigmentation on anterior
aspects of legs. All ten toes amputated. No lower extremity
edema, bilaterally.
NEURO: CAO3. Answered questions appropriately. [**6-7**] flexion and
extension in upper extremities and hip flexors
Pertinent Results:
BLOOD CULTURES:
BETA STREPTOCOCCUS GROUP B
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN------------<=0.12 S
VANCOMYCIN------------ <=1 S
[**2166-7-28**] 04:01AM BLOOD WBC-6.0 RBC-3.74* Hgb-11.6* Hct-35.3*
MCV-94 MCH-31.1 MCHC-32.9 RDW-17.1* Plt Ct-215
[**2166-7-28**] 04:01AM BLOOD PT-15.1* PTT-37.1* INR(PT)-1.4*
[**2166-7-28**] 04:01AM BLOOD Glucose-102 UreaN-48* Creat-7.2*# Na-136
K-4.9 Cl-96 HCO3-26 AnGap-19
[**2166-7-28**] 04:01AM BLOOD ALT-16 AST-24 AlkPhos-228* TotBili-0.3
[**2166-7-23**] 02:28AM BLOOD Lipase-17 GGT-236*
[**2166-7-24**] 01:52PM BLOOD CK-MB-4 cTropnT-0.13*
[**2166-7-28**] 04:01AM BLOOD Calcium-8.6 Phos-5.7* Mg-2.6
[**2166-7-23**] 02:28AM BLOOD Ammonia-65*
[**2166-7-23**] 02:28AM BLOOD TSH-5.9*
[**2166-7-25**] 05:23AM BLOOD Free T4-1.1
[**2166-7-26**] 06:45AM BLOOD Vanco-20.5*
TTE
The left and right atrium are moderately dilated. The estimated
right atrial pressure is >20 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis. No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic valve leaflets are moderately
thickened. No discrete vegetation is seen (cannot exclude).
Moderate or greater aortic stenosis is not suggested (minimal
aortic stenosis may be present). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-4**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The tricuspid valve
leaflets fail to fully coapt. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-4-2**],
the left ventricular cavity is slightly larger and the estimated
pulmonary artery systolic pressure is higher. Valvular
morphology and the severity of regurgitation are similar.
TEE: Conclusions:
The left atrium is dilated. Mild spontaneous echo contrast is
seen in the body of the left atrium. No mass/thrombus is seen in
the left atrium or left atrial appendage. The right atrium is
dilated. No atrial septal defect is seen by 2D or color Doppler.
LV systolic function appears depressed. Right ventricular
systolic function appears depressed. 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 masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. IMPRESSION:
No echo evidence of endocarditis.
LIMITED ULTRASOUND EXAMINATION OF THE RIGHT FOREARM IN THE
REGION OF THE AV FISTULA: Arteriovenous fistula is identified
with appropriate aliasing on color flow images and appropriate
Doppler flow. No fluid collections were identified abutting or
in the region around the fistula. There is no soft tissue edema.
IMPRESSION: Appropriate flow within the AV fistula with no
evidence of fluid collection or abscess.
CT ABD and Pelvis
1. Left inguinal hernia containing normal-appearing loops of
small bowel. The exam is somewhat limited without the
administration of oral contrast.
2. Multiple bilateral renal cysts appear unchanged, with single
exophytic left renal lower pole lesion, possibly representing a
prior RF ablation site.
3. Stable cardiomegaly and diffuse atherosclerotic involvement
of the abdominal aorta and its branches.
4. Cholelithiasis with gallbladder wall thickening, unchanged.
5. Anasarca with mild increase in intra-abdominal free fluid.
.
CT HEAD
No intracranial hemorrhage or edema.
.
Brief Hospital Course:
Patient is a 65 year old man with coronary artery disease,
congestive heart failure with EF 20%, diabetes, and end stage
renal disease on hemodialysis who presents with mental status
changes and fever, found with streptococcal septicemia due to
Strep Viridans.
.
.
1) Septicemia - Streptococcal
- ID Consultation
- PV Consultation
- TEE/TTE negative for endocarditis
- Penicillin-G x 2 weeks IV at home
2) Peripheral [**Year (4 digits) **] Disease
- [**Year (4 digits) **] surgical consultation
- initial concern for infected grafts, ruled out by ultrasound
- LE: Distal occlusion of bilateral popliteal to tibial bypass
grafts
- No immediate intervention
- Continue Aspirin/[**Year (4 digits) **]
3) Paroxysmal atrial fibrillation:
- continue on amiodarone 200 mg QD
- Metoprolol
4) Systolic CHF and coronary artery disease:
- continue aspirin, atorvastatin 10mg, clopidogrel 75mg,
lisinopril 5mg, and metoprolol 25.
.
5) Depression:
- citalopram 30mg.
6) End Stage Renal Failure:
- continue dialysis sessions (M,W,F) via right AV fistula
- Continue cinacalcet 30 mg QD
- Renal consultation
- continue sevelamer 800mg TID
- Continue zinc supplementation.
7) Type 2 Diabetes controlled with complications
- insulin sliding scale
- metoclopramide 10 mg QIDACHS, and lorazepam 0.5 mg PO TID PRN
for nausea.
8) Hypothyroid:
- Continue levothyroxine 50mcg daily
9) Obstructive Sleep Apnea
- CPAP
MRSA and VRE precautions.
Medications on Admission:
-Amiodarone 200 mg QD
-Aspirin 81 mg QD
-Atorvastatin 10 mg QD
-Cinacalcet 30 mg QD
-Citalopram 30 mg QD
-Clopidogrel 75 mg QD
-Ipratropium Bromide 0.02% INH q6hr
-Lactulose TID PRN
-Levothyroxine 50 mcg QD
-Lisinopril 5 mg QD
-Metoclopramide 10 mg QIDACHS
-Oxycodone 5 mg PO q6hr PRN
-Pantoprazole 40 mg QD
-Zinc Sulfate 220/50 mg QD
-Metoprolol 25 QD
-Lorazepam 0.5 mg PO TID PRN nausea
-Sevelamer 800 mg TID
-Papain-Urea 830,000-10 unit TD QD
-Zolpidem 5 mg PO QHS PRN
-Insulin Regular Human
Discharge Medications:
1. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: One
(1) million units Injection Q4H (every 4 hours) for 14 days.
[**Year (4 digits) **]:*QS Recon Soln* Refills:*0*
2. PICC CARE
PICC Care per NEHT protocol
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO ONCE
(Once).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every six (6) hours.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Streptococcal Septicemia
Peripheral [**Hospital **] Disease
Paroxsysmal Atrial Fibrillation
Depression
Type 2 DM controlled with complications
Obstructive Sleep Apnea
CAD
ESRD
CHF - Systolic
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Return to the hospital if you have fevers, chills, redness at
your PICC site, cough, difficulty breathing
You will be on antibiotics 6 times a day for 2 weeks with VNA.
It is important that you receive all abtibiotics during this
course.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2166-8-7**] 8:50
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2166-9-9**]
1:45
|
[
"327.23",
"496",
"427.31",
"995.91",
"428.20",
"250.50",
"428.0",
"362.01",
"414.01",
"244.9",
"250.40",
"250.60",
"070.54",
"357.2",
"583.81",
"577.1",
"585.6",
"425.4",
"V45.1",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"03.31",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11181, 11239
|
7897, 9325
|
344, 358
|
11473, 11479
|
3678, 7874
|
11867, 12158
|
2801, 2819
|
9871, 11158
|
11260, 11452
|
9351, 9848
|
11503, 11844
|
2834, 3659
|
273, 306
|
386, 1366
|
1388, 2633
|
2649, 2785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,495
| 119,093
|
38923
|
Discharge summary
|
report
|
Admission Date: [**2178-3-8**] Discharge Date: [**2178-3-9**]
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation
central line placement
arterial line placement
History of Present Illness:
This is an 88 year old male with history of gastric CA, CKD HTN,
mental retardation (non-verbal at baseline) who was admitted
[**Date range (1) 86354**] for weakness and lethargy and found to have E.Coli UTI.
Today he presents from his nursing home where he was found to
have altered mental status with a BP of 144/85 and HR 150. He
had been vomiting the previous day.
.
In the ED, initial VS were T:99.1 BP:116/72 HR: 176 RR: 24
O2Sat: 98%NRB. Blood pressure reportedly dipped to systolics in
70's. He was found to be in Afib and cardioverted to sinus which
returned to Afib. Given RR of 48 and hypoxia to the 70's he was
intubated. Sepsis line in RIJ placed and levophed started. Got
Vanc and Zosyn. CT abdomen concerning for ischemic gut. Lactate
initially 8 resolved to 4 with IVF. Surgery was consulted wished
to speak with family to gauge goals of care. Also given Bicarb,
tylenol, fentanyl/versed gtt, kayexalate for hyperkalemia. He
received 6 liter of IVF.
.
Past Medical History:
Hypertension
Aspiration
GERD
Dysphagia
Arthritis
Renal insufficiency -- baseline Cr not documented
"Stomach cancer"
Hypothyroidism
Mental retardation: type unknown, nonverbal at baseline
Injury to back-- was wearing brace until [**2178-2-16**]
Arthritis
Social History:
Lives at [**Hospital **] Healthcare Center. Previously was living in a
group home. No known alcohol or tobacco use.
Family History:
Non-contributory
Physical Exam:
Vitals - T:99 BP:131/58 HR:120 RR:36 02 sat:99%
GENERAL: intubated, sedated
HEENT: NC/AT, PERRL, MMM
CARDIAC: s1/s2 present, no murmurs
LUNG: Anterior lung fields clear
ABDOMEN: no bowel sounds, firm, +guarding R>L
GI: foley in place, +hematuria
EXT: feet cool, no LE edema, no mottling
NEURO: sedated
DERM: no skin lesions
Pertinent Results:
ADMISSION LABS [**3-8**]:
CHM7:
08:12PM GLUCOSE-126* UREA N-59* CREAT-3.9* SODIUM-147*
POTASSIUM-5.5* CHLORIDE-122* TOTAL CO2-10* ANION GAP-21*
08:12PM CALCIUM-6.6* PHOSPHATE-5.3* MAGNESIUM-2.2
CBC:
WBC-7.6 RBC-4.41* HGB-12.6* HCT-40.1 MCV-91 MCH-28.6 MCHC-31.4
RDW-17.0*
[**2178-3-8**] 08:12PM NEUTS-74.8* LYMPHS-17.7* MONOS-5.1 EOS-1.2
BASOS-1.2
Arterial Blood Gas:
TYPE-ART PO2-349* PCO2-33* PH-7.13* TOTAL CO2-12* BASE XS--17
LACTATE-8.0* K+-5.0
=========
MICROBIOLOGY [**3-8**]:
Stool: + Cdiff toxin
Blood Cultures: Pending
Sputum Cx: pending
Urine: Negative
=========
ECG:
Probable multifocal atrial tachycardia. Low limb lead QRS
voltage. Left axisdeviation may be due to left anterior
fascicular block and/or possible prior inferior myocardial
infarction. Delayed R wave progression with late precordial QRS
transition is non-specific. Since the previous tracing of
[**2178-3-8**] there is probably no significant change.
==========
IMAGING:
CXR:
Indwelling devices are unchanged in position, and
cardiomediastinal
contours are stable in appearance. Worsening opacity in left
retrocardiac
region is likely due to a combination of atelectasis and small
pleural
effusion, but infectious pneumonia should also be considered in
the
appropriate clinical setting.
CT Torso:
1. No evidence of pulmonary embolism or dissection. Aneurysm of
the ascending
aorta. Trace pericardial fluid.
2. Dilated, ahaustral, and hypoenhancing segments of the sigmoid
colon with
bowel wall thickening and adjacent fat stranding, concerning for
infectious
process, less likely ischemia.
3. Enlarged prostate with prostatic stent. Foley catheter ends
proximal to
stent with balloon inflated within the prostate.
4. Small atrophic bilateral kidneys.
Brief Hospital Course:
88 yo male presenting with altered mental status, hypotension
and hypoxia. Patient required emergent intubation, central line
placement, and initiation of pressors in emergency department. A
CT abdomen showed thickening of the sigmoid colon with
surrounding fat stranding suggesting inflammatory process. On
exam abdomen was distended and guarded. Given high suspicion for
CDiff he was given PO Vancomycin and IV flagyl. Patient was seen
and evaluated by the general surgical service. The surgical team
discussed option of surgical intervention with the [**Hospital 228**]
health care proxy who ultimately decided that surgery was too
aggressive. [**Name (NI) **] HCP decided on DNR/DNI code status. The
patient was admitted to the MICU where he was aggressively
hydrated and continued on vasopressor support (a total of 3
vasopressors were eventually needed). Hemodynamics were further
complicated by MAT for which he was started on IV amiodarone.
Despite aggressive fluid resucitation and eventual initiation of
a total of three vasopressors patient remained hypotensive with
a rising lactate. [**Name (NI) **] HCP decided on comfort measures at
which time vasopressor support was stopped and patient died soon
after. His HCP requested an autospy be performed. Notably,
Clostridium Difficile toxin returned positive.
Medications on Admission:
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Name (NI) **]: 1-2
Drops Ophthalmic Q 8H (Every 8 Hours).
Levothyroxine 125 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
Terazosin 5 mg Capsule [**Name (NI) **]: One (1) Capsule PO HS (at
bedtime).
Fluticasone 50 mcg/Actuation Spray, Suspension [**Name (NI) **]: One (1)
Spray Nasal DAILY (Daily).
Lisinopril 20 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
Simethicone 80 mg Tablet, Chewable [**Name (NI) **]: One (1) Tablet,
Chewable PO four times a day as needed for gas/bloating.
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Polyethylene Glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One
(1) PO once a day: Please hold for loose stool.
Tylenol Extra Strength 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
every six (6) hours as needed for pain.
Fluoxetine 40 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
Simvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Artificial Tears Drops [**Last Name (STitle) **]: [**12-20**] Ophthalmic three times
a day.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Clostridium Difficile Colitis
Septic Shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2178-3-10**]
|
[
"486",
"276.2",
"V10.09",
"724.2",
"403.90",
"585.9",
"008.45",
"787.20",
"276.7",
"244.9",
"716.90",
"518.81",
"530.81",
"038.9",
"995.92",
"319",
"599.0",
"427.31",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04",
"38.91",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
6523, 6532
|
3912, 5232
|
283, 342
|
6619, 6628
|
2144, 3889
|
6680, 6714
|
1766, 1785
|
6496, 6500
|
6553, 6598
|
5258, 6473
|
6652, 6657
|
1800, 2125
|
222, 245
|
370, 1339
|
1361, 1617
|
1633, 1750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,395
| 182,837
|
45523
|
Discharge summary
|
report
|
Admission Date: [**2142-5-6**] Discharge Date: [**2142-5-10**]
Date of Birth: [**2088-8-12**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 53 year woman with PMH significant for diabetes s/p
pancreatectomy and ESRD on HD who presents with melena and
"feeling crappy for 2 days. She was at baby shower at 11 am Sat
morning, noticed sugars higher than normal. She was also having
of shortness of breath at rest. Had decreased appetite but blood
sugar still elevated. Felt better, so didn't come to the ED. On
Sunday she had bloody stool and started feeling dizzy. She
continued to feel worse and called EMS to come to the ED.
.
In the ED she was noted to have melena but her vitals were
stable. NG lavage was negative by the ED and by the GI consult
attending. Inital labs were notable for troponin of 0.11, ABG
with pH 7.30, K 8.0, and lactate of 5.2, glucose close to 400.
She was treated with insulin, D50, calcium, bicarb for
hyperkalemia, the K decreaed slightly to 6.9. Her initial HCT's
came back hemolyzed, but eventually her HCT was determined to be
18 and 1 unit of blood was started. Her systolic bloodpressure
trended down to the 100's from 130's and she was urgently
transferred to the MICU for further management.
.
Today she has had intemittent SOB at rest. Has had some chest
pain radiating to left arm but is now gone, not like previous MI
which was silent, and lasted 30 minutes in ED. Denies fevers but
has had chills yesterday. Had nausea, no vomiting. Feels weak
and slightly numb in hands. No changes in vision. Able to move
extremities. Feels anxious.
.
Past Medical History:
1. DM type 1
2. HTN
3. seizure history
4. dyslipidemia
5. hemorrhoids
6. Chronic renal fialure
7. CAD s/p NSTEMI in [**9-17**], cardiac cath [**2140-10-7**] showed 3vd,
mild diastolic dysfunction, and mild mitral regurgitation
8. Anemia: secondary to renal failure and chronic inflammation
Social History:
married, lives with husband, worked in a school cafeteria until
[**2140**], quit smoking 22 years ago, 2 [**1-15**] PPD x 8 years,
non-drinker, no current drug use
.
Family History:
Father had MI at 49, died age 76. Mother has [**Name2 (NI) **], had
breast cancer age 40's. Brother with [**Name2 (NI) **].
Physical Exam:
PE:
V: T98.2 P106 BP 166/88 12 100% RA
Gen: lying in bed, eyes closed, no apparent distress
HEENT: PERRLA, MMM dry, NG tube in place
Resp: clear bilaterally no crackles
CV: RRR nl s1s2 no murmurs, gallops, rubs
Abd: soft, nontender, nondistended, normoactive bowel sounds.
lateral inverted V surgical scar with reducible 4 cm hernia.
Ext: no cyanosis, clubbing, edema. 1+ DP bilaterally.
Neuro: A+Ox3, moving all extremities well.
Pertinent Results:
[**2142-5-6**] 11:15PM CK-MB-44* MB INDX-5.5 cTropnT-1.13*
[**2142-5-6**] 11:15PM CK(CPK)-796*
[**2142-5-6**] 03:15PM WBC-10.3# RBC-1.79*# HGB-5.5*# HCT-18.1*#
MCV-101* MCH-30.6 MCHC-30.4* RDW-16.9*
echo [**2142-5-9**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%).
There may be mild focal inferolateral hypokinesis. Tissue
velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears
structurally normal with trivial mitral regurgitation. There is
no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**10-24**]/2204, left ventricular function is probably similar
(images not
available for direct comparison).
EGD- erosive gastritis, jejunitis, no ulcers very friable mucosa
with stigmata of recent bleed. We are not convinced it is the
sole source of her blood loss
Colonoscopy- poor prep but negative for source of bleeding.
Brief Hospital Course:
This is a 53 year old woman with PMH of ESRD and NSTEMI presents
with malaise x 2 days, melena, and metabolic acidosis.
.
#) GI bleed with melena and presented with HCT 17 but
hemodynamically stable except tachycardia. Pt had periodic
melena since admission (?old blood). Serial Hct [**Hospital1 **] were stable
for 24 hours prior to d/c. During this admission patient was
followed by GI; an egd, colonoscopy done- but neither really
accounted for source. Patient was planned to get capsule
endoscopy as outpatient. She was given IV PPI [**Hospital1 **] throughout
the admission and d/c'd on po protonix [**Hospital1 **].
.
#) metabolic acidosis - Patient had a mixed picture contributing
to metabolic acidosis with uremia (BUN 120), DKA (small
acetone), lactic acidosis (lactate 5) with hyperkalemia with
peaked T waves. Insulin drip was d/c'd on monday (last day in
ICU) to lantus and ISS. Patient was initially started on
vanco/levo but d/c'd after one day as low liklihood of
infection. Renal followed patient during this admission- their
recs: included routine dialysis, restart renagel, and hold
cinacalcet. Acidosis resolved while in MICU. Subsequently [**1-17**]
bottles of blood cx from [**5-6**] showed gram + rods- likely
contaminant. Because the patient looked well and had no signs
of infection- she was not started on abx. urine cx neg, follow
up blood cultures were negative to date at d/c. Please follow
up blood cultures from this hospitalization.
.
#) troponin leak - history of NSTEMI and 3VD and having chest
pain. Troponin chronically elevated including setting of NSTEMI.
EKG not suggesting STEMI. Subsequently, CK 796, MB 44, MBI 5.5
and TropT 1.13--> ruled in for NSTEMI.
Restarted on low dose BB after first night of admission. Held
aspirin in setting of gib, plavix as no history of stents. She
was continued on lipitor 80 QD
.
#) Diabetes mellitus - wean insulin drip and started 4 units
lantus (slightly lower than home dose) plus sliding scale. She
was later transitioned to lantus 6u and RISS
.
#) ESRD on HD. Has AV fistula. Patient was dialyzed emergently
[**5-6**] for hyperkalemia, acid base disturbance, and volume
management in the setting of getting blood. Then she was
dialzyed on a regular schedule. restarted renagel when came out
to medical floor and cinacalcet at d/c.
.
#) history of HTN. Held hydralazine, imdur due to bleed but
continued beta blocker.
We restarted ace day prior to discharge.
.
#) history of pancreatic IPMT and surgical resection
- no active issues unless tumor seen on workup
.
#) history of seizures
- continue phenobarb
.
Medications on Admission:
per ED note - pt states list was taken by ED but is gone now)
Lipram (not generic) 4500 Q6H
hydralazine 50 mg po tid
[**Month/Year (2) 97116**] 150 mg po bid
renagel 800 mg po 4x daily and prn
sensopar 90 mg po qd
plavix 75 mg po qd
imdur 30 mg po qd
aspirin 325 po qd
lisinopril 10 mg po qd
phenabarbatol 30mg (8 pills on non-dialysis days, 6 pills on
dialysis days) daily
humalog sliding scale depending on 1:13 carbs
lantus 6 qhs
lipitor 80 po qhs
Discharge Medications:
1. Phenobarbital 30 mg Tablet Sig: Eight (8) Tablet PO QD NON
DIALYSIS DAYS ().
2. Phenobarbital 30 mg Tablet Sig: Six (6) Tablet PO QD AFTER
HEMODIALYSIS ON DIALYSIS DAYS ().
3. Lipram 4500 20,000-4,500- 25,000 unit Capsule, Delayed
Release(E.C.) Sig: 4500 (4500) Capsule, Delayed Release(E.C.)s
PO Q6H (every 6 hours).
4. [**Month/Year (2) **] 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
5. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) units
Subcutaneous at bedtime: please use your sliding scale as
prescribed in addition.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO QID (4 times
a day).
8. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. 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*
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointesinal bleed
Non ST elevation MI
diabetes type 1
hypertension
history of seizures
chronic kidney disease
Discharge Condition:
stable
Discharge Instructions:
Please call if you have chest pain or shortness of breath
WE ARE HOLDING YOUR HYDRALAZINE, AND PLAVIX
Followup Instructions:
Please call GI ([**Telephone/Fax (1) 2233**] to schedule your capsule endoscopy
Please follow up with Dr. [**Last Name (STitle) 2539**] within 2 weeks [**Telephone/Fax (1) 61108**]
Please follow up with Dr. [**Last Name (STitle) **] regarding restarting your
hydralazine and plavix
Other appointments:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-5-28**] 2:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-5-31**]
11:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Location (un) 54638**] PRACTICE ([**Location (un) **])
Date/Time:[**2142-8-16**] 10:00
Completed by:[**2142-5-11**]
|
[
"272.4",
"410.71",
"285.1",
"585.6",
"780.39",
"276.7",
"403.91",
"414.01",
"578.9",
"250.01",
"424.0",
"285.21",
"276.2",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"45.23",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8457, 8463
|
4150, 6752
|
274, 281
|
8621, 8630
|
2870, 4127
|
8781, 9500
|
2278, 2403
|
7254, 8434
|
8484, 8600
|
6778, 7231
|
8654, 8758
|
2418, 2851
|
231, 236
|
309, 1757
|
1779, 2078
|
2094, 2262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,729
| 140,625
|
54095
|
Discharge summary
|
report
|
Admission Date: [**2177-3-24**] Discharge Date: [**2177-4-8**]
Date of Birth: [**2093-6-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea, chest pain and pre-syncope
Major Surgical or Invasive Procedure:
[**2177-3-25**] - Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] tissue)
[**2177-3-31**] - Exploratory laparotomy, right colectomy
History of Present Illness:
83 year old female transferred from OSH for cardiac
catheterization. She had been experiencing a constellation of
symptoms including chest pressure, palpitations,
lightheadedness, dyspnea on exertion, and presyncope for several
days prior to admission. On [**3-11**] she presented to her
cardiologist's office where TTE showed (NEW?) aortic stenosis.
EKG revealed Afib with ST segment and T wave abnormalities in
the inferior and lateral leads. She was admitted to an OSH for
further evaluation. Given the severity of aortic stenosis seen
on echo, she was referred to [**Hospital1 18**] for right and left cardiac
catheterization and for a surgical evaluation for an aortic
valve
replacement.
Past Medical History:
Aortic Stenosis, s/p AVR
cecal perforation, s/p ex-lap, right hemicolectomy
PMH:
Hypertension
Hyperlipidemia
Afib
CKD (stage II)
Chronic pedal edema
? meningioma
Degenerative arthritis
Gout L great toe
Social History:
Lives alone. Previously a teacher, now [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and writer.
- Tobacco history: quit [**2142**]
- ETOH: 1/month
- Illicit drugs: denies
Family History:
Mother with CHF in her 70s, Father died of CVA at age [**Age over 90 **],
prostate cancer.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:59 Resp:18 O2 sat:98/RA
B/P 117/68
Height:5'4" Weight:157 lbs
General:
Skin: intact [x]
HEENT: EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade 3 systolic, best
heard at R 2nd rib interspace
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: Left:
DP Right: 1+ Left:1+
Radial Right: Left:
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2177-3-25**] - ECHO
PREBYPASS: Preserved LV systolic function with LVEF > 55%. The
left atrium is mildly dilated. There is severe symmetric left
ventricular hypertrophy. Right ventricular chamber size and free
wall motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and have minimal
atherosclerotic plaque. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
Mild TR, Mild PI. There is no pericardial effusion. No PFO, No
clot in LAA seen.
POSTBYPASS: Normally functioning AV prosthesis in place. No AI
No AS. Otherwise unchanged.
[**2177-3-31**] Chest XRay
Final Report
CHEST RADIOGRAPH
INDICATION: Followup to look for free intraperitoneal air.
TECHNIQUE: Upright and lateral chest views were read in
comparison with the
prior radiograph from [**2177-3-30**].
FINDINGS: Large free intraperitoneal air has substantially
increased over the
last 24 hours. Right-sided PICC line tip ends at lower
SVC/cavoatrial
junction. Mildly enlarged heart size is stable. Mediastinal and
hilar
contours are unremarkable. Both lungs are clear, no opacities
concerning for
pneumonia or aspiration. There is evidence of prior median
sternotomy and
sternal sutures are intact.
IMPRESSION: Large free intraperitoneal air substantially
increased over the
last 24 hours.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] discussed the findings with [**Last Name (LF) **], [**First Name4 (NamePattern1) 1439**]
[**Last Name (NamePattern1) **], by phone on
[**2177-3-31**] at 9:14 a.m.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: MON [**2177-3-31**] 11:43 AM
Imaging Lab
There is no report history available for viewing.
.
[**2177-4-4**] Abd
Final Report
INDICATION: Recent colectomy. Evaluation for ileus or
obstruction.
COMPARISON: [**2177-4-1**].
FINDINGS: Supine and upright abdominal radiographs demonstrate
dilated loops
of small bowel and air-fluid levels measuring up to 5 cm in
diameter. There
is no evidence of free intraperitoneal air. Midline surgical
staples are
noted. Mild left pleural effusion is unchanged. Osseous
structures are
unremarkable.
FINDINGS: Marked small-bowel dilatation, most likely
representing
post-operative ileus. However, if there is concern for
obstruction, CT would
be beneficial.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 251**] [**Name (STitle) 20492**]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2177-4-5**] 9:46 AM
.
[**2177-4-8**] 05:11AM BLOOD WBC-13.5* RBC-3.59* Hgb-10.6* Hct-33.7*
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.8 Plt Ct-416
[**2177-4-7**] 05:45AM BLOOD WBC-12.5* RBC-3.80* Hgb-11.0* Hct-36.0
MCV-95 MCH-28.8 MCHC-30.5* RDW-15.2 Plt Ct-425
[**2177-4-8**] 05:11AM BLOOD PT-29.8* INR(PT)-2.9*
[**2177-4-7**] 05:45AM BLOOD PT-34.2* INR(PT)-3.3*
[**2177-4-6**] 05:27AM BLOOD PT-29.8* INR(PT)-2.9*
[**2177-4-5**] 04:01AM BLOOD PT-17.5* INR(PT)-1.6*
[**2177-4-4**] 04:32AM BLOOD PT-16.0* INR(PT)-1.5*
[**2177-4-3**] 05:08AM BLOOD PT-18.3* PTT-32.9 INR(PT)-1.7*
[**2177-4-2**] 05:14AM BLOOD PT-30.3* PTT-35.1 INR(PT)-2.9*
[**2177-4-1**] 10:57PM BLOOD PT-42.7* PTT-41.3* INR(PT)-4.2*
[**2177-4-1**] 02:08AM BLOOD PT-25.8* PTT-32.0 INR(PT)-2.5*
[**2177-3-31**] 12:56PM BLOOD PT-22.8* PTT-31.8 INR(PT)-2.2*
[**2177-3-31**] 11:14AM BLOOD PT-29.6* PTT-33.5 INR(PT)-2.9*
[**2177-3-31**] 06:40AM BLOOD PT-27.2* INR(PT)-2.6*
[**2177-3-30**] 09:46PM BLOOD PT-34.0* INR(PT)-3.3*
[**2177-3-30**] 12:37PM BLOOD PT-35.6* INR(PT)-3.5*
[**2177-4-8**] 05:11AM BLOOD Glucose-114* UreaN-33* Creat-1.7* Na-142
K-4.0 Cl-102 HCO3-32 AnGap-12
[**2177-4-7**] 05:45AM BLOOD Glucose-137* UreaN-35* Creat-1.7* Na-140
K-3.6 Cl-102 HCO3-27 AnGap-15
[**2177-4-6**] 05:27AM BLOOD Glucose-107* UreaN-39* Creat-1.5* Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2177-4-7**] 05:45AM BLOOD Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 110877**] was admitted to the [**Hospital1 18**] on [**2177-3-24**] for surgical
management of her aortic valve disease. She was placed on
heparin as she had been off her coumadin for five days. She was
worked-up in the usual preoperative manner. On [**2177-3-25**], she was
taken to the operating room where she underwent an aortic valve
replacement using a tissue valve. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one, she was
neurologically intact and extubated. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. Chest tubes and pacing wires were discontinued without
complication. She developed rapid atrial fibrillation.
Amiodarone was started and Lopressor titrated. Also,
anti-coagulation was intiated with Warfarin. The patient
converted to sinus rhythm then developed bradycardia with 1st
degree AV block. Amiodarone and lopressor were discontinued.
Rapid AFib returned and Lopressor was titrated accordingly.
The patient was noted to have free air under the diaphragm on
routine CXR. Initially, abdominal exam was benign, she was soft
and non-tender. Tenderness developed and the abdomen became
distended. Follow-up Abdominal film revealed significant
increase in free air. General surgery took the patient
emergently to the OR for exploratory laparotomy. She was found
to have perforation of the cecum. She underwent a right
hemicolectomy on [**2177-3-31**] with Dr. [**Last Name (STitle) **]. Overall, she
tolerated this procedure well and was transferred back to CVICU
post-operatively. ID was consulted for appropriate antibiotic
recommendations. Diet was advanced as tolerated. Coumadin was
resumed.
The patient was transferred to the telemetry floor for further
recovery. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on post-op days 14 and 8 the patient was ambulating
freely, the wounds were healing and pain was controlled with
oral analgesics. The patient was discharged home with [**Name (NI) 269**], PT
and home infusion services for antibiotics. Appropriate
follow-up instructions are given. Dr. [**First Name (STitle) 7756**] will follow the
patient's coumadin dosing. She will follow-up with the [**Hospital 2536**]
clinic and Cardiac Surgery clinic.
Medications on Admission:
Lopressor 100(3)
Lovenox [**Hospital1 **]
Lipitor 40(1)
Aspirin 81mg Daily
Cipro 250(2) started [**2177-3-19**] for e.coli UTI
mupiricin 2%NU [**2177-3-19**] for MSSA swab
Discharge Medications:
1. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 Recon
Solns Intravenous Q6H (every 6 hours) for 6 days.
Disp:*24 doses* Refills:*0*
2. Outpatient Lab Work
Labs: PT/INR for, Dx: AFib
Goal INR 2.0 - 2.5
First draw [**2177-4-9**]
Dr. [**First Name (STitle) 7756**] to manage via [**Hospital **] clinic
Results to phone [**Telephone/Fax (1) 4496**], fax [**Telephone/Fax (1) 71187**]
3. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Dose to change daily per Dr. [**First Name (STitle) 7756**] for goal INR 2-2.5, dx:
afib.
Disp:*30 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily x 1 week, then 200mg daily until further instructed.
Disp:*60 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. 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.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO twice a day for 10 days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
CBC, Creatinine, BUN
[**2177-4-10**]
results to [**Hospital **] clinic: fax: [**Telephone/Fax (1) 11959**]
phone: ([**Telephone/Fax (1) 4170**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Aortic Stenosis, s/p AVR
Cecal perforation, s/p ex-lap, right hemicolectomy
PMH:
Hypertension
Hyperlipidemia
Afib
CKD (stage II)
Chronic pedal edema
? meningioma
Degenerative arthritis
Gout L great toe
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Abdominal - staples, healing well, no erythema or drainage
2+ Edema bilateral lower extremities
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check [**Hospital Ward Name **] [**Location (un) 551**] [**Hospital Unit Name **] [**2177-4-15**] at 10:30am
ACUTE CARE CLINIC Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2177-4-17**] 4:00
Surgeon: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 170**], [**2177-5-7**] 1:15 in the [**Hospital **]
medical office building [**Hospital Unit Name **], [**Doctor First Name **].
.
Cardiologist/PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 20**] [**Telephone/Fax (1) 71179**], [**2177-4-21**] at 2:00pm
.
**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, Dx: AFib
Goal INR 2.0 - 2.5
First draw [**2177-4-9**]
Dr. [**First Name (STitle) 7756**] to manage via [**Hospital **] clinic
Results to phone [**Telephone/Fax (1) 4496**], fax [**Telephone/Fax (1) 71187**]
Completed by:[**2177-4-8**]
|
[
"428.22",
"403.90",
"274.9",
"E849.7",
"280.0",
"428.0",
"997.49",
"041.49",
"715.90",
"599.0",
"427.31",
"V15.82",
"585.2",
"560.1",
"458.29",
"272.4",
"E878.6",
"424.1",
"540.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
11263, 11330
|
6767, 9199
|
345, 497
|
11576, 11829
|
2513, 6744
|
12803, 13787
|
1672, 1878
|
9422, 11240
|
11351, 11555
|
9225, 9399
|
11853, 12780
|
1893, 2494
|
269, 307
|
525, 1220
|
1242, 1445
|
1461, 1656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,215
| 150,822
|
38780
|
Discharge summary
|
report
|
Admission Date: [**2117-3-4**] Discharge Date: [**2117-3-10**]
Date of Birth: [**2053-12-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Codeine
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
ERCP [**3-5**]
at OSH: percutaneous biliary tube placement, cholecystectomy,
Rt sided AKA
History of Present Illness:
63M with PVD, EtOH and cocaine abuse, admitted to [**Hospital **]
Hospital on [**2117-2-22**] with septic shock and E.coli bacteremia, now
transferred to [**Hospital1 18**] for further workup and potential ERCP.
.
He presented on [**2-22**] with lethargy, disorientation, and fever to
105 with abdominal pain after his roommate called EMS. Blood
cultures grew E.coli bacteremia and he developed septic shock
and was admitted to the ICU. He was intubated and required both
vasopressin and norepinephrine. Started on meropenem (and later
changed to irtapenem). He had perc CCY tube placed on [**2-24**].
Pressors were weaned off. He also had NSTEMI in setting of his
sepsis with peak troponin 37.88 on [**2-24**]. Echo showed EF 25-30%
with severe global LV HK. There was also concern for worsening
RLE ischemia on pressors vs. true graft thrombosis. On [**3-1**] he
went to the OR for RLE AKA and cholecystectomy. Procedure
notable for somewhat difficult to remove gallbladder with some
resultant bleeding in gallbladder fossa. No intraop
cholangiogram per procedure notes. He was extubated on [**2117-3-1**].
Post op noted to have increasing amylase (to 551) and lipase
(to 288). Also developed fever to 100.8. Could not get MRCP
due to shrapnel in eye (though wife does not know anything about
this), so being transferred to [**Hospital1 18**] for ERCP to evaluate these
new changes.
.
Speaking with patient's wife, she notes a change in mental
status since extubation. Extubated on [**3-1**] and she reports that
he recognized her and other family members that night. However,
the following day and yesterday he has been confused about where
he is and who friends and family were. Also slurring speech
worse (has some slur at baseline). No noted weakness in
UEs/LEs. Has baseline facial asymmetry since MVA.
.
In the [**Hospital Unit Name 153**], patient appears comfortable. Delerious and
disoriented but calm. Denies pain of any type. ROS as below.
Past Medical History:
- Severe PVD s/p multiple bypass surgeries of LEs (L femoral to
above knee bypass [**2115**], R external iliac to superficial femoral
artery bypass [**2115**] and R common iliac to above knee [**Doctor Last Name **] bypass
[**2116**]) and carotids (L CEA [**2115**]).
- HTN
- Hyperlipidemia
- Polysubstance abuse including EtOH and cocaine, ?others
- ?COPD
- Motorcycle accident resulting in need for reconstructive
surgery of L jaw.
Social History:
Married though is estranged from wife (lives with a few
roommates) mainly related to EtOH abuse. Very heavy drinker.
Smoking history of approx 1 PPD per wife. Cocaine positive on
tox, wife does not know much abuse illicit drug use history.
Family History:
Mother had [**Name2 (NI) 499**] cancer.
Physical Exam:
General: Alert but somewhat lethargic at times, no distress.
HEENT: Sclera anicteric, PERRL, MMM, appears to have some thrush
on posterior tongue. Poor dentition with most teeth missing.
Neck: supple, JVP not elevated, no LAD. L CEA scar. Denies
posterior neck TTP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, but very poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: All incisions C/D/I. RUQ port incision had been
draining small amount serous fluid, no purulence or bleeding.
Old healed RLQ scar from bypass. +BS. Soft, appears to be
diffusely tender, non-distended, no rebound tenderness or
guarding, no organomegaly.
Ext: warm, well perfused. 2+ L DP and PT pulses. No edema.
s/p R AKA, wrapped.
Neuro: Alert. Oriented to person only. Facial asymmetry with
?droop of L lower face, though appears c/w past trauma and
asymmetric tooth loss. Initially ?very mild L ptosis and
inability to raise L eyebrow, but able to do so later in exam.
Difficulties with cooperating and following commands (won't
smile). Tongue does show some deviation to R. EOMs not able to
be completely tested but will move in all directions. PERRL.
Denies sensory deficits. Extremity strength testing also
difficult. Of LLE, [**5-12**] in dorsi/plantar flexing, but will not
move rest of muscle groups. Of bilateral UEs, can get [**5-12**] elbow
flexion and [**5-12**] elbow extension on R, weaker on L vs. not fully
participating. [**4-11**]+/5 intrinsic hand muscles. Difficulty with
testing proximal UE muscle groups. Unable to look for pronator
drift or asterixis due to lack of patient participation. Tone
appears normal.
Pertinent Results:
[**2117-3-4**] 09:18PM GLUCOSE-96 UREA N-20 CREAT-0.5 SODIUM-138
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2117-3-4**] 09:18PM estGFR-Using this
[**2117-3-4**] 09:18PM ALT(SGPT)-192* AST(SGOT)-92* LD(LDH)-211
CK(CPK)-130 ALK PHOS-263* AMYLASE-516* TOT BILI-0.7
[**2117-3-4**] 09:18PM LIPASE-241*
[**2117-3-4**] 09:18PM CK-MB-2 cTropnT-0.16*
[**2117-3-4**] 09:18PM IRON-65
[**2117-3-4**] 09:18PM ALBUMIN-3.4* CALCIUM-8.9 PHOSPHATE-4.1
MAGNESIUM-2.0
[**2117-3-4**] 09:18PM calTIBC-313 FERRITIN-314 TRF-241
[**2117-3-4**] 09:18PM VIT B12-GREATER TH FOLATE-15.8
[**2117-3-4**] 09:18PM TRIGLYCER-131
[**2117-3-4**] 09:18PM TSH-1.7
[**2117-3-4**] 09:18PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2117-3-4**] 09:18PM HCV Ab-POSITIVE*
[**2117-3-4**] 09:18PM WBC-11.9* RBC-4.06* HGB-11.2* HCT-33.5*
MCV-83 MCH-27.7 MCHC-33.5 RDW-14.8
[**2117-3-4**] 09:18PM NEUTS-69.4 LYMPHS-22.2 MONOS-5.4 EOS-2.3
BASOS-0.7
[**2117-3-4**] 09:18PM PLT COUNT-647*
[**2117-3-4**] 09:18PM PT-12.9 PTT-23.6 INR(PT)-1.1
on dishcarge from the [**Hospital1 **], pt.s platelet count was 1,049,000.
This is felt to be a reactive thrombocytosis due to the combined
effects of: multiple recent surgeries, and also possibly post
alcohol abuse thrombocytopenia recovery. ESR and CRP were
checked and are elevated supporting this etiology. This will
need to be monitored - please check weekly CBC. If platelet
count is continuing to rise, pt. will need evaluation by
hematology to rule out underlying ET or PV by peripheral smear
review and or bone marrow biopsy. Here thre were no stigmata or
symptoms of thrombotic complication of this thrombocytosis
(uncommon in reactive thrombocytosis) and aspirin 325 mg was
started for combined effect of platelet inhibition and secondary
prevention given known cad and nstemi suffered at outside
hospital prior to admission here.
ERCP Report
major papilla s/p sphincterotomy, PD stent in place PD stent
(later removed)
CCY clips Dilated PD Distal CBD
No cystic duct leak Balloon sweep
Date: Friday, [**2117-3-5**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) 19087**], MD (attending)
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)
Patient: [**Known firstname **] [**Last Name (NamePattern1) 86101**]
Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**], MD
Assisting Nurse(s)/
Other Personnel: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 52485**], RN
Birth Date: [**2053-12-5**] (63 years) Instrument: TJF-160VF
([**Telephone/Fax (5) 86102**] Indications: A level 4 consult was performed
Elevated LFTs s/p complicated cholecystectomy, and abnormal CT
scan showing a dilated CBD and fluid in the gallbladder fossa.
Rule out retained CBD stone and/or bile leak.
Medications: Cetacaine topical spray
Monitored anesthesia care
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. The patient was placed in the supine position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization was performed. The procedure was
not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the pancreatic duct was performed
with a sphincterotome after a guidewire was placed in order to
place a PD stent to facilitate biliary cannulation. Contrast
medium was injected resulting in partial opacification.
Cannulation of the biliary duct was performed with a
sphincterotome after a guidewire was placed. Contrast medium was
injected resulting in complete opacification.
Biliary Tree: A mild dilation was seen at the main duct with the
CBD measuring 9-10 mm. These findings are compatible with benign
papillary stenosis. No stones were seen in the CBD. There was no
extravasation of contrast seen from the cystic duct stump or
from any ducts of Luschka. A sphincterotomy was performed in the
12 o'clock position using a sphincterotome over an existing
guidewire. A small amount of biliary sludge was extracted from
the CBD successfully using a 9-12mm Rx balloon catheter.
Pancreas: A mild dilation of approximately 5mm was seen at the
distal main pancreatic duct. A 4cm by 5FR pancreatic stent was
placed successfully to aid in biliary cannulation. The plastic
pancreatic duct stent was removed successfully with a snare.
Impression: Normal major papilla.
Cannulation of the pancreatic duct was performed with a
sphincterotome after a guidewire was placed in order to place a
PD stent to facilitate biliary cannulation. Contrast medium was
injected resulting in partial opacification.
A mild dilation of approximately 5mm was seen at the distal main
pancreatic duct.
A 4cm by 5FR pancreatic stent was placed successfully to aid in
biliary cannulation.
Cannulation of the biliary duct was performed with a
sphincterotome after a guidewire was placed. Contrast medium was
injected resulting in complete opacification.
A mild dilation was seen at the main duct with the CBD measuring
9-10 mm. These findings are compatible with benign papillary
stenosis.
No stones were seen in the CBD.
There was no extravasation of contrast seen from the cystic duct
stump or from any ducts of Luschka.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A small amount of biliary sludge was extracted from the CBD
successfully using a 9-12mm Rx balloon catheter.
The plastic pancreatic duct stent was removed successfully with
a snare.
Recommendations: Return to the ICU.
NPO overnight with aggressive IV fluid hydration with LR at 200
cc/hr if he can tolerate the rate.
Recommend MRCP to evaluate his dilated pancreatic duct.
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the GI fellow.
Thank you Dr. [**Last Name (STitle) 4427**] for allowing me to participate in the care
of Mr. [**Last Name (Titles) 86101**].
_________________________________
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD (attending)
_________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)
Case documentation started on [**2117-3-5**] 3:22:40 PM
Patient: [**Known firstname **] [**Last Name (NamePattern1) 86101**] ([**Numeric Identifier **])
Brief Hospital Course:
63M with PVD, EtOH abuse, presents with septic shock from
presumed biliary source, now transferred to [**Hospital1 18**] for
consideration of ERCP and further management of abnormal LFTs
and lipase.
.
# Elevated lipase and abnormal LFTs. ERCP done, report above.
LFTs and lipase imrproved. Pt. found to have hcv - ab positive
and viral load of:
[**2117-3-5**] 5:41 am IMMUNOLOGY
CHEM S# [**Serial Number 24032**]D QUANTITATION BEYOND 850,000 IU/ML ADDED
[**3-5**].
**FINAL REPORT [**2117-3-8**]**
HCV VIRAL LOAD (Final [**2117-3-8**]):
13,800,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
If HCV genotype on patient's sample is desired, please
contact
laboratory at ext. [**7-/3125**] within two weeks.
Clinically, he had no abdominal pain, n/v, jaundice, fevers. He
tolerated resumption of a regular diet without difficulty once
his ileus resolved with holding of large narcotic doses given in
the ICU.
.
# Septic shock/bacteremia. Shock resolved and normotensive with
no evidence of poor perfusion; note - pt. had undergone rt. leg
BKA prior to admission for ischemia of the rt. LE when pressors
given at outside hospital, and, our CT here demonstrated
thrombosis of his prior bypass grafts (likely old) - he
maintained good perfusion of the Lt. LE and remaining rt LE
without any evidence of diminished perfusion (warm, good
capillary refil, no pallor or dusky appearance, no pain other
than some tenderness at the rt. BKA incision site). Treatment
for bacteremia continued with meropenem, and course was
completed on [**2117-3-9**]. His cultures obtained here remained
negative.
.
# Altered mental status consistent with delerium. Likely due to
combined effects of illness and narcotic medications. This
resolved slowly, with holding of nacotics. He required some
parenteral haldol for agitation while in the intensive care
unit. His mental status continues to clear at time of
discharge, but wife indicates he is not at his baseline.
.
# NSTEMI. Very elevated trops (and CKs) in setting of
hypotension/sepsis, though patient with bad PVD (thus likely
CAD) and may have had more classic thrombotic infarct. ECG with
inferior Q waves and poor transition - present on ECGs early
this admission though unclear exactly how old. Was on heparin
early this admit, now off. After ERCP, aspirin was started -
his aspirin allergy is GERD only, so a PPI was added for
prophylaxis and protection. Beta blockers were continued. He
should be considered for statin and ace inhibitor as an
outpatient in follow up with a cardiologist.
.
# RLE ischemia/PVD. Now s/p AKA as above. Unclear if was graft
or arterial thrombus formation vs. global effects of pressors.
CT abdomen obtained and seemed to show graft thrombosis.
Antiplatelet [**Doctor Last Name 360**] as above. Vascular was consulted and
provided recs here.
- Post op followup as indicated in the discharge instructions.
.
# Polysubstance abuse. EtOH and cocaine known. Folate, MVI,
thiamine started.
No evidence for withdrawal.
.
# Thrombocytosis. From recent infection and acute stressors
most likely.
- Continue to monitor as indicated in discharge instructions.
.
Communication: Patient, wife [**Name (NI) **] [**Telephone/Fax (1) 86103**]
Medications on Admission:
Medications at home:
Atenolol 25 mg daily per notes (not clear that he was actually
taking any)
.
Medications at transfer:
Ertapenem 1 gram daily
Metoprolol 5 mg IV Q6H
Protonix 40 mg daily
Albuterol nebs Q2H prn
Morphine 2-4 mg prn
Haldol 4 mg Q8H prn agitation
Heparin SC
NS at 75 cc/hr
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) as needed for nausea.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: maximum of 2 grams per day.
12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Delerium
CAD, PVD
Likely reactive thrombocytosis
Ileus (resolved)
E Coli bacteremia (two week course of abx. therapy completed,
surveillance cultures no growth to date)
s/p open ccy
s/p rt LE BKA amputation
Deconditioning
HCV infection, chronic
Ongoing polysubstance abuse and tobacco use (alcohol, cocaine)
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:
See below
Followup Instructions:
Primary MD: ([**Doctor First Name **] J. [**Doctor Last Name **] [**Telephone/Fax (1) 86104**]), [**Hospital **] Hospital,
Dr. [**Last Name (STitle) 86105**] (surgery at [**Hospital **] hospital), will also need
hepatologist and cardiology outpatient care established through
primary MD as outpatient given CAD, HCV infection
|
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"305.60",
"530.81",
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"305.1",
"414.01",
"303.91",
"440.4",
"401.9",
"997.4",
"496",
"440.30",
"577.0",
"576.2",
"070.54",
"790.7",
"112.0",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
16757, 16837
|
11807, 15216
|
313, 405
|
17188, 17188
|
4911, 11784
|
17401, 17729
|
3143, 3184
|
15556, 16734
|
16858, 17167
|
15242, 15242
|
17367, 17378
|
15263, 15533
|
3199, 4892
|
252, 275
|
433, 2410
|
17203, 17343
|
2432, 2867
|
2883, 3127
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,856
| 105,347
|
37913
|
Discharge summary
|
report
|
Admission Date: [**2144-8-17**] Discharge Date: [**2144-8-21**]
Date of Birth: [**2065-9-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Chief Complaint: abdominal pain, nausea
Major Surgical or Invasive Procedure:
ERCP [**2144-8-17**] with sphincterotomy and stent placement
History of Present Illness:
This is a 78 year old woman with PMH of HTN, asthma, pemphigus
vulgaris, and sarcoidosis, who was transferred from [**Hospital1 3325**] with evident cholangitis after calling an ambulance and
presenting with complaints of feeling poorly since the prior day
only, with abdominal pain, nausea, and some vomiting during that
time.
At [**Hospital3 3583**], RUQ U/S showed gallstones and dilated CBD,
as well as the following labs: AST: 165, ALT: 114, AP: 149,
Total Bili: 5.2, and WBC: 27.6. With suspicion for cholangitis,
she was given Zosyn and Zofran, and transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vs were: T100.3, P 118, BP 112/57, R 18, O2
sat 98%. She was given 1 L NS, zosyn X 1 and zofran. Her labs
were notable for leukocytosis of 32.5, AST: 147, ALT: 112, AP:
161, TBili: 5.1, Albumin: 3.7. Right upper quadrant U/S showed
gallstones and a dilated common bile duct. Surgery saw pt in
the ED and recommended ERCP, with which the ERCP team agreed,
and she was sent to the [**Hospital Unit Name 153**] in anticipation of an ERCP
procedure.
.
On the floor, she was seen briefly before procedure and was
cheerful and conversant and in no apparent distress. She went
quickly to procedure where a biliary stent was placed with good
drainage; sphincterotomy was performed; CBD had been dilated to
8mm. On her return she continued to report that she was feeling
well without abdominal pain, subjective fever, breathing
difficulty, or nausea.
Past Medical History:
Past Medical History:
HTN
asthma
bullous pemphigoid
sarcoidosis
osteoporosis
.
Past Surgical History:
Right TKR [**5-5**]
Social History:
Social History: lives with husband; non-smoker
Family History:
No significant history
Physical Exam:
Physical Exam:
Vitals: (on return from procedure) T: 99.4 BP: 104/51 P: 97 R:
17 18 O2: 97%3L
General: Alert, oriented, no acute distress; observed sleeping
prior to exam and pt noted to snore audibly
HEENT: icteric sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, intact air movement
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, slight distension, bowel sounds
present, no guarding and no tap tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 1 2cm bulla on medial side of 3rd toe on R foot; no other
rashes or bullae in limited exam, no sarcoid nodules appreciated
Pertinent Results:
[**2144-8-17**] 05:47PM LACTATE-2.1*
[**2144-8-17**] 05:45PM GLUCOSE-107* UREA N-13 CREAT-1.2* SODIUM-136
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
[**2144-8-17**] 05:45PM ALT(SGPT)-112* AST(SGOT)-147* CK(CPK)-180*
ALK PHOS-161* TOT BILI-5.1*
[**2144-8-17**] 05:45PM LIPASE-212*
[**2144-8-17**] 05:45PM cTropnT-0.02*
[**2144-8-17**] 05:45PM CK-MB-5
[**2144-8-17**] 05:45PM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2144-8-17**] 05:45PM WBC-32.5* RBC-4.32 HGB-13.2 HCT-37.4 MCV-87
MCH-30.5 MCHC-35.2* RDW-13.7
[**2144-8-17**] 05:45PM NEUTS-82* BANDS-14* LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2144-8-17**] 05:45PM PLT SMR-NORMAL PLT COUNT-175
[**2144-8-17**] 05:45PM PT-15.0* PTT-31.2 INR(PT)-1.3*
[**2144-8-17**] 05:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-7.0 LEUK-NEG
[**2144-8-17**] 05:45PM URINE RBC-[**10-16**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2144-8-17**] 05:45PM URINE GRANULAR-0-2
[**2144-8-17**] 05:45PM URINE AMORPH-FEW
RUQ U/S:
FINDINGS: There is no evidence of focal lesions in the liver.
The
gallbladder appears normal. There is no evidence of wall edema
in the
gallbladder. There are multiple mobile gallstones. The CBD
measures 7 mm in
maximum diameter. There is no intrahepatic biliary duct
dilatation. In the
visualized portion of the right kidney, there is a simple cyst
measuring 2.6
cm. Main portal vein is patent.
IMPRESSION: Cholelithiasis without signs of cholecystitis
.
ERCP:
ERCP: Images demonstrate cannulation of the common bile duct
with a large
stone in the distal CBD and post-obstructive dilatation. A
plastic biliary
stent was placed. Please refer to the operative note for further
details.
IMPRESSION: Distal CBD stone.
.
Blooc Culture:
[**2144-8-17**] 5:45 pm BLOOD CULTURE #1.
**FINAL REPORT [**2144-8-21**]**
Blood Culture, Routine (Final [**2144-8-21**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
ESCHERICHIA COLI. 2ND MORPHOLOGY. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ <=1 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2144-8-18**]):
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Hospital Course:
.
# Cholangitis: Patient underwent urgent ERCP from the MICU with
distal CBD stone identified. Sphincterotomy was performed with
successful stent placement. She tolerated the procedure well
with improvement in her LFTs and abdominal pain. Surgery was
consulted and recommended laparoscopic cholecystectomy in the
next 4-6 weeks. Follow up was arranged. However, 1 day after
admission, her blood culture returned positive for GNR.
Cefepime was started empirically. Her blood cultures cleared
and the GNRs returned as E. coli and Klebsiella sensitive to
Cipro. She was started on cipro and tolerated well. She will
require follow up ERCP in [**5-4**] weeks, and to complete 14 days of
ciprofloxacin 500mg q12.
.
# Sarcoidosis: Outpatient follow up
.
# Asthma: Home Advair was continued.
.
# Hypertension: Restarted Diltiazem at 120mg daily to be
uptitrated by the PCP at their discretion.
.
# Pemphigus Vulgaris: Stable during this hospitalization
.
# Osteoporosis: Continued Evista, calcium, vitamin D
.
Code: DNR/DNI
Medications on Admission:
Medications:
- advair 500
- evista 60mg
- diltiazem 420?
- iron 65 mg
- ecotrin 81mg
- folic acid 800mg
- fish oil 1200mg
- tylenol PM
- aleve
- MVI
- calcium and vitamin D
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
3. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: through [**2144-8-31**].
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Choledocholithiasis
Bacteremia, gram negative rod
Asthma
Sarcoidosis
Osteoporosis
Discharge Condition:
Good, afebrile, hemodynamically stable
Discharge Instructions:
You were admitted with infection of the biliary system with
obstruction due to gallstones. You underwent an intervention
called "ERCP" which cleaned out the stone and the associated
infection (cholangitis). Also, your blood grew bacteria
(E.coli, Klebsiella) for which we're treating with 14 days of
antibiotics. Because a stent was placed in your bile duct, you
will need to return in [**5-4**] weeks to have this re-assessed (see
below). Moreover, because this was caused by gallstones, you
will need to have your gallbladder removed to prevent further
episodes. You have an appointment arranged with our surgeon to
discuss this further.
.
Please resume all home medications and take all medications as
prescribed and keep all follow up appointments. Return to the
hospital with fevers/chills, abdominal pain, yellowing of skin,
or any concerning symptoms.
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23388**]
Specialty: Family Practice / PCP
Date and time: Wednesday, [**8-26**], 3pm
Location: [**Last Name (un) **], [**Location (un) 22287**] (building 9, [**Apartment Address(1) **])
Phone number: [**Telephone/Fax (1) 23387**]
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Surgery
Date and time: Wednesday, [**9-2**], 3pm
Location: [**Hospital Ward Name 516**], [**Location (un) 8661**] building, [**Location (un) 470**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 2998**]
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2799**], next week to schedule
your repeat endoscopy in [**5-4**] weeks.
|
[
"401.9",
"790.7",
"694.4",
"135",
"V43.65",
"574.91",
"733.00",
"576.1",
"493.90",
"788.5",
"458.29",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8154, 8160
|
6007, 6007
|
357, 420
|
8298, 8339
|
2938, 5984
|
9252, 10018
|
2158, 2182
|
7274, 8131
|
8181, 8277
|
7076, 7251
|
6024, 7050
|
8363, 9229
|
2054, 2076
|
2212, 2919
|
295, 319
|
448, 1930
|
1974, 2031
|
2109, 2142
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,446
| 150,030
|
7519
|
Discharge summary
|
report
|
Admission Date: [**2112-2-16**] Discharge Date: [**2112-2-23**]
Date of Birth: [**2042-4-10**] Sex: F
Service: MEDICINE
Allergies:
Thiazides
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 year-old woman who presented with a week-long history of
malaise. The pt is Mandarin speaking woman who was in her USOH
until last week when developed a low-grade fever, cough,
lethargy and was started on a medication amoxicillin, the a
course of azithromycin by her PCP without any improvement and
received IVFs by PCP without [**Name9 (PRE) 65**] improvement.
She continued to experience malaise and lethargy, requiring
assistance in ambulating for generalized weakness (baseline is
self ambulating) She denied focal weakness, numbness or
parasthesiae. There is no history of back pain. Pt was seen
again by PCP on day of presentation to the ED and was told that
she had a distended abdomen and was sent to the ED for further
work up.
In the ED, a foley was placed and 1700cc of urine was cleared.
The patient had no urge to urinate and last urinated the AM of
admission. She stated that she feels that she was able to
appreciate a full bladder and has had no recent difficulties
urinating. In addition, she denied any bowel retention or
incontinence and has had regular bowel movements as is usual.
She denied any headache,loss of vision, blurred vision,
diplopia. Denied dysarthria, dysphagia. Denied lightheadedness
or vertigo. Denied any difficulties with her speech. Also + low
grade fever with her URI, no chills or nightsweats, no CP or
SOB, no palpitation,n,v,diarrhea, dysuria or abdominal pain,
myalgia, arthralgia or rash.
Past Medical History:
HTN
Hyperlipidemia
Social History:
The pt lives with her husband in [**Name (NI) 778**]. She is fully
independent in all of her ADLs. There is no history of tobacco,
alcohol or illicit drug use. Immigrated to USA in '[**97**], has not
worked eversince.
Family History:
NC
Physical Exam:
Gen- Appears stated age, pleasant, in NAD
Vs- 96.1 129/74 69 17 98RA
HEENT- NC/AT PERRL EOMI,
Neck- supple, JVP flat, no thyromegaly or LAD
CV- rrr, normal s1,s2, no m/r/g
Pulm- good air movement, no w/r/r
Back- no spinal or CVAT
Abd- Soft, NT, ND, +BS
Extr- no C/C/E. DP and PT pulses strong b/l
Neuro-global hyporeflexia, motor strength 5/5 b/l upper and
lower
Pertinent Results:
RENAL U.S. [**2112-2-16**] 11:24 PM: The right kidney measures 10.2 cm
and contains mild hydronephrosis. No stones or masses are
visualized. The left kidney measures 11 cm, and has minimal
fullness of the collecting system. There are no renal masses or
stones. The bladder is collapsed with a Foley catheter within
it.
IMPRESSION: Mild hydronephrosis, right greater than left.
[**2112-2-23**] 07:15AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.2* Hct-33.8*
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.8 Plt Ct-652*
[**2112-2-17**] 06:00AM BLOOD PT-11.9 PTT-27.9 INR(PT)-1.0
[**2112-2-16**] 06:40PM BLOOD Glucose-173* UreaN-25* Creat-1.8* Na-104*
K-3.3 Cl-67* HCO3-18* AnGap-22*
[**2112-2-16**] 08:40PM BLOOD Glucose-167* UreaN-24* Creat-1.5* Na-107*
K-2.9* Cl-70* HCO3-23 AnGap-17
[**2112-2-17**] 02:25AM BLOOD Glucose-116* UreaN-20 Creat-1.2* Na-116*
K-3.5 Cl-84* HCO3-23 AnGap-13
[**2112-2-17**] 06:00AM BLOOD Glucose-104 UreaN-19 Creat-1.0 Na-121*
K-3.1* Cl-87* HCO3-22 AnGap-15
[**2112-2-17**] 12:05PM BLOOD Glucose-121* UreaN-19 Creat-1.0 Na-121*
K-3.0* Cl-90* HCO3-22 AnGap-12
[**2112-2-18**] 05:32AM BLOOD Glucose-88 UreaN-19 Creat-0.9 Na-127*
K-3.6 Cl-95* HCO3-22 AnGap-14
[**2112-2-19**] 05:45AM BLOOD Glucose-91 UreaN-16 Creat-0.8 Na-128*
K-3.6 Cl-94* HCO3-24 AnGap-14
[**2112-2-22**] 07:30AM BLOOD Glucose-146* UreaN-16 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2112-2-23**] 07:15AM BLOOD Glucose-164* UreaN-17 Creat-0.9 Na-131*
K-4.1 Cl-96 HCO3-25 AnGap-14
[**2112-2-17**] 06:00AM BLOOD Cortsol-19.7
[**2112-2-16**] 08:40PM BLOOD T4-8.4
[**2112-2-16**] 08:40PM BLOOD TSH-0.68
[**2112-2-16**] 08:40PM BLOOD Osmolal-234*
[**2112-2-16**] 10:15PM URINE Osmolal-102
[**2112-2-16**] 10:15PM URINE Hours-RANDOM Creat-8 Na-28 K-4 Cl-24
HCO3-LESS THAN
.
MICROBIOLOGY
Urine cx (-) x3. Blood cx x2 negative at time of d/c.
Brief Hospital Course:
A/P: 69 yo Cantonse speaking female who presented with letargy,
gait abnormality and a serum sodium of 104. In ED she was found
to have obstructive uropathy resolving with foley placement. Of
note she has been of HCTZ/Triamtrene for number of years as
treatment of her HTN.
1. Hyponatremia: Pt with profound hyponatremia thought likely
secondary to her diuretic use. In the ED she appeared dry on
exam. The patient had an initial FeNa of 4.91 and a urine Na of
26 which was consistent with renal losses and inconsistent with
SIADH. In the ED she received one liter of normal saline and
her sodium increased from the nadir of 104 to 121 by the time of
arrival to the ICU. She was not given any more saline at that
time, and her sodium was monitored while tolerating a regular
diet. It slowly increased to 127, she was noted to have global
hyporeflexia but no other neurological deficits at time of
transfer to the floors. Pt was monitored and all IVFs were
held, as her sodium level slowly increased to normal on HD#5.
It was thought that her neurogenic bladder caused a decrease in
GFR, and a build of thiazide diuretic which led to her severe
hyponatremia. Once a Foley was placed in the [**Name (NI) **], pt was able to
urinate and auto-correct, and her sodium drifted to normal with
minimal intervention. No neurologic sequelae was seen due to
the correction of her sodium during this admission. Pt was
instructed at discharge to never restart her thiazide diuretic
as this alone may have precipitated her severe hyponatremia.
.
2. Urine outflow obstruction:
It remained unclear what caused her initial neurogenic bladder
and bladder residual of 1700cc at time of admission. It was
thought that perhaps a medication effect, whether OTC medication
or anticholinergic benadryl in cough syrup, that perhaps
contributed to her neurogenic bladder. Pt was attempted
multiple voiding trials on HD#5 and HD#7 but each time patient
had PVR of >700cc, and the Foley was reinserted. Urology was
consulted who recommended leaving the Foley in place for 1 week
after discharge, and to f/u with urology in 1 week for voiding
trial at that time. A spinal MRI perfomed at this admission did
not show mass or any cord compression that would lead to urinary
retention.
.
3. Cough: She developed a productive cough with mild hemoptysis
at time of transfer to the floors, this was associated with a
fever of 101 the night prior. She was therefore contained on
precautions and ruled out for TB, although with no history of TB
and no evidence of opacities on chest xray
.
4. Renal Failure:
ARF on admission with Cr 1.8 due to obstructive uropathy,
resolved with Foley placement, returning to 0.9 on discharge.
Renal u/s with R>L hydro appears to be resolving.
.
5. HTN: normotensive on presentation to the ED. Pt's previous
cardizem and dyazide were stopped, and patient was started on
Metoprolol for BP control. Pt was instructed to never restart
her dyazide diuretic.
.
DISPO:
Spoke to PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on day of discharge regarding f/u sodium
recheck in 3 days after discharge, and f/u appointment with Dr.
[**Last Name (STitle) 27479**] from urology on [**2112-3-1**].
Communications: Daughter [**Name (NI) 27480**] [**Known lastname 22924**] [**Telephone/Fax (1) 27481**]
(mandarin/cantonese speaking)
[**Name (NI) 27482**] [**Name (NI) **] Granddaughter [**Telephone/Fax (1) 27483**]
[**Name (NI) 27484**] [**Name (NI) 22924**] Granddaughter [**Telephone/Fax (1) 27485**]
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital1 27486**] Basement, [**Location (un) 745**] Ctr, MA
[**Telephone/Fax (1) 27487**]
Medications on Admission:
cardizem 180mg
dyazide 2tabs day
xalatan 0.005% 1 drop qhs
saline eye drops
lipitor 10mg qd
ASA 81 mg qd
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Outpatient Lab Work
Please have a sodium (Na) level drawn, Friday, [**2-26**], and fax
results to Dr.[**Name (NI) 27488**] office.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
1) hyponatremia, suspected thiazide induced
2) URI
3) urinary retention
Discharge Condition:
Good, hyponatremia resolved, foley in place to be re-evaluated
by urology in one week.
Discharge Instructions:
1) Please take your medications as directed. Your aspirin has
been held because you coughed up blood in the ICU. Please
discuss with your primary care physician whether to restart this
medication or not. You should NEVER take any THIAZIDE
medication. You have been prescribed a new blood pressure
lowering medication, Toprol.
.
2) Please attend your follow-up appointments.
.
3) Please have your sodium level rechecked on Friday, [**2-26**].
Please fax results to Dr.[**Name (NI) 27488**] office.
.
4) You were not given the pneumococcal vaccine in-house. Please
discuss this with your primary care physician.
Followup Instructions:
1) You are scheduled to see Dr. [**Last Name (STitle) 4229**](Urology) on [**3-1**] at
4pm to have your Foley removed. Call [**Telephone/Fax (1) **] to reschedule
that appointment.
.
2) Please call the office of your primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) **]
Completed by:[**2112-2-24**]
|
[
"596.54",
"293.0",
"285.9",
"591",
"788.20",
"E944.3",
"288.8",
"272.0",
"276.1",
"401.9",
"465.9",
"276.8",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8640, 8715
|
4300, 7987
|
280, 286
|
8850, 8939
|
2463, 4277
|
9602, 9935
|
2060, 2064
|
8143, 8617
|
8736, 8829
|
8013, 8120
|
8963, 9579
|
2079, 2444
|
231, 242
|
314, 1764
|
1786, 1807
|
1823, 2044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,507
| 164,485
|
46434
|
Discharge summary
|
report
|
Admission Date: [**2132-2-19**] Discharge Date: [**2132-2-29**]
Date of Birth: [**2050-1-17**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization x2 (one via groin, the other via left arm)
Blood transfusion
History of Present Illness:
82-year-old male patient with a past medical history of
hypertension and a renal mass presented with chest pain found to
have NSTEMI, now s/p BMS stent in [**Hospital 54969**] transferred to CCU after
emesis with Hct drop.
.
Patient previously underwent preoperative evaluation for his
renal mass in [**2131-12-31**] which included a nuclear stress
test. He was found to have a large moderately severe reversible
perfusion defect involving the mid to distal anterior wall,
extending into the septum and also a moderately severe partially
reversible partially fixed defect involving the entire apex. His
LVEF was 56%. The exercise portion demonstrated ischemic EKG
changes and chest pain. He was scheduled for a cardiac
catheterization at the [**Hospital1 **] with Dr. [**Last Name (STitle) 14522**].
.
However, on [**2132-2-18**] patient experienced chest discomfort while
at the [**Company 3596**]. Patient was doing his routine exercise of walking
around the track when he experienced 6/10 chest pain which was
localized to the right side and radiated to his back. Pain was
described as "tightening" and was associated with nausea. No
vomiting, no diaphoresis, no associated shortness of breath.
Pain became maximal at [**2133-8-6**]. Patient was taken to the [**Hospital1 392**]
ER where he was given ASA, and 2 sublingual nitroglycerin.
Patient reports chest pain improvement to 4=>2=> 0/10 after
sublingual nitroglycerin. Patient was also given Lovenox and
12.5 of lopressor and admitted to the hospital. His initial
troponin was < 0.01. He was admitted to ICU and his troponin on
day of admission was 1.9 with a CPK of 85. He has had no further
episoded of chest discomfort.
.
He was transferred to the [**Hospital1 18**] on [**2132-2-19**], underwent a cath on
[**2132-2-20**] that showed a 90% stenosis in the LAD but stenting was
unsuccessful due to inability to engage the left main with any
guide. He underwent a repeat cath on [**2132-2-21**] with left brachial
arterial insertion and this time received a BMS stent in his
LAD. Post-cath course was notable for pseudoaneurysm in his
brachial site requiring thrombin injection by IR on [**2132-2-22**]. In
the afternoon of [**2132-2-22**] he had a small, prune-colored emesis
that was guaiac negative. His Hct dropped from 30 to 26 then 22
despite 1 unit of pRBC. He was transferred to the CCU for
further management.
.
On arrival to the CCU, patient was clinically stable, with no
more emesis.
.
Review of systems postive for worsening dyspnea on exertion.
Patient describes shortness of breath when exercising at the
[**Company 3596**]. patient states that when he walks around the track gets
SOB and + angina similar to episode described above. In
addition, patient endorses + presyncopal feeling with these
episodes but denies any exertional syncope.
.
Past Medical History:
hypertension
Hematuria - ?prostatitis
Glaucoma left eye
left cRenal mass
Colon adenoma
CAD - diagnosed by stress test
? Depression
Elevated PSA
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +Hypertension
Social History:
Pt quit smoking 20 years ago used to smoek 3-4 packs per day x
20 years. There is no history of alcohol abuse.
Family History:
heart attack in patient's father at age 60. [**Name (NI) **] father
died of aortic aneurysm at age 68.
Physical Exam:
VS - Temp 97.2, BP 167/90, P 64, R 22, 100% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. + anisocoria. EOMI. Conjunctiva
non-injected, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
Neck: Supple with JVP to clavicle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds throughout. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2132-2-20**] 05:45AM BLOOD Hct-29.9*
[**2132-2-22**] 10:13PM BLOOD WBC-10.7 RBC-3.15* Hgb-9.3* Hct-26.6*
MCV-85 MCH-29.4 MCHC-34.7 RDW-15.0 Plt Ct-242
[**2132-2-29**] 07:20AM BLOOD Hct-28.7*
[**2132-2-24**] 07:35AM BLOOD Neuts-68.8 Lymphs-17.5* Monos-9.4
Eos-4.1* Baso-0.2
[**2132-2-20**] 03:00AM BLOOD PTT-68.0*
[**2132-2-20**] 05:45AM BLOOD PT-13.3 INR(PT)-1.1
[**2132-2-20**] 05:45AM BLOOD Glucose-127* UreaN-36* Creat-1.4* Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2132-2-29**] 07:20AM BLOOD Glucose-96 UreaN-27* Creat-1.4* Na-140
K-5.0 Cl-105 HCO3-31 AnGap-9
[**2132-2-19**] 09:31PM BLOOD CK(CPK)-60
[**2132-2-20**] 05:45AM BLOOD ALT-16 AST-27 LD(LDH)-159 CK(CPK)-50
AlkPhos-57 TotBili-0.4
[**2132-2-19**] 09:31PM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2132-2-22**] 10:13PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2132-2-23**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2132-2-20**] 05:45AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3 Cholest-185
[**2132-2-21**] 07:35PM BLOOD Iron-168*
[**2132-2-29**] 07:20AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.2
[**2132-2-21**] 07:35PM BLOOD calTIBC-264 VitB12-1180* Folate-GREATER
TH Ferritn-42 TRF-203
[**2132-2-20**] 05:45AM BLOOD Triglyc-34 HDL-60 CHOL/HD-3.1 LDLcalc-118
.
Echo [**2132-2-21**]- The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Moderate (2+) aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
.
EGD [**2132-2-25**] Impression: Erythema and congestion in the antrum
compatible with gastritis Esophagitis in the lower third of the
esophagus and gastroesophageal junction. Hiatal hernia.
Otherwise normal EGD to third part of the duodenum
Recommendations: Biopsies not performed as patient is on Plavix.
Continue PPI b.i.d. indefinitely. Follow-up with primary care
physician
.
IMPRESSION: Normal biventricular regional and global systolic
function. Moderately dilated ascending aorta and mildly dilated
aortic root with moderate aortic regurgitation.
.
Cardiac catherization [**2132-2-20**]- COMMENTS:
1. Coronary angiography of this right dominant system revealed
single vessel CAD. The LMCA, LCx, and RCA had no
angiographically apparent obstructive CAD. The LAD had a 99%
proximal stenosis.
2. Hemodynamic evaluation revealed normal right sided filling
pressures (RVEDP 7 mm Hg) and elevated left sided filling
pressures (LVEDP 17 mm Hg). Mean PCWP was 11 mm Hg. Systemic
arterial pressures were elevated with aortic systolic pressure
of 151 mm Hg. Cardiac index was preserved at 2.8 l/min/m2.
3. Left ventriculography was not performed.
4. Attempt at PCI of the LCX was unsuccessful due to the
inability to
engage the left main coronary artery with a JL 4, JL 4.5, JL 5,
XB LAD 3.5, XB 4.0, XB 4.5, [**Doctor Last Name **] 2m [**Doctor Last Name **] 3 and a MPA guide.
Eventually a diagnostic JL5 reengaged the artery and the LCX was
wired with a prowater wire. We attempted to exchange the JL 5
for a guide but lost wire position during the exchange. After 60
minutes of fluro time we elected to terminate the procedure and
plan to bring the patient back for a radial approach.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Systemic arterial hypertension.
4. Unsuccessful guide engagement of the LMCA.
.
Repeat ultrasound of left upper extremity - findings: the left
brachial artery widely patent with normal flow, pseudoanuersym
is thrombosed without flow. successful injection which no longer
contains flow. native brachial artery with normal flow.
Brief Hospital Course:
82 year old male with PMHx of HTN, CAD, renal mass presents with
exertional chest pain. Patient with history of positive imaging
stress test who was planning to undergo routine catherization
went to cardiac catherization x2 with intervention to LAD.
Hospital course complicated by pseudoaneurysm at site of left
arm catherization as well as upper GI bleed.
.
#. CAD/ upper extremity hematoma - patient with ischemia at near
maximal workload in the distribution of the LAD with qualitative
transient ischemic dilatation on stress with imaging from
12/[**2131**]. EKG from admission with chest pain with
pseudonormalization of T waves in anterior distribution of V2-V4
which suggests anterior wall ischemia. In addition, chest pain
is classic anginal chest pain as it occurs with exertion,
improves with rest, relieved by nitroglycerin. Patient underwent
initial cardiac catherization which demonstrated LAD lesion with
failed attempt with intervention. Repeat catherization via left
arm with LAD stent complicated by psuedoaneurysm requiring
thrombin injection. Lipids on admission with HDL 60, LDL 118,
triglycerides 34. Repeat upper extremity ultrasound demonstrates
normal brachial artery flow with complete occlusion of the
pseudoaneursym that was there before. Telemetry demonstrates 7
PVCs. Patient was started on high dose statin, aspirin, and beta
blocker. LFTs on admission WNL. Beta blocker initially held in
the setting of GI bleed restarted on discharge. Patient also
started on plavix. Patient will need to be on aspirin/plavix for
3 month minimum on discharge.
.
# Hct drop and emesis: likely upper GI bleed. Patient underwent
upper endoscopy on [**2132-2-25**] which demonstrated esophagitis and
gastritis. CT abd/pelvis showed absence of RP bleed. Other
sources of blood loss include Hct drop include hematoma in L
arm. Patient on PPi [**Hospital1 **] and crits measured [**Hospital1 **] with transfusion
for crit less than 28. Patient initially transferred to CCU in
the setting of falling crit with transfusions. Patient started
on PO PPi [**Hospital1 **] and was transfused several units. EGD demonstrated
severe esophagitis, gastritis without continued bleed.
colonscopy demonstrated diverticulosis without any active
bleeding.
.
#. Pump - patient with echo from stress which demonstrate EF
56%. Clinically no evidence of heart failure with absence of
lower extremity edema, clear lungs, and no elevation of JVP.
Repeat echo demonstrates normal biventricular regional and
global systolic function. Moderately dilated ascending aorta and
mildly dilated aortic root with moderate aortic regurgitation.
Patient started on aspirin, statin, plavix on admission.
.
#. Rhythm - patient in NSR with normal intervals. Repeat EKG
from [**2132-2-22**] demonstrates Sinus rhythm. The P-R interval is
0.18. The Q-T interval is prolonged. Anterior, anterolateral and
lateral ST-T wave changes are consistent with ischemia or
myocardial infarction. Compared to the previous tracing of
[**2132-2-21**] there is no significant change. Patient started on beta
blocker as above.
.
#. HTN: Pt currently controlled. 117/76 on transfer. Patient on
beta blocker and HCTZ as an outpatient which were continued.
.
# Mild to moderate aortic regurgitation - patient with mild to
moderate aortic regurgitation. Patient on low dose beta blocker
because of CAD. Would consider addition of ACEi for afterload
reduction as an outpatient. Patient needs routine outpatient
echo follow-up as per primary cardiologist
.
# Chronic renal failure - patient with Cr 1.4 which appears to
be at his baseline. Patient recieved routine post catherization
hydration. Medications were renally dosed and nephrotoxins
avoided.
.
#. Renal Mass - as per the radiology report appears likely
malignancy. Patient is undergoing pre-operative clearance for
surgery. Also patient noted to have elevated PSA from OSH to 21.
In addition, patient had bare metal stent placed so that patient
will not have to be on aspirin/plavix combination as long.
.
# Glaucoma - continue home medications
.
# Depression - continue outpatient fluoxetine
.
#. Access: 2 peripheral IVs at all time
.
#. PPx: subQ heparin, colace, senna, [**Hospital1 **] PPi PO
.
#. Code: Full Code
Medications on Admission:
OUTPATIENT MEDICATIONS:
Azopt 1% OS TID
Prozac 20 mg PO daily
HCTZ 12.5 mg Po daily
Dorzolamide 1% TID
Timolol 1 drop L eye daily
.
Medications recieved at OSH:
Lovenox
Predisone
Benadryl
Zantac
Metoprolol
ALLERGIES:
Iodine dye-hives
Discharge Medications:
1. Azopt 1 % Drops, Suspension Sig: One (1) drop Ophthalmic
three times a day: OS.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Dorzolamide 2 % Drops Sig: One (1) drop Ophthalmic three
times a day.
5. Timolol 0.25 % Drops Ophthalmic
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*10 Tablet, Sublingual(s)* Refills:*0*
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
10. 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*
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary: chest pain, NSTEMI, CAD with LAD stent placement, upper
GI bleed
.
Secondary:
HTN
glaucoma
renal mass
colon adenoma
? Depression
h/o elevated PSA
esophagitis
gastritis
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted to the hospital for cardiac catherization. You
underwent two cardiac catherizations and had a stent placed to
the LAD during the second catherization. Your cardiac
catherization was complicated by a left arm hematoma which
resulted in a hematocrit drop and subsequent need for several
blood transfusions. Prior to catherization you were treated
with IV heparin as well as aspirin, plavix, statin and beta
blocker.
.
Your hospitalization course was complicated by an upper GI bleed
for which you underwent endoscopy which demonstrated erosive
esophagitis as well as gastritis. You were transfused several
units of blood with this blood loss as well as started on a PPi
[**Hospital1 **]. In addition, you underwent colonoscopy which demonstrated
no evidence of active bleed and only evidence of diverticulosis.
.
You are being discharged home on multiple new medications given
your coronary artery disease:
1) You were started on metoprolol (beta blocker) for your
coronary artery disease
2) You were started on a atorvastatin for your coronary artery
disease
3) You were started on Plavix for your coronary artery disease
4) You were started on a PPi for your GI bleed
5) You were started on full dose enteric coated aspirin
.
You were continued on the remainder of your outpatient
medications.
.
You should follow up with Dr. [**Last Name (STitle) **] within 2 weeks of discharge.
Please call at your convenience to arrange follow-up. In
addition, you should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 98645**] within
2 weeks.
.
You should return to the ED if you experience any chest pain,
shortness of breath, or worsening pain at your catherization
site. It has been a pleasure taking care of you at [**Hospital1 **].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. You can reach him at
([**Telephone/Fax (1) 5455**] to schedule at your convenience.
In addition, please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 98645**] within 2
weeks. please call ([**Telephone/Fax (1) 98646**] to schedule.
.
We have schedule you follow up appointment with gastroenterology
listed below:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2132-4-21**] 7:30
Provider: [**First Name11 (Name Pattern1) 870**] [**Last Name (NamePattern4) 80703**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2132-4-21**] 7:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7960**] Follow-up appointment
should be in 2 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 35985**] Follow-up appointment
should be in 2 weeks
Completed by:[**2132-3-2**]
|
[
"414.2",
"365.9",
"593.9",
"410.71",
"790.93",
"403.90",
"442.0",
"311",
"530.10",
"585.9",
"E879.0",
"V12.72",
"535.50",
"285.1",
"997.2",
"998.12",
"424.1",
"414.01",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"37.22",
"88.56",
"37.23",
"99.20",
"45.23",
"00.66",
"00.45",
"36.06",
"00.40",
"99.04",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
14628, 14685
|
8837, 13070
|
297, 382
|
14905, 14935
|
4549, 8383
|
16759, 17782
|
3607, 3711
|
13356, 14605
|
14706, 14884
|
13096, 13096
|
8400, 8814
|
14959, 16736
|
3726, 4530
|
13120, 13333
|
247, 259
|
410, 3230
|
3252, 3463
|
3479, 3591
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,049
| 180,330
|
39979
|
Discharge summary
|
report
|
Admission Date: [**2163-6-19**] Discharge Date: [**2163-6-21**]
Date of Birth: [**2088-2-8**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2163-6-20**]
History of Present Illness:
Mr. [**Known lastname 122**] is 73M with history of CAD, NSTEMI in [**2160**], found to
have 80% proximal LAD lesion s/p DES who is being transferred
from [**Hospital3 3583**] with ongoing chest pain. Patient had been
symptom free since [**2160**] until two days prior to admission.
Patient had a regular day- finished his karate routine and ran
errands at the bank followed by a mediterranean diet and 2
drinks of gin. He was resting in his chair after the meal when
he felt pressure in his chest, about [**2161-3-16**] and took a SL
nitroglycerin which took most of the pain away. He then
experienced a tingling sensation/numbness in his left arm and
became very concerned and went to [**Hospital3 3583**]. Pt denies
any orthopnea, PND, LE swelling, n/v, although did have one
episode of diaphoresis with his initial presentation of
symptoms. Patient follows with Dr. [**Last Name (STitle) **] as his cardiologist and
recently got his aspirin dose decreased from 325mg to 81mg
daily.
In the [**Hospital3 3583**] ED, he was given nitro past and his
symptoms completely resolved and was watched overnight.
Troponins trended from 0.02->0.06->0.08->0.04, peaking yesterday
morning with the latest value this morning. Today, the patient
had two episodes of chest pain whichassociated slight ST segment
depresision and T wave inversion in leads V3-V5. Both episodes
were promptly relieved with SL nitro x 2. He was then
transferred to critical care at [**Hospital1 46**] and place on IV
nitroglycerin gtt and received Lovenox 1mg/kg subq. Plans were
made to transfer him to [**Hospital1 18**] for possible catheterization.
Past Medical History:
REVIEW OF SYSTEMS
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Social History:
No smoking, social alcohol use, no drug use. Worked as a
financial planner, now mostly retired. Married with 2 grown
children and 2 grandchildren.
Family History:
His father died of cardiac causes at age 59.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=97.8 BP=107/59 HR= 59 RR= 12 O2 sat= 98%
GENERAL: Pleasant in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no visible JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2163-6-19**] 08:48PM PT-11.8 PTT-33.3 INR(PT)-1.1
[**2163-6-19**] 08:48PM PLT COUNT-174
[**2163-6-19**] 08:48PM WBC-6.0 RBC-3.78* HGB-11.5* HCT-34.7* MCV-92
MCH-30.4 MCHC-33.2 RDW-13.9
[**2163-6-19**] 08:48PM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2163-6-19**] 08:48PM CK-MB-3 cTropnT-0.02*
[**2163-6-19**] 08:48PM estGFR-Using this
[**2163-6-19**] 08:48PM GLUCOSE-93 UREA N-18 CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-15
Discharge:
[**2163-6-21**] 04:10AM BLOOD Hct-34.8* Plt Ct-196
[**2163-6-20**] 05:44AM BLOOD WBC-6.2 RBC-3.61* Hgb-10.9* Hct-32.8*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.7 Plt Ct-163
[**2163-6-19**] 08:48PM BLOOD WBC-6.0 RBC-3.78* Hgb-11.5* Hct-34.7*
MCV-92 MCH-30.4 MCHC-33.2 RDW-13.9 Plt Ct-174
[**2163-6-21**] 04:10AM BLOOD Plt Ct-196
[**2163-6-21**] 04:10AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-27 AnGap-10
Brief Hospital Course:
ASSESSMENT AND PLAN: Mr. [**Known lastname 122**] is a 75M with history of NSTEMI
s/p DES to LAD in [**10/2161**] who is being transferred from [**Hospital1 3325**] for chest pain with evidence of unstable angina vs.
NSTEMI
# CORONARIES: The patient is s/p DES to the LAD in [**10/2161**] in
setting of NSTEMI, now with recurrent chest pain c/w past
episodes of angina. Patient was placed on heparin gtt,
nitroglycerin gtt, aspirin, plavix, and home dose of statin the
night of admission and was chest pain free over night. He was
taken to the cath lab the next morning where there was 99%
occlusion of the previously placed stent in the mid-LAD with
sequential 50% stenosis of the mid-vessel; TIMI 2 flow. This
was considered to be restenosis of the old stent. Patient
returned from cath lab without any complications. He will be
continued pm same admission doses of all medications including
his aspirin, plavix, statin, lisinopril, and metoprolol. The
nitroglycerin drip was discontinued after cardiac cath.
# PUMP: Most recent EF 54% in 1/[**2161**]. Currently denies any
symptoms of heart failure, including dyspnea, PND, or orthopnea.
His metoprolol and lisinopril home doses were continued. There
were no dramatic fluid shifts nor need for diuresis during this
admission.
# Anxiety/Insomnia
Patient received lorazepam while an inpatient. He will be
discharged on his home dose of temazepam.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
Hold if SBP <90 or HR <60
3. Atorvastatin 80 mg PO HS
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Temazepam 15 mg PO HS:PRN Insomnia
7. elidel PRN for ezcema
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
Hold if SBP <90 or HR <60
6. Temazepam 15 mg PO HS:PRN Insomnia
7. Elidel *NF* (pimecrolimus) 1 % Topical prn
* Patient Taking Own Meds *
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
unstable angina status post heart catheterization
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 122**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were trasferred here because you were having
chest pain. You had a heart catheterization done and two more
stents were placed in one of your heart vessels. The old stent
that was placed one year ago was found to be restenosed, or
occluded, and we needed to open up the vessel again. You will
be discharged on the same medications you came up on- Lisniopril
5 mg, Metoprolol 12.5 mg, and Atorvastain 80 mg. In addition
you will still be taking your aspirin 81 mg and clopidogrel 75
mg daily.
Please continue to take all of your other medications as
directed.
Followup Instructions:
Please see your outpatient cardiologist within one week of
leaving the hospital. He already had an appointment with his
cardiologist prior to admission which is this upcoming week with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.01",
"412",
"780.52",
"300.00",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"00.46",
"37.22",
"88.56",
"00.40",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
6756, 6762
|
4628, 6042
|
295, 336
|
6899, 6899
|
3699, 4605
|
7766, 8155
|
2736, 2782
|
6435, 6733
|
6783, 6783
|
6068, 6412
|
7050, 7743
|
2797, 2797
|
2819, 3680
|
245, 257
|
364, 1994
|
6802, 6878
|
6914, 7026
|
2016, 2555
|
2571, 2720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,158
| 123,815
|
27414
|
Discharge summary
|
report
|
Admission Date: [**2189-4-23**] Discharge Date: [**2189-5-19**]
Date of Birth: [**2152-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
s/p 20ft fall
Major Surgical or Invasive Procedure:
ICP bolt placement
right craniotomy and hematoma evacuation
thoracic laminectomy with fusion and instrumentation
PEG tube placement
History of Present Illness:
37yo man admitted s/p witnessed 20 foot fall from ladder. He was
initiall responsive with agonal respirations at the scene, but
no movement. Head CT scan demonstrated multiple contusions with
bilateral subdural and subarachnoid hemorrhages. An ICP bolt was
emergently placed in the ER with intracranial pressures in the
80s. He was taken emergently to the operating room for a right
hemicraniectomy with right temporal lobectomy.
Past Medical History:
"Hole in heart"
Social History:
Mother, [**Name (NI) **] [**Name (NI) **], is next-of-[**Doctor First Name **]. He is engaged.
Family History:
Not elicited
Physical Exam:
On arrival:
General: skin cool, TM clear
regular rhythm
CTAB, C-collar w/ no step off
abdomen soft, NT. normal rectal tone, no rectal blood
2+ distal pulses
Neuro: moves all four spontaneously, does not follow commands,
does not
open eyes
Pertinent Results:
Admission labs:
[**2189-4-23**] 11:35AM TYPE-[**Last Name (un) **] PH-7.26*
[**2189-4-23**] 11:35AM GLUCOSE-210* LACTATE-2.2* NA+-142 K+-3.7
CL--106
[**2189-4-23**] 11:35AM freeCa-1.07*
[**2189-4-23**] 11:25AM UREA N-18 CREAT-1.2
[**2189-4-23**] 11:25AM AMYLASE-68
[**2189-4-23**] 11:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2189-4-23**] 11:25AM URINE HOURS-RANDOM
[**2189-4-23**] 11:25AM URINE HOURS-RANDOM
[**2189-4-23**] 11:25AM URINE GR HOLD-HOLD
[**2189-4-23**] 11:25AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-4-23**] 11:25AM WBC-17.7* RBC-4.65 HGB-14.6 HCT-42.1 MCV-91
MCH-31.5 MCHC-34.8 RDW-13.6
[**2189-4-23**] 11:25AM PLT COUNT-262
[**2189-4-23**] 11:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2189-4-23**] 11:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2189-4-23**] 11:25AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2189-4-23**] 11:25AM URINE GRANULAR-0-2
Micro:
[**2189-5-16**] 10:48 pm URINE
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
sensitivities pending.
all other cx to date negative, sputum cxs contaminated, c diff
neg; CVL line tip negative
Imaging:
CT torso ([**2189-4-23**]): 1. Multiple thoracic vertebral fractures,
including comminuted, displaced burst fracture of T10 vertebra
with narrowing of the spinal canal due to the retropulsed
fragment and listhesis at the T9-T10 level. Additional probable
epidural hematoma at this level. Findings were discussed with
Dr. [**Last Name (STitle) **] at the time of image acquisition and interpretation
(12:20 p.m.).
2. Fractures of T7, T9, and T11; bilateral ribs, sternum and
left scapula.
3. Mediastinal and retroperitoneal hematoma and retroperitoneal
gas, without evidence of aortic injury. Findings are likely
related to the adjacent thoracic vertebral fracture and
associated vacuum effect.
4. Bilateral hemothorax. Tiny basilar left-sided pneumothorax.
5. No evidence of solid organ injury or pneumoperitoneum.
Chest/Abd CT: 1. Small to moderate sized bilateral pleural
effusions with associated atelectasis. 2. Fixation hardware seen
at the T7 through L1 levels with burst fracture at T10 again
noted. No evidence of adjacent fluid collections.
TTE ([**2189-4-28**]): 1. Left ventricular wall thickness, cavity size,
and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. There is a questionable, high
membranous ventricular septal defect (VSD).
2. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen.
3. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
4. There is a trivial/physiologic pericardial effusion.
Head CT [**2189-4-29**] : 1) Right occipital epidural hematoma with an
overlying non-displaced skull fracture, subdural hemorrhage
along the posterior falx cerebri, and hemorrhagic contusion at
the right frontal lobe remain stable in appearance since
[**2189-4-25**].
2) Small amount of residual hemorrhage at the posterior [**Doctor Last Name 534**] of
the left lateral ventricle.
3) Interval development of a 4-mm displacement of the septum
pellucidum to the right, with no overt CT features of cerebral
edema - probably a result of "negative mass effect" secondary to
the large right craniectomy.
4) Previously described hemorrhagic foci of diffuse axonal
injury at the posterior aspect of the brainstem now appear less
conspicuous.
CT Tspine [**2189-4-29**]: Burst fracture at the T10 vertebral body with
a small retropulsed fragment, compression fracture at the body
of T7, and paraspinal soft tissue swelling at T9-T11 levels
remain unchanged in appearance. There is now posterior metallic
fixating hardware spanning from T7-T12 levels inclusively. A
left pedicle screw is present at T9. Bilateral pedicle screws
are noted at T7, T8, and T12 levels. Laminectomy has been
performed at T10 level. The pedicle screws appear well-placed
within the confine of the pedicles and the vertebral bodies.
CTA ([**2189-5-5**]): There are multiple filling defects within the
right
major branches of the pulmonary arteries including the right
upper segment, and filling defects within the lower segments
consistent with pulmonary emboli. No filling defects are
identified on the left. There is a small left pleural effusion
with associated atelectasis. The heart and other great vessels
of the mediastinum are only remarkable for atherosclerotic
disease. NG tube is in the stomach. 2. Multiple fractures with
thoracic spine fixation rods.
CXR ([**2189-5-7**]): A feeding tube tip is in the stomach. The right
subclavian line tip is in distal superior vena cava. The left
lower lobe atelectasis is unchanged. There is no pleural
effusion or congestive heart failure. The recent surgery changes
are stable.
Abd u/s ([**2189-5-7**]): 1. No evidence of liver abscess.
2. Small fluid collections around that the bony implant in the
subcutaneous tissues in the right lower quadrant.
HCT ([**2189-5-7**]): Somewhat limited study due to motion.
Postoperative changes and right craniectomy, with prior
contusion in the right frontal lobe. Unchanged appearance of
small right epidural hematoma in the posterior fossa with skull
fracture. No new intracranial hemorrhage.
CXR ([**2189-5-10**]): NGT placement (removed just after exam):
+atelectasis, no PNA
CT OF THE CHEST WITH IV CONTRAST: Small to moderate bilateral
pleural effusions with associated atelectasis are seen. No focal
consolidations are identified. Several small mediastinal lymph
nodes are seen, however, none appear to meet CT criteria for
pathological enlargement. The heart and great vessels appear
unremarkable.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
pancreas, spleen, adrenal glands, and kidneys appear
unremarkable. There is no evidence of free fluid or free air
within the abdomen.
CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid appear
unremarkable. Foley catheter is noted within the bladder. There
is a small amount of air within the bladder, likely secondary to
catheterization. Subcutaneous chains noted in the soft tissue
overlying the pelvis.
BONE WINDOWS: Fixation hardware is seen from the T7-L1 levels.
Displaced burst fracture of T10 vertebral body is again
identified. Cortical defect seen in the right posterior superior
iliac crests, possibly representing bone donor site. Evaluation
of the hardware is limited by streak artifact, however, no
adjacent fluid collections or lucency are identified.
Multiplanar reformatted images confirm the axial findings.
IMPRESSION:
1. Small to moderate sized bilateral pleural effusions with
associated atelectasis.
2. Fixation hardware seen at the T7 through L1 levels with burst
fracture at T10 again noted. No evidence of adjacent fluid
collections.
Head CT ([**2189-5-18**]): FINDINGS: Post-surgical changes related to a
partial right hemicraniotomy are seen. No evidence of acute
intracranial hemorrhage or shift of normally midline structures
is seen. An epidural collection in the right occipital region
has decreased in size compared to [**2189-5-7**]. No new areas of
hemorrhage are seen. Areas of hypodensity in the right frontal
and temporal lobe, presumably related to prior post-traumatic
post-surgical change are again noted. The ventricles are not
dilated. The imaged paranasal sinuses show an air-fluid level
within the maxillary sinus. A hypodense fluid collection
adjacent to the left posterior frontal lobe is unchanged.
IMPRESSION: 1. No significant change compared to [**2189-5-7**]. No
new areas of hemorrhage identified.
Brief Hospital Course:
37yo man s/p traumatic injury with SAH/SDH s/p hemicraniectomy
and hematoma evacuation, vertebral burst fractures s/p hardware
placement, with course c/b multiple PEs.
Hospital course is reviewed by problem:
1. s/p fall -
a. SAH/SDH - The patient was taken to the operating room
emergently and underwent a R hemicraniectomy with temporal lobe
resection. He was transferred intubated to the ICU. He was
stablized from a medical standpoint and was taken to the CT
scanner which demonstrated marked diffuse brain edema with
transtentorial herniation and a new lens-shaped extra-axial
fluid collection extending from cerebellum along the right
parietal dura. He was maintained on dilantin (changed to keppra,
see below) and frequent neuro checks. Over the next few days,
the patient was observed to follow commands with his right hand.
He remained stable. He will need follow up with the
neurosurgeons 3 months after discharge to replace cranium.
b. burst fractures - The patient did have a known T10 burst
fracture. He was taken to the operating room again on HD 6 for a
thoracic laminectomy with arthrodesis and placement of
instrumented pedicle screws. Postoperatively he was again
transferred to the ICU intubated. He was treated with oxycodone
for pain. His staples were removed prior to discharge. He will
need to follow up with the neurosurgeons 3 months after
discharge.
2. fevers - The patient did spike intermittent fevers with
cultures being essentially unrevealing with the exception of a
potential pulmonary infiltrate. He was started on antibiotics
for presumptive treatment of a pneumonia. He remained stable and
his ventilator was weaned and he was successfully extubated on
HD9.
During the next few days, the patient continued to spike fevers
and his white blood cell count continued to climb up to 27. An
infectious disease consult was obtained for further evaluation.
The patient was then switched from dilantin to keppra to
eliminate the possibility of drug fever. His fevers persisted on
transfer to the medical service. At this time, his central line
was removed. When the cultures were negative for 24-48 hours,
all antibiotics (vancomycin, cefepime, flagyl) were
discontinued. At the same time, he was treated for newly
diagnosed pulmonary emboli. He defervesced after discontinuation
of the line and antibiotics, and the initiation of heparin. His
fevers may have been secondary to medications or possibly to an
infection followed by the pulmonary emboli. He then spiked again
and was found to have a urine culture positive for pseudomonas.
He was started on ciprofloxacin after discussion with the ID
fellow to avoid IV antibiotics. He was afebrile on discharge. He
will need to have a follow up urinalysis and urine culture in
several days to assess for cipro resistance. Urine culture
sensitivities were pending on discharge and need to be followed
up.
3. pulmonary emboli - He was noted to have acute hypoxic
respiratory failure on [**5-8**]. At this time a CTA showed right
upper and lower PEs and he was started on a heparin drip. He was
briefly treated in the ICU. He did not require reintubation and
was quickly transferred to the floor. He was started on lovenox
with goal anti-factor Xa level 0.6 (the lower level of therapy).
His dose was adjusted as indicated by his level and will need to
be further adjusted per level. He was saturating well on room
air at discharge.
4. transaminitis - The patient had a transaminitis thought to be
secondary to antibiotic use. RUQ u/s was negative for etiology.
The transaminitis was improving on discharge.
5. hyponatremia - This was found to be secondary to SIADH by
urine electrolytes. The most likely cause of SIADH was his CNS
process. His Na level remained stable and >130 throughout his
hospital stay.
6. tachycardia - The patient was persistently tachycardic during
the hospitalization. This was thought to be multifactorial - due
to an infection, fevers, and pulmonary emboli. He was also
treated initially with albuterol; this was changed to atrovent
and his HR decreased. His blood pressures remained stable.
7. FEN - A swallow evaluation demonstrated that he could take
thin liquids and pureed foods. The nutrition service was
consulted, who did not feel his po intake was adequate to meet
his nutritional requirements (approx 600 cals/day w/ goal 2100).
After discussions with his mother (next of [**Doctor First Name **]), he had a PEG
tube placed on [**5-15**]. He was started on tube feeds the next day.
8. hyperphosphatemia - He has had an elevated phos over the last
several days. This is likely partially due to diet. He was
discharged on a low phos diet and renagel with instructions to
monitor his phos and adjust his diet and renagel accordingly.
Communication - mother (next of [**Doctor First Name **]) [**Name (NI) **] [**Name (NI) 47400**] [**Telephone/Fax (1) 67113**]
Code status - full
Medications on Admission:
none
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): hold for loose stools.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: asdir
Subcutaneous four times a day: Glucose Insulin Dose
0-70 mg/dL [**12-1**] amp D50
71-120 mg/dL 0 Units
121-140 mg/dL 3 Units
141-160 mg/dL 6 Units
161-180 mg/dL 9 Units
181-200 mg/dL 12 Units
201-220 mg/dL 15 Units
221-240 mg/dL 18 Units
241-260 mg/dL 21 Units
261-280 mg/dL 24 Units
> 280 mg/dL Notify M.D. .
10. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous Q12H (every 12 hours).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain: hold for sedation, RR<10.
12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
13. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold for phos<3.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
T10 thoracic spine burst fracture
Increased intracranial pressure
Subarachnoid hemorrhage
Subdural hemorrhage
Status post craniotomy
Status post laminectomy and fusion
Pulmonary embolus
Anemia of inflammation
Hyponatremia
Discharge Condition:
Afebrile, tolerating tube feeds, able to verbalize minimally and
follow commands, with BLE paralysis.
Discharge Instructions:
Continue all medications.
You will need to follow up with neurosurgery in three months for
further procedures. Please have your x-rays and head CT
performed prior to this.
Please come to the emergency room if you have fever >101.4,
nausea or vomiting, new changes in mental status or confusion,
shortness of breath, chest pain or any other concerns.
Followup Instructions:
Please follow up in the neurosurgery clinic in 3 months after
discharge. Call [**Telephone/Fax (1) 2731**] for appointment with Dr. [**Last Name (STitle) 548**].
Follow up with Dr. [**Last Name (STitle) **] on [**8-19**] at 9am; [**Last Name (NamePattern1) **], [**Location (un) 470**], rm 3B.
.
You need a repeat head CT and AP/lateral x-ray of the
thoracolumbar spine prior to your neurosurgery appointments;
when you make the appointment, please ask them to schedule these
studies.
|
[
"811.00",
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"800.12",
"253.6",
"E881.0",
"801.12",
"285.29",
"599.0",
"518.5",
"415.19",
"807.2",
"860.4",
"041.7",
"807.02",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.18",
"03.53",
"96.72",
"77.79",
"81.05",
"43.11",
"99.07",
"01.59",
"86.09",
"96.6",
"99.04",
"81.63",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15805, 15877
|
9174, 14070
|
328, 462
|
16143, 16247
|
1377, 1377
|
16647, 17135
|
1088, 1102
|
14125, 15782
|
15898, 16122
|
14096, 14102
|
16271, 16624
|
1117, 1358
|
275, 290
|
2525, 9151
|
490, 921
|
1393, 2490
|
943, 960
|
976, 1072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,178
| 147,827
|
2727
|
Discharge summary
|
report
|
Admission Date: [**2170-8-11**] Discharge Date: [**2170-8-24**]
Date of Birth: [**2092-4-15**] Sex: M
Service: MEDICINE
Allergies:
Bee Sting Kit
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78yo man with cerebellar and throacic spinal RCC metastasis, s/p
recent spinal mass decompression (vertebrectomy and
instrumentation) on [**8-3**] presented with difficulty in speech.
Recently discharged on [**8-8**] from [**Hospital1 **] to [**Hospital 100**] rehab C after
spinal surgery as noted above. Per report, following surgery, he
has been well, walking speaking as usual. On the morning of
admission, he was found to have have difficulty in speech,
confusion and generalized weakness, but especially in the upper
extremities, noted by the rehab staff.
.
In the ED: Temp 101 HR 96 162/73. CXR showed retrocardiac
opacity rx. Head CT showed interval development of layering high
density within occipital [**Doctor Last Name 534**] of left lateral ventricle
worrisome for small hemorrhage. Cerebellar mets were somewhat
improved from previous. Neurosurgery consulted, change in mental
status thought to be secondary to toxic/metabolic encephalopathy
ensuing from infection and interevention not recommended. In the
ICU, pt started on ceftriaxone and vancomycin for empiric
treatment of pneumonia and pansensitive ecoli. On day of
transfer, febrile to 101.1.
.
Currently reports non-productive cough. Denies nausea,
vomitting, diarrhea, dysuria, back pain
Past Medical History:
Renal cell cancer with cerebellar metastasis:
During work up for sepsis in [**7-/2168**] was found to have a left
renal mass. He subsequently underwent nephrectomy in [**2168-11-7**].
He was
diagnosed with a bladder metastasis in [**1-/2169**], which was per
the
patient's report, resected cystoscopically. In [**6-/2169**] he was
diagnosed with spinal metastases in his lumbar and thoracic
spine, and eventually in [**10/2169**] these metastases became
clinically relevant, and he was started on dexamethasone and
received radiation therapy. This occurred at [**Hospital3 13503**], and he received proton beam radiation. In
[**11/2169**], he was diagnosed with brain metastases and received
whole brain radiation. He had been on Sutent since [**2170-4-10**],
also on Zometa, last dose on [**2170-7-2**].
.
Middle cerebral artery stenosis
Hyperlipidemia
Hypertension
h/o colonic polyps
h/o adrenal adenoma
Chronic kidney disease, baseline Cr 1.4-1.6
Social History:
ETOH: rare
Tobacco: 25pyrs, stopped [**2133**]
Occupation: retired
Living situation: married, children, lives with his wife
Family History:
NC
Physical Exam:
VS: 96.5 75 165/73 99% 3L
GEN: resting, NAD, alert to person, [**Location (un) **], year but not month
or hospital name
Skin: mx ecchymotic lesions and swelling bilat upper/lower ex.
Open 2x2 cm wound right lower ex very superficial. Back has
long wound with staples and no obvious purulent drainage.
dressing c/d/i
HEENT: atraumatic. PERRLA, EOMI, MM dry. OP clear
Neck: JVP flat. CVL right IJ
Cards: RRR nl S1S2 no MGR
Lungs: decreased bs at bases, nl effort. + cough
Abd: BS+ NT ND soft no masses
Ext: edema bilat with lesions as above. pulses dopplerable
Neuro:
- MS: speeching slowly but clearly. alert as above. able to
count to 10, can count months from [**Month (only) **] to [**Month (only) **] but slows and
stops
- CN: ii-xii intact
- Motor: [**4-14**] bilat upper/lower, tremor noted but no asterixis
- [**Last Name (un) **]: nl to light touch
- Reflexes: hyperreflexic bilat and down toes
- Coordination: not assessed
- Gait: not assessed
- no nuchal rigitidy
Pertinent Results:
Labs:
136 100 13
-------------< 125
3.6 22 0.9
Ca: 8.9 Mg: 2.2 P: 3.1 D
ALT: 25
AST: 36
LDH: 364
[**Doctor First Name **]: 20 Lip: 13
AP: 96 Tbili: 2.0 Alb: 3.0
Acetone:Small
.
WBC 7.9
HCT 29 - at baseline
Plt 149
N:89.2 Band:0 L:6.2 M:4.2 E:0.4 Bas:0
PT: 12.3 PTT: 92.7 INR: 1.1
.
EKG: NSR, nl axis, W III, aVF, TWI III, V1, poor R wave
progression. TWI III slightly worsened from prior.
.
Data:
Head CT [**8-11**]:
1. Interval development of layering high density within the
occipital [**Doctor Last Name 534**] of the left lateral ventricle may represent tiny
focus of hemorrhage. No other intra- or extra-axial hemorrhage
identified.
2. Known left cerebellar metastasis less conspicuous compared
to [**2170-4-10**] study. Clearly, a contrast enhanced examination
will be more capable of revealing a more subtle metastatic
lesion than the present non-contrast study.
.
CXR: New left retrocardiac opacity and small left-sided pleural
effusion
Brief Hospital Course:
78yo man with metastatic RCC with metastases to the left
cerebellum, thoracic spine, s/p recent spinal mass decompression
(vertebrectomy and instrumentation) admitted with delerium
secondary to PNA and GNR bactermia. MS is improving on
Zosyn/Vanco.
.
PNA and GNR bacteremia. On admission the patient had a CXR
consistent with pneumonia and was started on zosyn and
vancomycin empirically. Blood cultures from [**8-11**] grew [**3-14**]
bottles of pansensitive ecoli and he was switched to
levofloxacin. However, on [**8-16**] due to continued confusion,
levofloxacin was discontinued (given theoretical risk of altered
mental status with levofloxacin) and was continued on
ceftriaxone. He was switched to a PO regimen of Cefpodoxime on
[**8-22**] and was discharged with instructions to complete a 14 day
course. For pt's pneumonia, he was given levofloxacin, followed
by ceftriaxone. He also completed a 10 day course of flagyl for
presumed aspiration pneumonia.
.
Delerium. On admission the patient was noted to have difficulty
with his speech and with confusion. He was initially admitted
to the ICU because of a questionable cerebral bleed. However,
upon evaluation by neurosurgery and neuroogy, the MRI finding of
left lateral ventricular hemorrhage and brain metastases were
thought not to be the cause of his mental status changes. His
confusion was thought mostly secondary to toxic-metabolic
etiologies, most notably his infection. Decadron was also
thought to be compoundign his delerium and thus his decadron was
tapered.
.
HTN. Pt's hypertension was poorly controlled early on during his
admission. His lisinopril was titrated up to 20, and he was
started on norvasc 10, and metoprolol 75 [**Hospital1 **].
.
RCC. Patient has extensive metastases to brain, thoracic spine,
bladder. His decadron fgor post-op edema following spine
surgery was tapered from 2 mg PO BID to 1 mg [**Hospital1 **]. Pt's staples
from his vertebral surgery were removed on [**8-20**]. Pt has been
scheduled a follow up appointment with radiation oncology.
.
Colitis. On his last day of hospitalization, he was found to
have c diff positive x 1. Because he had been receiving flagyl
for aspiration pneumonia for a 10 day course, he was started on
PO vancomycin for a 10 day course.
Medications on Admission:
Lisinopril 10 mg a day.
Oxycodone p.r.n. 5-10mg q4-6h
Protonix 40 daily
dulcolax prn
decadron 2mg PO BID
colace 100mg [**Hospital1 **]
lipitor 5 daily
Lactulose prn
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*5 ML(s)* Refills:*0*
5. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days: until [**8-25**].
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours: For a 10 day course starting on [**8-25**] (to [**9-4**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
Bacteremia
Secondary
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with an altered mental status. You were
evaluated by both the neurology and neurosurgery team who found
that your altered mental status is most likely secondary to an
infectious process. You were found to have an infection in your
blood stream and also a pneumonia. You were treated with
antibiotics.
You were also found to have clostridium diff colitis.
You should take all of your medications as directed.
If you have any of the following symptoms, you should return to
the ED or see your PCP:
[**Name10 (NameIs) **] pain, fever, chills, shortness of breath, weakness, or any
other serious concerns.
Followup Instructions:
You have the following appointments:
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2170-8-27**] 3:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2170-9-1**]
|
[
"431",
"585.9",
"784.3",
"041.4",
"V10.52",
"486",
"272.0",
"507.0",
"790.7",
"V12.72",
"403.90",
"253.6",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8207, 8273
|
4728, 7017
|
296, 302
|
8356, 8365
|
3747, 4705
|
9039, 9358
|
2727, 2731
|
7233, 8184
|
8294, 8335
|
7043, 7210
|
8389, 9016
|
2746, 3728
|
235, 258
|
330, 1595
|
1617, 2569
|
2585, 2711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,072
| 184,897
|
43020
|
Discharge summary
|
report
|
Admission Date: [**2184-8-26**] Discharge Date: [**2184-9-1**]
Date of Birth: [**2143-11-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hard time breathing
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter attempted
History of Present Illness:
40 year old female with morbid obesity, chronic Co2 retention,
dCHF and afib presents from home with 7 days of SOB and fevers.
She is on home O2 and BIPAP. She is somnolent and is unable to
give many details. She reports fevers but did not take her
temperature. She has been coughing for 7 days but she denies
sputum. She reports not taking her medication compliantly,
including her lasix.
.
In the ED: Initial vitals: 99.2, 114, 209/100, 20, 100% on NRB.
In Afib (HR 115-140s); dilt given w/ good effect on tachycardia,
nitropaste w/ good effect on BP, levoquin for possible RLL PNA,
ativan for anxiety, lasix for CHF, percocet for pain, CEs #1-
trop at baseline EKG at; d/w Dr. [**Last Name (STitle) **] pcp: [**Name10 (NameIs) **] to medicine
for chf exacerbation, ? pna, treat for both.
Past Medical History:
1. Hypertension
2. CHF diagnosed [**3-3**]. EF 40%
3. afib diagnosed [**3-3**]
4. History of hypercarbic respiratory failure
5. Obesity
6. influenza [**3-3**]
7. Mild pulm HTN
8. 2+ TR
9. PFTs with a mild restrictive defect
10. h/o hyperglycemia
11. h/o ETOH abuse
12. w/u for sleep apnea
Social History:
Single mother of two children (aged 19 and 12). History of tob
but not currently. Has been in alcohol rehabilitation last year
but no current drinking. Lst drink 2 months ago. She lives with
her children and her mother. Used cocaine ten years ago. Denies
any IVDU. Lives in [**Location 686**], worked as cashier at [**Last Name (un) 59330**].
Family History:
non-contributory
Physical Exam:
VITALS: 97.2, 87, 103/59, SaO2 100% BIPAP 14/4
GEN: A+Ox2, somnelent, opens eyes to name but falls asleep
giving phone number, follows commands, answer short questions
HEENT: BIPAP
NECK: cannot assess JVP due to obesity
CV: distant heart sounds, irregular, no m/g/r/
PULM: crackles 1/2 up on right and 1/4 up on left, no rhonchi or
wheeze
ABD: soft, obese, NT, ND, +BS
EXT: trace to 1+ edema to knees bilaterally
Pertinent Results:
[**2184-8-26**] 07:30PM CK(CPK)-85
[**2184-8-26**] 07:30PM cTropnT-0.04*
[**2184-8-26**] 07:30PM CK-MB-NotDone
[**2184-8-26**] 03:23PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2184-8-26**] 03:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-8-26**] 03:23PM URINE RBC-[**3-29**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2184-8-26**] 03:23PM URINE HYALINE-0-2
[**2184-8-26**] 12:50PM GLUCOSE-112* LACTATE-2.0 NA+-146 K+-3.8
CL--102 TCO2-37*
[**2184-8-26**] 12:50PM HGB-12.1 calcHCT-36
[**2184-8-26**] 12:30PM GLUCOSE-105 UREA N-14 CREAT-0.9 SODIUM-144
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-33* ANION GAP-14
[**2184-8-26**] 12:30PM estGFR-Using this
[**2184-8-26**] 12:30PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-104
AMYLASE-32 TOT BILI-1.2
[**2184-8-26**] 12:30PM cTropnT-0.03*
[**2184-8-26**] 12:30PM CK-MB-6 proBNP-9857*
[**2184-8-26**] 12:30PM TOT PROT-7.8 CALCIUM-8.8 PHOSPHATE-3.6
MAGNESIUM-2.2
[**2184-8-26**] 12:30PM URINE HOURS-RANDOM
[**2184-8-26**] 12:30PM URINE HOURS-RANDOM
[**2184-8-26**] 12:30PM URINE HOURS-RANDOM
[**2184-8-26**] 12:30PM URINE UHOLD-HOLD
[**2184-8-26**] 12:30PM URINE UHOLD-HOLD
[**2184-8-26**] 12:30PM URINE GR HOLD-HOLD
[**2184-8-26**] 12:30PM WBC-12.9* RBC-4.54 HGB-11.8* HCT-39.2 MCV-86
MCH-26.0* MCHC-30.1* RDW-19.3*
[**2184-8-26**] 12:30PM NEUTS-83.1* LYMPHS-12.5* MONOS-2.6 EOS-0.9
BASOS-1.0
[**2184-8-26**] 12:30PM PLT COUNT-460*
[**2184-8-26**] 12:30PM PT-19.3* PTT-31.5 INR(PT)-1.8*
.
Brief Hospital Course:
On the floor, she got progressively more somnelent. ABG was
done: 7.26, 106, 81 on NC. She was then transferred to the MICU
for BIPAP.
.
[**Hospital 12145**] Hospital Course [**0-0-**]
.
In the MICU, the patient was weaned from BIPAP to 4LNC and her
pCO2 trended down to 85. She was then weaned to 1LNC and
tolerated the transition well, with a O2 sat goal of 88-93%, and
a pCO2 of 60-69. She also seemed to have volume overload on
initial presentation which further contributed to her
respiratory decline; on initial CXR, she had bilateral pleural
effusions. During her overnight stay in the MICU, she continued
to diurese, with a goal of -500 today. She admitted to Lasix
noncompliance, exhibited bilateral rales and peripheral edema on
physical exam, and her BNP was elevated to 9800--all pointing to
signs of CHF.
.
Additionally, ED blood cultures grew gram positive cocci, but
speciated as group B strep in one bottle and Viridans
Streptococci in 2 other bottles. This was felt to be
contamination from her femoral line, as repeat cultures drawn
peripherally remained negative and she remained afebrile and
without leucocytosis throughout the hospitalization. She did
received several days of Ancef, but was discontinued prior to
discharge.
.
Urine cultures--+MRSA and proteus. Since MRSA in the urine
usually comes from the blood and given no MRSA in blood, likely
a contaminant. Noted difficulty obtaining a clean catch due to
body habitus. Urinalysis and urine culture were repeated prior
to discharge. Patient refused nasal and rectal swab to test for
MRSA. Suggested that she could get these tests whenever she felt
the time was right.
.
# AFIB: She is rate controlled with Toprol XL and on coumadin
for anticoagulation at home. In the ED, RVR to 140's but
controlled with IV dilt. Diltiazem was discontinued prior to
discharge. Rate controlled on metoprolol.
.
# CHF: Probably diastolic dysfucntion with EF 55%, on lasix at
home. 1+ MR. She had crackles on both lungs and peripheral
edema. BNP 9800. She also was not compliant with her lasix.
CXR with bilateral pulm edema. Was diuresed, and placed back on
home furosemide dose prior to discharge.
.
# HTN: At home, she takes metoprolol and lisinopril. She was
hypertensive in the ED to the SBP 170's but became normotensive
on the floor with reinstituation of her home medications.
.
# ANXIETY: She takes citalopram at home, which was continued.
Medications on Admission:
# Aspirin 81 mg Daily
# Quetiapine 37.5 mg QAM and Qnoon, 50mg QPM
# Warfarin 2.5 mg QHS
# Citalopram 10mg Daily
# Lisinopril 5 mg Tablet QD
# Metoprolol Tartrate 200 mg QD
# Lorazepam 2 mg Q6hrs PRN
# Furosemide 40 mg QD
# Pantoprazole 40mg daily
# Percoset PRN
.
MEDICATION ON TRANSFER (from SIRS Service:
# Aspirin 81 mg PO DAILY
# Senna 1 TAB PO BID:PRN constipation
# Docusate Sodium 100 mg PO BID:PRN constipation
# FoLIC Acid 1 mg PO DAILY
# Levofloxacin 750 mg PO Q24H
# Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
# Ibuprofen 400 mg PO Q6H:PRN pain
# Warfarin 3 mg PO DAILY
# Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
# Ipratropium Bromide Neb 1 NEB IH Q6H
# Citalopram Hydrobromide 10 mg PO DAILY
# Pantoprazole 40 mg PO Q24H
# Vancomycin 1000 mg IV Q 12H
# Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
# MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
# Metoprolol 50 mg PO TID
.
ALLERGIES: Penicillin and morphine, unknown reactions
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 1 mg Tablet [**Hospital1 **]: 2.5 Tablets PO at bedtime.
3. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Quetiapine 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO QAM and QPM.
5. Quetiapine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
6. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
7. Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once
a day.
8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two
(2) Tablet, Delayed Release (E.C.) PO once a day.
9. Celexa 20 mg Tablet [**Hospital1 **]: [**1-27**] Tablet PO once a day.
10. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) puffs
Inhalation 2 puffs inhaled four to six times a day as needed for
shortness of breath or wheezing.
11. Aerochamber MV Inhaler [**Month/Day (2) **]: One (1) puffs Miscellaneous
use with inhaler every four (4) hours as needed for shortness of
breath or wheezing.
12. Advair Diskus 100-50 mcg/Dose Disk with Device [**Month/Day (2) **]: One (1)
puff Inhalation twice a day: Rinse mouth after use.
13. Colace 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO twice a day.
14. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
15. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoventilatory respiratory syndrome
Hypertension
Depression
Alcoholism
Asthma
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 to the hospital for difficulty breathing. In
the hospital you were transferred to the Medical Intensive Care
Unit where you were put on Bilevel Positive Airway
Pressure(BiPAP). This helped your breathing and you were
eventually taken off this and put on oxygen delivered via a
nasal cannula.
.
Please make sure you use your BiPAP every night for the entire
night. In addition, please remember to always take your
furosemide (Lasix).
.
If you have any difficulty breathing, chest pain, heart
palpitations, worsening of your symptoms, or any other
concerning symtoms please call your doctor or come to the
hospital.
Followup Instructions:
Cardiology appointment with Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD
Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2184-9-6**] 9:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5259**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2184-9-10**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22387**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2184-9-24**] 11:00
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**] [**10-1**] at 10:30 AM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2184-9-10**]
|
[
"300.00",
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63,733
| 145,445
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39835
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Discharge summary
|
report
|
Admission Date: [**2177-10-28**] Discharge Date: [**2177-11-20**]
Date of Birth: [**2100-8-22**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right PICC insertion [**2177-11-7**]
IR guided drainage of large abdominal hematoma [**2177-10-29**]
Angiography of the celiac artery, SMA, GDA, and abdominal aorta
[**2177-10-28**]
Left Internal Jugular central Line insertion [**2177-10-28**]
Arterial Line Placement [**2177-10-28**]
History of Present Illness:
This is a 77 year old male with PMH of multiple myeloma s/p 11
months of chemotherapy through [**7-/2177**], RCC s/p left nephrectomy,
CKI newly started on HD M/W/F as of 2 weeks ago, DM2 c/b
gastroparesis/peripheral neuropathy, HTN, and CAD being
transferred from [**Hospital6 5016**] with altered mental
status, Afib with RVR, hypotension requiring neosynephrine drip,
and for IR embolization for what was thought to be a large fluid
collection in his abdomen representing an actively extravasating
hemorrhagic right renal cyst. His current medical issues all
seemed to start with several falls starting about a month ago
when one of his outpatient doctors started [**Name5 (PTitle) **] on a new diuretic
regimen which made him lose 40lbs in 2 weeks and threw off all
of his electroyltes. After one of these falls, he was most
hospitalized at [**Hospital6 5016**] from [**10-11**] to [**10-21**] for a
syncope work-up. He also was found to have epigastric pain with
coffee-ground vomiting at that time. Per OSH records, a CT
abdomen revealed a hemorrhagic cyst of the liver vs. a right
renal hemorrhagic cyst but no management of this fluid
collection was initiated at the time. The patient was
transferred to [**Hospital3 **] following transfusion of 3 units
of pRBCs, dialysis, and treatment with Epogen. This morning, he
began complaining of intensifying abdominal pain and the rehab
staff noted pallor on physical exam. He also developed altered
mental status and EMS was called. He was found to be hypotensive
to the 50s, diaphoretic, and pale; but was mentating according
to report. He was transported back to [**Hospital3 **] where his
hematocrit was found to be 24 and a CT abdomen/pelvis was
performed that showed marked interval enlargement of what was
read as an exophytic right renal cyst with concern for active
hemorrhage. He was also noted to be in Afib with RVR to the
120s-130s and a diltiazem drip was started. A neosynephrine drip
was also started for hypotension and he was given 3L of NS. He
was then sent in an ambulance to [**Hospital1 18**] on a neo drip and dropped
his SBP to the 80s transiently which responded to 110s systolic
after a 1L NS bolus.
.
In the ED, initial VS were T=97.4, HR=120, BP=116/64, RR=16,
POx=100% on NRB. He was noted to be in Afib with RVR in the 120s
despite a diltiazem drip started at OSH when he arrived with a
SBP in the 110s on a low dose of neosynephrine drip. On physical
exam he was noted to have a large, tender mass on the right side
of his abdomen. General surgery, urology, and IR were all
consulted. His OSH scans were reviewed and on preliminary read
it looked as though he had a chronic free standing fluid
collection with subacute blood in it, but no active
extravasation. It was unclear if the fluid collection was
originating from the pancreas or the gastroduodenal artery.
There was also a separate right renal/adrenal cyst noted. IR
decided to take the patient for an aortogram to see if there was
any active bleeding that could be embolized. He was also noted
on CXR to have a RLL infiltrate concerning for PNA and was given
a dose of vancomycin and ceftriaxone in the ED. The diltiazem
drip was also stopped and his HR remained in the 120s. The ED
also tried to shut off the neosynephrine drip, but his SBPs fell
to the 90s and it was turned back on prior to going to IR for
his procedure. He also got 2 units of pRBCs for a hematocrit of
26.6 with an unknown baseline. A left IJ triple lumen was also
placed for access in the ED and blood cultures were sent.
.
In the IR suite, the fluid collection was felt to be a
pancreatic pseudocyst. Arteriograms of the aorta, celiac, and
SMA systems revealed no active extravasation or bleeding. The
fluid from this collection was not sampled.
.
In the ICU, initial VS were Temp: 97.2, BP: 122/57, HR: 69 RR:
21, and O2sat: 98% on NC. The patient's main complaint was back
pain which he has chronically and was exacerbated from laying
still after his IR procedure. Besides the pain the patient was
feeling much better and was no longer confused. He mentions that
he was being treated for a PNA found on CXR at his rehab since
[**10-22**]. Otherwise, he denied any shortness of breath, cough,
fevers, chills, headache, or chest pain. He does report having
recent difficulty focusing his vision, new onset palpitations
earlier today which have since resolved, and constipation. He
also reports right sided abdominal pain which has become less
severe and increasing edema.
Past Medical History:
PMH
- Plasma cell dyscrasia IgM - not myeloma but ? Wadenstrom's
variant s/p 11 months Melphalan and prednisone (last chemo
[**7-/2177**])
-Renal cell carcinoma s/p left nephrectomy in [**2168**]
-DM2
-peripheral neuropathy
-gastroparesis
-ESRD on HD M/W/F
-HTN
-CAD with mild, nonobstructive lesions seen on cath in [**2166**]
-Hyperlipidemia
-BPH
-gout
-hypothyroidism
-GERD
.
Past Surgical History:
-RCC s/p L nephrectomy in [**2168**]
-s/p splenectomy for ITP
-hernia repair
Social History:
The patient lived at home with his son, [**Name (NI) **], up until this
most recent hospitalization at the OSH when he was started on HD
and discharged to [**Hospital 8612**] Rehab. He has 2 sons and 1 daughter.
[**Name (NI) **] remains independent in his ADLs and this is his first
admission to a rehab facility. He is widowed and his wife passed
away in [**2173**]. He is a retired clerical worker for the IRS. He
currently denies smoking, but does have a history of cigar
smoking for approximately 40 years. He reports no EtOH or
illicit drug history. He mobilises independently and has an ET
of 20yrds.
Family History:
His father died of lung cancer at 81 and his mother died at 90.
His brother died of lung cancer. Uncles with DM2, gout.
Physical Exam:
Admission
VS: Temp: 97.2, BP: 122/57, HR: 69 RR: 21, O2sat: 98% on NC
GEN: pleasant, comfortable elderly male in NAD
HEENT: PERRL, EOMI, anicteric, dry MM
Neck: supple, Left IJ in place c/d/i
RESP: Coarse breath sounds anteriorly on the right, but with
good air movement throughout and no wheezing
CV: RRR, 2/6 SEM noted
ABD: Soft with large, firm, tender right sided mass palpated.
BS+.
EXT: 3+ edema bilaterally, palpable pulses, right sided groin IR
cath site c/d/i with no hematoma or bruit
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
.
Discharge
VS: Temp: 98.8, BP: 145/86, HR: 79 RR: 18, O2sat: 97% RA
GEN: pleasant, comfortable elderly male in NAD. R tunnelled
dialysis cath
HEENT: PERRL, EOMI, anicteric, MMM. Loose tooth upper left
incisor m1 tooth medial to left canine. Anisocoria left pupil
larger than right R=3mm+ L=4mm +
Neck: supple
RESP: Decreased breath sounds both bases no crackles
CV: RRR, [**1-11**] ESM noted. JVP not elevated.
ABD: Soft with large, firm, tender right sided mass palpated.
BS+.
EXT: 2+ edema bilaterally to knees - much improved, palpable
pulses, Calves SNT
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. GCS 15/15. Cn II-XII intact. 5/5 strength
throughout. No sensory deficits to light touch appreciated.
Pertinent Results:
Admission labs
[**2177-10-28**] 05:35PM BLOOD WBC-5.5 RBC-2.52* Hgb-8.2* Hct-26.6*
MCV-106* MCH-32.8* MCHC-30.9* RDW-20.0* Plt Ct-104*
.
Other labs
[**2177-11-6**] 08:00AM BLOOD Ret Man-6.8*
[**2177-10-29**] 12:29AM BLOOD CK(CPK)-41*
[**2177-10-29**] 08:26AM BLOOD CK(CPK)-40*
[**2177-10-29**] 11:59AM BLOOD LD(LDH)-995*
[**2177-10-28**] 05:35PM BLOOD Lipase-41
[**2177-10-28**] 05:35PM BLOOD cTropnT-0.10*
[**2177-10-29**] 12:29AM BLOOD cTropnT-0.13*
[**2177-10-29**] 08:26AM BLOOD cTropnT-0.14*
[**2177-11-8**] 05:59PM BLOOD CK-MB-2 cTropnT-0.17*
[**2177-11-9**] 06:21AM BLOOD CK-MB-2 cTropnT-0.17*
[**2177-10-29**] 11:59AM BLOOD Hapto-154
[**2177-11-6**] 08:00AM BLOOD VitB12-687 Folate-18.0
[**2177-11-5**] 10:44AM BLOOD Triglyc-124 HDL-24 CHOL/HD-3.4 LDLcalc-33
[**2177-11-6**] 08:00AM BLOOD TSH-17*
[**2177-11-6**] 08:00AM BLOOD Free T4-0.91*
[**2177-10-30**] 04:57AM BLOOD Cortsol-21.7*
[**2177-10-30**] 04:57AM BLOOD Cortsol-31.6*
.
Discharge labs
[**2177-11-20**] 05:54AM BLOOD WBC-7.2 RBC-2.70* Hgb-8.7* Hct-28.6*
MCV-106* MCH-32.3 MCHC-30.4* RDW-24.1* Plt Ct-69*
[**2177-11-17**] 06:45AM BLOOD PT-13.3 INR(PT)-1.1
[**2177-11-20**] 05:54AM BLOOD Glucose-86 UreaN-17* Creat-3.8*# Na-140
K-4.1 Cl-101 HCO3-32* AnGap-11
[**2177-11-17**] 06:45AM BLOOD ALT-11 AST-18 AlkPhos-93 TotBili-0.4
.
Abdominal cystic fluid
[**2177-10-29**] 01:07PM ASCITES WBC-[**Numeric Identifier 87675**]* HCT,fl-26* Polys-99*
Lymphs-0 Monos-1*
[**2177-10-29**] 01:07PM ASCITES TotPro-6.6 Amylase-0 Lipase-29
[**2177-10-29**] 1:07 pm PERITONEAL FLUID
GRAM STAIN (Final [**2177-10-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN, Cx Negative for growth
.
[**2177-10-29**] 10:45 am FLUID,OTHER Site: HEMATOMA
GRAM STAIN (Final [**2177-10-29**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2177-11-1**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
.
.
Microbiology:
BC [**10-28**] and 2x [**10-30**] -ve
UCx [**10-28**] and [**11-16**] -ve
Left IJ CVC tip [**11-8**] -ve
.
.
Radiology.
CT ABDOMEN W/O CONTRAST Study Date of [**2177-10-28**] 6:05 PM
IMPRESSION:
1. Massive complex cystic lesion in the right hemiabdomen with
internal
hyperdensity suggestive of hemorrhagic components, with limited
assessment of
internal enhancement. This lesion appears separate from the
right kidney and
liver, and while closely associated with the pancreatic head,
appears to
remain separate as well from the pancreas. No active
extravasation. This
lesion may represent a hematoma, possibly from trauma.
2. Large right adrenal myelolipoma.
3. Status post left nephrectomy without evidence of local
disease recurrence.
Status post splenectomy.
4. Right middle lobe ground-glass nodules measuring up to 8 mm,
possibly
infectious or inflammatory in etiology. Recommend followup in
three months to
document stability especially in a patient with known primary
malignancy.
6. Moderate bilateral pleural effusions with compressive
atelectasis.
7. Multiple right renal cysts, some of which hyperdense and some
minimally
complex.
8. Diffuse atherosclerotic disease.
9. Mild-to-moderate anasarca.
10. Moderate pericardial effusion.
11. Cholelithiasis.
.
Angiography of the celiac artery, SMA, GDA, and abdominal aorta
[**2177-10-28**] 7:10 PM
FINDINGS:
1. Conventional arterial anatomy.
2. There is displacement of the GDA and SMA vessels medially and
inferiorly,
corresponding to CT findings of a large cystic mass. No focal
arterial
extravasation or pseudoaneurysm is identified. Additionally,
tiny vessels
from the GDA distribution appear to extend inferiorly along the
wall of this
cystic mass.
3. The abdominal aortogram demonstrated no evidence of
extravasation.
IMPRESSION: No evidence of active extravasation or
pseudoaneurysm
.
U/S guided drain placement of hematoma [**2177-10-29**] 9:51 AM
IMPRESSION: Technically successful aspiration and drainage (8F
Navare
catheter) of right abdominal collection with imaging and gross
findings
representing a hematoma. Specimen sent to microbiology for
further analysis
immediately following the procedure
.
XR CHEST (PORTABLE AP) Study Date of [**2177-10-30**] 2:40 AM
FINDINGS: In comparison with study of [**10-28**], the catheters
remain in
position. Continued enlargement of the cardiac silhouette with
increasing
pulmonary vascular congestion. Bibasilar opacifications are
consistent with
atelectasis and pleural effusions
.
CTA ABDOMEN/PELVIS W&W/O C & RECONS Study Date of [**2177-11-10**] 5:22
PM
IMPRESSION:
1. Interval decrease in size of right abdominal hematoma with
drainage
catheter in place. The hematoma now measures 14 x 12 cm
(previously 17 x 15
cm). No evidence of active extravasation.
2. Cholelithiasis and vicarious contrast excretion within the
gallbladder.
3. Stable appearance of right kidney with multiple simple and
slightly
complex cysts.
4. Large right adrenal myelolipoma.
5. Status post left nephrectomy with no evidence of local
disease recurrence.
Status post splenectomy.
6. Moderate bilateral pleural effusions, moderate anasarca, and
moderate
pericardial effusion, all unchanged.
7. Diffuse atherosclerotic disease.
.
XR CHEST (PORTABLE AP) Study Date of [**2177-11-17**] 11:28 AM
FINDINGS: In comparison with the study of [**10-30**], the cardiac
silhouette
remains enlarged, though there is no evidence of vascular
congestion or the
diffuse opacification previously seen on the right. There is
continued
opacification at the left base with silhouetting of the
hemidiaphragm, most
likely consistent with volume loss in the left lower lobe and
small effusion.
No evidence of acute focal pneumonia.
Dialysis catheter and PICC line remain in place.
.
Portable TTE (Complete) Done [**2177-10-31**] at 2:30:00 PM
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. 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. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is a
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
.
TTE (Focused views) Done [**2177-11-3**] at 3:08:22 PM
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are structurally normal. There is a small to moderate
sized circumferential pericardial effusion most prominent
(1.3cm) around the apex of the right and left ventricle and
relatively little inferolateral (<0.5cm) to the left ventricle.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2177-10-31**],
the findings are similar.
.
Pathology
.
Cytology Report PERITONEAL FLUID Procedure Date of [**2177-10-29**]
DIAGNOSIS: Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS.
Inflammatory cells, mostly neutrophils.
Blood.
.
Brief Hospital Course:
77 year old male with PMH of plasma cell dyscrasia s/p 11 months
of Melphalan and Prednisone through [**7-/2177**] RCC s/p left
nephrectomy, ESRD recently started on HD, DM and HTN who was
admitted with hypotension, rapid AF and confusion for possible
IR embolisation of what was thought to be a large intra-abd
hematoma with concern for ongoing hemorrhage.
.
# Large intra-abdominal hematoma: Pt was transferred from an OSH
due to concern for possible enlarging hemorrhagic renal cyst.
However, the fluid collection was felt to be separate from both
the kidney and pancreas. Pt had required blood transfusions
prior to transfer and was hypotensive with a pressor requirement
on arrival to [**Hospital1 18**]. Repeat CT abdomen without contrast on
[**10-28**] demonstrated the large hematoma which was causing IVC
compression and was felt possibly secondary to trauma. Surgery
and IR were consulted and this was felt possibly due to duodenal
hemorrhage. Pt underwent angiograms of the aorta, celiac, and
SMA on [**10-28**] which did not showed any evidence of extravasation
or pseudoaneurysm. The hematoma was drained on [**10-29**] by IR and
put out 750cc. BP improved after drainage and pt was able to
weaned off pressor support in the following days. Peritoneal
fluid results showed WBC: [**Numeric Identifier 87675**] 99% Polys, HCT: 26, Amylase 0.
Both cultures and cytology returned negative. Pt had
considerable abdominal pain at the drain site which improved
with IV dilaudid. He was transferred from the ICU to the general
medical [**Hospital1 **] on [**11-2**]. Pt had a repeat CTA abd and pelvis on
[**11-10**] which showed an interval decrease in size but still a large
residual hematoma with no blush to suggest active bleeding. His
Hb/HCt remained stable and abdominal pain improved
significantly. He will be followed by general surgery in their
[**Hospital 2536**] clinic on [**11-25**]. His case was frequently discussed with IR
and drain continued to have approx 100cc of serosang drainage
each day. The drain output will need to be monitored regularly
at the LTAC with a plan for follow up with IR once the output
decreases to <10cc/day. Interventional radiology contact
details were included in the page 1 and both pt/family were
given instructions regarding the importance of re-imaging and
surgical follow up once the drain output decreases and it is
removed.
.
# Pneumonia. The patient had been diagnosed with pneumonia at
his rehab hospital and was given one dose of vancomycin on [**10-22**]
and continued on ceftriaxone and vancomycin for a 10 day course.
He was initially confused and this resolved as his hypotension
was managed. CXR at [**Hospital1 **] showed RLL infiltrate and bilateral
pleural effusions secobdary to his volume status. He completed a
course of ABx for HAP after which he remained afebrile without
respiratory complaints
.
# ESRD on HD: Mr [**Known lastname 87676**] had worsening renal unction prior to
admission and this was initially felt due to worsening of his
plasma cell dyscrasia and previous RCC s/p nephrectomy. Pt had
been started on HD 3 weeks prior to admission and presented with
massive volume overload/anasarca that was complicated by his low
albumin. While in house, he underwent almost daily HD/UF for
aggressive volume removal but this was limited by low BPs at HD.
This was managed with midodrine/albumin as needed. Latterly
his BP permitted significant fluid removal of 3-4L without the
aid of albumin and his anasacra greatly improved as a result of
this. He was discharged with plan continued HD on Mon, Wed, Fri.
.
# Fast AF: This was noted on the outside hospital ECG, and
required IV diltiazem and resolved. He continued in sinus rhythm
throughout the remainder of his hospital stay and he was
monitored on telemetry. He did not require any other nodal
agents and was not anticoagulated given his large hematoma and
relative thrombocytopenia.
.
# Left Eye conjunctivitis: On [**11-10**] there was noted evidence of
left conjunctival erythema and exudate clinically compatile with
mild bacterial conjunctivitis. He was therefore treated with a 1
week course of Erythromycin eye drops which stopped [**11-17**]. This
resolved before his treatment course was completed.
.
# Pericardial effusion: On [**11-3**] there was evidence of a
moderate pericardial effusion on echo and was not causing
tamponade. He went on to a repeat echo [**11-3**] which showed normal
LV/RV (LVEF>55%)and a small to moderate sized circumferential
pericardial effusion most prominent (1.3cm) around the apex of
the right and left ventricle and relatively little inferolateral
(<0.5cm) to the left ventricle with no echocardiographic signs
of tamponade.
.
# Plasma cell dyscrasia: Initially documented on admission to be
myeloma but on further discussion with his outpt hematologist,
it was felt that the exact nature of his plasma cell dyscrasia
was not entirely understood. Pt had been treated with Melphalan
and Prednisone prior to admission which he did not tolerate
well. His pathology was reviewed at [**Hospital1 2025**] and a second opinion is
awaited. He was noted to have a large MCV while in house with
high retic count and further hematology managment was deferred
to the outpatient setting. His hematologist Dr [**Name (NI) 87677**]
was planning for more chemotherapy but this on hold until his
acute issues have resolved.
.
# Malnutrition/Ascites: Pt presented with a low albumin and
anasarca. Pt was noted to have poor oral intake which was felt
to be as a result of abdominal dyscomfort. He was therefore
treated with TPN for approx 2 wks and as his fluid collection
decreased in size, his intake improved. Albumin with trending
back to normal and nutrition consult felt he could maintain his
caloric requirements without TPN. Pt should continue to ENSURE
TID with meals and will need follow up with nutrition.
.
# DM2. This was initially treated with HISS but he had a poor
nutrition status and minimal oral intake. He was initially
treated with TPN including insulin. Pt was transitioned back to
regular diet when his intake improved and his blood sugars
remained well controlled without any short acting insulin
coverage. The gabapentin was decreased to 100mg qhs and
neuropathic pain was controlled.
.
# Anisocoria: Noted to have left pupil larger than right which
was persistent with GCS 15/15. No focal neurological deficit.
.
#. Hypothyroidism: Pt was noted to have an elevated TSH at 17
and low fT4 0.91 on [**11-6**]. We increased his levothyroxine dose
to 137.5mcg daily, TSH/fT4 should be repeated in [**5-13**] weeks.
.
# FOLLOW UP***
1. CT-abd [**10-28**] showed right middle lobe ground-glass nodules
measuring up to 8 mm, possibly infectious or inflammatory in
etiology. He was treated with an eight day course of Abx for
HAP. Radiology recommended followup in three months with
CT-chest to document stability especially in a patient with
known primary malignancy.
2. Needs follow up thryoid function tests in [**2177-12-6**]
3. Needs follow up with hematology once these acute issues
resolved
Medications on Admission:
-Tylenol 650mg PO q4h PRN pain, fever
-Morphine 2mg IV q6h PRN pain
-Tramadol 50mg PO BID PRN pain
-Tramadol 50mg at 8PM standing
-Synthroid 125mcg daily
-Vanco 500mg once on [**10-22**]
-Ceftriaxone 1gm IV daily stopping [**11-1**]
-Gabapentin 100mg [**Hospital1 **], 200mg HS
-Reglan 10mg q6h
-Nephrocaps daily
-Simvastatin 40mg daily
-Allopurinol 100 mg daily
-Aspirin 81 mg daily
-Procrit 10,000 units with hemodialysis
-Nexium 40 mg po daily
-Multivitamin daily
-Novolog sliding scale
-Diet: Renal/diabetic diet with 40grams of Nepro TID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
8. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. midodrine 5 mg Tablet Sig: Two (2) Tablet PO QHD (each
hemodialysis).
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
12. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-7**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush.
18. Outpatient Lab Work
Please check TSH and fT4 in 6 weeks and forward results to rehab
doctor/PCP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary diagnoses:
Intra abd hematoma s/p IR guided drain insertion
End-stage renal failure on hemodialysis
Episode of rapid Atrial Fibrillation in the context of sepsis
Pneumonia (hosp acquired)
Hypotension
.
Secondary diagnoses:
Plasma cell dyscrasia IgM - not myeloma but ? Wadenstrom's
variant s/p Melphalan and prednisone
Renal cell carcinoma s/p left nephrectomy
Type 2 Diabete Mellitus with peripheral neuropathy and
gastroparesis
End-stage renal failure on hemodialysis
Hypertension
Coronary artery disease
Hyperlipidemia
Benign prostatic hyperplasia
Gout
Hypothyroidism
Gastro-esophageal reflux disease
s/p splenectomy for ITP
s/p hernia repair
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 looking after you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
.
You were initially transferred from [**Hospital6 5016**] with
confusion and a low blood pressure requiring medications to
support this in addition to an increasing collection of blood
within the abdomen. The outside hospital had taken a chest X-ray
which showed pneumonia and you were treated with intravenous
antibiotics for this completing a 10-day course. You had no
further fevers during your hospital stay. You also briefly had a
fast irregular hreat beat which was treated with medications to
slow the heart and resolved with no futher episodes. Your
confusion resolved.
.
Given inncreasing abdominal pain, you were reassessed with a
CT-scan which showed an enlarging collection of blood (called a
hematoma) in your abdomen. You were transferred to the ICU for
monitoring and had an angiogram to look at the blood vessels and
there was no evidence of active bleeding or any swellings of the
blood vessels. After this, you had a drain inserted by
interventioanl radiology under ultrasound guidance to drain the
hematoma. Following initial drainage of this, your blood
pressure was much easier to control as this was felt to have
been compressing one of the major veins in the abdomen. The
cause of this collection of blood is not known but may have been
related to a bleed from the gut. We had many discussions with
interventioanl radiology and once your drain is drainig <10mL in
24 hours you will have your abdomen re-scanned and as necessary
your drain removed or re-positioned. You will also be followed
up by the general surgeons on [**11-25**] regarding this blood
collection. You required no transfusions while at the [**Hospital1 18**]
although you did have some prior to your arrival here and your
blood count remained stable. Due to the blood collection, we
held your aspirin and pain was controlled with appropriate
pain-killers and improved during your admission. Your drain was
still draining on trasfer to rehab on [**11-20**].
.
You also required frequent dialysis due to having a lot of
additional fluid in your body. They were able latterly to take
off 3-4 liters of fluid but there were problems regarding your
blood pressure which tended to drop during dialysis. For this
you received the medication midodrine and occasionally required
fluids to support your blood pressure with albumin. You did well
on your dialysis and on transfer you will have a
Monday/Wednesday/Friday dialysis regimen.
.
You were incidentally found to have right sided lung nodules on
your CT scan which was in teh context of being treated for
pneumonia. As a precautionary measure, these should be followed
up with a repeat scan in 3 months.
.
You initially required nutrition through the veins due to poor
oral intake but latterly you no longer required this and were
eating well.
.
You also noted a loose left upper incisor tooth and this should
be followed up by a dentist at your rehab.
.
You were treated for a possible bacterial infection on the
outside of the eye called bacterial conjunctivitis with eye
drops. This resolved.
.
You were discharged to rehab on [**11-20**].
.
.
Medication changes:
We stopped aspirin due to your abdominal blood collection
WE increased your levothyroxine to 137mcg daily
Given your kidney function we reduced gabapentin to 100mg daily
.
Patient instructions:
Once you are draining <10ml/day you should be reassessed with a
scan and seen by interventional radiology.
Your dialysis regimen will be Monday/Wednesday/Friday.
Followup Instructions:
We made the following appointments for you:
.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2177-11-25**] at 3:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Regarding your loose tooth, you should make a dentistry
appointment to address this.
|
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icd9pcs
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[
[
[]
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24448, 24522
|
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|
306, 593
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14,507
| 100,738
|
24798
|
Discharge summary
|
report
|
Admission Date: [**2144-10-22**] [**Month/Day/Year **] Date: [**2144-10-26**]
Date of Birth: [**2099-1-29**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 45M with history of alcoholism and pericarditis who
presents to the ED with 2 days of chest pain consistent with his
pain associated with pericarditis. Pt states that he has flairs
every 3-4 months treated with ibuprofen. In the ED, vitals 96.5
132 129/87 12 98% RA. Patient noted diaphoresis, pain worse with
inspiration, vomiting after eating. Not associated with change
in position, radiation. Also dry cough, chills (no fevers). Pt
states that this pain is similar to pain that he has had in the
past with pericarditis. Pt is also a heavy drinker. Last
alcohol consumed evening of [**10-21**]. Normal consumption [**2-5**] pints
of vodka daily. Patient does have a history of seizures with
withdrawal. Is in active withdrawal requiring hourly valium.
Tox screen in ED significant for alcohol level 334. The tox
screen was also positive for benzos, however, the patient had
concurrent dosing of valium for his alcohol withdrawal and
[**Month/Day (2) **] benzo use.
.
Pt also notes that he has had right arm numbness for the last 2
weeks. He states that he had a fall and since them his arms and
hand have been numb with pins and needle sensation. Arm is
notable for swelling but full ROM.
Past Medical History:
Chronic heavy etoh abuse x 20 years (hx of withdrawal seizures,
last 4 weeks ago)
Hx of pericarditis (s/p window; few years ago)
s/p bilateral shoulder dislocataions in setting of seizures
Depression
Social History:
Homeless, divorced. One daughter. Drinks [**2-5**] pints of vodka
daily. Does not smoke. Remote history of smoking 1ppw x 8
years. No illicit drug use.
Family History:
Mother - healthy. Father - unknown. Aunts and uncles with
alcoholism
Physical Exam:
General Appearance: Well nourished, No acute distress, Thin,
Diaphoretic
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)
Endotracheal tube, No(t) NG tube, No(t) OG tube
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
, No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Purposeful, Tone: Not assessed
Pertinent Results:
[**2144-10-22**] 09:15AM BLOOD WBC-4.5 RBC-4.09* Hgb-13.5* Hct-39.0*
MCV-96 MCH-33.0* MCHC-34.5 RDW-14.8 Plt Ct-135*
[**2144-10-22**] 09:15AM BLOOD Neuts-43.9* Lymphs-51.0* Monos-3.6
Eos-1.1 Baso-0.5
[**2144-10-22**] 09:15AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.1
[**2144-10-22**] 09:15AM BLOOD Plt Ct-135*
[**2144-10-22**] 09:15AM BLOOD Glucose-101 UreaN-6 Creat-0.6 Na-145
K-3.8 Cl-102 HCO3-26 AnGap-21*
[**2144-10-22**] 09:15AM BLOOD ALT-42* AST-106* LD(LDH)-266*
CK(CPK)-230* AlkPhos-89 TotBili-0.7
[**2144-10-22**] 09:15AM BLOOD Lipase-38
[**2144-10-22**] 09:15AM BLOOD cTropnT-<0.01
[**2144-10-23**] 05:10AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.4 Mg-1.5*
[**2144-10-22**] 09:15AM BLOOD [**Month/Day/Year **]-NEG Ethanol-334* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
chest x-ray - IMPRESSION: No acute intrathoracic process.
CTA chest - IMPRESSION: 1. No pulmonary embolism, aortic
dissection or pericardial effusion 2. Fatty infiltration of the
liver.
upper extremity ultrasound - PRELIM read - No son[**Name (NI) 493**]
evidence of compartment syndrome. Normal examination of the
forearm.
forearm x-ray Two views of the right forearm are obtained. An
intravenous catheter is present. No fracture or dislocation is
identified.
Brief Hospital Course:
A&P: 45M with history of alcoholism and pericarditis admitted
to initially to ICU for alcohol withdrawal and later transferred
to medicine service.
<br>
Alcohol withdrawl - Pt has history of seizures during wihdrawal.
Has been drinking [**2-5**] pints of vodka daily. Last drink 10pm
[**10-21**]. Patient was monitored on CIWA scale and received a
significant amount of valium. He was also seen by the addiction
consult. At time of [**Month/Year (2) **], patient was walking comfortably
without any clinical evidence of active ETOH withdrawal. Given
mild tremors and that pt sx mildly worsened [**10-25**] of original
anticipated d/c - pt will be d/c with tail of end librium taper
(given 50mg today and tomorrow, and 25mg next 2 days). Pt has
already Rx by Dr. [**Last Name (STitle) **] yesterday diazepam for breath through
tremors/anxiety. PCP otherwise to [**Name Initial (PRE) **]/u on pt and assess
progress.
<br>
Pericarditis - History of flairs every 3-4 months. Per report,
had pericardial window 10 years ago at the [**Hospital1 756**]. Symptoms
responded well to ibuprofen. No evidence of pericardial
effusion on CT. D/C with ibruprofen.
<br>
Right Arm Numbness - Pt describes numbness and tingling in arm
and hand. Right arm swollen and tight distal to elbow. Full
range of motion. No tenderness to palpation. Had trauma to arm
two weeks ago. X-rays and U/S were unremarkable, no evidence of
fracture, nerve entrapment or compartment syndrome.
<b>
Anemia, nos - pt with all cell counts mildly low - chronic and
consistant with etoh marrow suppression. PCP to [**Name Initial (PRE) **]/u as
indicated - etoh cessation d/w pt along with S.W. consult as
above.
Medications on Admission:
Seroquel 50mg qhs
[**Name Initial (PRE) **] Medications:
1. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2*
6. Diazepam 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for tremulousness.
[**Name Initial (PRE) **]:*4 Tablet(s)* Refills:*0*
7. Chlordiazepoxide HCl 25 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily): TAKE 2 TABS FOR NEXT TWO DAYS EVERY MORNING, THEN
TAKE ONLY 1 TAB EVERY MORNING FOR NEXT 3 DAYS (THEN YOU WILL BE
DONE).
[**Name Initial (PRE) **]:*7 Capsule(s)* Refills:*0*
[**Name Initial (PRE) **] Disposition:
Home
[**Name Initial (PRE) **] Diagnosis:
ETOH Withdrawal
Pericarditis
Depression
Anxiety
Right Arm Numbness
[**Name Initial (PRE) **] Condition:
Vital Signs Stable, ambulating without difficulty.
[**Name Initial (PRE) **] Instructions:
Return to ED if having worsening tremulousness, worsening signs
of ETOH withdrawal.
DO NOT DRINK ANY ALCOHOL
Use motrin as needed for pericarditis pain.
<br>
Do not plan to operate any heavy machinery or drive for atleast
next 1 week. If your tremulousness gets worse, first take one
of your as needed diazepam medications (only take if you need
it), if that does not settle your symptoms call your PCP or
return to ED as above. The librium prescription is intended so
you won't need the diazepam medication.
Followup Instructions:
1. PCP f/u with Dr. [**First Name (STitle) **], [**First Name3 (LF) **] on [**2144-11-9**] at 10:30am.
([**Location (un) **], [**Telephone/Fax (1) 4326**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2144-10-26**]
|
[
"300.4",
"V60.0",
"276.2",
"291.81",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4322, 6016
|
302, 308
|
3057, 4299
|
7877, 8177
|
1964, 2037
|
6042, 7854
|
2052, 3038
|
244, 264
|
336, 1549
|
1571, 1773
|
1789, 1948
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,596
| 118,069
|
36078
|
Discharge summary
|
report
|
Admission Date: [**2200-1-23**] Discharge Date: [**2200-1-28**]
Date of Birth: [**2167-5-30**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Trazodone overdose, EtOH intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 32 yoF with h/o prior suicide attempts, who
presents after taking trazodone in an attempt to kill herself.
Around noon this afternoon, she drank "five drinks" (not
"shots") of vodka, and then around 2 pm, she ingested 30 pills
of 50 mg trazodone. Within the next hour, she called the
ambulance herself. This was done at her apartment, and she
reports that she did this because she was upset about her
boyfriend.
Of note, she has had three prior SA since [**2199-11-9**], two of
which resulted in hospitalization at [**Hospital3 **], at which
point she was put on Celexa. She has a PCP (Dr. [**First Name4 (NamePattern1) 1399**] [**Last Name (NamePattern1) 81854**]?)
but no psychiatrist or psychologist currently.
In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA.
The toxicology team saw her; she was considered out fo the time
window for activated charcoal; no stomach pumping was performed.
while she was wiating for a bed, she became hypotensive with BP
70-80, which improved with 2 L NS. On arrival to the MICU, VS
were T 97.6, HR 86, BP 90/51, 100% RA, RR 19. She denied
nausea, HA, F/C, CP, SOB, abd pain; she was somnolent but easily
arousable and conversant.
Past Medical History:
Depression
Social History:
-- has lived with her boyfriend 4 years; readily admits to
emotional and physical abuse by boyfriend (he has put out
cigarettes on her in the past; has been hit in the face before)
-- drinks occ on weekends; denies having a "drinking problems"
in the past; denies drinking daily; no h/o withdrawal symptoms
-- smokes cigarettes socially when she drinks; does not smoke
daily
-- denied IVDU, snorting drugs
-- originally from Western Mass
-- works as an ESL instructor
Family History:
-- mother: breast CA, Bipolar disorder
-- father: [**Name (NI) 81855**], diet controlled
-- older sister: MS
-- older brother: healthy
Physical Exam:
VS 99.5, 80, 101/52, 64, 16, 99/RA
General: Alert sitting upright in bed, friendly and conversant
[**Name (NI) 4459**]: [**Name (NI) 5674**], 1 mm pupils R=L (PEERL)
Lungs: CTA b/l, no wheezes or crackles
Cardio: RRR, no m/r/g
Abd: Active bowel tones, soft, NT/ND without masses
Extremities: no LE edema
Skin: no rash
Neuro: Alert & O x 3; CN II - XII intact; normal muscle tone,
normal strength throughout
Pertinent Results:
ADMISSION LABS:
[**2200-1-23**] 03:00PM BLOOD WBC-4.7 RBC-4.34 Hgb-12.7 Hct-36.7 MCV-85
MCH-29.3 MCHC-34.6 RDW-17.0* Plt Ct-290
[**2200-1-23**] 03:00PM BLOOD Neuts-65.0 Lymphs-27.7 Monos-5.8 Eos-1.1
Baso-0.5
[**2200-1-23**] 03:00PM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-145
K-3.8 Cl-110* HCO3-21* AnGap-18
[**2200-1-24**] 04:32AM BLOOD ALT-10 AST-13 AlkPhos-35* TotBili-0.4
[**2200-1-24**] 04:32AM BLOOD Albumin-3.5 Calcium-6.9* Phos-3.2 Mg-1.5*
TOX SCREENS:
[**2200-1-23**] 03:00PM BLOOD ASA-NEG Ethanol-281* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-1-23**] 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
URINALYSIS:
[**2200-1-23**] 03:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-<=1.005
[**2200-1-23**] 03:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-SM
[**2200-1-23**] 03:00PM URINE RBC-0-2 WBC-[**3-13**] Bacteri-FEW Yeast-NONE
Epi-0
ECG Study Date of [**2200-1-24**] 12:35:14 AM
Sinus rhythm. Minor non-diagnostic T wave flattening. Compared
to the
previous tracing no major change.
Rate 80, PR 112, QRS 78, QT/QTc 404/439, P 31, QRS 57, T 29
IRON STUDIES:
[**2200-1-25**] 06:22AM BLOOD calTIBC-345 Ferritn-9.7* TRF-265
Brief Hospital Course:
32 yo F w/ depression hx and prior SA, admitted to the MICU for
trazodone OD with EtOH intoxication; now transferred to the
floor for further monitoring and recovery.
# TRAZODONE OVERDOSE: Risk of hypotension with anti-alpha 1
effects; no evidence of serotonin syndrome since admission. Tox
fellow notified upon admission, who advised monitoring for
hypotension, CNS depression and Qtc prolongation. Once
medically stable, she was transferred to the floor for further
monitoring. EKG notable for TWI V1/2, no QT prolongation. EKG
rechecked with only T-wave inversions in V1. Remained
hemodynamically stable and repeat orthostatics were negative.
By hospital day #2, patient with no remaining sypmtoms of
overdose.
# SUICIDE ATTTEMPT, DEPRESSION: Patient states this been
worsened in recent past by abusive relationship with boyfriend
(living partner). Initially continued to hold Celexa for given
trazodone OD. Consults included Social Work, Center for
Violence Prevention consult given domestic abuse and Psychiatry.
She was also kept on a 1:1 Sitter and had a safety tray for all
meals. On hospital day #2, Citalopram was restarted at prior
dosing. Psychiatry considered her a danger to herself under
section 12. She was then discharged to a inpatient psychiatric
facility once one became available for further monitoring and
improvement.
# DOMESTIC ABUSE: As above, closely related to depression.
Requested consultation from the Center for Violence Prevention.
While inpatient, she was on a safety alert / privacy alert to
avoid further contact with her abusive partner.
# EKG CHANGES: Patient with TWI in V1/2 on repeat EKG early [**1-24**]
AM. Patient denied any symptoms of CP, SOB or other anginal
equivalents. No known correlation with Trazodone overdose.
Repeat EKG with resolution of inversion in V2, remaining T-waves
nonspecific. Further EKG were not clinically indicated.
# ANEMIA: The patient had a 9 pt Hct drop in the setting of
aggressive volume resuscitation. There was no evidence of
bleeding, chronic disease or infection/process to cause
hemolysis. Repeat HCTs revealed stable blood counts. Her trend
was 36.7 --> 27.4 --> 29.4 --> 28.4. Iron studies were
consistent with iron deficiency with a normal TIBS, low ferritin
and low-normal iron. She was started on iron therapy.
Medications on Admission:
Celexa 40 mg QD
Trazodone 50 mg QHS PRN (takes about two per month)
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Trazodone overdose, alcohol intoxication
Secondary: Depression, history of suicide attempt,
Iron-deficiency anemia.
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted after drinking alcohol and overdosing on
Trazodone. You were evaluated for toxic effects including
altered thinking or heart problems. Once stable, you were
transfered to the floor. You are now discharged to a
psychiatric facility for further recovery.
Please take all medication as prescribed.
Please seek medical assistance if you notice fevers, chills,
difficulty breathing, chest pain or any other symptom which is
concerning to you.
Followup Instructions:
To be followed in psychiatry facility until safe to discharge.
Upon discharge, follow-up should be scheduled with Dr. [**First Name4 (NamePattern1) 1399**]
[**Last Name (NamePattern1) 71206**] [**Telephone/Fax (1) 67474**] for outpatient primary care follow-up.
Completed by:[**2200-2-4**]
|
[
"794.31",
"E967.0",
"995.85",
"E968.8",
"280.9",
"969.0",
"311",
"458.29",
"305.00",
"305.1",
"V62.84",
"E950.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.68"
] |
icd9pcs
|
[
[
[]
]
] |
6858, 6873
|
3963, 6284
|
311, 318
|
7042, 7081
|
2678, 2678
|
7590, 7882
|
2100, 2236
|
6402, 6835
|
6894, 7021
|
6310, 6379
|
7105, 7567
|
2251, 2659
|
233, 273
|
346, 1564
|
2694, 3940
|
1586, 1598
|
1614, 2084
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,433
| 198,959
|
41537
|
Discharge summary
|
report
|
Admission Date: [**2129-4-24**] Discharge Date: [**2129-6-8**]
Date of Birth: [**2062-5-24**] Sex: F
Service: SURGERY
Allergies:
Nitrofurantoin / Yellow Dye / Iron / Calcium
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
[**2129-4-25**]: EUS
[**2129-4-25**]: EGD with duodenal stricture dilation. Biopsies taken
of pyloric ulcer. EUS performed with peri-gastric lymphnode
biopsy.
[**2129-5-5**]: Vagotomy and antrectomy with B2 reconstruction.
[**2129-5-7**]: Re-exploration with placement of lateral duodenostomy
tube and feeding jejunostomy tube.
[**2129-6-1**]: Successful CT-guided catheter drainage of liver abscess
History of Present Illness:
66 year-old woman with gastric outlet obstruction from a pyloric
ulcer and duodenal stricture status post dilitation by Dr.
[**First Name (STitle) **] [**Name (STitle) **] on [**4-13**], who was admitted to [**Hospital **] Hospital on
[**4-20**] with vomiting and abdominal pain as well as diarrhea for 2
days. Diarrhea was new. Stool was watery and profuse. Her
abdominal pain was mild and located in the upper abdomen. She
felt weak and had mild chills and diaphoresis.
At [**Hospital **] Hospital, her WBC is noted to be 18 on admit, which
came down to 9. KUB showed dilated stomach. Her symptoms
initially improved and diet was advanced to pureed diet, but
this triggered further nausea, abdominal cramps. She was
transferred to [**Hospital1 18**] further management.
She currently has mild crampy abdominal pain periumbilical and
lower abdomen, no epigastric symptoms. No nasuea currently, her
symptoms of cramping are post prandial, her nausea is
intermittent and not related to food intake. Her diarrhea which
was profuse and watery lasted only 24 hours on Wednesday and has
completely resolved. No bleeding. Mild fatigue. Chills lasted
for one day, and have resolved. Denies chest pain and shortness
of breath. Review of systems is otherwise negative.
Past Medical History:
PMH: chronic back pain, sciatica, HTN, PUD, adrenal adenoma,
uterine CA s/p hysterectomy
PSH: perforated cyst/appendix s/p SBR, appendectomy, cystectomy
as a teenager, s/p hysterectomy at age 29 for uterine cancer.
[**Last Name (un) 1724**]: lisinopril 20', PPI, vicodin, soma(muscle relaxant)
Social History:
Lives with husband. [**Name (NI) **] [**Name2 (NI) 1818**], half pack per day. Denies
alcohol use.
Family History:
Father with peptic ulcer disease
Physical Exam:
ADMISSION P/E:
VS: T 96.7 HR 80 BP 152/70 RR 16 O2 100% on RA
GEN: No acute distress
HEENT: Mucous membranes moist, oropharynx clear
NECK: Supple
CV: Regular rate and rhythm, no murmurs, rubs or gallops.
CHEST: Clear to auscultation bilaterally
ABD: Soft, mild periumbilical tenderness, no rebound or
guarding, normal bowel sounds present.
EXT: Warm and well perfused. No lower extremity edema.
SKIN: No rash
NEURO: Alert and oriented to person, place, and time. Moves all
four extremities, fluent speech, normal 5/5 strength upper and
lower extremities.
PSYCH: Calm, appropriate
DISCHARGE P/E:
Pertinent Results:
[**2129-4-20**] KUB
1. no bowel obstruction, free air or wall thickening
2. stomach is distended with both gas and fluid
[**2129-4-26**] KUB: No free air on supine radiographs.
CT ABDOMEN WITH CONTRAST [**2129-4-25**]:
1. Diffuse symmetric thickening of the gastric wall at the level
of the
pylorus, with few perigastric lymph nodes. These findings are
concerning for a gastric malignancy with local lymph nodal
disease.
2. No evidence of distant metastases in the abdomen and pelvis.
3. Multiple bilateral adrenal lesions, consistent with adenomas.
GASTRIC ULCER BIOPSY: [**2129-4-25**]
1. Antral/pyloric-type mucosa with extensive ulceration,
granulation tissue formation, acute and chronic inflammation and
focal reactive epithelial changes.
2. No dysplasia is identified.
Note: Immunostain for H. pylori is in progress; results will be
reported in an addendum. Case reviewed by Dr. [**Last Name (STitle) **]. [**Doctor Last Name **], who
concurs.
3. Immunostain is negative for H. pylori, with satisfactory
controls.
LYMPH NODE BIOPSY: [**2129-4-25**]
CYTOLOGY INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.
[**2129-5-14**] ABD CT:
IMPRESSION:
1. Large inflammatory phlegmon involving the transverse
mesocolon extending up to the right subhepatic space where it is
continuous with a small air and fluid collection adjacent to the
gallbladder. Given its location, this would be extremely
difficult to access percutaneously. However, there may be a
small access window posterolaterally on the right. Also of note,
there is very little fluid within this inflammatory phlegmon,
though a very large percutaneous drain would be required to
drain it.
2. Stable left adrenal nodule which remains indeterminate.
3. Enlarged mesenteric lymph nodes are likely reactive.
4. Bilateral pleural effusions are moderate.
[**2129-5-23**] ABD CT:
IMPRESSION:
1. Slight decrease in size of fluid collections along segment IV
of the liver as well as the peri-pancreatic collections.
2. Unchanged size and appearance of collection in the transverse
mesocolon.
3. Narrowing of the SMV as it crosses the duodenum and T-tube
without venous thrombus, increased from the prior study.
4. Stable left adrenal nodule which remains indeterminate.
5. Decreased size of bilateral pleural effusions and associated
compressive atelectasis.
[**2129-5-31**] ABD CT:
IMPRESSION:
1. Large liver abscess, new compared with prior. There is
associated
periportal edema and gallbladder wall edema related to systemic
inflammation.
2. T-tube remains in place within the duodenal stump with near
complete
resolution of previously described fluid collection. There is a
moderate
amount of free fluid within the pelvis.
[**2129-6-6**] CARDIAC ECHO:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No 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. Moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
MICRO:
[**2129-5-31**] 12:50 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-picc.
BLOOD/FUNGAL CULTURE (Preliminary):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR FUNGUS.
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
320-4294G
[**2129-5-31**].
ENTEROCOCCUS FAECIUM.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 90343**]
[**2129-5-31**].
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
320-4294G
[**2129-5-31**].
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 3:05PM
[**2129-6-3**].
FINAL SENSITIVITIES.
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.
Daptomycin Susceptibility testing requested by DR. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Daptomycin AND LINEZOLID SUSCEPTIBILITY TESTING
REQUESTED BY DR.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
BLOOD/AFB CULTURE (Final [**2129-6-1**]):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR AFB.
Myco-F Bottle Gram Stain (Final [**2129-6-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM NEGATIVE ROD(S).
[**2129-5-31**] 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
THIS IS A CORRECTED REPORT [**2129-6-4**] 1825.
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 90344**] #[**Numeric Identifier 90345**] @1820.
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
320-4294G
[**2129-5-31**].
ENTEROCOCCUS SP..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
320-4294G
[**2129-5-31**].
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.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. PREVIOUSLY REPORTED AS ([**2129-6-4**] @1442).
BACTRIM (=SEPTRA=SULFA X TRIMETH) sensitivity testing
performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. BACTRIM (=SEPTRA=SULFA X TRIMETH) =
Intermediate.
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.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. PREVIOUSLY REPORTED AS ([**2129-6-4**] @1442).
BACTRIM (=SEPTRA=SULFA X TRIMETH) sensitivity testing
confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. BACTRIM (=SEPTRA=SULFA X TRIMETH) =
Resistant.
CLOSTRIDIUM SPECIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROBACTER CLOACAE
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R 32 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- I =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2129-6-1**]):
THIS IS A CORRECTED REPORT 12:50PM [**2129-6-3**].
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 12:18
[**2129-6-3**].
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM POSITIVE ROD(S) CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
PREVIOUSLY REPORTED WITHOUT GRAM POSITIVE ROD(S) [**2129-6-1**].
Aerobic Bottle Gram Stain (Final [**2129-6-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM NEGATIVE ROD(S).
[**2129-6-1**] 1:15 am ABSCESS Source: CT perc drained liver
abscess.
GRAM STAIN (Final [**2129-6-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2129-6-4**]):
ENTEROBACTER CLOACAE. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
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.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2129-6-5**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2129-6-4**] 7:10 am BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending):
[**2129-6-4**] 1:39 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2129-6-5**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-6-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
The patient is a 66 year-old woman with gastric outlet
obstruction from pyloric ulcer and duodenal stricturing s/p
duodenal balloon dilation on [**2129-4-13**] and [**2129-4-25**] without
improvement in symptoms. Patient could not tolerate POs without
increase in nausea, vomiting, and abdominal pain. Transferred
to surgery service on [**2129-5-1**] to prepare for gastrojejunostomy.
On [**2129-5-5**], the patient underwent vagotomy and antrectomy with
B2 reconstruction, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
NPO with NGT, on IV fluids and antibiotics, with a foley
catheter, and epidural catheter for pain control. The patient
was hemodynamically stable. On [**2129-5-7**], (POD2), the patient's
drain output turned bilious and she developed peritonitis on
exam, concerning for duodenal stump leak. The patient was
brought back to OR, and underwent re-exploration with placement
of lateral duodenostomy tube and feeding jejunostomy tube. Post
operatively in the PACU, the patient was tachycardic and was
given IV Metoprolol 5mg x 2 with good effect. The patient's
epidural was adjusted by APS. When stable, the patient was
transferred on the floor in satisfactory condition. The
patient's recovery course was complicated by prolonged diarrhea
[**3-16**] tube feeding despite multiple changes of feed, abdominal
cramps relieved by hyoscyamine, liver abscess and
bacteremia/sepsis.
Neuro: The patient has a history of chronic back and abdominal
pain, she is on Vicodin and Soma at home prior admission. Post
operatively, the patient received Bupivacaine/Hydromorphone via
epidural catheter for pain control. The epidural was split on
POD # 1 [**3-16**] hypotension/tachycardia on Bupivacaine via epidural
and Dilaudid PCA. The pain was adequately controlled. The
patient was started on Toradol after second operation for better
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications regiment. The patient's
pain was not adequately controlled on home medications regiment
and Vicodin was changed to Dilaudid PO. The patient was
restarted on Soma, Hyoscyamine was added to help with abdominal
cramps. Currently the patient's pain is adequately controlled.
CV: The patient was tachycardic and hypertensive
postoperatively, her symptoms were treated with IV Metoprolol
and her epidural was splitted. The patient's heart rate was
monitored with telemetry device. Telemetry was discontinued on
[**2129-5-10**] and the patient remained stable from a cardiovascular
standpoint. On [**2129-5-31**], the patient was found hypotensive with
SBP 30-70s, the patient was transferred into the ICU. She was
intubated and she was required levothed to control her BP. This
episode of hypotension was [**3-16**] bacteremia/sepsis, BP improved on
[**6-1**]. Pressors were discontinued and the patient was extubated.
The patient was transferred back on the floor in stable
position. Vital signs were checked regularly and were stable.
Cardiac echo was done on [**6-6**] to rule out endocarditis. Echo
revealed normal LVEF > 55% and was grossly normal. The patient
will continue on Lisinopril and Metoprolol to control her BP and
HR.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization. On [**5-31**] the patient
received large amount of fluid [**3-16**] hypotension, she developed
SOB and wheezing and was intubated in the ICU. The patient was
extubated on [**6-1**] without difficulties. Chest x-ray revealed
bilateral small pleural effusions. The patient remained stable
from pulmonary standpoint.
GI: On [**4-30**] the patient underwent PICC line placement and TPN
was started. The patient was continued on TPN until [**2129-5-22**]. The
patient was started on trophic tube feed (Fibersource) on
[**2129-5-12**]. The patient developed severe abdominal cramps and TF
was held. The TF was restarted on [**5-13**] and was advanced to 60
cc/hr. TF was held again [**3-16**] severe abdominal cramps and
diarrhea. The patient's TF was on and off, and on [**2129-5-17**] TF was
changed to Vivonex. The patient continued to have significant
diarrhea and abdominal cramps. She was started on Reglan and
Hyoscyamine, TF was changed to Isosource on [**2129-5-25**]. The
patient's diarrhea and abdominal cramps decreased. Nutritional
service was consulted with goal to educate patient about post
partial gastrectomy diet. The patient was started on clear
liquids on [**2129-5-24**] and her diet was advanced to regular post
gastrectomy diet on [**2129-5-29**]. The TF was discontinued on [**2129-5-31**],
the patient currently tolerating regular diet. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's was afebrile with normal WBC on admission, her
urine cultures were negative. On [**2129-5-7**], the patient was taken
back in OR to fix her duodenal stump leak, postoperatively the
patient was started on IV Flagyl and Cipro as empirical
treatment for possible peritonitis. The abx was changed on
[**2129-5-14**] to Vancomycin/Zosyn. On [**2129-5-13**] WBC went up to 26 and
Fluconazole was started. The patient completed course of
Vanco/Zosyn/Fluconazole and all abx were discontinued on
[**2129-5-23**]. The patient's WBC was 12 on [**2129-5-23**] and continued to
downward. On [**2129-5-25**], the patient's stool was checked for c-diff
[**3-16**] diarrhea and was negative for c-diff. On [**2129-5-31**], the
patient WBC went up to 36.2, she was found hypotensive with SOB.
PICC line was removed and cultured, blood cultures were sent for
microbiology as well. The patient was transferred into ICU,
abdominal CT revealed large liver abscess. The patient underwent
IR guided drainage of the abscess and JP drain placement on
[**2129-6-1**]. The patient's blood and abscess cultures came back
positive for multiple organisms including VRE and MRSA.
Infectious Diseases was called for consult and patient was
started on Meropenem/Linezolid IV per ID recs. The patient's WBC
reached 48.4 and started to downward. The antibiotics regiment
was changed prior discharge to Ertapenem and Daptomycin per ID
recs. The patient remains afebrile. She will continue on IV abx
until her follow up with ID on [**2129-6-23**].
Wound care: The patient's midline incision healed well and
currently open to air. The patient's D-tube started to leak
around the tube on [**2129-5-10**], ostomy/wound nurse was called for
consult. The patient's D-tube was connected to ostomy appliance.
Currently, D-tube continued to have minimal leak around the
tube, the tube is capped and attached to small ostomy pouch. JP
drain located in the liver bed and it's to bulb suction, site is
clear/dry and intact. Drains should remain as is, while at rehab
and will be reevaluated in follow up.
Endocrine: The patient's blood sugar was monitored throughout
his stay; no insulin administration was required.
Hematology: The patient has baseline anemia with HCT 30s on
admission. The patient's HCT was stable between 23-28
postoperatively. On [**6-1**], the patient was found to have HCT
21.2, she received 3 units of RBC total. Post transfusion HCT
was 28.8. The patient's HCT remained stable until discharge no
more transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible with PT. At the time of
discharge in Rehab, the patient was doing well, afebrile with
stable vital signs. The patient was tolerating a regular diet,
ambulating with assist, voiding without assistance, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Prilosec 40mg po
Lisinopril 20mg po daily
Vicodin
Premarin 1.25mg
Soma 350 tid
Discharge Medications:
1. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: [**2-13**]
Tablet, Chewables PO QID (4 times a day) as needed for
heartburn.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO DAILY (Daily).
Disp:*30 Capsule,Extended Release 12 hr(s)* Refills:*2*
6. 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*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
9. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth yeast.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
13. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Hold if constipated.
15. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln
Injection Q24hr (): Give until follow up with ID on [**2129-6-23**].
16. Daptomycin 300 mg IV Q24H
17. 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.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care- [**Location (un) 1121**]
Discharge Diagnosis:
1. Gastric outlet obstruction
2. Peptic ulcer disease.
3. Duodenal stump leak
4. Tachycadria
5. Liver abscess
6. Sepsis
7. Chronic pain
8. Anemia of chronic disease
9. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid.
Discharge Instructions:
You were admitted to the pancreatobiliary surgery service for an
antrectomy, vagotomy and Bilroth II reconstruction for gastric
outlet obstruction. This was complicated by a duodenal stump
leak requiring exploratory laparotomy, repair, placement of a
duodenostomy tube, liver abscess requiring percutaneous drain
placement, and bacteremia
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
Duodenostomy Drain Care:
*Please look at the drain site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warmth, and fever).
*Keep drain open into the pouch. The pouch needs to be changed
every 3 days, [**Location (un) 269**] nurses will assist you with changes.
*Record the color, consistency, and amount of fluid from around
the drain. Call the surgeon, nurse practitioner, or [**Location (un) 269**] nurse
if the amount increases significantly or changes in character.
*Change the pouch system Q72H or PRN.
*You may shower and wash the drain site gently with warm, soapy
water. You may also wash with half strength hydrogen peroxide
followed by saline rinse.
*Keep the insertion site clean and dry otherwise. Place a drain
sponge for cleanliness.
*Avoid swimming, baths, and hot tubs. Do not submerge yourself
in water.
*Attach the drain securely to your body to prevent pulling or
dislocation.
Jejunostomy Tube Care:
*Similar to drain care as above.
*Flush with 30cc sterile water every 8 hours.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Location (un) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Radiology: You scheduled for abdominal CT scan on [**2129-6-22**].
Please arrive in Radiology Department at 9 am for registration.
Please do not eat after midnight on [**2129-6-21**]. Radiology located:
[**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2129-6-22**]
12:45 [**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
.
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-6-23**] 1:50 Infectious [**Hospital 2228**] Clinic, [**Hospital Ward Name **] Bld,
[**Last Name (NamePattern1) 439**]
.
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-7-14**] 1:50
Completed by:[**2129-6-8**]
|
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"263.9",
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"997.4",
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icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93",
"38.91",
"46.39",
"99.15",
"40.11",
"38.97",
"43.7",
"44.00",
"00.14",
"46.85",
"96.6",
"96.04",
"96.71",
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
25284, 25389
|
15210, 21669
|
336, 739
|
25612, 25612
|
3169, 7266
|
29716, 30793
|
2497, 2531
|
23327, 25261
|
25410, 25591
|
23224, 23304
|
25778, 26119
|
26913, 29693
|
2546, 3150
|
9540, 14750
|
14783, 14857
|
14892, 15187
|
26151, 26898
|
264, 298
|
21681, 23198
|
767, 2043
|
25627, 25754
|
2065, 2364
|
2380, 2481
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,105
| 103,388
|
12201
|
Discharge summary
|
report
|
Admission Date: [**2110-5-11**] Discharge Date: [**2110-6-25**]
Date of Birth: [**2047-9-19**] Sex: M
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with a history of moderately differentiated squamous
cell lung cancer at the left upper lobe diagnosed in [**2107**].
He presented to [**Hospital1 **] [**Hospital1 **] on [**2110-4-23**] with
excessive fatigue and shortness of breath two weeks after
completing his chemotherapy and radiation therapy. The
patient at that time initially had deferred surgery. At the
time of admission to [**Hospital1 **] [**Hospital1 **] the patient denied any
fevers or chills, cough or sputum production, but noted
increasing weight loss. While at [**Hospital **] [**Hospital3 2063**]
the patient was found to have a small PE and was placed on
intravenous heparin. He underwent multiple bronchoscopy
procedures, which resulted in his being intubated afterwards.
He also was found to have a large abscess and multiple
secretions, which precluded extubation. He had low
platelets, which was thought to be secondary to his overall
medical condition. He was placed on multiple intravenous
antibiotics with minimal change in status. He was also noted
to have episodes of rapid atrial fibrillation, which were
controlled with AV nodal blockers. On [**2110-5-11**] the
patient was transferred to the [**Hospital1 188**] for a left pneumonectomy of the necrotic left lung.
He was transferred on a ventilator and continued on
intravenous heparin. He also developed hyperglycemia and was
controlled with NPH.
On [**2110-5-14**] the patient underwent surgery and had a left
extra pleural intrapericardial pneumonectomy, a pedicled
thoracic latissimus dorsi muscle flap, a pedicled omental
flap, a G tube placed, open tracheostomy tube placed, right
thoracoscopy tube placed and he also underwent a flexible
bronchoscopy with tracheal bronchial tree aspiration. Mr.
[**Known lastname **] postoperative course was complicated by
cardiovascularly the patient required pressors for a short
period of time. Pulmonary, the patient required continued
ventilation on AC, but later was switched over to pressure
support after a long period of trials. His renal issues were
stable. His ID issues, the patient was found to hve gram
negative rods on his sputum culture and he underwent multiple
antibiotic regimens. The organisms were found to be
sensitive to Bactrim and he received a fourteen day course
for that. Gastrointestinal, the patient received tube feeds
through his peg tube. Heme/onc wise the patient required
transfusions immediately postoperative. Endocrine wise, the
patient required an insulin sliding scale for his episodes of
hyperglycemia and neurologically the patient was
intermittently agitated, but was being sedated with Haldol,
Ativan and/or Morphine.
The main issue during Mr. [**Known lastname **] hospital stay was
difficulty weaning from his ventilator support. After
numerous trials of gradually decreasing his pressure support
and PEEP on his ventilator the patient still required
increasing amounts of ventilatory support. On chest x-ray he
was found to have a loculated pleural effusion on his right
side, which may have contributed to his weaning difficulties.
Overall, the patient remained in stable condition until the
afternoon of [**2110-6-24**] when the patient acutely
decompensated. The patient was noted to have decreased urine
output and a drop in his systolic blood pressure into the 70s
and 80s. He was unresponsive to fluid boluses. The patient
was started on neo-synephrine and Levophed drips to support
his blood pressure and he received several liters of normal
saline boluses.
At about 8:00 p.m. on [**6-25**] the patient began complaining of
abdominal and chest pain and found to have right upper
quadrant tenderness on examination. His [**Known lastname **] count was
found to be elevated at 23 and his hematocrit had fallen to
24.2. The patient was cultured and a left subclavian line
and left arterial line was placed and Ativan drip was added
for sedation and comfort. The patient also received 2 units
of packed red blood cells. He then received an emergent
abdominal CT scan with contrast, which showed bilateral
pleural effusions, a rightward shift in his mediastinum,
large pericardial effusion, slight thickening of the cecal
wall, dilated colon with fluid and small pockets of free air
in the peritoneum, large amount of ascites and anasarca and a
suggestion of a calculus cholecystitis given the appearance
of the gallbladder on CT scan. The patient was started on
broad spectrum antibiotics including Flagyl, Triazene and
Ampicillin. He had an emergent cardiac echocardiogram
performed which initially showed a small circumferential
pericardial effusion, but later on review revealed tamponade
physiology of both the right and left ventricles and a large
loculated anterior pericardial effusion with right atrial and
right ventricular compression.
The patient because of his falling blood pressure was started
on vasopressin and hydrocortisone and morphine drip was added
for sedation. The colorectal surgery attending who consulted
on the case felt that exploratory laparotomy would not
reverse his current situation and throughout the day of [**6-25**] the patient's condition continued to deteriorate. The
patient required wide open pressors. Both of his brothers
[**Name (NI) **] and [**Name (NI) 32342**] were contact[**Name (NI) **] regarding his condition and
decided to withdraw life support and provide comfort
measures, which was done. The patient expired at
approximately 3:23 p.m. on [**2110-6-25**].
DISCHARGE STATUS: The patient expired.
DISCHARGE DIAGNOSES:
1. Cardiac arrest.
2. Septic shock.
3. Respiratory failure.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2110-6-25**] 15:53
T: [**2110-6-30**] 08:53
JOB#: [**Job Number **]
|
[
"262",
"427.5",
"038.9",
"789.5",
"162.3",
"785.59",
"287.5",
"513.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"43.19",
"32.5",
"96.72",
"83.82",
"38.91",
"31.29",
"54.74",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
5744, 6077
|
173, 5723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,322
| 180,458
|
41511
|
Discharge summary
|
report
|
Admission Date: [**2127-3-3**] Discharge Date: [**2127-3-26**]
Date of Birth: [**2050-10-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
Total percutaneous repair of the aortic aneurysm with
endovascular aortic aneurysm repair, bilateral ultrasound
guidance for femoral access, bilateral catheters in aorta. Left
renal artery stent 6 x 20 Genesis
Exploratory laparotomy, splenic flexure, mobilization, extended
left hemicolectomy, proctectomy and gastrostomy tube placement
History of Present Illness:
This is a 76-year-old gentleman, with a 5.4-cm infrarenal
abdominal aortic aneurysm who was previously evaluated and
prepared to undergo treatment, who has severe problems with the
hips, in particular on the left, and was
about to undergo abdominal aortic aneurysm repair when it was
determined that because of contracture with the leg this would
not be a safe procedure and he was referred for possible
percutaneous treatment.
Past Medical History:
PMH: AAA, htn, ^lipids
PSH: R Fem-[**Doctor Last Name **] & SFA stent [**2-10**], L CEA, CABGx1, CCY, coronary
stentx3
Social History:
n/c
Family History:
n/c
Physical Exam:
Gen: NAD, AOx3
Neuro: CNII-XII intact. Pt unable to lift left arm but can
squeeze hand.
CVS: RRR, no m/r/g
Resp: CTAB
Abd: soft, NT/ND. Ostomy in place, intact. Wound: wet-to-dry
dressing
Ext: 1+ edema b/l, DP/PT dopplerable b/l
Pertinent Results:
[**2127-3-19**] 03:58AM BLOOD WBC-9.3 RBC-3.64* Hgb-9.7* Hct-29.5*
MCV-81* MCH-26.7* MCHC-33.0 RDW-20.1* Plt Ct-412
[**2127-3-20**] 03:56AM BLOOD WBC-11.3* RBC-3.66* Hgb-9.5* Hct-29.6*
MCV-81* MCH-26.0* MCHC-32.3 RDW-19.7* Plt Ct-353
[**2127-3-20**] 06:56PM BLOOD WBC-11.1* RBC-3.56* Hgb-9.4* Hct-29.1*
MCV-82 MCH-26.3* MCHC-32.2 RDW-19.8* Plt Ct-344
[**2127-3-21**] 05:33AM BLOOD WBC-8.2 RBC-3.33* Hgb-8.7* Hct-26.9*
MCV-81* MCH-26.2* MCHC-32.5 RDW-20.0* Plt Ct-323
[**2127-3-22**] 04:30AM BLOOD WBC-7.6 RBC-3.53* Hgb-9.3* Hct-28.7*
MCV-81* MCH-26.3* MCHC-32.3 RDW-19.2* Plt Ct-277
[**2127-3-24**] 04:00AM BLOOD WBC-6.6 RBC-3.65* Hgb-9.6* Hct-29.6*
MCV-81* MCH-26.3* MCHC-32.4 RDW-19.3* Plt Ct-254
[**2127-3-25**] 07:45AM BLOOD WBC-6.5 RBC-3.53* Hgb-9.3* Hct-28.3*
MCV-80* MCH-26.3* MCHC-32.8 RDW-19.1* Plt Ct-239
[**2127-3-19**] 03:58AM BLOOD PT-13.3 PTT-24.4 INR(PT)-1.1
[**2127-3-19**] 03:58AM BLOOD Plt Ct-412
[**2127-3-20**] 06:56PM BLOOD PT-13.6* PTT-24.3 INR(PT)-1.2*
[**2127-3-20**] 06:56PM BLOOD Plt Ct-344
[**2127-3-21**] 05:33AM BLOOD Plt Ct-323
[**2127-3-22**] 04:30AM BLOOD Plt Ct-277
[**2127-3-24**] 04:00AM BLOOD Plt Ct-254
[**2127-3-25**] 07:45AM BLOOD Plt Ct-239
[**2127-3-19**] 03:58AM BLOOD
[**2127-3-20**] 03:56AM BLOOD
[**2127-3-20**] 06:56PM BLOOD
[**2127-3-21**] 05:33AM BLOOD
[**2127-3-22**] 04:30AM BLOOD
[**2127-3-24**] 04:00AM BLOOD
[**2127-3-25**] 07:45AM BLOOD
[**2127-3-19**] 03:58AM BLOOD Glucose-144* UreaN-26* Creat-1.0 Na-143
K-3.8 Cl-107 HCO3-32 AnGap-8
[**2127-3-19**] 05:04PM BLOOD Glucose-122* UreaN-26* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-32 AnGap-9
[**2127-3-20**] 03:56AM BLOOD Glucose-148* UreaN-26* Creat-1.1 Na-143
K-3.7 Cl-105 HCO3-30 AnGap-12
[**2127-3-20**] 06:56PM BLOOD Glucose-142* UreaN-28* Creat-1.1 Na-147*
K-3.7 Cl-105 HCO3-32 AnGap-14
[**2127-3-21**] 05:33AM BLOOD Glucose-142* UreaN-31* Creat-1.0 Na-147*
K-3.8 Cl-107 HCO3-32 AnGap-12
[**2127-3-21**] 03:35PM BLOOD Glucose-138* UreaN-29* Creat-0.9 Na-145
K-3.9 Cl-106 HCO3-31 AnGap-12
[**2127-3-22**] 04:30AM BLOOD Glucose-137* UreaN-28* Creat-0.9 Na-142
K-3.8 Cl-103 HCO3-30 AnGap-13
[**2127-3-22**] 08:57PM BLOOD Glucose-120* UreaN-26* Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-31 AnGap-11
[**2127-3-23**] 04:00AM BLOOD Glucose-136* UreaN-26* Creat-0.8 Na-136
K-4.0 Cl-99 HCO3-30 AnGap-11
[**2127-3-24**] 04:00AM BLOOD Glucose-140* UreaN-23* Creat-0.8 Na-135
K-3.9 Cl-100 HCO3-29 AnGap-10
[**2127-3-25**] 07:45AM BLOOD Glucose-126* UreaN-23* Creat-0.8 Na-137
K-4.5 Cl-101 HCO3-27 AnGap-14
[**2127-3-18**] 05:38PM BLOOD Calcium-7.7* Phos-3.7 Mg-2.2
[**2127-3-19**] 03:58AM BLOOD Calcium-7.5* Phos-2.8 Mg-2.2
[**2127-3-19**] 05:04PM BLOOD Calcium-7.9* Phos-2.6* Mg-2.1
[**2127-3-20**] 03:56AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.2
[**2127-3-20**] 06:56PM BLOOD Calcium-7.9* Phos-2.9 Mg-2.4
[**2127-3-21**] 05:33AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.6
[**2127-3-21**] 03:35PM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3
[**2127-3-22**] 04:30AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.1
[**2127-3-22**] 08:57PM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1
[**2127-3-23**] 04:00AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
[**2127-3-24**] 04:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.1
[**2127-3-25**] 07:45AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2127-3-3**] to the Vascular Surgery
Service to undergo percutaneous endovascular repair of abdominal
aortic aneurysm. The patient tolerated the procedure well (the
reader is referred to the operative note for details) and was
brought to the PACU in stable conditions. In the PACU he
developed oliguria and hypotension and received boluses of IVF
with improvement of his renal output. He remained intubated in
the PACU overnight. Pt did c/o left abdominal pain. A surgery
consult was obtained. This was thought top be secondary to
mesenteric ischemia. Pt taken to the OR, See GI section below.
Also see review of systems as below for rest of hospital course.
Neuro: the patient was sedated on propofol while intubated.
Dilaudid and were administered for pain control with good
results. Whn patient woke up it was noticed that he had LUE and
LLE weakness. Neurology was consulted. Head CT was negtive. They
recommended a MRI of the head, but given his respiratory status
and inability not to lie down this was deferred. Neurology did
not think this was an acute or subacute, Thougt to chronic in
nature. Pt weakness is still there but much improved.
CVS:Pt complaining of chest pain on HD2, rising troponins and
EKG changes (ST depression). Dr. [**Last Name (STitle) **] (Cardiology) consulted,
recommended echo and Swan-Ganz to better evaluate volume status.
Started on ASA, plavix, beta-blocker, statin. Echo performed on
HD2 showed mild regional left ventricular dysfunction c/w CAD.
Cadiology decided to get a cardiac cath. Patent LIMA to LAD with
non critical coronary artery disease apart from an occluded OM2,
there recommendation was medical therapy. On DC pt has not
complained of any more chest pain
Resp: intubated HD1, kept intubated for prolong period of time,
Untill bowel deficits resolved. Pt eventualy weaned from
Ventilator on HD 10. On Dc o2 sats are stable, not requiring 02
at this time.
GI: Abdominal pain on HD2, General Surgery consulted, lactate
trended. On HD3 the patient underwent exploratory laparotomy,
extended left hemicolectomy with colostomy, proctectomy and
gastrostomy tube placement for mesenteric ischemia. Abd wound
left open, (fascia closed) VAC placed. Pt was kept NPO. Trophic
tube feeds were started on HD3. Pt fascia was closed. Pt has had
a problem with his J tube. Pt eventually taken down to IR, this
was replaced with new J tube. Tolerating tube feeds on DC.
GU/FEN: a foley was placed at the time of surgery for UOP
monitoring, patient's intake and output were closely monitored,
and volume was repleted when necessary. CVVH x1 and lasix
administered while in the ICU, goal 1L negative. The ARF was
thought to be secondary to caontrast load and having a
hypovolemic state. His high creatinine was 1.7, on DC 0.6. Pt
did have urinary retention. Flomax was started. On DC pt still
has foley. When stable please DC foley.
Heme: Received PRBCx1 on HD2 (Hct 27) and 3 additional units
intraoperatively during exploratory laparotomy. Heperin was
stopped, pt did have low platelets, the embolic event was
considered for HIT, placed on bivalrudin on HD3. HIT panel was
negative, Platelets recovered. Pt now stable on SQ heperin.
Endo: patient was on an ISS then transitioned to an insulin drip
for better glycemic control. BS are stable on DC
ID: on cipro/flagyl for abdominal surgery. WBC and fever curves
were closely followed. WBC peaked at 19 on HD3. Blood Cx on HD3
showed GPC, vancomycin started on HD3. Abx regimen changed to
Vanc/[**Last Name (un) **]/FLuc/Mica on HD4. IV antibiotics were continued. The
regime was changed multiple times. ID was following the patient.
Eventually the patients IV antibiotics were stopped. Pt has been
afebrile since. To note pt was on antibiotics was mostly for the
esenteric ischemia.
Prophylaxis: received sqh and boots for DVT prophylaxis.
Received H2 blockers for stress ulcer prophylaxis.
Medications on Admission:
amlodipine 5', metformin 500', allopurinol 300', simvastatin
60', metoprolol succinate 100', benicar/hctz 40/25', plavix 75',
quinapril 20'', asas 325'
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-2**]
Puffs Inhalation Q6H (every 6 hours) as needed for .
14. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for .
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for pulm congestion.
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for pulm congestion.
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain: please wean for pain.
Disp:*1 Adhesive Patch, Medicated(s)* Refills:*1*
19. Insulin
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 3 Units
160-199 mg/dL 6 Units
200-239 mg/dL 9 Units
240-279 mg/dL 12 Units
> 280 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
Cherry [**Doctor Last Name **] Manor
Discharge Diagnosis:
AAA
Mesenteric ischemia
Urinary retention, need foley replace
Left sided weakness, not associated with acute or subacute
stroke. Needs MRI of brain when stable
ARF creatinine normalized, thought to secondary to contrast
nephrology
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:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? If instructed, take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-6**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**5-7**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-4-11**] 10:00.
Please call to confirm location
[**Doctor First Name **], [**Location (un) 442**], Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-4-11**] 10:45
[**Doctor First Name **], [**Location (un) 436**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-4-3**] 1:40
Completed by:[**2127-3-26**]
|
[
"441.4",
"250.00",
"349.82",
"557.0",
"410.71",
"278.01",
"584.9",
"287.5",
"V45.81",
"414.01",
"788.5",
"276.52",
"E947.8",
"414.2",
"401.9",
"V85.37",
"458.29",
"041.19",
"790.7",
"728.89",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.10",
"44.39",
"45.75",
"97.03",
"88.56",
"00.40",
"48.69",
"00.45",
"88.47",
"96.6",
"39.71",
"39.50",
"39.90",
"96.72",
"37.22",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10955, 11018
|
4801, 8730
|
331, 671
|
11293, 11293
|
1578, 4778
|
14066, 14641
|
1309, 1314
|
8932, 10932
|
11039, 11272
|
8756, 8909
|
11469, 13486
|
13512, 14043
|
1329, 1559
|
264, 293
|
699, 1128
|
11308, 11445
|
1150, 1272
|
1288, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,444
| 122,139
|
15069
|
Discharge summary
|
report
|
Admission Date: [**2131-12-5**] Discharge Date: [**2131-12-6**]
Date of Birth: [**2094-12-7**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Polymyxin B
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Intoxication
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 37-year-old woman with a PMHx of Non-[**First Name3 (LF) **]'s
lymphoma (tx [**2110**]), anorexia, and several MRSA sinus infections
who reportedly drove herself to the dermatologist this morning,
and then was found to be unresponsive in the office. Her
husband spoke to her around noon and said she sounded sober and
normal; he was called by the dermatologist around 2pm and told
to come immediately. When he arrived, she was not responsive.
EMS was called and bagged the patient in the field. FS at that
time was 112. She was reportedly given narcan en route without
significant response (although not documented).
.
In the ED, initial vs were: P 87 BP 107/72 R 20 O2 sat. 100%
NRB. On arrival, she had a GCS of 3; intubation was attempted
without meds and the patient had a gag reflex. She was
subsequently intubated with medications. Labs showed a normal
CBC and lytes, serum EtOH level of 458, lactate 3.4, AST 273,
ALT 173, LHD 282, urine amphetamines pos and ABG of
7.43/37/528/25 on FiO2 100%. Patient was started on a propofol
drip and given 5 L of normal saline. Urinalysis was neg, CXR and
NCHCT were unremarkable. Vitals on transfer were: 97.3 92
107/79 20 100%.
.
Per the patient's husband, she has been suffering from a
longstanding MRSA sinus infection and has been seeing an ID
specialist, Dr. [**Last Name (STitle) **] in [**Location (un) **]. She has had fevers to
101-102 daily for approximately 6 months and had several
different courses of antibiotics. She also has a history of
binge alcohol drinking, but according to her husband has been
sober for many years. She has depression as well, but has
reportedly seemed in better spirits lately.
Past Medical History:
-Hx Anorexia -- purging type
-Non-[**Location (un) **]'s lymphoma in the early [**2110**]'s; she was treated
with CHOP x three cycles and XRT. She has had no further
evidence of lymphoma
-hx several MRSA abscesses, and chronic MRSA nasal infection for
several months
-S/p breast augmentation
-S/p bilateral buttock implants
Social History:
Lives with husband. [**Name (NI) **] husband, hx of EtOH abuse but no recent
EtOH use. No illicits or tobacco.
Family History:
Her maternal grandmother had non-[**Name (NI) **]??????s lymphoma. Her mother
is alive but she has obesity, an eating disorder, and arthritis.
Her father is alive and well.
Physical Exam:
Initial exam:
Vitals: T: 97.4 BP:109/41 P:89 R: 18 O2:
General: intubated and sedated, not responding to verbal or
painful stimuli
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2131-12-5**] 06:24PM TYPE-ART RATES-/18 TIDAL VOL-450 O2-100
PO2-528* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1 AADO2-161 REQ
O2-36 -ASSIST/CON INTUBATED-INTUBATED
[**2131-12-5**] 05:57PM GLUCOSE-102 LACTATE-3.4* NA+-148 K+-4.0
CL--98* TCO2-29
[**2131-12-5**] 05:57PM HGB-14.5 calcHCT-44
[**2131-12-5**] 05:57PM freeCa-1.01*
[**2131-12-5**] 05:40PM GLUCOSE-99 UREA N-14 CREAT-0.7 SODIUM-142
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-18
[**2131-12-5**] 05:40PM ALT(SGPT)-173* AST(SGOT)-273* LD(LDH)-282*
ALK PHOS-88 TOT BILI-0.5
[**2131-12-5**] 05:40PM LIPASE-48
[**2131-12-5**] 05:40PM ALBUMIN-4.7 CALCIUM-8.9 PHOSPHATE-3.8
MAGNESIUM-2.4
[**2131-12-5**] 05:40PM ASA-NEG ETHANOL-484* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-12-5**] 05:40PM URINE UCG-NEGATIVE
[**2131-12-5**] 05:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
CXR [**2131-12-5**]:
Appropriate position of ET and NG tubes. Otherwise, unremarkable
appearance of the chest.
Brief Hospital Course:
Assessment and Plan: The patient is a 36-year-old woman with
PMHx of anorexia and NHL in remission who was found to be
unresponsive, likely secondary to EtOH intoxication.
.
# UNRESPONSIVENESS/INTOXICATION: Patient admits to drinking
large amount of vodka in her car yesterday, prior to her
dermatologist appointment. Ms. [**Known lastname **] says that she hardly ever
drinks, but the holidays are hard for her. She was very anxious
about going to her parents' house for [**Holiday **]. Patient was
initially intubated in the ED for airway protection, but was
easily extubated overnight in the ICU. She was given a "banana
bag" and put on a CIWA scale after extubation but did not score.
She was seen by social work and psychiatry, who felt she was
safe for discharge. She was given information regarding
follow-up with [**Hospital1 882**] outpatient Psychiatry evening program
and also given contact information to consider establishing care
with a new psychiatrist or therapist (Dr. [**Last Name (STitle) 44020**]/[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1655**]).
.
# MRSA INFECTIONS: Unclear history from husband and [**Name (NI) **] notes.
Patient was put on MRSA precautions. She remained afebrile
throughout her stay and resumed her home medications.
.
# DEPRESSION/ADD: Patient on Prozac and Adderall. She was seen
by social work and psychiatry as above and referred for
outpatient psych follow-up.
Medications on Admission:
-PCN VK 500 mg TID (script dated [**9-26**])
-Prednisone 10 mg daily (dated [**11-29**])
-Adderal ([**Last Name (un) 5487**] dose - in pillbox)
-Zyrtec
-Calcium
-Clonidine (unkown dose - in pillbox), per husband used to help
her sleep
-Prozac (per husband, not labeled in pt's container of meds)
-"acid blocker" labeled on one pillbox
Discharge Medications:
1. Zyrtec Oral
2. Adderall Oral
3. Calcium 500 Oral
4. clonidine Oral
5. Prozac Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Respiratory Failure; Intubation for airway
protection in setting of binge drinking
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the ICU after you drank too much alcohol
and had to be placed on a breathing machine because you were not
breathing on your own. We discussed the dangers of excessive
alcohol use and binge drinking with you and you were seen by
both our social workers and our psychiatry team. Follow-up was
arranged as below.
We did not make any changes to your medications.
Please refrain from alcohol and drug use as this is dangerous to
your health.
Followup Instructions:
Please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 8324**] to book a follow up appointment for your
hospitalization within 1 week.
You have been referred to [**Hospital1 882**] Intensive Outpatient Evening
program. PLease call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next week to follow up at [**Telephone/Fax (1) 44021**].
You may also call the office of Dr. [**Last Name (STitle) 44020**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1655**]
if you would like a new psychiatrist. Please call [**Telephone/Fax (1) 44022**]
if you would like to establish care with these providers.
|
[
"202.80",
"314.00",
"311",
"303.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6276, 6282
|
4337, 5776
|
296, 303
|
6428, 6463
|
3287, 4314
|
6972, 7718
|
2511, 2687
|
6161, 6253
|
6303, 6303
|
5802, 6138
|
6487, 6949
|
2702, 3268
|
244, 258
|
331, 2017
|
6322, 6407
|
2039, 2365
|
2381, 2495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,327
| 119,001
|
26245
|
Discharge summary
|
report
|
Admission Date: [**2147-7-13**] Discharge Date: [**2147-7-17**]
Date of Birth: [**2078-11-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2147-7-13**] coronary artery bypass times four (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to PDA)
History of Present Illness:
Mr. [**Known lastname 31823**] is a 68 year old gentleman with known coronary
artery disease s/p RCA stenting with a recent
abnormalsurveillance stress test, referred for cardiac
catheterization and found to have four vessel coronary artery
disease. Therefore, he was referred for surgical
revascularization.
Past Medical History:
Coronary artery disease, s/p RCA stenting
Hypertension
Hyperlipidemia
Hx of prior MI [**52**] years ago
Moderate carotid artery disease
Sleep apnea s/p soft palate surgery (does not use CPAP)
Remote Hernia repair
Bilateral shoulder surgeries (right x 2, left x 1) - now with
chronic right shoulder pain
Social History:
Mr. [**Known lastname 31823**] is a retired line man for a phone company. He lives
with his wife who has MS and poor short term memory. He smoked
as a teenager for a few years. He reports drinking one beer per
week.
Family History:
Mr. [**Known lastname 31823**] had a father who had a myocardial infarction at age
46. He died from congestive heart failure at age 72. His
brother [**Known lastname 1834**] a coronary artery bypass grafting at age 61.
Physical Exam:
Pulse:51 Resp:14 O2 sat: 97%RA
B/P Right:135/71 Left: 127/71
Height:5'8" Weight:202 LBS
General:Alert & oriented
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X], reduced vision on left eye
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur, No murmur, rubs or Gallops
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
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:
[**2147-7-16**] 06:50AM BLOOD WBC-5.3 RBC-2.73* Hgb-8.9* Hct-26.5*
MCV-97 MCH-32.7* MCHC-33.6 RDW-12.8 Plt Ct-146*
[**2147-7-16**] 06:50AM BLOOD Glucose-109* UreaN-24* Creat-0.9 Na-137
K-4.8 Cl-102 HCO3-30 AnGap-10
[**2147-7-15**] 07:00AM BLOOD Mg-2.2
Cardiology Report C.CATH Study Date of [**2147-6-19**]
BRIEF HISTORY: 68 yo male with history of MI [**52**] years ago,
hypertension, hypercholesterolemia, prior RCA stent at OSH,
repeat cath
with evidence of total occlusion of the proximal RCA treated
with
rotational atherectomy, 2.5 X 28 mm Cypher and two 2.5 X 18
mm Minivision stents in the proximal-mid RCA, 20% LM, 40-50% mid
LAD,
40% ostial LCx, who presents with positive Lexi-MIBI (reversible
defects
in the anterolateral, anteroapical, inferoapical, and
posterolateral
territories, EF 66%). He is asymptomatic for any chest pain or
shortness
of breath.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, prior PCI to RCA, positive Lexi-MIBI.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 4 French angled pigtail catheter,
advanced
to the left ventricle through a 4 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 4
French JL4 and a 4 French JR4 catheter, with manual contrast
injections.
Left Ventriculography: was performed in the 30 degrees [**Doctor Last Name **]
projection,
using 36 ml of contrast injected at 12 ml/sec, through the
angled
pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV end diastolic volume index (nl 50-90 ml/m2). 100
LV end systolic volume index (nl 15-30 ml/m2). 40
LV stroke volume index (nl 35-75 ml/m2). 60
LV ejection fraction (nl 50%-80%). 60
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - normal
2. Antero lateral - normal
3. Apical - normal
4. Inferior - normal
5. Postero basal - normal
Other findings:
Mitral valve was normal.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 45 minutes.
Arterial time = 27 minutes.
Fluoro time = 6.80 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 91 ml
Premedications:
ASA 325 MG mg P.O.
Fentanyl 50 mcg iv
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin [**2138**] units IV
Other medication:
Nitroglycerine bolus 600 mcg ic
Adenosine bolus 150 mcg ic
Complications:
Prolonged chest pain
Cardiac Cath Supplies Used:
.035IN [**Company **], MAGIC TORQUE 180CM
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
4FR CORDIS, MULTIPACK
COMMENTS: 1. Coronary angiography in this right dominant
system
revealed three vessel coronary artery disease. The LMCA had a
30%
stenosis. The LAD had a 60-70% origin stenosis and a distal 70%
stenosis. The LCx had a 70% proximal stenosis. The RCA was
occluded
proximally and filled via collaterals.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with LVEDP of 18 mmHg. There was mild arterial
systolic hypertension with SBP of 148 mmHg and DBP of 70 mmHg.
3. Left ventriculography revealed no mitral regurgitation. The
LVEF was
calculated to be 60% with no wall motion abnormalities.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal left ventricular systolic function.
3. Mild left ventricular diastolic dysfunction.
4. CABG consult recommended.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 65013**] (Complete)
Done [**2147-7-13**] at 10:05:30 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2078-11-29**]
Age (years): 68 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
Hypertension. Mitral valve disease. Pulmonary hypertension.
ICD-9 Codes: 786.51, 440.0, 424.0
Test Information
Date/Time: [**2147-7-13**] at 10:05 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA or RAA. A catheter or pacing
wire is seen in the RA and extending into the RV. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Calcified tips of papillary
muscles. No MS. Mild to moderate ([**2-3**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage.
3. No atrial septal defect is seen by 2D or color Doppler.
4. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 50%).
5. Right ventricular chamber size and free wall motion are
normal.
6. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-3**]+) mitral regurgitation is seen. The MR was 1+ at a
systolic pressure of 100 mmHg and 2+ at a systolic blood
pressure of 150 mmHg. Vena contracta = .48 cm.
9. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of 0.5 mcg/kg/min patient was weaned off
CPB. The mitral regurgitation was improved to trace-mild. There
were no regional wall motion abnormailities that could be
identified. The EF was approximately 50-55%. The aorta was
examined for evidence of dissectiuon, but none was identified.
Brief Hospital Course:
On [**2147-7-13**] Mr. [**Known lastname 31823**] [**Last Name (Titles) 1834**] a coronary artery bypass
grafting times four (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA). Please see the operative note for details. This
procedure was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. He tolerated
this procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. He was extubated
and weaned from his pressors. By the following day he was
transferred to the surgical step down floor. His chest tubes
were removed and his beta blockade was titrated up as tolerated.
His epicardial wires were removed and he was gently diuresed
toward his pre-operative weight. Post-operative course was
uneventful. The physical therapy service was consulted for
assistance with post-operative strength and mobility. By the
time of discharge on POD 4, the patient was ambulating freely,
the wound was healing and pain was controlled with oral
analgesics. He was discharged to home with VNA services in good
condition with appropriate follow-up instructions.
Medications on Admission:
Trazodone 50mg daily every evening
Atenolol 25mg one tablet daily every evening
Niaspan 500mg daily every evening
Atacand 16mg one tablet daily every evening
Norvasc 5mg daily every evening
Prevacid 30mg daily every evening
Crestor 20mg one and a half tablets daily every evening
*Plavix 75mg daily every evening
Tricor 145mg daily every evening
Ambien 6.25mg daily every evening
Aspirin 325mg daily every evening
Vitamin C, MVI, Calcium
Fish oil 2 every morning
Discharge Medications:
1. Trazodone 50 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
2. Rosuvastatin 20 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*180 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (NamePattern1) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Niacin 500 mg Capsule, Sustained Release [**Last Name (NamePattern1) **]: One (1)
Capsule, Sustained Release PO daily ().
Disp:*90 Capsule, Sustained Release(s)* Refills:*0*
6. Menthol-Cetylpyridinium 3 mg Lozenge [**Last Name (NamePattern1) **]: One (1) Lozenge
Mucous membrane Q2H (every 2 hours) as needed for pain.
Disp:*30 Lozenge(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet [**Last Name (NamePattern1) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*90 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
9. Fenofibrate Micronized 145 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
daily ().
Disp:*90 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Last Name (STitle) **]: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Atenolol 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] (cardiac surgeon) in 4 weeks ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65014**] (PCP) in [**2-3**] weeks ([**Telephone/Fax (1) 65015**]) please call
for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 65016**] (cardiologist) in [**3-7**] weeks please
call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2147-7-17**]
|
[
"272.4",
"719.41",
"412",
"401.9",
"447.9",
"458.29",
"780.57",
"V45.82",
"414.01",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.14",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
14242, 14300
|
10688, 11823
|
285, 387
|
14368, 14375
|
2258, 3129
|
14886, 15472
|
1307, 1530
|
12337, 14219
|
14321, 14347
|
11849, 12314
|
5822, 8906
|
14399, 14863
|
8955, 10665
|
1545, 2239
|
4466, 5805
|
3162, 4447
|
233, 247
|
415, 727
|
749, 1054
|
1070, 1291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,656
| 165,911
|
8591
|
Discharge summary
|
report
|
Admission Date: [**2163-9-6**] Discharge Date: [**2163-9-17**]
Date of Birth: [**2111-7-17**] Sex: M
Service: [**Last Name (un) **]
HISTORY: Patient is a 52 year old African-American male with
end-stage renal disease secondary to longstanding diabetes
type 2. His last hemodialysis was done on [**2163-9-5**].
Patient on hemodialysis for 7 years prior to cadaveric renal
transplant which occurred on [**2163-9-6**]. Patient gets
dialysis through right arm fistula. Denied fevers, chills,
nausea, hyperglycemia or urinary tract infections recently.
Patient was admitted preoperatively. Evaluation for cadaveric
renal transplantation.
PAST MEDICAL HISTORY: Diabetes type 2, high cholesterol,
GERD, end-stage renal disease.
MEDICATIONS AT HOME: Protonix 40, NPH 20 in the a.m.,
PhosLo, Lipitor 40, Nephrocaps, Epogen and vitamins.
PAST MEDICAL HISTORY: He had an open cholecystectomy in
[**2153**], Charcot's foot a year ago, an AV fistula x2 placed.
ALLERGIES: Quinine to which he gets anaphylaxis.
SOCIAL HISTORY: He denies alcohol, tobacco or illicit drugs.
PHYSICAL EXAMINATION ON ADMISSION: He is [**Age over 90 **].5, 122/52, heart
rate of 94, 97% on room air. His admission weight is 130 kg.
LABORATORY DATA: White count is 5, hematocrit is 42,
platelets are 208, INR is 1.2.
HOSPITAL COURSE: Patient was admitted--please see operative
dictation--and underwent cadaveric renal transplantation.
Postoperatively, patient did well from a medical perspective;
however, his renal function was delayed. He had delayed graft
function, and this delayed graft function invariably led to
prolongation of his hospital stay because there were several
instances where there was a rejection, and he potentially
would be rebiopsied.
Patient also with his morbid obesity did have some
prolongation of his hospital stay due to the fact that he had
some respiratory issues. He an O2 requirement immediately
after surgery and needed to be weaned from oxygen over a
period of [**2-4**] days.
Physical therapy worked aggressively with Dr. [**Known lastname 1968**] and was
instrumental in facilitating his recovery. However,
approximately 5 or 6 days into the hospital stay, the patient
nearly became comatose with BUN extremely high, asterixis and
was in dire need of dialysis as he was up approximately 22 kg
from his admission weight. Eventually, he did get onto a
regular dialysis schedule. He did make small amounts of urine
prior to being discharged. His mental status cleared readily
with dialysis, and his O2 requirement decreased with
dialysis, as well, in addition to his ability to become more
mobile.
DISCHARGE CONDITION: Patient was discharged in stable
condition on [**2163-8-18**]. Status post cadaveric renal
transplantation.
DIAGNOSES:
1. Need for prolonged dialysis.
2. End-stage renal disease.
3. Morbid obesity.
4. Diabetes.
5. Hypercholesterolemia.
6. Gastroesophageal reflux disease.
7. Metabolic derangement of electrolytes due to need for
dialysis.
8. Mental status changes due to need of dialysis
We expect to end delayed graft function. We expect the kidney
has started to progressively make more urine over the last
several days, and we suspect the kidney will open up after a
period of time.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], INT
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2163-9-18**] 05:39:15
T: [**2163-9-18**] 11:28:30
Job#: [**Job Number 30133**]
|
[
"787.91",
"278.01",
"285.9",
"403.91",
"272.0",
"996.81",
"250.40",
"458.29",
"530.81",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"39.95",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
2659, 3505
|
1335, 2637
|
768, 855
|
1127, 1317
|
878, 1028
|
1045, 1112
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,793
| 131,410
|
3608
|
Discharge summary
|
report
|
Admission Date: [**2195-12-31**] Discharge Date: [**2196-1-4**]
Service: ACOVE Medicine Service
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female resident at a nursing home with advanced dementia who
presented to the Emergency Department on [**12-31**] in
respiratory distress.
The patient had been her usual state of health until
approximately one week prior to admission when she developed
pneumonia. She had been on day 7 of a 10-day course of
levofloxacin and Flagyl for a presumed aspiration pneumonia.
The patient was doing reasonably well until [**12-31**] when
she developed respiratory distress with a respiratory rate of
28, and an oxygen saturation of 90% on room air, and
hypotension with a blood pressure of 88/50.
She was transferred to the Emergency Department where she was
found to be in paroxysmal atrial fibrillation which was
treated with diltiazem. She was also treated with several
liter intravenous fluid bolus for hypotension and was
subsequently admitted to the Medical Intensive Care Unit on
face mask oxygen.
PAST MEDICAL HISTORY:
1. Dementia; nonverbal at baseline and dependent for all
activities of daily living and not ambulatory.
2. History of syncope.
3. History of osteoporosis.
4. History of depression.
5. History of heel ulceration.
6. History of incontinence.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg by mouth once per day.
2. Multivitamin one tablet by mouth every day.
3. Milk of Magnesia every other day.
4. Tums twice per day.
5. Remeron 15 mg by mouth at hour of sleep.
6. Trazodone 25 mg by mouth at hour of sleep.
7. Levaquin 500 mg by mouth once per day (started on
[**12-23**]).
8. Flagyl 500 mg by mouth three times per day (started on
[**12-23**]).
9. Promote twice per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is widowed. She has two
daughters. She lives in a nursing home. Her health care
proxy is her daughter [**Name (NI) 16405**] [**Name (NI) 349**] (telephone number
[**Telephone/Fax (1) 16406**]).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 102
degrees Fahrenheit, her blood pressure was 96/56, her heart
rate was 57, her respiratory rate was 20, and her oxygen
saturation was 100% on nonrebreather with 12 liters. In
general, this is an elderly female in moderate distress. She
was not responsive to pain but awake and apparently alert.
Head, eyes, ears, nose, and throat examination revealed the
pupils were equal and reactive. There were anicteric
sclerae. The oropharynx was dry. The patient was
edentulous. The neck was supple. No meningismus. No
lymphadenopathy. No thyromegaly. Lung examination revealed
coarse breath sounds bilaterally, crackles at the bases, and
diffuse rhonchi. Cardiovascular examination revealed the
heart was irregular. There was a 2/6 systolic ejection
murmur. The abdomen had decreased breath sounds. The
abdomen was soft, nontender, and nondistended. Extremity
examination revealed trace edema. The dorsalis pedis pulses
were 1+ bilaterally. The right toe with dry gangrene at the
tip. There was a right heel grade 2 ulceration. Neurologic
examination revealed the patient responded to pain and
occasionally to command but not reliable. There were
contractures of the upper extremities. The toes were
downgoing bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 15.5 (with 83% neutrophils and no bands), her hematocrit
was 46.2, and her platelets were 285. Chemistry-7 revealed
the patient's sodium was 156, potassium was 4.2, chloride was
121, bicarbonate was 24, blood urea nitrogen was 52,
creatinine was 1, and blood glucose was 118. Her lactate was
10.3. Her troponin was 0.08. Urinalysis was normal.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed a question
of a left lower lobe opacity and cardiomegaly. No effusions.
An electrocardiogram revealed a normal sinus rhythm at 94.
There were T wave inversions in V1 through V6. No old
electrocardiogram for comparison.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: In the
Emergency Department, the patient was treated with
ceftriaxone 1 gram and azithromycin 500 mg intravenously.
She was placed on telemetry and found to be in atrial
fibrillation. Her rapid atrial fibrillation was treated with
diltiazem 10 mg intravenously. She subsequently became
hypotensive in the 70s and was treated with 2.5 liters of
intravenous fluids and transferred to the Intensive Care
Unit.
While in the Intensive Care Unit, she continued to need fluid
boluses overnight for blood pressures. She was also given
additional vancomycin 1 gram given her septic picture.
1. PNEUMONIA ISSUES: Pneumonia thought to be secondary to
an aspiration event. A sputum culture showed greater than 25
polymorphonuclear neutrophils and 2+ gram-positive cocci. No
species were identified at this time. She was placed on
broad coverage antibiotics including vancomycin to cover
methicillin-resistant Staphylococcus aureus or possible
Pseudomonas and Flagyl for anaerobes given concern for
aspiration. On this regimen, she became afebrile and her
white blood cell count decreased.
She continued to have thick sputum production; however, she
was saturating well on nasal cannula. Awaiting culture to
further narrow antibiotics. Will treat for a full 14-day
course.
2. HYPOTENSION ISSUES: The patient's hypotension was felt
to be multifactorial; likely sepsis, and rapid atrial
fibrillation, and medications. The hypotension resolved with
adequate fluid rehydration.
3. ATRIAL FIBRILLATION ISSUES: A new diagnosis of
paroxysmal atrial fibrillation. This was stable. The
patient was in a sinus rhythm after infectious process under
treatment.
4. HYPERNATREMIA ISSUES: Hypernatremia was likely secondary
to dehydration. This was treated with free water repletion.
5. QUESTION ADRENAL INSUFFICIENCY: A.m. cortisol was 22.8;
however, the patient had been given stress-dose steroids
while in the [**Hospital Ward Name 332**] Intensive Care Unit. Given normal
cortisol, this was discontinued.
6. DEMENTIA ISSUES: The patient is severely demented at
baseline with full dependence for activities of daily living.
7. CODE STATUS ISSUES: The patient's code status was
discussed with her family by the primary physician and
confirmed to be do not resuscitate/do not intubate. However,
the family continued to wish for hospitalization and
aggressive management with those limitations.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Hypernatremia.
3. Hypotension.
4. Dementia.
5. Atrial fibrillation.
MEDICATIONS ON DISCHARGE: To be included in an Addendum at a
later date.
DISCHARGE DISPOSITION: The patient was to be discharged
back to her nursing home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient will need to continue the complete 14-day
course of intravenous antibiotics for which she has received
a peripherally inserted central catheter line.
2. In addition, the patient will need close monitoring of
her electrolytes to insure adequate hydration and maintenance
of normal sodium.
3. The patient's diet should be pureed or ground with
thickened liquids.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12.AIY
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2196-1-2**] 11:21
T: [**2196-1-2**] 11:37
JOB#: [**Job Number 16407**]
|
[
"507.0",
"707.0",
"785.52",
"276.0",
"294.8",
"787.6",
"518.82",
"427.31",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6832, 6892
|
6630, 6732
|
6759, 6807
|
1377, 1827
|
6925, 7546
|
4203, 6609
|
135, 1082
|
1104, 1351
|
1844, 4169
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,429
| 184,543
|
22226
|
Discharge summary
|
report
|
Admission Date: [**2115-7-21**] Discharge Date: [**2115-7-23**]
Date of Birth: [**2039-7-14**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
76M w/CAD s/p CABG '[**08**], HTN, hyperlipid and h/o syncopal episode
6 mo ago in setting of LGIB and Hct 18 ([**Hospital3 **]) who p/w
syncope while exerting himself. +LH so sat down & then +LOC for
few min. Denies preceding CP, palpit, diaphor, or other Sx. LOC
was witnessed by family & no seizure activity, bowel/bladder
incont, or tongue lac. In [**Name (NI) **], pt became nauseated & the lost
consciousness again in stretcher & tele at this time showed
sinus->sinus brady->jxnal escape->asystole x 13 sec.
Past Medical History:
Hypercholesterolemia
HTN
CAD s/p CABG [**2108**]
Social History:
Pt lives with his wife. Denies tobacco or EtOH use.
Family History:
No h/o premature CAD
Brother died of cancer (unk type)
Physical Exam:
98.9 88 118/43 20 96% 2L NC
Gen: in NAD
HEENT: PERRLA, EOMI, no sceral icterus
Neck: supple, no lymphadenopathy
CV: RRR, I/VI SEM at apex. No JVD.
Lungs: CTA bilaterally. No wheezes or crackles
Abd: S/NT/ND. +BS. No HSM
Ext: no c/c/e.
Neuro: A&Ox3. non-focal. strength 5/5 throughout. Sensation in
tact to light touch.
Rectal: Occult positive per ED.
Pertinent Results:
Echo ([**2115-7-22**]):
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic root is moderately dilated.
5.The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve
stenosis. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen.
7.The estimated pulmonary artery systolic pressure is normal.
8.There is no pericardial effusion.
CXR ([**2115-7-23**]):
Successful pacemaker placement. No pneumothorax. Lead position
may be documented with an additional lateral view if clinically
indicated.
Brief Hospital Course:
76 yo M with CAD s/p CABG in '[**08**], HTN, h/o recent GIB who
presented with syncopal episode with tele showing sinus
bradycardia evolving to asystole x 13 seconds.
1. Rhythm: Pt was admitted for syncopal episode and while in the
ED had another episode of syncope while sitting in bed -
asystole x 13 seconds. Following this he had 2 other episodes of
brady & pauses since admission. Etiology was thought to be
vagally-mediated since asystole occurred. Pacer was placed [**7-22**]
and CXR indicated proper placement. Pacer was interrogated prior
to discharge and was found to be pacing appropriately. Pt will
take Keflex for first 48 hours after procedure and will follow
up with the device clinic in one week.
2. Pump: Echo LVEF 65%. Mild symmetric LVH. Mildly dilated LA.
Nml e/a ratio. Given these results, it was thought unlikely that
pump dysfunction was contributing to asystolic episodes.
3. Anemia: h/o GIB, now on FeSo4. On admission Hct was 29.6. Pt
states he had a GIB in [**Month (only) 956**] and Hct was 18 at that time. He
gives h/o receiving 4 units of blood at that time in addition to
a scope where "vessels were cauterized" and on d/c Hct was 33.
He reported that he had followed up with his PCP [**Name Initial (PRE) **] 4 months
and Hct was still 33. Since then he has had dark stools, but
reports he has been taking Iron. On admission guiac was + for
occult blood. Given cardiac disease, pt was transfused one unit
and Hct bumped to 32.4. He was found to be Coombs positive for
IgG warm antibody. Pt reports no h/o autoimmune diseases, no
recent PCN, methyldopa, or other medication intake. Thus, it was
thought he likely had AIHA from prior transfusion. Hemolysis
labs were not impressive, however. Pt was seen by GI team and it
was felt that he should have a repeat scope to investigate for
sources of blood loss. He will call his GI doctor for an
appointment in the next week and will arrange a colonoscopy. He
will also have his Hct checked with his PCP in one week who will
follow up and treat his anemia appropriately. Pt will continue
Iron and B12 therapy.
4. CAD: s/p CABG '[**08**]; no Sx currently. Pt was restarted on 81 mg
ASA and was started on Atenolol 25 mg po qd while Norvasc was
d/c'd. This change was made given the plethora of data that BB's
are extremely helpful in pt's with a prior MI. Pt states he was
on Zocor but d/ced by outpt doctor. He will f/u with his PCP in
one week to verify that he is stable on this regimen.
5. Renal: creat 1.4 at admission and decreased to 1.2 the
following day with some fluids. It was thus thought to be
prerenal. Pt will have this checked with his PCP in the next
week as well.
6. FEN: cardiac diet
FULL CODE
Medications on Admission:
Norvasc 5 po qday
Protonix 40 mg po qd
FeSO4
Vitamin B
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 6 doses.
Disp:*6 Capsule(s)* Refills:*0*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day.
6. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
Discharge Condition:
stable
Discharge Instructions:
Please take new medications as prescribed (Keflex and Atenolol).
Do not take the Norvasc any longer. Follow up for pacemaker
appointment in one week and make appoinments to see your PCP and
GI doctor within the next week. If you feel extremely
light-headed or pass out, call your doctor right away.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-7-31**] 1:00
Please call Dr. [**Last Name (STitle) 57979**] for an appointment in 1 week. Have your
Hct (blood test checked) at this time. Please let him know that
your blood pressure meds have been changed (stopped Norvasc and
added Atenolol).
Please call your GI doctor [**First Name (Titles) **] [**Last Name (Titles) **] an outpatient GI
appointment and colonoscopy within the next week.
|
[
"401.9",
"272.0",
"578.1",
"E870.8",
"584.9",
"285.9",
"998.2",
"780.2",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5715, 5721
|
2367, 5059
|
342, 364
|
5773, 5781
|
1508, 2344
|
6128, 6663
|
1065, 1122
|
5165, 5692
|
5742, 5752
|
5085, 5142
|
5805, 6105
|
1137, 1489
|
295, 304
|
392, 907
|
929, 980
|
996, 1049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,288
| 123,026
|
21093
|
Discharge summary
|
report
|
Admission Date: [**2137-8-28**] Discharge Date: [**2137-9-10**]
Date of Birth: [**2091-11-28**] Sex: M
Service: SURGERY
Allergies:
Tomato
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2137-8-28**]:
1. EGD
2. Exploratory laparotomy
3. Reduction of gastric volvulus
4. Removal of foreign body
[**2137-9-1**]:
1. Reopening of prior laparotomy.
2. Leak test of gastrostomy.
3. Debridement of fascia.
4. Interrupted closure primarily of fascia.
5. Abdominal washout.
History of Present Illness:
45 yo M with PMH of ADD, bipolar disorder and tylenol overdose
presented to the ED from [**Hospital **] [**Hospital **] Hospital with
increasing abdominal pain over the past 3 weeks. As of last
night, the pain was [**9-7**] when he rolled on his right side. The
pain is mostly in his left abdoman and is worse when he lies
down or walks, better when he is sitting. He has had nausea,
increasing over the past week. He has not vomited. He had a
typical BM this morning and ate dinner last night without n/v.
He has not had a fever. He denies swollowing anything other than
food and has no idea what could be in his stomach that we are
seeing on imaging.
Past Medical History:
Bipolar disorder
GERD
Social History:
The patient lives in [**Location (un) 538**]. He works in sales. He
smokes one pack per day of cigarettes. History of cocaine use.
Family History:
Diabetes on his mother's side
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Vitals: T97.4 P59 BP120/80 RR16 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, diffusely tender- worse on left,
worse on deep palpation, no rebound or guarding, hypoactive
bowel
sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2137-8-28**] 11:20PM GLUCOSE-133* UREA N-16 CREAT-1.5* SODIUM-135
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2137-8-28**] 03:09PM ALBUMIN-3.8 CALCIUM-9.3 PHOSPHATE-4.8*
MAGNESIUM-2.1
[**2137-8-28**] 10:11AM WBC-14.8* RBC-4.64 HGB-14.7 HCT-40.7 MCV-88
MCH-31.7 MCHC-36.1* RDW-13.2
[**2137-8-28**] 10:11AM PLT COUNT-516*
[**2137-8-27**] 11:06PM PT-12.7 PTT-28.1 INR(PT)-1.1
[**2137-8-27**] 04:00PM ALT(SGPT)-37 AST(SGOT)-23 ALK PHOS-109 TOT
BILI-0.2
[**2137-8-27**] 04:00PM LIPASE-26
CT abd/pelvis:
IMPRESSION:
1. 10.2-cm ovoid, hyperdense, likely foreign body within the
gastric body. Given the appearance of the corticated edges and
peripheral increased metal density, possible etiologies include
foreign material wrapped in aluminum foil.
2. Leftwardly displaced gastric body suspicious for volvulus
perhaps with an internal hernia.
3. No free air or small-bowel obstruction is seen.
4. Hypoattenuating left renal lesion for which non-urgent
ultrasound is
recommended.
Brief Hospital Course:
He was admitted to the Acute Care Surgery team and underwent CT
imaging of his abdomen showing hyperdense mass with corticated
edges in the gastrointestinal tract. He was then prepped and
taken to the operating room for removal of the foreign objects
(which turned out to be coins totaling approximately $55.00) and
abdominal washout. Intravenous antibiotics were initiated.
Postoperatively he was monitored in the Trauma ICU where he
remained hemodynamically stable. He was placed on 1:1 sitter and
evaluated by Psychiatry once extubated. Several medication
recommendations were made including resuming his home
medications once able to take orals and avoiding
benzodiazepines, rather use Haldol instead while monitoring QTc
interval.
He was eventually transferred to the regular nursing unit with
continued 1:1 sitters in place. On POD# 4 he was taken back to
the operating room for wound infection with fascial dehiscence
and necrotic fascia and underwent reopening of prior laparotomy,
leak test of gastrostomy, debridement of fascia, interrupted
closure primarily of fascia and abdominal washout.
Postoperatively he was taken to the PACU where he was recovered
and once stable was transferred back to the regular nursing
unit. On POD# 9 a wound VAC was placed. His antibiotics were
continued for another several days and then stopped on [**9-9**].
His diet was advanced for which he has tolerated without any
difficulty.
He was screened to return back to [**Hospital3 4339**] for the
remainder of his psychiatric and medical care. After several
discussions with MD leadership at [**Hospital1 **] it was deemed that
the VAC could not be accommodated and he would therefore have to
go back to having wet to dry dressing changes. This was
discussed with the ACS attending and was approved.
Medications on Admission:
benztropine 1'', bupropion 150'', tegretol 300'', levetiracetam
1000'', prilosec 20'', nicoderm CQ 21, olanzapine 10qAM, 15qPM,
propranolol 20'', Maalox oral Q4-6 PRN, ibuprofen 400mg Q4-6 PRN
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
3. carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO QAM (once a day (in the morning)).
7. olanzapine 5 mg Tablet, Rapid Dissolve Sig: Three (3) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
8. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
15. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
Foreign body ingestion
Gastric volvulus
Fascial dehiscence with visible omentum.
Fascial edge necrosis and purulence.
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 following ingestion of foreign
objects, which required an urgent operation. Your hospital
course was complicated with opening of your stapled incision
requring that the remainder of your staples be removed and a
special dressing called a VAC was placed to help with the
healing process. You were given a short course of antibiotics
which have now been completed.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Continue to ambulate several times per day, and drink adequate
amounts of fluids. Avoid lifting weights greater than [**5-7**] lbs
until you follow-up with your surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 600**]
Date/Time:[**2137-9-19**] 2:30 pm
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2137-9-10**]
|
[
"296.80",
"599.0",
"935.2",
"998.31",
"998.59",
"E849.7",
"E915",
"530.81",
"401.9",
"041.04",
"345.90",
"553.3",
"E878.8",
"537.89",
"041.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"45.13",
"44.92",
"83.39",
"43.0",
"83.65"
] |
icd9pcs
|
[
[
[]
]
] |
6538, 6585
|
2961, 4758
|
281, 564
|
6747, 6747
|
1930, 2938
|
9045, 9296
|
1461, 1492
|
5002, 6515
|
6606, 6726
|
4784, 4979
|
6897, 8712
|
8727, 9022
|
1507, 1911
|
227, 243
|
592, 1247
|
6762, 6873
|
1269, 1292
|
1308, 1445
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,036
| 115,827
|
14539
|
Discharge summary
|
report
|
Admission Date: [**2117-3-21**] Discharge Date: [**2117-3-31**]
Date of Birth: [**2073-12-15**] Sex: M
Service: SURGERY
Allergies:
Morphine / Compazine / Penicillins / Codeine / Nsaids
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Discharge per anum.
Major Surgical or Invasive Procedure:
Exam under anesthesia and arrest of hemorrhage.
Perineal proctectomy.
History of Present Illness:
This patient had previously undergone ileoanal
pouch surgery. The pouch failed and eventually I removed his
ileoanal pouch. At the time there was so much inflammatory
change down in the remaining rectal area that I did not
tackle that at the same time. The patient continued to have
discharge per anum which troubled him and therefore he
requested removal of this area.
Past Medical History:
1. Inflammatory bowel disease status post proctocolectomy with
ileal pouch-anal anastomosis [**9-1**]
- [**12/2113**] LOA for SBP, closure of ileostomy with end-to-end
anastomosis.
- [**8-/2114**] Ileostomy replaced
- [**10/2115**] Ileostomy revision with conversion to a functional end
ileostomy.
2. Seizure disorder
3. Chronic back pain s/p C-spine fracture [**1-1**] MVA
4. Narcotic dependence, pain contract with [**Company 191**]
5. Recurrent C.difficile enteritis
6. Anxiety
7. GERD
Social History:
Married x 25 years. Lives with his wife and children on the
water in [**Name (NI) 392**]. Used to work in law enforcement. + marijuana
about 3 times per week, no IVDU. No tob or EtOH in last 20 yrs
Family History:
His mother had "Crohn's disease" and died at the age of 63 from
colon cancer. His father is still alive, at age 79, without any
known health problems. His 5 brothers and one sister are all
alive and healthy.
Pertinent Results:
[**2117-3-29**] 04:06AM BLOOD WBC-6.8 RBC-2.82* Hgb-8.8* Hct-24.9*
MCV-88 MCH-31.2 MCHC-35.3* RDW-14.2 Plt Ct-430
[**2117-3-28**] 07:31AM BLOOD WBC-6.4 RBC-2.75* Hgb-8.4* Hct-24.6*
MCV-89 MCH-30.6 MCHC-34.3 RDW-14.1 Plt Ct-368
[**2117-3-20**] 11:16PM BLOOD Neuts-72.5* Lymphs-19.8 Monos-7.3 Eos-0.3
Baso-0.2
[**2117-3-26**] 01:06AM BLOOD PT-11.9 PTT-30.5 INR(PT)-1.0
[**2117-3-28**] 07:31AM BLOOD Glucose-102 UreaN-4* Creat-0.6 Na-138
K-4.2 Cl-101 HCO3-31 AnGap-10
[**2117-3-27**] 06:07AM BLOOD Glucose-154* UreaN-3* Creat-0.7 Na-136
K-3.9 Cl-102 HCO3-28 AnGap-10
[**2117-3-20**] 11:16PM BLOOD ALT-89* AST-41* AlkPhos-140* Amylase-82
TotBili-0.8
.
[**3-20**] KUB: No evidence of obstruction or free air.
.
[**3-24**] CXR: The cardiomediastinal silhouette is normal. The right
subclavian catheter is unchanged, with its tip at the level of
the mid-distal portion of the superior vena cava. Lung hila are
symmetric. No focal lung consolidation or infiltrate is seen,
and the prior right-sided lung infiltrate is no longer visible.
The left lateral costophrenic angle is incompletely imaged. In
this conditions, no obvious pleural effusion is seen on either
side.
Brief Hospital Course:
This patient was admitted on [**3-21**] for dehydration. On
admission, he was made NPO and started on IV fluids. His home
medications were resumed. A central line was inserted the same
day - he was taken to the OR on [**3-22**] for his procedure
(completion proctectomy). He was prepared and consented as per
standard; he was brought to the PACU in a stable condition. He
had a Foley in place, and was given sips (which he tolerated
well). Overnight, he had no issues with the exception of
difficult pain control despite being on a dilaudid PCA.
On POD1, he was advanced to a regular diet. He was seen by
physical therapy, and continued on his Dilaudid PCA. On [**3-25**],
the patient was noted to have oozing from his wound. Direct
pressure was applied, and then a pressure dressing but this did
not control the bleeding. His vitals remained unremarkable (not
tachycardiac, blood pressure within a normal range). It was
decided to take him back to the OR overnight for direct
observation and exploration of the site of bleeding. After taken
to the OR, he went to the ICU for furthur monitoring and for
serial Hct's. He also remained intubated and was extuabted on
[**3-26**] in the early morning on arrival to the SICU. His Hct's
remained stable and he was transfered to the floor later that
day ([**3-26**]). The remainder of his hospital course was
significant for pain management. He was tolerated a regular
diet, was seen by physical therapy, and had adequate urine
output.
His pain, however, was not well-controlled on a Dilaudid PCA,
and hence, a chronic pain service consult was called. Their
reccomendations were followed, and after a discussion with the
patient, the patient's PCP and the pain service, he was started
on methadone 15mg tid, in addition to oxycodone prn. His pain
initially remained inadequately controlled, but with time and a
combination of pain medications including oxycodone and tylenol
(in addition to methadone), he was only complaining of
minimal-moderate pain. He was discharged with VNA for daily
dressing changes (wet to dry, to be done daily). He was given
2weeks of pain medications; his PCP will follow his pain
management as necessary from then on.
During the rest of this patient's admission, his serial Hct's
remained stable and his dressings were changed daily (with
pre-medication with Ativan and Dilaudid).
Medications on Admission:
Trileptal 300 [**Hospital1 **], Keppra 1000 [**Hospital1 **], Alprazolam 2 [**Hospital1 **], Klonopin 2
[**Hospital1 **], Oxycontin 30 [**Hospital1 **], mesalamine pr QD
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Amitriptyline 10 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
Disp:*20 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
Disp:*20 Tablet(s)* Refills:*2*
4. Methadone 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day) for 2 weeks.
Disp:*63 Tablet(s)* Refills:*0*
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO [**Hospital1 **] (4 times a
day) as needed.
9. Oxycodone 30 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain for 2 weeks.
Disp:*150 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Postoperative hemorrhage following perineal proctectomy.
Chronic ulcerative colitis status post failed pouch.
Discharge Condition:
Stable.
Discharge Instructions:
Continue home medications. Engage in physical exercise. Continue
dressing changes as you have been taught (a nurse [**First Name (Titles) **] [**Last Name (Titles) **] at
home). Your pain medications will be managed by your primary
care physician. [**Name10 (NameIs) **] this reason, it is important for you to
schedule an appointment with your PCP [**Name Initial (PRE) 176**] 1 week for furthur
management. Take Colace as you need for constipation.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or in your
ostomy.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Arrange an appointment with your surgeon within 1-2weeks: [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], M.D. -- ([**Telephone/Fax (1) 9011**]
.
You should see your PCP [**Name Initial (PRE) 176**] 1 week for management of your
pain medications. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 42923**]
Completed by:[**2117-4-2**]
|
[
"997.4",
"556.9",
"998.11",
"304.01",
"276.51",
"558.9",
"E878.2",
"345.10",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"48.5",
"49.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6423, 6494
|
2964, 5319
|
331, 403
|
6648, 6658
|
1779, 2941
|
8068, 8475
|
1548, 1760
|
5539, 6400
|
6515, 6627
|
5345, 5516
|
6682, 8045
|
272, 293
|
431, 803
|
825, 1316
|
1332, 1532
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,258
| 139,169
|
10710
|
Discharge summary
|
report
|
Admission Date: [**2127-12-26**] Discharge Date: [**2128-1-5**]
Date of Birth: [**2073-7-13**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with a past medical history significant for poorly
controlled diabetes mellitus and hypertension as well as
known coronary disease and a previous non Q myocardial
infarction and right coronary artery stenting in [**2123**]. He
was admitted to an outside hospital on the day prior to
admission with unstable angina and found to have borderline
positive troponin, hypertension and ST depressions in the
lateral lead. He was given Aspirin, Nitrates, Beta Blockers,
Morphine and Lovenox and transferred to [**Hospital6 649**] for cardiac catheterization.
At the time he had a prior history of a year of occasional
chest pain which had worsening and increasing frequency in
the prior four days. He denied paroxysmal nocturnal dyspnea,
orthopnea, dyspnea on exertion, nausea and edema.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Myocardial infarction.
3. Status post right coronary artery stent in [**2123**].
4. Noninsulin dependent diabetes mellitus.
5. Hypertension.
6. Pericarditis.
7. Lyme disease.
8. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Past surgical history includes
bilateral knee surgical repair.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 q d.
2. Plavix 75 mg p.o. q d.
3. Lopressor 25 mg p.o. b.i.d. started at the outside
hospital.
4. Isordil 10 mg p.o. t.i.d. started at the outside
hospital.
5. Nexium 20 mg p.o. q. d started at the outside hospital.
6. Lipitor 10 mg p.o. q d started at [**Hospital3 3583**].
7. Amaryl 2 mg p.o. b.i.d.
8. .................... 80 mg p.o. q d.
ALLERGIES: He is ALLERGIC TO CODEINE AND CONTRAST DYE.
SOCIAL HISTORY: He has a heavy smoking history and is
currently smoking 2.5 packs a day. Denied alcohol use and is
disabled.
PHYSICAL EXAMINATION: On the examination on admission, he
had a heart rate of 64 with a blood pressure of 210/116 which
came down to 134/80 on the Nitroglycerin drip. He was in
moderate distress. He had no jugular venous distention.
Palpable carotid pulses and no bruits. Heart was regular
rate and rhythm with a normal S1. No 2. No murmurs or rubs.
Chest had increased AP diameter. His lungs were coarse and
rhonchorous with intermittent wheezing. His abdomen was
obese, nontender and nondistended with no hepatosplenomegaly
and no palpable masses. He had bilateral palpable pulses in
both the upper and lower extremities and no peripheral edema.
His extremities were warm and well perfused.
LABORATORY ON ADMISSION AS FOLLOWS: White count, 9.4;
hematocrit, 44.8; platelet count, 167,000. Sodium, 137; K4,
.8; BUN, 16; creatinine, 1.2; glucose, 187. Troponin, 0.3
and 0.28 with CKs of 130 and 126.
Electrocardiogram showed Q waves in leads 3 and F. T wave
inversions in 2, 3, F and ST depressions in 1L and 3 through
6.
HOSPITAL COURSE: He was admitted for cardiac catheterization
which showed a right dominant system with a 60% left main,
moderate disease of his left anterior descending, 90% lesions
of his circumflex and 90% lesion of the right coronary artery
with minimal instant restenosis.
He was started on a Heparin drip, Integrelin and
Nitroglycerin drip and admitted to the Cardiology Service and
stabilized in the Intensive Care Unit and referred to Dr.
[**Last Name (STitle) 1537**], Cardiac Surgery. On [**12-29**], he went to the
Operating Room, had an intra-aortic balloon pump placed and
underwent a coronary artery bypass grafting x 5. Please refer
to the Operative Note.
He tolerated the procedure well and was transferred intubated
in stable condition to the Intensive Care Unit on a
Dobutamine drip at 5 and Nitroglycerin drip at .5, Propofol
drip at 10 and Neo-Synephrine at 0.75. He was also on
Amiodarone drip at .1 mg per minute and Insulin drip.
His Neo and Dobutamine were weaned as his index was greater
than 2.2. Weaning was begun from his intra-aortic balloon
pump due to bleeding from the site though the patient
hemodynamic stability. He was extubated without difficulty.
On postoperative day #2, balloon pump was removed. Site
remained stable. He was weaned off all drips and put on oral
meds and diuresis was begun with Lasix. Later on
postoperative day #2, chest tubes and pacing wires were
removed. The patient was stable for transfer to the Regular
Floor which occurred later in the afternoon.
On the Floor, he continued to have extremely coarse lung
sounds and heavy secretions and was quite uncooperative with
incentive spirometry, chest PT and coughing exercises. He
was also uncooperative with his physical therapy secondary to
issues of pain control and spent little time ambulating. He
did, however, continue to do extremely well from a cardiac
standpoint.
He was also uncooperative for Physical Therapy and had issues
of pain control and spent very little time ambulating. He
did continue to do extremely well from a cardiac standpoint.
On the evening of postoperative day #2, he had some drainage
of serosanguinous fluid at the inferior pole of the sternal
incisions. This continued to drain over the next day and a
half despite an attempt at Dermabonding the incision.
The decision was made to take the patient back to the
Operating Room for tightening of the sternal wires and
reclosure of his wound. He was sent to the Operating Room on
postoperative day #4 and concurrently underwent bronchoscopy
to help treat his many secretions. He tolerated this well
and spent the first night in the Cardiac Intensive Care Unit
for a Nitroglycerin drip for hypertension and observation.
After an uneventful night, he was transferred back to the
Floor on the following morning. He began at that time to
complain of burning on urination and was found to have a
marginally positive urinalysis and was started on oral
Levofloxacin.
He did well over the next day despite continued refusal to
participate in aggressive pulmonary toilet and physical
therapy activities but it was felt he was stable and ready
for discharge. He should go to extended care facility to
build mobility and strength and for further pulmonary
therapy.
At the time he was afebrile, had a heart rate of 92 and sinus
rhythm. Blood pressure, 134/83. He was alert and oriented x
3. Moved all extremities and followed commands. His heart
showed a regular rate and rhythm with no murmurs. His
sternum was stable with no further drainage. His lungs were
coarse and rhonchorous diffusely and bilaterally due to
secretions. His abdomen was soft, nontender and nondistended
and he had minimal lower extremity edema.
DISCHARGE MEDICATIONS WERE AS FOLLOWS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. x ten days.
3. KCl 20 mEq p.o. b.i.d. x ten days.
4. Enteric coated Aspirin 325 mg p.o. q d.
5. Colace 100 mg p.o. b.i.d.
6. Zantac 150 mg p.o. b.i.d.
7. Isordil 60 mg p.o. q d.
8. Nicotine patch 21 mg transdermal q d.
9. Lipitor 10 mg p.o. q d.
10. Dilaudid 2 to 4 mg p.o. prn q 4 to 6 hours for pain.
11. Levofloxacin 500 mg q d p.o. x seven days.
12. Amaryl 2 mg p.o. b.i.d.
13. Albuterol inhalers one to two puffs q 6 hours prn.
14. Ibuprofen 400 mg q 6 hours prn pain.
DISPOSITION: He was discharged to an extended care facility
on a cardiac and diabetic diet in stable condition. He was
encouraged to increase the pulmonary toilet and have
aggressive physical therapy.
FOLLOW UP: The patient was instructed to follow up with the
Cardiologist in the next one to two weeks and to follow up
with Dr. [**Last Name (STitle) 1537**] in the office at four weeks and also follow up
with his Primary Care Physician in three to four weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass grafting x 5 with a
take back for sternal wire retightening.
3. Status post bronchoscopy for persistent secretions.
4. Noninsulin dependent diabetes mellitus.
5. Hypertension.
6. Lyme disease.
7. Pericarditis.
8. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2128-1-16**] 14:05
T: [**2128-1-16**] 15:36
JOB#: [**Job Number 35060**]
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icd9cm
|
[
[
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[
"88.56",
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icd9pcs
|
[
[
[]
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] |
7775, 8375
|
1390, 1813
|
2996, 7491
|
1300, 1364
|
7503, 7754
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1964, 2978
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184, 1003
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1025, 1276
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1830, 1941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,403
| 128,159
|
45987
|
Discharge summary
|
report
|
Admission Date: [**2185-3-20**] Discharge Date: [**2185-4-17**]
Date of Birth: Sex: M
Service: CT [**Doctor First Name 147**]
ADMISSION DIAGNOSIS: Aortic valve endocarditis.
PROCEDURE PERFORMED:
1. Aortic valve replacement with a Number 23 [**Last Name (un) 3843**]
[**Doctor Last Name **] Pericardial Valve and placement of ventricular pacing
leads.
2. Exploratory laparotomy with a left hemicolectomy and a
Hartmann's procedure.
3. Exploratory laparotomy with further resection of the
distal sigmoid.
BRIEF HISTORY: This is a 70-year-old man with a history of
diabetes, end-stage renal disease on hemodialysis as well as
hypertension, hypercholesterolemia, right subclavian and
superior vena cava thrombosis as well as infected
endocarditis of the aortic valve who was found to have
Enterococcus infection in the blood secondary to aortic
valve.
He underwent the aortic valve replacement on [**2185-3-29**].
Please refer to the operative note for further details.
Postoperatively on day number one, he was noted to have a
fever to 104. On postop day number three there was an
associated with an increasing lactic acidosis. A General
Surgery consult was obtained and, due to exam findings
consistent with peritoneal signs, patient was taken to the
Operating Room for exploration.
He was found to have an ischemic left colon and underwent a
left colectomy and takedown of the splenic flexure and
colostomy and Hartmann's pouch.
He was taken back to the CSRU in critical condition where he
remained on epinephrine drip and multiple broad-spectrum
antibiotics. He was followed by several services, including
Renal, for CVDH therapy and Infectious Diseases, who
monitored his broad-spectrum antibiotic coverage.
Because of elevated fluid issues, he was not able to be
extubated until postop day number nine from his aortic valve
and postop day number six from his left colectomy. He was
maintained on CVDH therapy per Renal and broad-spectrum
antibiotics which included Vancomycin, Levofloxacin, Flagyl,
and Fluconazole.
He was followed by [**Last Name (un) 9718**] Endocrinology service for his
glucose issues and had oral feeds slowly advanced. He
continued to require aggressive pulmonary toilet and was able
to be transitioned eventually to hemodialysis on post
colectomy day number 10.
By post colectomy day number 12 a Daublin tube was placed to
improve nutrition and was slowly begun on tube feedings.
On postoperative day number 14 from his colectomy, he
underwent a tunneled dialysis catheter placement in the right
inguinal region. Immediately postoperatively he was noted to
be obtunded and had increasing metabolic acidosis with an
elevated lactate. General Surgery evaluated the patient, who
at that time was requiring fluid and a resumption of his
cardiovascular pressor agents, including Neo-Synephrine and
Levophed.
A transesophageal echocardiogram was performed at the bedside
which showed intravascular depletion and adequate cardiac
contractility, ruling out any myocardiac source of shock.
Neurology had also seen the patient and felt that there was a
low likelihood of any embolic disease to his brain.
With the rise in his lactate level and evidence of peritoneal
signs on exam, General Surgery took the patient to the
Operating Room for an exploratory laparotomy that night.
They found increasing ischemic areas in the distal end of the
Hartmann's stump and underwent further resectional therapy of
this, including an abdominal washout and resection of the
rectal stump. The anterior wall of the rectum was necrosed
with localized peritonitis. He was taken back to the CSRU in
critical condition and had a Malecot catheter drain to drain
the rectal stump, as well.
However, his pressor requirements continued to increase and
he was requiring over 12 liters of fluid on postoperative day
number one from his repeat exploration of his abdomen to
maintain cardiac index above 2 despite being on high-dose
Levophed and phenylephrine to maintain a blood pressure.
Concomitant with this is liver function tests had increased
to threefold what they were preoperatively, and he required
maximal pressor agents as well as switching over to pressure
control ventilation due to his inability to oxygenate
adequately.
By post repeat exploration day number two patient had a
progressive metabolic acidosis with the lactate level in the
20s. General Surgery continued to evaluate the patient and
felt that there was no indication for any further
exploration. Despite the maximal pressor application,
patient was unable to maintain a blood pressure above 70
systolic and his ventilation became progressively more
difficult and his peak airway pressures continued to rise
despite pressure controlled ventilation.
At 7:37 p.m. on [**2185-4-17**] the patient went into asystole
rhythm and underwent advanced cardiac life support protocol
for 15 minutes without a regaining of any pulse or blood
pressure. He was pronounced death at 19:51 on [**2185-4-17**].
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 70**] were notified, as well as the
patient's wife.
ADMISSION DIAGNOSIS: Aortic valve endocarditis.
DIAGNOSES UPON DEATH:
1. Aortic valve endocarditis.
2. Status post aortic valve replacement.
3. Ischemic left colon status post left colectomy with
[**Doctor Last Name 3379**] procedure.
4. Ischemic distal [**Doctor Last Name 3379**] stump status post abdominal
re-exploration with intraperitoneal pelvic sepsis.
5. Cardiopulmonary collapse.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 12027**]
MEDQUIST36
D: [**2185-4-17**] 20:55
T: [**2185-4-19**] 14:28
JOB#: [**Job Number 97906**]
|
[
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"421.0",
"557.0",
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icd9cm
|
[
[
[]
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] |
[
"37.22",
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"39.95",
"46.11",
"45.75",
"37.74",
"88.56",
"88.49",
"86.09",
"88.72",
"39.61",
"37.83",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
5149, 5815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,017
| 110,203
|
10261
|
Discharge summary
|
report
|
Admission Date: [**2153-11-19**] Discharge Date: [**2153-12-3**]
Date of Birth: [**2078-9-11**] Sex: F
Service: CCU
HISTORY OF THE PRESENT ILLNESS: This 75-year-old woman was
admitted to the CCU for decompensated heart failure. She has
a history of hypertension, dyslipidemia, type 2 diabetes
mellitus, and coronary artery disease. She had a myocardial
infarction in [**2152-2-24**] and received a catheterization
with stent placement to the LAD that re-stenosed. In [**2152-4-23**], she had an ICD placed for nonsustained ventricular
tachycardia. She had a repeat catheterization in [**2153-9-23**] revealing 70% lesions in LAD and first diagonal as
well as a totally occluded proximal right coronary artery.
She underwent three vessel bypass on [**2154-10-15**] (LIMA
to LAD, SVG to first diagonal, SVG to PDA) with a
bioprosthetic mitral valve replacement for severe mitral
regurgitation. She was discharged from [**Hospital1 18**] on [**2153-10-26**].
Of note, she was discharged off of levothyroxine which she
had been prescribed for hypothyroidism. An echocardiogram on
[**2153-10-23**] revealed an LVEF of [**11-11**]%, dilated left
ventricle, 1+ aortic regurgitation, and 4+ tricuspid
regurgitation.
The patient presented to [**Hospital3 **] Hospital on [**2153-11-16**] after three days of progressive dyspnea. Her
laboratories were notable for an INR of greater than 5.8 and
a TSH of 42. The patient developed respiratory distress and
was intubated on [**2153-11-18**]. The same day, the patient
reportedly had an episode of ventricular tachycardia with
rate in the 140s to 150s, systolic blood pressure in the 50s
to 60s. She was started on Amiodarone, Vasopressin, and
transferred to [**Hospital1 18**] for further management.
PAST MEDICAL HISTORY:
1. Coronary artery disease with history of MI, LAD stent and
re-stenosis, CABG with bioprosthetic mitral valve
replacement, congestive heart failure with LVEF of [**11-11**]%, 4+
TR, 1+ AR, paroxysmal atrial fibrillation with rapid
ventricular response, ICD placement for nonsustained
ventricular tachycardia.
2. Diabetes mellitus type 2.
3. Hypercholesterolemia.
4. Chronic renal failure with baseline creatinine 1.3 to
1.9.
5. Anemia.
6. Peptic ulcer disease.
7. Hypothyroidism.
8. Peripheral arterial disease.
MEDICATIONS ON TRANSFER:
1. Amiodarone 0.5 mg per hour.
2. Vasopressin drip.
3. Nisiritide drip.
4. Levothyroxine 0.075 mg IV q.a.m.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: Positive for smoking. The patient lives
with her husband.
LABORATORY DATA AT [**Hospital3 **] ON [**2153-11-19**]: Sodium 134,
potassium 3.8, chloride 95, total C02 28, BUN 77, creatinine
2.6, glucose 169. CK 158, 126, 125, 141. TSH 41.6, free T4
6.7. ABG with pH 7.53, PC02 31, P02 76. INR greater than
5.8.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.0, heart rate 71, blood pressure 105/48, weight 75.6
kilograms. Ventilator settings with assist controlled with
500 cc: Tidal volume respiratory rate 18, FI02 50%, and
oxygen saturation 97%. General: The patient was intubated,
responsive to voice, and in no acute distress, pale. HEENT:
Pupils 3 mm in diameter, light reactive. Oral mucosa was
moist. Extraocular motility intact. Neck: Supple, no
carotid bruits, JVP difficult to asses. Lungs: Scattered
crackles bilaterally. Heart: Soft heart sounds, regular
rate and rhythm, with normal S1, S2, positive S3. Abdomen:
Obese, soft, nondistended, normal sounds. Extremities:
Cool, 1+ pitting lower extremity edema. Neurologic: Cranial
nerves II through VIII intact, IX through XII not assessed.
The patient moves four extremities spontaneously.
HOSPITAL COURSE: 1. CARDIOVASCULAR: A. Pump: The patient
was admitted with known systolic dysfunction and
decompensated heart failure with multiple possible
contributing factors including uncontrolled hypothyroidism,
Rosiglitazone use, and dietary indiscretion. She was taken
off of Vasopressin and started on dopamine for its inotropic
effects and blood pressure support. She was placed on
Carvedilol 6.25 mg b.i.d. and diuresed with a furosemide drip
so as to lower her preload. She diuresed well in response to
the furosemide and was extubated on [**2153-11-24**] without
event. At this time, the dopamine drip was also taken off
and the patient maintained mean arterial pressures over 60
mmHg off of dopamine. The furosemide drip was weaned off and
furosemide was started at a dose of 80 mg p.o. q.d.
On [**2153-11-27**], low-dose Captopril (6.25 mg) was
initiated for afterload reduction. The furosemide was
titrated to a dose of 160 mg p.o. q.d. and spironolactone was
initiated on [**2153-11-29**].
On [**2153-11-30**], the patient received a Heart Failure
Service consultation. They recommended holding the beta
blocker while the patient was fluid overloaded and
re-initiating it once she is in compensated heart failure.
The patient was seen by a nurse practitioner for heart
failure teaching and arranged for follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for further management of her heart failure as an
outpatient.
Prior to discharge, the patient's furosemide was decreased to
80 mg p.o. q.d. and her ACE inhibitor was changed to
lisinopril at a dose of 2.5 mg q.d.
B. Rhythm: As aforementioned, the patient had a reported
episode of ventricular tachycardia while at [**Hospital3 **]
Hospital. On transfer here, she was taken off of intravenous
Amiodarone and placed on oral Amiodarone at a dose of 200 mg
p.o. t.i.d. She received an interrogation of her ICD on
[**2153-11-20**]. She was placed on heparin for
anticoagulation in the setting of her paroxysmal atrial
fibrillation and diffuse akinesis. Her rhythm remained
A-sensed, V paced throughout admission. She completed an
Amiodarone load for her ventricular tachycardia totaling 6
grams prior to conversion to a dose of 200 mg q.d.
2. PULMONARY: On admission, the patient was noted to have
significant pulmonary edema as well as bilateral pleural
effusions, left-sided greater than right-sided. Despite her
aggressive diuresis, she had a persistent large left pleural
effusion. After she was extubated, the CT Surgery Service
was consulted to place a chest tube and this was done
successfully.
The cytology of the pleural fluid was negative for malignant
cells. Fluid contained blood, lymphocytes, and neutrophils,
and was exudative on the basis of Light's criteria.
After the placement of the chest tube with drainage of
pleural fluid, it was noted that the patient had an elevated
left hemidiaphragm likely secondary to postsurgical
diaphragmatic paralysis.
On [**2153-11-28**], the chest tube was discontinued. On
[**2153-11-30**], she received chest fluoroscopy which
revealed that her left hemidiaphragm was indeed paralyzed.
However, by this point in her hospitalization, the patient
was breathing much better with oxygen saturations over 95% on
room air.
3. RENAL: The patient was noted to have a creatinine of 2.6
on admission as compared with her baseline creatinine of 1.3
to 1.9. The differential diagnosis for the increase in GFR
was felt to include prerenal insufficiency from decreased
effective intravascular volume as well as ATN from
hypotension and decreased renal perfusion. She did not have
casts in her urine sediment. With successful diuresis and
inotropic support, the patient's renal function improved,
with creatinine downtrending consistently until it reached a
level of 1.6 on [**2153-12-2**].
4. ENDOCRINE: The patient's endocrine issues at the time of
admission included severe hypothyroidism by TSH at the
outside hospital as well as type 2 diabetes mellitus. She
was placed on oral levothyroxine for the hypothyroidism and a
regular insulin sliding scale for her type 2 diabetes. The
Endocrine Service was consulted for evaluation and management
of her hypothyroidism and they recommended continuing
levothyroxine at 175 micrograms p.o. q.d. and checking a free
T4 and TSH level in six weeks.
DISCHARGE DIAGNOSIS:
1. Decompensated heart failure.
2. Paroxysmal atrial fibrillation.
3. Coronary artery disease.
4. Severe tricuspid regurgitation.
5. Left diaphragm paralysis with pleural effusion.
6. Hypothyroidism.
7. Type 2 diabetes.
8. Status post acute on chronic renal failure of prerenal
etiology.
9. Anemia.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: To home with home services.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **].
DISCHARGE MEDICATIONS:
1. Lisinopril 2.5 mg p.o. q.d.
2. Furosemide 80 mg p.o. q.d.
3. Spironolactone 25 mg q.d.
4. Coumadin 5 mg q.h.s.
5. Amiodarone 200 mg q.d.
6. Aspirin 81 mg q.d.
7. Lipitor 10 mg q.d.
8. Levothyroxine 175 micrograms q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2154-5-16**] 05:52
T: [**2154-5-19**] 17:50
JOB#: [**Job Number 34161**]
|
[
"414.8",
"518.81",
"244.9",
"V42.2",
"V45.81",
"511.9",
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"428.21",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.91",
"96.72",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8442, 8607
|
8630, 9138
|
8111, 8420
|
3732, 8090
|
2874, 3714
|
2337, 2504
|
1791, 2312
|
2521, 2859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,557
| 170,606
|
14509
|
Discharge summary
|
report
|
Admission Date: [**2128-7-14**] Discharge Date: [**2128-8-6**]
Date of Birth: [**2070-7-3**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 5253**] is a 58-year-old
female with metastatic pancreatic neuroendocrine cancer. In
[**2128-4-28**], the patient noted a decline in weight, appetite,
and energy after being diagnosed with metastatic pancreatic
neuroendocrine cancer. Her disease is extensive, involving
the liver, axial skeleton, and retroperitoneum.
On [**2128-6-14**], the patient received chemoembolization.
The following day, she became encephalopathic and her
Lactulose was increased. In addition, her BUN and creatinine
began to rise. Status post her chemoembolization therapy, it
is presumed that this resulted in her hepatic encephalopathy,
as well as acute renal failure secondary to acute tubular
necrosis (presumably by dye, dehydration, chemo).
On [**2128-6-16**], the patient became hypocalcemic as well as
hypotensive. At that point in time, the patient was nearly
unresponsive, and was admitted to the MICU for mental status
changes and questionable sepsis. She was started on
hemodialysis, as well as broad spectrum antibiotics.
On [**2128-6-18**], the patient was intubated. A central line
was placed and a right femoral Quinton catheter placed for
hemodialysis. Throughout her MICU admission, the patient had
fevers of 102-103, and on [**2128-6-23**], the patient was
extubated and made DNR/DNI status.
Over the next few days, the patient's fevers defervesced, and
the patient was transferred to the floor.
PAST MEDICAL HISTORY:
1. Left thigh melanoma.
2. Diet-controlled diabetes mellitus.
3. Hypothyroidism.
4. Metastatic pancreatic neuroendocrine cancer times two
months.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. Fentanyl patch 100 micrograms q. 72 hours, Fentanyl drip
at 175 micrograms IV q. one hour.
2. Flagyl 800 mg IV q. eight hours.
3. Ceftazidime 1 gram q. 48 hours.
4. Vancomycin by levels.
5. Protonix 40 mg IV q.d.
6. Ativan 0.5 to 2.0 mg IV q. one hour p.r.n.
7. Calcium acetate two tablets t.i.d. with meals.
8. Desitin.
9. Nystatin.
10. Miconazole.
11. Epo three times per week, Monday, Wednesday, and Friday.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs on transfer
to the floor: Temperature 95.9, blood pressure 106/68, heart
rate 112, respiratory rate 20, 02 98% on 4 liters nasal
cannula. General: This patient has severe cachexia of the
face, cervical area, upper limbs, and chest. She is very
frail appearing. HEENT: The pupils were equal, round, and
reactive to light. No cervical lymphadenopathy. The mucous
membranes were extremely dry. The tongue was shriveled. The
tongue was completely dry. The oropharynx was pink,
oropharynx dry. Positive maxillary torus. CV:
Tachycardiac, very loud flash prominent heart sounds, no
murmurs. Lungs: Auscultated and anteriorly only, but very
clear breath sounds, shallow breathing with limited movement
of air, the patient becomes fatigued with breathing and
respirations are mildly labored, able to visualize each rib
and intercostal space separately. Abdomen: Taut abdomen,
dull to percussion. Liver palpable approximately 15 cm below
the costal margin from the rib cage inferiorly, anasarca is
present. She has pitting edema from her costal margins to
her toes, although no weeping is present. Extremities:
Grossly edematous, strong dorsalis pedis pulses, palpable
posterior tibialis pulses. Capillary refill less than two
seconds, warm to touch. Right groin: Quinton catheter
present. Skin: Numerous cherry hemangiomas on the abdomen.
Pallor is present on all skin. Area of skin around Quinton
catheter clean, dry, no erythema, no warmth, no signs or
symptoms of infection. GU: Foley catheter present.
LABORATORY DATA: On transfer, the white blood count was 7.8,
hematocrit 28.3, platelets 210,000. Sodium 139, potassium
4.0, chloride 101, bicarbonate 22, BUN 49, creatinine 2.2,
glucose 157.
ASSESSMENT/PLAN: The patient is a 58-year-old female who is
at the terminal stage of her disease (metastatic pancreatic
neuroendocrine cancer). She was admitted to the floor for
minimally invasive care so that the patient would gain enough
strength to return home. She was hydrated gently with D5
half normal saline at 50 cc an hour, and received antibiotics
(vancomycin, Flagyl, ceftazidime) as well as PPI (Protonix)
for stomach discomfort.
Her pain was controlled with a Fentanyl drip (175 micrograms
per hour, which was titrated to 0) as well as a Fentanyl
patch (100 micrograms q. 72 hours) transdermally.
During this patient's admission much of her family was
involved in deciding her patient care. The patient and her
family were both very distraught over the abrupt change in
her health (during the year prior to hospitalization she was
very well functioning and was doing extremely well).
A Palliative Care consult was placed for the patient,
Palliative Care was to help with social as well as supportive
care in dealing with her pain as well as terminal illness.
When presented with the option of hemodialysis, the patient
stated that she was "not ready to throw in the towel". The
patient stated that she was very weak and that she was very
confused. She was able to review the options of continuing
hemodialysis-needing a permanent catheter placed, as well as
a possible need to remain inpatient for her hemodialysis.
The patient stated that the time frame for her illness was
faster than she was prepared for and needed more time to deal
with her illness. She stated that she would like to try the
permanent catheter with the goal of increased life expectancy
as well as increased movement, meaning that the patient would
like to be able to transfer herself to the chair.
After discussing this with the patient, it was arranged for
the patient to have a permanent hemodialysis catheter placed.
On [**2128-8-3**], after the patient had her hemodialysis
catheter placed, the patient was noted in hemodialysis to be
tachycardiac, tachypneic, low oxygen saturation, with a
respiratory distress.
The patient's condition at this point in time was discussed
with the attending, Dr. [**First Name (STitle) **], as well as the Renal Fellow,
Dr. [**Last Name (STitle) 1860**], and the consensus was to continue the hemodialysis
as her blood pressure tolerated. If the patient was without
improvement, the option remained to start empiric heparin,
but no CTA angiogram (concern for PE). The plan was
discussed with the patient's husband, daughter, and they
agreed and all the family's questions were answered.
On the day after this event, the events were discussed with
the patient and she stated "I don't know if I can do this
anymore". Her physical examination had not changed at this
point in time and her ascites/anasarca still remained from
her costal margin to her toes. Her Perma-Cath site was
intact with no signs or symptoms of infection. However, the
patient understood that she was in a very frail condition,
and she understood that it was very evident that she would
not tolerate transport to hemodialysis. The patient had
initially hoped to be discharged to home, with transport to
hemodialysis three times per week.
However, after her episode during hemodialysis, it was
evident that the patient could possibly not even tolerate the
transport back home. At this point in time, the family as
well as the patient expressed a desire to have the patient
return to home as the number one priority, instead of having
hemodialysis as the number one priority. This was discussed
with Palliative Care, and it was decided that the patient
would be discharged to home, and at that point in time the
family and the patient could decide on hemodialysis if it was
still desired.
On [**2128-6-5**], the patient received her last dialysis
treatments as an inpatient which she tolerated quite well.
Her blood pressure predialysis was 120/75, pulse rate 111,
and her blood pressure postdialysis was 107/59, pulse 124;
2.7 kilograms were removed from the patient, and she
tolerated this procedure well without any shortness of
breath.
The following day, [**2128-8-6**], the patient and family
were at bedside. The patient was discharged to home via
stretcher and ambulance. The patient's home is in [**State 1727**]. On
the day of discharge, the patient appeared comfortable, and
understood that she was going home. The patient was given
prescriptions for all of her pain medications (Oxycodone
elixir/Fentanyl patches) as well as her nausea and anxiety
(Ativan).
Dictated By:[**Last Name (NamePattern1) 14484**]
MEDQUIST36
D: [**2129-2-2**] 05:58
T: [**2129-2-5**] 17:01
JOB#: [**Job Number 30179**]
|
[
"197.7",
"584.5",
"518.81",
"572.2",
"157.8",
"198.5",
"V58.1",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"99.25",
"96.04",
"39.95",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2311, 8781
|
1608, 2296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,409
| 172,994
|
53632
|
Discharge summary
|
report
|
Admission Date: [**2161-2-19**] Discharge Date: [**2161-2-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
CC:[**CC Contact Info 110158**]
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
HPI: An 81yoM with HTN, BPH, and anxiety, who was in his usual
state of good health until this morning when as he was about to
start his routine mornine exercises, he noted the onset of
L-sided chest pressure/ache. He occasionally experiences
musculoskeletal chest pain which he describes as different in
character from the pain this morning. He stopped exercising and
laid down, but the sensation persisted. He took one of his
wife's nitro SL (which may have expired) with no improvement in
symptoms. He also reported onset of nausea and diaphoresis, and
vomited green/yellow emesis (he had not eaten breakfast). He had
a normal bowel movement, which was followed several minutes
later by non-bloody diarrhea. Of note, Pt. reports several falls
within the last year (?syncope).
.
He was reluctant to go to hospital, mostly becuase he does not
tolerate laying down due to bone/joint pain, but his daughter
insisted that he go to [**Name (NI) **]. In ED, ECG revealed NSR, L axis,
1st-degree heart block, RBBB, widened QRS, 3mm STE in II, III,
AvF, reciprocal STD in V1-V4, nl R-wave progression. R-sided ECG
revealed 1mm STD in V4. (prior ECG [**2159-7-26**]: NSR with first
degree AVB, LAFB and RBBB). Pt. was given 600mg plavix and 325mg
ASA. 5000U heparin bolus and gtt, and integrillin gtt started in
preparation for PCI.
.
On ROS, Pt. denied HA, vision changes, lightheadedness,
dizziness, vertigo, SOB/DOE, palpitations, constipation,
abdominal pain, dysuria, hemetemesis, or hematochezia/BRBPR.
.
Pt. underwent left heart catheterization, left ventriculography,
coronary angiography, and DES to RCA lesion.
Past Medical History:
HTN
uveitis
anxiety
BPH
R hip fusion secondary to scarlet fever in childhood
cholecystetomy s/p cholecystitis, '[**58**].
CRI with crcl 20ml/min
Social History:
SH: He is a nonsmoker and does not drink any alcohol. He is a
retired theoretical physicist, lives with his wife, who was
diagnosed with NHL in [**2155**] but is currently in remission.
Family History:
FH: Both parents were healthy with no chronic health problems.
His mother died at 84yo, father died at 70yo from complications
s/p stroke. He has one sister who is 82yo and alive and well. He
has two children who are healthy.
Physical Exam:
PE: VS: 103/54 | 82 | 24 | 100% on 3L NC
gen: NAD, pleasant, resting comfortably in bed, chest-pain free.
HEENT: L>R pupil (old), reactive, EOM intact, OP clear, MMM, no
JVD, no carotid bruit.
neck: no masses, no LAD.
CV: RRR, nl s1s2, no murmurs.
chest: CTA b/l, no crackles or wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: R groin cath site with pressure dressing, LE warm well
perfused, 2+ dp pulses, no cyanosis, no LE edema.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly non-focal.
Pertinent Results:
[**2161-2-19**] 12:38PM BLOOD WBC-15.5* RBC-3.93* Hgb-12.4* Hct-34.5*
MCV-88 MCH-31.6 MCHC-36.0* RDW-14.0 Plt Ct-168
[**2161-2-21**] 07:35AM BLOOD WBC-14.0* RBC-3.53* Hgb-10.4* Hct-29.9*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.2 Plt Ct-131*
[**2161-2-19**] 12:38PM BLOOD PT-11.9 PTT-25.3 INR(PT)-0.9
[**2161-2-20**] 05:20AM BLOOD PT-12.4 PTT-29.2 INR(PT)-1.0
[**2161-2-19**] 12:38PM BLOOD Glucose-135* UreaN-24* Creat-1.2 Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
[**2161-2-21**] 07:35AM BLOOD Glucose-93 UreaN-26* Creat-1.3* Na-142
K-4.0 Cl-107 HCO3-26 AnGap-13
[**2161-2-19**] 12:38PM BLOOD CK(CPK)-122
[**2161-2-20**] 05:20AM BLOOD CK(CPK)-1253*
[**2161-2-19**] 09:47PM BLOOD CK(CPK)-1608*
[**2161-2-19**] 12:38PM BLOOD CK-MB-6
[**2161-2-19**] 12:38PM BLOOD cTropnT-<0.01
[**2161-2-19**] 09:47PM BLOOD CK-MB-234* MB Indx-14.6* cTropnT-9.67*
[**2161-2-20**] 05:20AM BLOOD CK-MB-150* MB Indx-12.0* cTropnT-9.96*
Cardiac Cath:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system
with acute occlusion of the distal RCA. The LMCA had mild distal
tapering. The LAD had diffuse plaquing with mild calcification.
There
were serial 50% stenoses in a major septal branch. The mid LAD
had 60%
stenosis. The LCx had a proximal 50% stenosis at the origin of
a high
OM1. The OM1 had 60% origin stenosis and 70% proximal stenosis.
The RCA
had moderate diffuse plaquing up to 40% in its proximal and mid
segments. It was totally occluded after the rPDA.
2. Limited hemodynamics revealed slightly elevated LVEDP
(after
intervention). There was no gradient on pull back of the
catheter from
the LV to the aorta.
3. Left ventriculography performed after intervention
demonstrated
slightly reduced ejection fraction of 50-55% with inferior and
posterobasal severe hypokinesis.
4. Successful PCI of the totally occluded distal RCA/RPL with
two
overlapping Cypher DES (3.0 x 13 mm and 2.5 x 28 mm, both
post-dilated
with a 3.0 mm balloon).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Acute occlusion of the distal RCA.
3. Successful PCI of the RCA.
Brief Hospital Course:
A/P: 81yoM with HTN, p/w inferior STEMI s/p cath; 3VD and DES to
RCA.
.
# Cardiac: s/p DES to RCA lesion. Patient did well after
procedure.
* ischemia: continue statin, ACE-i, aspirin. B blocker held
initially given prolong PR interval and initial bradycardia.
Re-started on [**2161-2-23**] tolerating it well.
* pump: EF=55-60% (diastolic dysfunction); continue ACE-i for
afterload reduction. Switched to Lisinopril/day. euvolemic on
exam. goal I/O: even.
* rhythm: NSR on telemetry EKG: 1 degree AV block and posterio
inferior hemiblock.
.
# HTN: patient normotensive during his hospital stay. Patient
stable on lisinopril and betablocker regimen.
.
# Hct: 35 to 28 s/p cath. He also developed a right groin
hematoma and a scrotal hematoma. Patient was transfuse one unit
of RBC with an adequate increased in HCT.
His HCT remained stable afterwards. HCT on day of discharged
27.70
.
# renal: slight increased in Cr following cath, no known h/o
renal disease. However creatinine came back to baseline levels.
(Cre 1.1 on day of discharge)
.
# Hem: Platelets slowly trended down to 125. Plateletes have
been stable over the last 72 hours prior to discharge
.
# Scrotal Hematoma: Scrotal hematoma developed [**2161-2-21**].
Improving by discharge day.
.
# hematuria: Pt. has ?prostate ca. hematuria either [**3-5**]
traumatic foley vs. prostate ca. Dr [**Last Name (STitle) 1007**] was made aware. -
will continue workup as outpt.
.
# anxiety: Patient was continued on his outpatient medication.
paxil.
.
# BPH: will continue proscar (finasteride) and Flomax
.
# Physical therapy evaluated him and cleared him to go home with
cardiac rehab in the near future.
.
# Disposicion: Patient was sent home. During hospitalization,
patient was educated on the importance of taking plavix and
aspirin everyday to prevent complications.
Medications on Admission:
ASA EC 81mg qd
lisinopril 10 mg qd
paxil 20mg qd
proscar
flomax
vitamins B6, B12 and C
folic acid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior ST elevation MI
Discharge Condition:
Good
Discharge Instructions:
Please continue your medications as prescribed.
Please follow up your appointments as scheduled.
It is very important to continue your aspirin and Plavix every
morning.
If you have any chest pain, shortness of breath, or any other
symptoms that may concern you call your PCP or come to the ED.
Followup Instructions:
Please follow up with your Dr [**Last Name (STitle) 1007**] on Monday 30th 2 pm
Please Follow up with Dr [**Last Name (STitle) **] in Cardiology. You have an
appointment on [**4-23**] at 10 am. However, Please call Dr [**Last Name (STitle) **]
office in 2 days for an update in your appointmet to see whether
it was re-scheduled for an early apppointment. Phone: [**Telephone/Fax (1) 110159**]
Completed by:[**2161-2-24**]
|
[
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"300.00",
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"403.91",
"599.7",
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.04",
"00.66",
"37.22",
"36.07",
"00.40",
"00.46",
"88.53",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
8102, 8108
|
5232, 7063
|
292, 306
|
8177, 8184
|
3134, 5083
|
8527, 8952
|
2337, 2564
|
7212, 8079
|
8129, 8156
|
7089, 7189
|
5100, 5209
|
8208, 8504
|
2579, 3115
|
222, 254
|
334, 1950
|
1972, 2118
|
2134, 2321
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,598
| 132,863
|
52255
|
Discharge summary
|
report
|
Admission Date: [**2126-6-11**] Discharge Date: [**2126-6-14**]
Date of Birth: [**2059-6-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Vicodin /
Ciprofloxacin / Keflex / Codeine / OxyContin / Clindamycin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fever, chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
66F with PMH diabetes and psoriatic arthritis on Infliximab,
methotrexate, prednisone taper who p/w ~5 day hx of fevers (to
103), B/L rib pain, and chills. Pt was on cruise in Bermuda and
returned 4d ago. During the cruise, she had an allergic reaction
on her face to a spa facial, resolved after about a week. [**12-17**]
days after, her rigors and fever started. Also noted pain in B/L
ribs recently. Has a h/o CP that her cardiologist has attributed
to costochondritis. Her last dose of infliximab was 4 weeks ago,
was scheduled for next dose on day of admission but cancelled
due to fevers. She saw her PCP in clinic yesterday, who was
concerned about infection given the rigors, fever, and
immunosuppressive meds, and wanted her to get cultures and
abdominal CT to r/o abdominal abscess. Of note, the patient
underwent liver biopsy one month ago at [**Hospital1 112**] after she had
developed liver "problems" when on MTX previously, biopsy was
normal per pt. this time. Endorses recent weight gain from
prednisone, about 50 pounds over the past year.
In the ED, initial VS: 98.8 81 106/67 16 96% RA. On exam, she
was TTP in ribs, LLQ, knee and hand joints. Abdominal CT w/
contrast and CTA chest showed no PE or PNA, increased central
lymphadenopathy of undetermined significance, no abscess. She
was noted to desaturate to the high 80s on room air and so was
admitted to medicine. VS at transfer: 98.7 78 134/67 17 95% 3L
NC. She was given 1L NS in the ED.
Overnight, her O2 requirement started to increase to the point
that she was persistent hypoxemic to low 80s on a 40% ventimask.
ABG showed 7.43/42/68. ID was consulted as there was concern
for PCP [**Name Initial (PRE) 1064**]. She was started on bactrim 2 DS TID for PCP
treatment, increased to prednisone 30 mg [**Hospital1 **] (from her 2.5 mg a
day taper dose). She was then admitted to the MICU for
persistent hypoxemia.
In the MICU, there was suspicion for volume overload causing her
hypoxemia in addition to possible infection. She was started on
IV lasix 20mg [**Hospital1 **] and continued on the bactrim/prednisone
regimen. Her hypoxemia improved. She no longer required
ventimask and was transferred back to the medicine floor. On the
floor, she did not complain of SOB but did complain of continued
chest wall tenderness and pain in her joints. She denied fever,
chills, night sweats, or LOA. She was mainly concerned about
being on a higher dose of prednisone, as it took her a long time
to be weaned down to 2.5mg per day.
Past Medical History:
-Psoriatic arthritis, currently treated with Humira, MTX, and
prednisone
-Methotrexate liver toxicity
-Hyperthyroidism s/p ablation
-DM, controlled with diet/exercise
-hypertension
-hyperlipidemia
-atrial flutter ([**2119**])
-OSA
-macular degeneration
Past GI History:
-rectal bleed: suspected hypoperfusion ischemic colitis([**7-/2120**])
-hemorrhoids
-diverticulosis
-IBS
-[**Last Name (un) 865**] esophagus (EGD [**2115**])
-cholelithiasis
Past MSK/Neurologic history:
-R ulnar nerve transposition
-lumbar disc disease
-frontal lobe dysfunction w/ early frontotemporal atrophy
possibly secondary to neurodegenerative process: Neuropsych
testing [**12/2120**] demonstrated mild deficits in attention and
executive function; average intellectual functions
-TIA, amaurosis fugax
-vertigo
-migraine headaches
Past Surgical History:
-L5-S1 fusion with L5 laminectomy ([**2114**])
-C5-C7 cervical spinal fusion with anterior instrumentation
([**2121**])
-Lumbar L3-5 vertebrectomy with fusion, anterior spacers, and
autograft, bone morphogenic protein and allograft ([**2123-1-17**])
-Posterior lumbar fusion and revision laminectomy ([**2123-1-17**]),
complicated by dural tear patched with Duragen and Tisseel, as
well as pseudomeningocoele and subdural hematoma
-hemorrhoidectomy [**2086**], [**2116**]
-Bilateral rotator cuff tear/repair (R [**10/2120**], L [**7-/2122**])
Social History:
Patient was born in [**Location (un) 3786**] and raised in [**Location (un) 2251**] and [**Location (un) 686**].
She graduated high school and worked her way up to a managerial
position at a supermarket chain. She retired several years ago.
She currently lives in [**Location 2203**] with her husband. She quit
smoking 5 years ago when her twin sister developed CHF. Had been
smoking since age 16, 3 cigarettes per day (~5 pack-years).
Minimal alcohol consumption. Denied use of other drugs.
Family History:
Patient has 3 sons and 3 grandsons. Family history of mental
illness/alcoholism (both parents), denied history of lung
problems.
[**Name (NI) 3495**] disease: twin sister developed CHF at 58(extensive smoking
history and HTN), father d. MI at 49, son had MI at 44.
Cancer: maternal aunt and grandmother had breast cancer in their
60s-70s. Maternal uncle had penile cancer. Paternal grandmother
had breast cancer in her 40s.
Diabetes: Twin sister, sister (d. 59), maternal aunt.
"Kidney nephrosis": twin sister awaiting renal transplant,
sister's son had episode of anuria and swelling at age [**1-18**].
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - satting 94% on 2L NC
Gen - well nourished, non-toxic appearing elderly woman in NAD
HEENT - NCAT, MMM, EOMI, PERRL, sclera anicteric, conjunctiva
pink, OP clear
CV - RRR, no m/g/r, normal S1 and S2, PMI nondisplaced
Resp - poor inspiratory effort (secondary to chest wall pain),
bibasilar crackles, no wheezes or rhonchi
Abd - s, nd, nt, no organomegaly, normoactive BS
Ext - WWP, no e/c/c, 2+ peripheral pulses
Neuro - CN II-XII intact, 5/5 strength, no sensory deficits,
normal finger-to-nose test
Skin - erythematous, dry skin on face and neck
DISCHARGE PHYSICAL EXAM:
Vitals - 98.4, 98/46, 57, 18, 94% on 2L NC
Gen - well nourished, non-toxic appearing elderly woman in NAD
HEENT - NCAT, MMM, EOMI, PERRL, sclera anicteric, conjunctiva
pink, OP clear
CV - RRR, no m/g/r, normal S1 and S2, PMI nondisplaced
Resp - normal inspiratory effort, mild crackles in R middle
lobe, no wheezes or rhonchi
Abd - s, nd, nt, no organomegaly, normoactive BS
Ext - WWP, no e/c/c, 2+ peripheral pulses
Neuro - CN II-XII intact, 5/5 strength, no sensory deficits,
normal finger-to-nose test
Skin - erythematous, dry skin on face and neck is stable
Pertinent Results:
ADMITTING LABS:
[**2126-6-10**] 04:00PM BLOOD WBC-6.9 RBC-3.94* Hgb-13.0 Hct-38.6
MCV-98 MCH-33.1* MCHC-33.8 RDW-15.0 Plt Ct-215
[**2126-6-10**] 04:00PM BLOOD Neuts-57.2 Lymphs-29.2 Monos-10.3 Eos-2.5
Baso-0.7
[**2126-6-10**] 04:00PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-143
K-3.9 Cl-105 HCO3-30 AnGap-12
[**2126-6-10**] 04:00PM BLOOD ALT-23 AST-24 AlkPhos-27* TotBili-0.3
[**2126-6-11**] 08:35AM BLOOD LD(LDH)-389*
[**2126-6-10**] 04:00PM BLOOD Lipase-14
[**2126-6-10**] 04:00PM BLOOD proBNP-202
[**2126-6-10**] 04:00PM BLOOD Albumin-4.3
[**2126-6-11**] 11:05AM BLOOD Type-ART Temp-38.9 FiO2-40 pO2-68*
pCO2-42 pH-7.43 calTCO2-29 Base XS-2 Intubat-NOT INTUBA
RELEVANT LABS:
[**2126-6-10**] 04:12PM BLOOD Lactate-1.4
[**2126-6-11**] 08:35AM BLOOD LD(LDH)-389*
[**2126-6-11**] 11:05AM BLOOD Type-ART Temp-38.9 FiO2-40 pO2-68*
pCO2-42 pH-7.43 calTCO2-29 Base XS-2 Intubat-NOT INTUBA
[**2126-6-10**] 04:12PM BLOOD Lactate-1.4
[**2126-6-11**] 12:45PM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-NEGATIVE
[**2126-6-11**] 08:35AM BLOOD B-GLUCAN-NEGATIVE
DISCHARGE LABS:
[**2126-6-14**] 06:50AM BLOOD WBC-9.6 RBC-4.16* Hgb-14.1 Hct-41.3
MCV-99* MCH-33.8* MCHC-34.0 RDW-15.1 Plt Ct-254
[**2126-6-14**] 06:50AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-135
K-4.1 Cl-101 HCO3-24 AnGap-14
[**2126-6-14**] 06:50AM BLOOD LD(LDH)-325*
PERTINENT MICRO/PATH:
DIPSTICK
U
R
I
N
A
L
Y
S
IS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
[**2126-6-10**] 18:10 NEG NEG TR NEG NEG NEG NEG 7.5 TR
[**2126-6-14**] 4:30 pm URINE Source: CVS.
**FINAL REPORT [**2126-6-15**]**
Legionella Urinary Antigen (Final [**2126-6-15**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2126-6-13**] 3:54 pm SPUTUM Source: Induced.
**FINAL REPORT [**2126-6-14**]**
GRAM STAIN (Final [**2126-6-13**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
[**2126-6-13**] 6:45 am BLOOD CULTURE
**FINAL REPORT [**2126-6-19**]**
Blood Culture, Routine (Final [**2126-6-19**]): NO GROWTH.
[**2126-6-12**] 5:53 am Blood (EBV) EBVP ADDED TO CHEM#[**Serial Number **]A.
**FINAL REPORT [**2126-6-13**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2126-6-13**]):
Test canceled and patient credited due to a prior EBV
panel sent on
[**2123-4-29**] indicating evidence of past infection (EBV
VCA-IgG positive,
EBNA IgG positive and EBV VCA-IgM negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3 months.
For any questions, contact the [**Hospital **] Medical
Director.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2126-6-13**]):
TEST CANCELLED, PATIENT CREDITED.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2126-6-13**]):
TEST CANCELLED, PATIENT CREDITED.
[**2126-6-11**] 12:45 pm Immunology ([**Month/Day/Year 1074**])
**FINAL REPORT [**2126-6-14**]**
[**Month/Day/Year 1074**] Viral Load (Final [**2126-6-14**]):
[**Month/Day/Year 1074**] DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
NOT FOR USE IN DIAGNOSTIC PROCEDURES.
FOR RESEARCH USE ONLY..
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2126-6-10**] 6:10 pm URINE
**FINAL REPORT [**2126-6-11**]**
URINE CULTURE (Final [**2126-6-11**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2126-6-11**] 8:35 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
PERTINENT IMAGING:
CHEST (PA & LAT) Study Date of [**2126-6-10**] 1:49 PM
IMPRESSION: No evidence of acute cardiopulmonary infectious
process.
CT ABD & PELVIS WITH CONTRAST and CTA CHEST Study Date of
[**2126-6-10**] 7:52 PM
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic syndrome.
2. Borderline central lymphadenopathy, of uncertain clinical
significance,
slightly increased in size since [**2123-5-14**] exam.
3. Cholelithiasis without evidence of acute cholecystitis.
4. A 12 x 10 mm left adnexal cyst, stable since [**2123-5-14**] exam,
which can be
further assessed with pelvic ultrasound exam on non-emergent
basis.
ECHO [**2126-6-12**]
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2122-2-6**],
the findings are similar.
Brief Hospital Course:
Primary Reason for Admission:
66 year old female with a past medical history of psoriatic
arthritis on infliximab, methotrexate, and prednisone presenting
with fevers, now with persistent hypoxemia.
Active Diagnoses:
# Hyoxemia/Fevers:
The source of the pt's fever was suspected to be the lungs, as
she was hypoxemic. The differential diagnosis was infectious
(PCP, [**Name10 (NameIs) 1074**], EBV, community acquired PNA), PE, volume overload, or
rheumatologic. However, her imaging studies were more consistent
with mild volume overload than infection or PE. There were
questionable foci of GGO on chest CT, and the ID team recommend
empiric treatment for PCP given her hx of immunosuppression. She
was put on Bactrim and prednisone. In the MICU, she was also
diuresed with IV lasix 20mg [**Hospital1 **] due to the appearance of volume
overload on repeat CXR. It was after receiving both of these
therapies that her hypoxemia improved, so it was unclear what
she was actually responding to. She had an ECHO which showed
normal systolic function and no hypertrophy, although diastolic
HF is still possible given the 1L bolus NS she received in the
ED. As her hypoxemia continued to improve and she remained
afebrile, ID re-examined her. All teams agreed that suspicion
for PCP was low, and her bactrim and prednisone were
discontinued (continued on home dose of prednisone). Lasix was
stopped when she appeared euvolemic. Her clinical status
improved, and we felt it was safe to discharge her. All of her
cultures came back negative, so the infectious source is still
unclear. We advised her to call her PCP or the [**Hospital **] clinic if her
fevers return.
# Hypotension:
The pt's BP fluctuated throughout the beginning of her stay, and
her family reports that this is typical. She had an incidence of
SBP to the 90s, but was asymptomatic. We held her home Imdur and
valsartan, and she remained hemodynamically stable. IVFs were
held for possible pulmonary edema. She was normotensive upon
discharge, and instructed to follow up with her cardiologist as
soon as possible to adjust her medications.
# Coag negative staph aureus blood culture:
The pt had one blood culture positive for coat negative staph
shortly after admission. Although most likely a contaminant, the
ID team recommended she be started on vanc given her
immunosuppression. She was on vanc for 3 days, when it appeared
she was having Red Man Syndrome. After discussing the likelihood
of contamination versus true infection, it was decided to stop
vanc rather than continue at a slower infusion rate. Vanc was
stopped, and her fever did not return. Suspicion for blood
stream infection was low.
# Cough:
On the last few days of her stay, the pt complained of a dry
scratchy cough and squeezing sensation in her throat. Although
the cough may have been related to her hypoxemia/fever, it
appeared most consistent with GERD, and she has a history of
[**Last Name (un) 27191**] esophagus. We continued her home PPI. If her symptoms
continue, she should probably have follow up with GI or perhaps
repeat endoscopy.
Chronic Diagnoses:
# Psoriatic arthritis:
She continued to complain of joint pain throughout her
hospitalization. We managed her pain with her home medications.
She missed her infliximab dose, and we advised her to skip the
next methotrexate dose given her recent fevers. We discharged
her on her home dose of prednisone, 2.5mg daily. A follow up
appointment was made within a week of discharge with her
rheumatologist.
# Diabetes:
She had acceptable FSBG requiring little insulin on ISS.
Transitional Issues:
# Follow up with [**Hospital **] clinic or PCP if fevers return.
# Imdur and valsartan were stopped due to low SBPs. These will
need readjustment when she sees her PCP at the appointment we
made for her soon after discharge.
#For her psoriatic arthritis, she will follow up with her
rheumatologist within the next week to discuss appropriate
treatment given her recent infection.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. PredniSONE 5 mg PO QOD Duration: 1 Doses Start: [**6-12**]
2. PredniSONE 2.5 mg PO QOD Duration: 14 Days Start: After 5 mg
tapered dose.
3. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral TID:PRN
migraine
4. Valsartan 40 mg PO DAILY
hold for SBP<100
5. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
apply to back, legs, other areas as directed by patient
6. Methotrexate 15 mg PO 1X/WEEK (MO)
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES [**Hospital1 **]
8. Infliximab Dose is Unknown IV Q4WEEKS
9. Pravastatin 40 mg PO HS
10. Multivitamins 1 TAB PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold for SBP<100
12. oxyCODONE-acetaminophen *NF* 10-325 mg Oral Q6H:PRN pain
13. Oxymorphone HCl 20 mg PO DAILY:PRN pain
Hold for sedation, RR<10
14. esomeprazole magnesium *NF* 40 mg Oral daily
15. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100
mg-unit Oral daily
16. Aspirin 81 mg PO DAILY
17. traZODONE 100 mg PO HS
18. Levothyroxine Sodium 100 mcg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
apply to back, legs, other areas as directed by patient
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES [**Hospital1 **]
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pravastatin 40 mg PO HS
7. PredniSONE 5 mg PO QOD Duration: 1 Doses
8. traZODONE 100 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. butalbital-acetaminophen-caff *NF* 50 mg ORAL TID:PRN
migraine
11. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100
mg-unit Oral daily
12. Esomeprazole Magnesium *NF* 40 mg ORAL DAILY
13. Methotrexate 15 mg PO 1X/WEEK (MO)
14. oxyCODONE-acetaminophen *NF* 10-325 mg ORAL Q6H:PRN pain
15. Oxymorphone HCl 20 mg PO DAILY:PRN pain
16. PredniSONE 2.5 mg PO QOD Duration: 14 Days
after completing course of 5mg every other day
17. Infliximab 0 mg IV Q4WEEKS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1. Hypoxemia
2. Fever
3. Hypotension
Secondary diagnoses:
1. psoriatic arthritis
2. diabetes mellitus
3. paroxysmal atrial fibrillation
4. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 66749**],
It was a pleasure taking care of you at [**Hospital1 18**]. You came to the
hospital for fever, chills, and chest pain. Your oxygen levels
were found to be dangerously low, so you were taken to the
intensive care unit to have supplemental oxygen delivered. A CT
scan of your chest was performed, which did not show an
explanation for your low oxygen levels. The infectious disease
team was consulted for your fever, and they initially
recommended treatment with antibiotics and steroids. You were
also given water pills to make you urinate and help relieve your
lungs of extra fluid. Your oxygen levels improved fairly
quickly, and we were able to stop the high dose prednisone and
antibiotics. It is not clear what the cause of the low oxygen
level was, but we now feel it is safe for you to leave the
hospital. If you develop a fever, please call the infectious
disease clinic at([**Telephone/Fax (1) 4170**] and your primary care doctor.
While in the hospital, your blood pressure became lower than
normal, so we stopped your home medications for hypertension.
Your blood pressure returned to [**Location 213**] range. We recommend you
refrain from taking these medications upon leaving the hospital
(see below).
When you leave the hospital, we recommend you skip your next
dose of methotrexate and return to your home regimen of
prednisone. We have made follow up appointments for you with
your primary care physician, [**Name10 (NameIs) 2085**], and rheumatologist
(see below).
We have made the following changes to your medications:
-STOP methotrexate x 1 dose
-STOP imdur
-STOP valsartan (diovan)
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2126-6-17**] at 11:15 AM
With: DR. [**First Name8 (NamePattern2) 507**] [**Name (STitle) **] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parki
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital6 9657**] ORTHOPEDIC & ARTHRITIS
Address: [**Location (un) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 4759**]
Appt: [**6-26**] at 10:20am
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]-[**Location (un) **],
CARDIAC SERVICES
Address: [**Street Address(2) 3001**], [**Location (un) 620**], MA
Phone: [**Telephone/Fax (1) 4105**]
Appt: [**7-3**] at 9am
ng
Department: VASCULAR SURGERY
When: MONDAY [**2128-1-26**] at 10:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] MEDICAL GROUP
When: WEDNESDAY [**2126-7-10**] at 9:45 AM
With: DR. [**First Name8 (NamePattern2) 507**] [**Name (STitle) **] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2126-6-22**]
|
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"E930.8",
"362.50",
"250.00",
"V15.82",
"427.31",
"V58.65",
"458.9",
"327.23",
"696.0",
"276.69",
"136.9",
"401.9",
"530.81",
"799.02",
"693.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17969, 17975
|
11911, 12111
|
396, 403
|
18183, 18183
|
6676, 7726
|
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|
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|
10890, 11888
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|
338, 358
|
431, 2940
|
18198, 18310
|
12129, 15490
|
2962, 3774
|
4357, 4851
|
6094, 6657
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,356
| 135,379
|
3475
|
Discharge summary
|
report
|
Admission Date: [**2119-10-31**] Discharge Date: [**2119-11-6**]
Date of Birth: [**2060-3-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
S/p arrest
Major Surgical or Invasive Procedure:
Intubation
CPR
History of Present Illness:
59 y/o male with h/o PAD s/p Rt BKA, Lt SFA-DP graft w/ recent
in graft angioplasty, ESRD on HD (T,Th,S) h/o noncompliance with
HD, HTN, DM, HLD presented from rehab with confusion, and was
found to have hyperkalemia and developed VT arrest.
.
Pt was recently admitted for PTA SFA-DP in graft stenosis
repair, and was discharged on [**10-27**] to rehab. Of note, his last
dialysis was on [**10-26**] (Thurs). His labs on [**10-27**] was notable for
K 4.9, BUN 43. Somehow, pt refused HD on Saturday. He was found
to be confused and lethargic today, and hypoglycemic at 40s. He
was subsequently sent to ED from the nursing home.
.
In the ED, initial VS was 95.0 96 108/74 18 93% 2L. Pt was
initially mentating well. Initial EKG showed wide QRS and QTc
prolongation, which later turned into polymorphic VT. Subsequent
lab work was notable for K 7.6, pH 7.13, bicarb 8, lactate 12.6
and glucose 47. CPR was given. ROSC was achieved without
defibrillation. Pt was intubated, and LIJ, REJ, R-femoral line
and L shin-IO were placed. He received calcium gluconate, D50
and ?insulin. Dialysis was started in the ED. After initial
stabilization, pt was transferred to the MICU.
.
On arrival to the MICU, his VS were: Temp 32.5, HR 75, BP
80s/40s, RR 14, O2 sat 98% on mechanical ventilation 550X16,
14/5, FiO2 60%. Levophed was started.
Past Medical History:
DMII
HTN
ESRD on HD TThSa
Peripheral neuropathy
Secondary hyperparathyroidism
Nephrotic syndrome
Hyperlipidemia
PAD s/p bypass, angioplasty [**2117-12-16**], s/p toe amputations [**2117-1-18**],
s/p R BKA [**2117**]
Diastolic Heart Failure
Psoriasis
MRSA wound infection
Social History:
Unemployed, came in from skilled nursing facility ([**Location (un) 582**]), no
pets. No cigs, EtOH, drugs.
Family History:
Diabetes in multiple family members
Physical Exam:
General: Intubated, abdominal muscle breathing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: bronchial breath sound on mechanical ventilation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, no clubbing, cyanosis or edema
Neuro: deferred.
Pertinent Results:
[**2119-11-6**] 01:52AM BLOOD WBC-36.4* RBC-2.50* Hgb-8.5* Hct-27.8*
MCV-111*# MCH-34.1* MCHC-30.6* RDW-18.7* Plt Ct-76*
[**2119-11-5**] 03:35AM BLOOD WBC-31.5* RBC-2.67* Hgb-9.3* Hct-31.6*
MCV-118* MCH-34.7* MCHC-29.4* RDW-18.4* Plt Ct-116*
[**2119-11-4**] 07:22PM BLOOD WBC-27.5* RBC-2.94* Hgb-10.1* Hct-33.5*
MCV-114*# MCH-34.2* MCHC-30.0* RDW-18.3* Plt Ct-119*
[**2119-11-4**] 02:52AM BLOOD WBC-23.6* RBC-2.77* Hgb-9.6* Hct-29.4*
MCV-106* MCH-34.5* MCHC-32.5 RDW-17.8* Plt Ct-109*
[**2119-11-3**] 03:29AM BLOOD WBC-21.5* RBC-2.45* Hgb-8.5* Hct-27.2*
MCV-111* MCH-34.8* MCHC-31.3 RDW-17.5* Plt Ct-131*
[**2119-11-2**] 03:03AM BLOOD WBC-19.0* RBC-2.53* Hgb-8.6* Hct-27.0*
MCV-107* MCH-33.8* MCHC-31.6 RDW-17.9* Plt Ct-113*
[**2119-10-31**] 10:00PM BLOOD WBC-11.3* RBC-2.42* Hgb-8.6* Hct-26.9*
MCV-111* MCH-35.3* MCHC-31.8 RDW-17.7* Plt Ct-145*
[**2119-10-31**] 05:23PM BLOOD WBC-12.5* RBC-2.62* Hgb-9.1* Hct-28.3*
MCV-108*# MCH-34.7* MCHC-32.2 RDW-17.5* Plt Ct-181
[**2119-10-31**] 11:24AM BLOOD WBC-21.4*# RBC-3.12* Hgb-10.9* Hct-36.8*#
MCV-118*# MCH-34.9* MCHC-29.6*# RDW-17.2* Plt Ct-202
[**2119-10-31**] 11:24AM BLOOD Neuts-96.2* Lymphs-2.2* Monos-1.4*
Eos-0.1 Baso-0.1
[**2119-11-6**] 01:52AM BLOOD Plt Ct-76*
[**2119-11-6**] 01:52AM BLOOD PT-25.2* PTT-45.8* INR(PT)-2.4*
[**2119-11-6**] 01:52AM BLOOD Glucose-213* UreaN-48* Creat-4.4* Na-129*
K-4.2 Cl-86* HCO3-22 AnGap-25*
[**2119-11-5**] 03:35AM BLOOD Glucose-98 UreaN-38* Creat-4.0* Na-135
K-5.0 Cl-94* HCO3-12* AnGap-34*
[**2119-11-4**] 07:22PM BLOOD Glucose-80 UreaN-33* Creat-3.6*# Na-137
K-4.5 Cl-99 HCO3-15* AnGap-28*
[**2119-10-31**] 01:00PM BLOOD Glucose-203* UreaN-122* Creat-11.3*
Na-138 K-6.4* Cl-96 HCO3-7* AnGap-41*
[**2119-10-31**] 11:24AM BLOOD Glucose-53* UreaN-121* Creat-11.6*#
Na-138 K-8.2* Cl-89* HCO3-8* AnGap-49*
[**2119-11-5**] 03:35AM BLOOD ALT-1052* AST-952* AlkPhos-219*
TotBili-6.0*
[**2119-11-4**] 02:52AM BLOOD ALT-1519* AST-483* AlkPhos-178*
TotBili-5.3*
[**2119-11-3**] 03:29AM BLOOD ALT-2357* AST-1254* AlkPhos-142*
TotBili-3.8*
[**2119-11-2**] 03:03AM BLOOD ALT-3311* AST-2818* AlkPhos-125
TotBili-2.5*
[**2119-11-1**] 02:56PM BLOOD ALT-3461* AST-3934* AlkPhos-110
TotBili-1.8*
[**2119-11-1**] 03:29AM BLOOD ALT-3807* AST-6531* AlkPhos-99
Amylase-389* TotBili-1.4
[**2119-10-31**] 01:00PM BLOOD ALT-2555* AST-4581* CK(CPK)-221
AlkPhos-105 Amylase-160* TotBili-0.7
[**2119-10-31**] 11:24AM BLOOD ALT-2196* AST-3730* LD(LDH)-5070*
CK(CPK)-215 AlkPhos-114 TotBili-1.0
[**2119-11-1**] 03:29AM BLOOD Lipase-111*
[**2119-10-31**] 01:00PM BLOOD Lipase-79*
[**2119-10-31**] 01:00PM BLOOD CK-MB-7 cTropnT-0.23*
[**2119-10-31**] 11:24AM BLOOD CK-MB-8 cTropnT-0.27*
[**2119-11-6**] 01:52AM BLOOD Calcium-7.9* Phos-6.1*# Mg-1.9
[**2119-11-5**] 03:35AM BLOOD Calcium-8.5 Phos-8.8*# Mg-2.2
[**2119-11-4**] 07:22PM BLOOD Calcium-8.3* Phos-6.5*# Mg-2.0
[**2119-11-3**] 08:07AM BLOOD Cortsol-52.9*
[**2119-10-31**] 01:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-NEGATIVE IgM HAV-NEGATIVE
[**2119-11-6**] 01:58AM BLOOD Type-ART pO2-61* pCO2-37 pH-7.43
calTCO2-25 Base XS-0
[**2119-11-5**] 06:12PM BLOOD Type-ART Temp-37.8 Rates-14/ PEEP-5
FiO2-40 pO2-168* pCO2-37 pH-7.37 calTCO2-22 Base XS--3
Intubat-INTUBATED Vent-CONTROLLED
[**2119-11-4**] 08:12PM BLOOD Type-ART Temp-37.6 PEEP-5 FiO2-40
pO2-185* pCO2-37 pH-7.27* calTCO2-18* Base XS--8
Intubat-INTUBATED
[**2119-10-31**] 01:32PM BLOOD Type-ART Rates-/13 PEEP-5 FiO2-60
pO2-238* pCO2-24* pH-7.04* calTCO2-7* Base XS--23
[**2119-10-31**] 11:53AM BLOOD Type-ART Tidal V-116 PEEP-5 O2 Flow-100
pO2-431* pCO2-28* pH-7.02* calTCO2-8* Base XS--23
Intubat-INTUBATED Vent-SPONTANEOU
[**2119-11-6**] 01:58AM BLOOD Lactate-8.1*
[**2119-11-5**] 02:27PM BLOOD Lactate-9.1*
[**2119-11-5**] 03:52AM BLOOD Glucose-85 Lactate-14.0*
[**2119-11-4**] 08:12PM BLOOD Lactate-11.0*
[**2119-11-4**] 12:09PM BLOOD Lactate-7.8*
[**2119-11-2**] 01:08AM BLOOD Lactate-2.9*
[**2119-10-31**] 01:32PM BLOOD Lactate-13.9*
[**2119-10-31**] 11:53AM BLOOD Glucose-146* Na-137 K-6.9* Cl-102
[**2119-10-31**] 11:22AM BLOOD Glucose-47* Lactate-12.6* Na-138 K-7.8*
Cl-100 calHCO3-8.0*
Echocardiography [**11-1**]:
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with septal, inferior and
inferolateral hypokinesis. The right ventricular cavity is
moderately dilated with depressed free wall contractility. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. [Due to acoustic shadowing, the severity
of aortic regurgitation may be significantly UNDERestimated.]
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional LV systolic dysfunction consistent
with CAD. Mild calcific aortic stenosis. At least mild mitral
and aortic regurgitation. Moderate pulmonary artery systolic
hypertension.
CT Abd/Pel [**11-1**]:
IMPRESSION:
1. Mediastinal adenopathy as described, no prior studies to
ensure stability.
No inflammatory process to suggest that these are reactive.
Would compare to
any prior outside studies to ensure stability or would consider
a six-month
followup.
2. Extensive calcification involving the coronary arteries,
aortic arch and
branches as well as the abdominal aorta and all its branches,
all consistent
with a history of diabetes.
3. Cardiomegaly.
4. Cholelithiasis, findings consistent with chronic renal
disease, all
unchanged.
Liver/Gallbladder US [**10-31**]:
IMPRESSION:
1. Slightly coarsened liver echotexture without focal lesions.
No biliary
duct dilation.
2. Cholelithiasis with marked gallbladder wall edema, likely
secondary to
hepatic dysfunction. If there is concern for acute
cholecystitis, however,
then a HIDA scan is recommended.
3. Mildly atrophic kidneys containing multiple cysts, likely
related to
hemodialysis.
Brief Hospital Course:
Pt s/p cardiac arrest in the emergency department where he
received 5 minutes of CPR. He was treated with broad spectrum
antibiotics for suspected sepsis. He received dialysis
throughout his stay in the ICU. [**Month/Year (2) **] surgery consulted for
prior leg stent. Throughout his ICU stay, lactate rising as high
as 13 with a pH of 7.14, poor lactate clearance and blood
cultures grew polymicrobial organisms including anaerobes,
enterococcus and strep viridians. Ultimately, patient lost gag
reflex and other brainstem functions despite being off sedation
medications for several days. After several family discussions,
patient made CMO and underwent palliative extubation. Patient
expired shortly after.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO four times
a day: prn for pain.
18. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. lactulose 10 gram/15 mL Solution Sig: One (1) PO once a day.
20. Insulin Sliding Scale
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
S/p cardiac arrest
Discharge Condition:
Pt expired
Completed by:[**2119-11-7**]
|
[
"276.2",
"275.42",
"427.5",
"790.4",
"427.1",
"570",
"585.6",
"518.81",
"696.1",
"572.3",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.07",
"99.60",
"39.95",
"38.91",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11131, 11140
|
8885, 9596
|
314, 330
|
11202, 11243
|
2624, 8862
|
2125, 2163
|
11105, 11108
|
11161, 11181
|
9622, 11082
|
2178, 2605
|
264, 276
|
358, 1688
|
1710, 1983
|
1999, 2109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,754
| 135,507
|
34751
|
Discharge summary
|
report
|
Admission Date: [**2145-9-30**] Discharge Date: [**2145-10-8**]
Date of Birth: [**2071-11-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastric carcinoma
Major Surgical or Invasive Procedure:
Subtotal gastrectomy.
History of Present Illness:
73-year-old man with a history of aortic stenosis and coronary
artery disease who was noted to be anemic and was further worked
up because of fatigue. An upper endoscopy showed a lesion at
the proximal fundus of the stomach. This has been biopsy-proven
adenocarcinoma. CT scan without contrast showed no other
abnormalities except for a probable cyst on the liver and a
renal stone. He has not had any dysphagia. After workup and
discussion at tumor conference it was decided with the patient
to schedule a gastrectomy.
Past Medical History:
-CAD
-aortic stenosis
-CABG x3 - [**2144-6-23**]
-aortic valve replacement (bioprosthetic) - [**2144-6-23**]
-dyslipidemia
-nephrolithiasis s/p laser lithotripsy
-polymyalgia rheumatica
-infected teeth
-s/p Multiple orthopedic surgeries
Social History:
Retired lawyer.
-Tobacco history: Non-smoker
-ETOH: No ETOH
-Illicit drugs: None
Family History:
No family history of early MI or gastric cancer, otherwise
non-contributory.
Physical Exam:
On physical examination, he is a well-developed,
healthy-appearing gentleman. Head, eyes, ears, nose, and throat
are normal. The neck is supple, without mass, nodes, or
thyromegaly. The chest is notable for some kyphosis. The lungs
are clear to percussion and auscultation. Heart sounds are
regular with a I-II/VI systolic ejection murmur heard best at
left sternal border. The abdomen is soft without tenderness,
mass, or organomegaly. There is a well-healed sternotomy scar.
The extremities are without cyanosis, clubbing, or edema. He
does have a saphenectomy scars which are well healed. He is
neurologically intact, though somewhat hard of hearing.
Pertinent Results:
[**2145-9-30**] 10:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2145-9-30**] 09:39PM GLUCOSE-121* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-26 ANION GAP-11
[**2145-9-30**] 06:40PM WBC-7.3 RBC-3.52* HGB-9.7* HCT-29.9* MCV-85
MCH-27.5 MCHC-32.5 RDW-16.6*
Brief Hospital Course:
The patient was admitted on same day for procedure, subtotal
gastrectomy was performed under general endotracheal anesthesia
through a vertical midline abdominal incision. Intraoperative
findings included a large tumor of the mid-stomach, mobile and
not well-attached to the wall. 2 enlarged lymph nodes were
noted around the mid stomach and lesser curvature, but there was
no evidence of metastatic disease to the liver or the peritoneal
surfaces. Intravenous antibiotics were given, and the procedure
was well tolerated.
In the PACU after the procedure the patient became tachycardic
to the 130's with max temperature of 102.6. He was
pan-cultured, given Tylenol x 2 doses, and became hypotensives,
requiring 1 unit packed red blood cells, and a Neo drip for
systolic blood pressure in the 80's. He was transferred to the
TICU for further monitoring.
A cardiology consult was obtained to further assist management.
Cardiac enzymes were noted to be elevated post-procedure, at
which point a heparin drip was started. An echo was performed,
showing persistently decreased LVEF of 20-25%, with possibly
worsened inferior hypokinesis. The heparin drip was
discontinued after 48 hours, at which point the troponin had
plateaued at 1.99 and the CK-MB was declining. After the
patient had stabilized clinically, he was transferred to the
floor. He did not complain of chest pain or shortness of breath
during this episode.
The patient gradually improved clinically, NG tube and Foley
were discontinued on post-operative day 6. His diet was
advanced, pain was increasingly well-controlled. He voided well
after the Foley was DC-ed, and ambulated independently.
The patient was discharged to home on post-operative day 8, at
which point the skin staples were removed, replaced with
steri-strips. The wound appeared clean, dry, and intact. He
was instructed to followup with Dr. [**Last Name (STitle) **] within the next
week, and he had an appointment scheduled with his cardiologist
in a week and a half. (Monday, [**10-18**]).
Medications on Admission:
1. METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet by mouth
daily
2. SIMVASTATIN [ZOCOR] - 40 mg by mouth daily
3. ASCORBIC ACID [VITAMIN C]
4. ASPIRIN [ENTERIC COATED ASPIRIN] 81 mg by mouth daily
5. IRON
6. MULTIVITAMIN
Discharge Medications:
1. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Carcinoma of stomach
Postoperative non-ST elevation myocardial infarction
Chronic coongestive heart failure, with acute exacerbation
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] MD if temperature greater than 100.5, increased redness or
drainage from incisions, pain not relieved with pain medication.
Do not immerse in water for 4 weeks.
You may shower. Pat incisions dry.
Do not drive while taking pain medication.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 2981**] for
an appointment. You should also call your cardiologist to
schedule an appointment in the next 2 weeks.
|
[
"426.3",
"272.4",
"414.00",
"535.10",
"997.1",
"V45.89",
"E878.8",
"725",
"285.9",
"428.23",
"410.71",
"V45.81",
"458.29",
"425.4",
"V43.3",
"151.3",
"785.6",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"43.7"
] |
icd9pcs
|
[
[
[]
]
] |
5406, 5412
|
2441, 4483
|
333, 357
|
5588, 5595
|
2064, 2418
|
5901, 6103
|
1287, 1365
|
4765, 5383
|
5433, 5567
|
4509, 4742
|
5619, 5878
|
1380, 2045
|
276, 295
|
385, 911
|
933, 1172
|
1188, 1271
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,989
| 181,518
|
40654
|
Discharge summary
|
report
|
Admission Date: [**2108-11-9**] Discharge Date: [**2108-11-13**]
Date of Birth: [**2056-12-24**] Sex: F
Service: MEDICINE
Allergies:
Benadryl
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 y/o with triple negative Stage II breast cancer s/p right
mastectomy currently on adjuvant chemotherapy with ACT presents
with persistent cough, hypoxia and low grade fevers with
evidence of bilateral ground glass opacities on CT scan
concerning of pneumonia.
Ms. [**Known lastname 88934**] reports gradual onset of shortness of breath with
associated pleuritic substernal chest pain and non productive
cough that started 3 weeks ago. She reports subjective fevers
which she started measuring last week and reports temperatures
ranging from 98 -102. She reports no change or progression in
her symptoms over the past three weeks despite notes detailing
phone calls from her niece reporting increasing severity. The
non productive cough is so bad she sometimes cannot speak and is
worse with lying flat. She reports a 1 day history of left lower
extremity swelling. She has occasional occasional nausea,
vomiting and some episode of diarrhea week prior. She denies
rigors, sweats. She has decreased apetite, but denies abdominal
pain, diarrhea, melena, hematochezia, hematemesis, skin rashes,
joint pains, oral ulcers, urinary symptoms, numbness or
tingling, muscle tenderness or weakness.
She was seen by her primary oncologist on Monday and reported
early symptoms. A 10 day course of levofloxacin was prescribed
and a CT scan was performed which demonstrated diffuse ground
glass opacities, new since prior imaging in addition to
progression of her pulmonary artery hypertension. As her
symptoms continued to progress she was seen in clinic today.
Her o2 sats were in the 80s prompting referral to the ED.
With regards to her oncologic history, she first presented to
her PCP with [**Name Initial (PRE) **] right breast lump in [**Month (only) **] of this year with
ultimate work-up and demonstrating multicentric invasive ductal
carcinoma, histiologic grade 3 with extensive necrosis and
priminent lymphoplasmacytic infiltrates. In late [**Month (only) 205**] she
underwent right sided total masectomy with staging at pT3, and
[**3-12**] LN negative. Her post-operative course was complicated by
admission in [**Month (only) 216**] for a chest wall abscess associated with a
surgical wound, with MSSA bacteremia and toxic shock syndrome.
In [**Month (only) **] she was initiated on systemic chemotherapy with
adriyamycin and cyclophosphamide completing 4 cycles. On
[**10-29**] she started on Taxol. She presented to oncology
clinic on [**11-5**] for week 2 of taxol which was held in
the setting of her cough and dyspnea.
In the ED inital vitals were, 99.2 128 117/72 40 96% 4L. Labs
were significant for LDH 532, wbc 11.1, hct 26.5 and lactate of
1.3. She was hypoxic to 92% in ED and 4L NC. She was noted to be
tachypneic to the 40s. A CTA chest was limited secondary to
suboptimal bolus timing and poor field of view selection. No PE
was visualized and worsening diffuse ground glass opacities. She
was given cefepime, vancomycin and bactrim. She was bolused 2
liters of NS with good blood pressure response. Concern for
imminent decompensation therefore request for admission to ICU
for overnight monitoring requested. Vitals on transfer were
101.3 128 110/58-40's 98% 2 liters.
On arrival to the ICU, initial vitals were 98.1 112 114/72 81
95% on 4L. She was lying in bed, mildly tachypneic and able to
answer questions in full sentences.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Stage IIB (pT3N0M0) invasive ductal carcinoma, triple negative,
grade III
Social History:
The patient is from [**Country 16465**] originally. She has lived in [**Location 86**]
for the past two years. She denies tobacco use. She denies
ethanol use. She is unemployed currently. She has one male
partner.
Family History:
Mom with an intra-abdominal cancer, unknown type. The patient
does not have any further details.
Physical Exam:
Admission exam:
Vitals: 98.1 112 114/72 81 95% on 4L.
General: Pleasant, calm, mildly tachypneic and fatigued
appearing
Heent: No scleral icterus, mm dry, no orpharyngeal lesions or
erythema
Neck: Supple with no lymphadenopathy or thyromegaly.
Breasts: Healed right-sided chest wound.
Pulm: CTAB
Cardiovascular: Pulse regular and good in volume. S1 S2 and
S3.
Abdomen: Soft and nontender. No palpable organomegaly or
masses. Normal bowel sounds.
Extremities: No edema. No joint swelling, redness, or
tenderness.
She appears euvolemic on exam.
DISCHARGE EXAM:
Vitals - T: 97.3 BP: 112/72 HR: 75 RR: 22 02 sat: 100% RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/ split S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admssion Labs:
[**2108-11-9**] 10:00AM BLOOD WBC-11.1* RBC-3.26* Hgb-9.3* Hct-26.5*
MCV-81* MCH-28.5 MCHC-35.1* RDW-15.6* Plt Ct-598*
[**2108-11-9**] 10:00AM BLOOD Neuts-73.7* Lymphs-9.7* Monos-10.0
Eos-6.0* Baso-0.6
[**2108-11-9**] 10:00AM BLOOD UreaN-13 Creat-0.9 Na-133 K-4.2 Cl-95*
HCO3-26 AnGap-16
[**2108-11-9**] 10:00AM BLOOD ALT-31 AST-36 LD(LDH)-532* AlkPhos-138*
TotBili-0.5
[**2108-11-11**] 04:54AM BLOOD LD(LDH)-429*
[**2108-11-10**] 05:01AM BLOOD proBNP-2784*
[**2108-11-9**] 10:00AM BLOOD TotProt-6.3* Albumin-3.3* Globuln-3.0
Phos-3.7 Mg-2.2
[**2108-11-9**] 06:36PM BLOOD Lactate-1.3
DISCHARGE LABS:
[**2108-11-13**] 05:55AM BLOOD WBC-9.0 RBC-3.45* Hgb-9.7* Hct-29.2*
MCV-85 MCH-28.2 MCHC-33.3 RDW-15.5 Plt Ct-665*
[**2108-11-13**] 05:55AM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-134
K-5.0 Cl-102 HCO3-22 AnGap-15
[**2108-11-13**] 05:55AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.9*
Imaging:
CXR [**2108-11-9**]:
IMPRESSION: Persistent bilateral diffuse airspace opacities,
similar compared to the prior CT allowing for differences in
modality. Findings again may be due to an atypical infectious
process including a viral infection, or possibly a drug
reaction.
CTA [**2108-11-9**]:
IMPRESSION:
1. Limited exam with excludion of the upper lobe pulmonary
arteries on the
CTA component; therefore pulmonary embolism within the upper
lobes cannot be excluded. No pulmonary embolism otherwise seen.
2. Worsening bilateral diffuse ground-glass opacities which
appear more
confluent. Differential considerations include drug reaction or
an
atypical/viral infection.
4. Pulmonary arterial hypertension.
CXR [**2108-11-10**]:
IMPRESSION:
1. Left subclavian central line with its tip in the distal SVC,
unchanged. Interval improvement in aeration but a persistent
bilateral interstitial airspace process is again seen, which
could represent an atypical pneumonia or drug toxicity. Clinical
correlation is advised. Overall cardiac and mediastinal contours
are likely unchanged. There is slight prominence of the main
pulmonary artery in this patient with known pulmonary
hypertension. No pneumothorax.
ECHO: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
There is no ventricular septal defect. with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
MICROBIOLOGY:
SPUTUM GRAM STAIN (Final [**2108-11-10**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2108-11-10**]):
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2108-11-12**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
Brief Hospital Course:
51 year old with triple negative Stage II breast cancer s/p
right mastectomy currently on adjuvant chemotherapy with ACT
presents with persistent cough, hypoxia and low grade fevers
with evidence of bilateral ground glass opacities on CT scan
concerning of pneumonia.
# Respiratory Distress: Patient presented with a several week
long history of dry cough that had worsened in the days prior to
admission. patient had been seen and evaluated by PCP and
oncologist in the weeks prior to admission reciving cough
suppressants and course of levofloxacin. Patient's symptoms
progressed despite these interventions and was evaluated in the
ED. In the ED patient was significantly tachypnic to the 40s but
was not hypoxemic. CTA was negative for PE, but showed diffuse
ground glass opacities. Patient was started on
vanc/zosyn/azithromycin adn transfered the ICU. In the
intensive care unit patient was continued on broad spectrum abx
with the addition of bactrim and prednisone for PCP [**Name Initial (PRE) 21150**].
Upon transfer to the general oncology [**Hospital1 **] patient was narrowed
discharged to complete a 7 day course of azithro and a 2 week
course of bactrim. Patient's prednisone taper was 40 mg [**Hospital1 **] for
5 days, 40 mg daily for 5 days 20 mg for 11 days. Patietn was
able to ambulate around the unit without difficult or SOB prior
to discharge.Although patient was clearly improving,the exact
etiology of pneumonitis unclear.
.
# Hyperglycemia: patient was noted to have elevated FSG to the
250s after initiation of prednisone. Patient was started on
metformin 500 mg [**Hospital1 **] with plan to have PCP follow up ongoing
need for hypoglycemics once steroid course had completed.
.
# Pulmonary Arterial Hypertension on Imaging: CXR on serial
exams demonstrate increasing size of the pulmonary arteries
similarly suggested on CT scans concerning for pulmonary
hypertension. Echo prior to initiation of chemotherapy
demonstrated normal pulmonary artery pressures. PE exluded on
CTA. Patient had repeat ECHO which again did not demonstrate
elevated pulmonary artery pressures.
.
# Stage II breast cancer: Currently day 11 of taxol therapy.
Day 8 treatment deferred in setting of respiratory symptoms.
Patient was discharged with follow up by her oncologist with a
plan to resume chemotherapy once acute illness had improved.
.
TRANSITIONAL ISSUES:
-patient is a Full code
-patient's blood cultures were pending, but no growth at the
time of discharge
-patient will need reassessment of need for metformin once
prednisone taper is complete
Medications on Admission:
BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times
a day as needed for cough
LORAZEPAM - 0.5 mg Tablet - [**12-11**] Tablet(s) by mouth twice a day
as
needed for nausea/vomiting
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - One
Capsule(s) by mouth Daily
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth four times
a
day as needed for nausea/vomiting
OXYCODONE - 5 mg Tablet - [**12-11**] Tablet(s) by mouth Q4-6H as needed
for pain Do not drive a car or operate machinery while taking
this medication.
PROCHLORPERAZINE MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for nausea/vomting
SCALP PROSTHESIS - - As instructed
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider; OTC) - Dosage uncertain
DEXTROMETHORPHAN-GUAIFENESIN [ADT ROBITUSSIN PEAK CLD DM MAX] -
200 mg-10 mg/5 mL Liquid - [**12-11**] tsp by mouth four times a day as
needed for cough
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day as needed for constipation
SODIUM CHLORIDE [SAFE WASH] - 0.9 % Solution - For dressing
twice
a day
Discharge Medications:
1. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO four times a day as needed for nausea.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 1 days.
Disp:*4 Tablet(s)* Refills:*0*
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
5 days: to start on [**11-15**] and end on [**11-20**].
Disp:*10 Tablet(s)* Refills:*0*
5. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
11 days: to start [**11-21**] and end on [**12-2**].
Disp:*11 Tablet(s)* Refills:*0*
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day) for 11 days.
Disp:*66 Tablet(s)* Refills:*0*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. azithromycin 600 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
13. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
four times a day as needed for nausea.
14. Calcium 500 Oral
15. dextromethorphan-guaifenesin 10-200 mg/5 mL Liquid Sig: [**12-11**]
tsp PO four times a day as needed for cough.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Pneumonia
Hyperglycemia (steroid induced)
SECONDARY
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 88934**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation and treatment of
your cough and shortness of breath. In the emergency department
you were breathing very rapidly so you were admitted to the
intensive care unit. There you recieved IV antibiotics and
improved very quickly. You continued to have a cough, but your
symptoms were much improved at the time of discharge. You were
started on two antibiotics azithromycin and bactrim as well as a
steroid called prednisone and a medication to control you blood
sugars called metformin. You will need to take these
medications as instructed below. The dose of your prednisone
will change over the next few days. You primary care [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will continue to follow your pnemonia. You will
need to call his office to schedule an appointment in the next
week. You have a follow up appointemnt with your oncologists
scheduled for [**11-19**] where discussion of restarting chemotherapy
will take place.
The following changes were made to your medications:
-START Azithromycin 500 mg daily for 4 days
-START Bactrim DS 2 tablets every 8 hours for 11 days
-START Prednisone 40 mg twice daily for 1 more day
-START Prednisone 40 mg daily from [**11-15**] until [**11-20**]
-START Prednisone 20 mg daily from [**11-21**] until [**12-2**]
-START Metformin 500 mg twice daily until steroid course
complete or instructed by your primary care doctor.
-CONTINUE Benzonatate 100 mg three times a day as needed for
cough
-CONTINUE Lorazepam 0.5 mg 1-2 tablets twice a day as needed for
nausea
-CONTINUE Omeprazole 20 mg daily
-CONTINUE Onadansetron 8 mg four times a day as needed for
nausea
-CONTINUE Oxycodone 5 mg [**12-11**] tables every 4-6 hours as needed
for pain
-CONTINUE Prochlorperazine 5 mg four times a day as needed for
nausea
-CONTINUE Calcium carbonate 500 mg as needed
-CONTINUE Dextromethorphan-guaifenesin [**12-11**] tsp four times [**Last Name (un) 5490**]
as needed for cough.
-CONTINUE Docusate 100 mg twice daily
Followup Instructions:
Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD
Specialty: Primary Care
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
When:You need a follow up in the next week. I have put a call
into the office but their system was down. I left a message to
call you home with an appointment. If you do not hear back
within 2 days, Please call the above number to schedule the
appointment.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2108-11-19**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**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: MONDAY [**2108-11-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"790.29",
"518.82",
"486",
"V58.69",
"V45.71",
"E932.0",
"416.8",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14432, 14438
|
9148, 11507
|
277, 283
|
14557, 14557
|
5703, 6303
|
16881, 18195
|
4430, 4530
|
12868, 14409
|
14459, 14536
|
11746, 12845
|
14708, 16858
|
6319, 9125
|
4545, 5099
|
5115, 5684
|
11528, 11720
|
3691, 4081
|
232, 239
|
311, 3672
|
14572, 14684
|
4103, 4179
|
4195, 4414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,105
| 149,801
|
53856
|
Discharge summary
|
report
|
Admission Date: [**2185-1-21**] Discharge Date: [**2185-1-27**]
Date of Birth: [**2104-12-3**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Ampicillin / Niacin / Mevacor / Prilosec /
Erythromycin Base / Clindamycin
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Hypotension, Sepsis, funguria, Acute Kidney Injury
Major Surgical or Invasive Procedure:
PICC Line Placement
History of Present Illness:
The patient is an 80 year-old female who was recently admitted
following a fall to [**Hospital 4199**] Hospital, where she was treated for
RLL pneumonia requiring vanco/ertapenem at [**Hospital 4199**] Hospital from
[**1-8**]- [**1-14**]. At the time of discharge, her creatinine was 0.6
which reportedly was her baseline value.
.
At the rehab facility, she was continued on vancomycin, but her
vancomycin was discontinued when her creatinine was found to be
3.8. A vanco level was checked and found to be high (reportedly
in the 40s). Vancomycin was discontinued and IVFs given at
rehab, but despite these measures, the Cr worsened to 4.1 on
subsequent measurement. She was also noted to be lethargic and
with poor urine output (50cc/8hr). She also had been having
non-bloody diarrhea that respected the night-time that had been
occuring for the last 2-3 days.
.
She was taken to the [**Hospital1 18**] ED, initial vitals were 98.0 63 86/46
16 98% 4L. Supine: 90/39, 71; sitting: 89/40, 69. Triggered for
hypotension into sBP 80s. Physical examinination notable for
being fairly unremarkable. Laboratory data significant for Na
131, creatinine 4.0, WBC 15.0 (9% bands), hematocrit 24.6, INR
1.4, lactate 3.0. UA with moderate leukocyte esterase, large
blood. Blood cultures, urine cultures sent. CT abdomen/pelvis
without contrast with bilateral effusion, atrophic pancreas, no
hydronephrosis, possible colitis. CXR 1V reportedly without
acute process. Received ciprofloxacin IV, 2L IVF (pressures
subsequently sBP 90s). On transfer to MICU, 72 96/54 18 99% RA.
Past Medical History:
S/P spinal fusion L5-S1 in [**9-/2173**]
S/P laminectomy L5-S1 in [**2169**]
GERD
HTN
Hypercholesterolemia
Chronic diarrhea
Diverticulosis
GI bleed
Hiatal hernia
Anemia
Migraines
Hypothyroidism
Hemorrhoids
Chronic back spasms
Anxiety
S/p cholecystectomy
S/p appendectomy
Social History:
Most recently at [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (rehab facility) after
hospitalization at [**Hospital 4199**] Hospital. Prior to this she lived
alone in [**Location (un) **] in [**Hospital3 **]. Two estranged daughters in
CA, she did not want them to be contact[**Name (NI) **]. [**Name2 (NI) **] HCP is a friend,
[**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 110499**]. Retired social worker. Denies
tobacco, alcohol, or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Admission Exam:
PHYSICAL EXAM:
VS: 97.3, 107/68, 81, 18, 100%RA
GENERAL - chronically ill appearing elderly female in NAD,
sleeping comfortably but easily arousable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS +bibasilar crackles without significantly decreased breath
sounds. No wheezes or rhonchi. good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, minimal tenderness to palpation, no masses
or HSM, no rebound/guarding, well-healing surgical scar
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, oriented to name, [**Location (un) 86**], month, year. CNs II-XII
grossly intact, +asymmetric pupils (known prior surgery) muscle
strength 4/5 throughout secondary to fatigue, sensation grossly
intact throughout, steady gait
GU: Foley in place, no surrounding erythema
.
Discharge Exam:
PHYSICAL EXAM:
VS: 97.7,128/70, 80, 18, 93%RA
GENERAL - chronically ill appearing elderly female in NAD,
sleeping comfortably but easily arousable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS +bibasilar crackles without significantly decreased breath
sounds. No wheezes or rhonchi. good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, minimal tenderness to deep palpation of
RLQ,
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, oriented to name, [**Location (un) 86**], month, year. CNs II-XII
grossly intact
Pertinent Results:
Admission Labs:
[**2185-1-21**] 11:19PM URINE HOURS-RANDOM UREA N-182 CREAT-118
SODIUM-23 POTASSIUM-16 CHLORIDE-13
[**2185-1-21**] 11:19PM URINE OSMOLAL-179
[**2185-1-21**] 08:29PM GLUCOSE-90 UREA N-24* CREAT-3.6* SODIUM-134
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
[**2185-1-21**] 08:29PM CALCIUM-7.5* PHOSPHATE-5.2*# MAGNESIUM-1.7
IRON-51
[**2185-1-21**] 08:29PM calTIBC-139* FERRITIN-630* TRF-107*
[**2185-1-21**] 08:29PM WBC-13.4* RBC-2.35* HGB-7.8* HCT-22.5* MCV-95
MCH-33.3* MCHC-34.9 RDW-19.9*
[**2185-1-21**] 08:29PM PLT COUNT-249
[**2185-1-21**] 08:29PM RET AUT-5.5*
[**2185-1-21**] 12:46PM GLUCOSE-96 LACTATE-3.0* NA+-130* K+-3.4*
CL--93* TCO2-25
[**2185-1-21**] 12:30PM GLUCOSE-106* UREA N-25* CREAT-4.0*#
SODIUM-131* POTASSIUM-3.6 CHLORIDE-94* TOTAL CO2-23 ANION GAP-18
[**2185-1-21**] 12:30PM ALT(SGPT)-6 AST(SGOT)-14 TOT BILI-0.3
[**2185-1-21**] 12:30PM WBC-15.0*# RBC-2.58*# HGB-8.4*# HCT-24.6*#
MCV-95# MCH-32.4*# MCHC-34.0 RDW-20.2*
[**2185-1-21**] 12:30PM NEUTS-49* BANDS-9* LYMPHS-19 MONOS-11 EOS-1
BASOS-0 ATYPS-1* METAS-7* MYELOS-3*
[**2185-1-21**] 12:30PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ STIPPLED-1+
[**2185-1-21**] 12:30PM PLT SMR-NORMAL PLT COUNT-256
[**2185-1-21**] 12:30PM PT-16.1* PTT-42.2* INR(PT)-1.4*
[**2185-1-21**] 12:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.008
[**2185-1-21**] 12:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2185-1-21**] 12:30PM URINE RBC-0-2 WBC-21-50* BACTERIA-FEW
YEAST-MOD EPI-0-2 TRANS EPI-0-2 RENAL EPI-[**2-5**]
[**2185-1-21**] 12:30PM URINE EOS-NEGATIVE
.
#Lytes
[**2185-1-21**] 12:30PM BLOOD Glucose-106* UreaN-25* Creat-4.0*#
Na-131* K-3.6 Cl-94* HCO3-23 AnGap-18
[**2185-1-21**] 08:29PM BLOOD Glucose-90 UreaN-24* Creat-3.6* Na-134
K-3.2* Cl-100 HCO3-23 AnGap-14
[**2185-1-22**] 02:34AM BLOOD Glucose-95 UreaN-23* Creat-3.6* Na-132*
K-3.7 Cl-98 HCO3-23 AnGap-15
[**2185-1-22**] 04:57PM BLOOD Glucose-99 UreaN-22* Creat-3.3* Na-129*
K-3.5 Cl-100 HCO3-20* AnGap-13
[**2185-1-23**] 06:00AM BLOOD Glucose-94 UreaN-20 Creat-3.0* Na-133
K-3.6 Cl-103 HCO3-21* AnGap-13
[**2185-1-24**] 04:03AM BLOOD Glucose-97 UreaN-20 Creat-3.0* Na-132*
K-3.7 Cl-104 HCO3-18* AnGap-14
[**2185-1-25**] 08:23AM BLOOD Glucose-98 UreaN-21* Creat-3.1* Na-135
K-3.9 Cl-105 HCO3-19* AnGap-15
[**2185-1-26**] 05:18AM BLOOD Glucose-99 UreaN-21* Creat-3.2* Na-135
K-3.9 Cl-105 HCO3-21* AnGap-13
[**2185-1-27**] 04:33AM BLOOD Glucose-113* UreaN-24* Creat-3.3* Na-137
K-3.9 Cl-107 HCO3-21* AnGap-13
.
#CBC/Diff
[**2185-1-21**] 12:30PM BLOOD WBC-15.0*# RBC-2.58*# Hgb-8.4*#
Hct-24.6*# MCV-95# MCH-32.4*# MCHC-34.0 RDW-20.2* Plt Ct-256
[**2185-1-21**] 08:29PM BLOOD WBC-13.4* RBC-2.35* Hgb-7.8* Hct-22.5*
MCV-95 MCH-33.3* MCHC-34.9 RDW-19.9* Plt Ct-249
[**2185-1-22**] 02:34AM BLOOD WBC-14.1* RBC-2.75* Hgb-9.0* Hct-26.0*
MCV-95 MCH-32.6* MCHC-34.5 RDW-19.3* Plt Ct-218
[**2185-1-22**] 03:46PM BLOOD Hct-25.0*
[**2185-1-23**] 06:00AM BLOOD WBC-13.4* RBC-2.84* Hgb-9.1* Hct-27.0*
MCV-95 MCH-32.0 MCHC-33.7 RDW-19.3* Plt Ct-242
[**2185-1-24**] 04:03AM BLOOD WBC-12.8* RBC-2.67* Hgb-8.7* Hct-25.6*
MCV-96 MCH-32.6* MCHC-34.1 RDW-19.3* Plt Ct-276
[**2185-1-25**] 08:23AM BLOOD WBC-10.8 RBC-2.57* Hgb-8.4* Hct-24.5*
MCV-95 MCH-32.9* MCHC-34.4 RDW-19.3* Plt Ct-318
[**2185-1-26**] 05:18AM BLOOD WBC-9.3 RBC-2.53* Hgb-8.2* Hct-24.0*
MCV-95 MCH-32.2* MCHC-33.9 RDW-19.2* Plt Ct-339
[**2185-1-27**] 04:33AM BLOOD WBC-11.0 RBC-2.62* Hgb-8.5* Hct-25.2*
MCV-96 MCH-32.2* MCHC-33.6 RDW-19.6* Plt Ct-312
[**2185-1-21**] 12:30PM BLOOD Neuts-49* Bands-9* Lymphs-19 Monos-11
Eos-1 Baso-0 Atyps-1* Metas-7* Myelos-3*
[**2185-1-22**] 03:46PM BLOOD Neuts-57 Bands-5 Lymphs-12* Monos-14*
Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-5*
[**2185-1-23**] 06:00AM BLOOD Neuts-56 Bands-1 Lymphs-15* Monos-16*
Eos-3 Baso-0 Atyps-1* Metas-8* Myelos-0
.
#UTI
[**2185-1-21**] 12:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.008
[**2185-1-21**] 12:30PM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-MOD
Epi-0-2 TransE-0-2 RenalEp-[**2-5**]
[**2185-1-21**] 12:30PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2185-1-27**] 04:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG
[**2185-1-27**] 04:33AM URINE Type-RANDOM Color-Straw Appear-Clear Sp
[**Last Name (un) **]-1.006
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
.
Microbiology
[**1-21**]- Urine Culture- Positive Yeast
[**1-23**]- Blood Culture (Fungus/Mycobacteria)- Negative
[**1-21**]- C-diff- Negative
[**1-21**]- Blood culture- Negative
[**1-27**]- Urine Culture- Pending (NGTD)
.
Radiology
#CXR [**2185-1-21**]
UPRIGHT AP VIEW OF THE CHEST: Right PICC tip terminates in the
SVC. The
heart size is upper limits of normal, unchanged. Mediastinal
contours are
stable. Pulmonary vascularity and hilar contours are within
normal limits. Patchy opacities in both lung bases are present.
These likely reflect atelectatic changes. No focal consolidation
is noted. No pleural effusion or pneumothorax is present. No
acute osseous findings are seen.
IMPRESSION: Minimal patchy opacities in both lung bases likely
reflect
atelectasis.
.
#CT ABD/PELVIS [**2185-1-21**]
STUDY: CT of the abdomen and pelvis without contrast; coronal
and sagittal
reformatted images were also generated.
COMPARISON: CT of the abdomen and pelvis from [**2176-12-19**].
FINDINGS:
ABDOMEN: In the visualized portion of the chest, calcified
atherosclerotic
disease is seen involving the aortic valve and coronary
arteries. A small
pericardial effusion is also seen (2; 4). Bilateral simple
pleural effusions
are seen, moderate on the right and small on the left, with
associated
bilateral lower lobe atelectasis. Small hiatal hernia is
present.
Within the limits of a non-contrast study, the liver, spleen and
adrenal
glands appear normal. The gallbladder has been removed. The
pancreas is
atrophic. The kidneys show no evidence of hydronephrosis or
calculi. The
small and large intestine show no signs of obstruction. Oral
contrast has
progressed just into the proximal right colon. Right colon is
underdistended
which likely makes the walls appear mildly thickened, but no
adjacent fat
stranding is noted. There is no lymphadenopathy or free air.
Small amount of
free fluid is seen around the liver (2; 33). Diffuse anasarca is
seen.
PELVIS: The bladder is decompressed around a Foley balloon. The
patient is
status post hysterectomy. Rectum appears unremarkable. There is
no
pericolonic fat stranding but again trace free fluid is seen in
the pelvis.
Diffuse anasarca is present.
BONES: Patient is status post posterior spinal fusion of L5-S1
with grade 1
anterolisthesis of L5 on S1. Additionally, a compression
deformity is seen in
the L1 vertebral body which is unchanged compared to the MR from
[**2179-5-26**].
There is loss of intervertebral disc height at L3-L4 with vacuum
phenomenon
within the intervertebral disc. There are no
aggressive-appearing lytic or
sclerotic lesions.
IMPRESSION:
1. Diffuse anasarca with trace ascites and bilateral small to
moderate sized
pleural effusions, right greater than left.
2. No definite evidence of colitis. Apparent wall thickening of
the proximal
right colon is likely due to underdistention and mixing with
oral contrast. No
pericolonic stranding is present.
.
#CXR [**2185-1-23**]
HISTORY: 80-year-old woman with new vomiting, evaluate for
aspiration.
IMPRESSION: AP chest compared to [**1-21**], 2:11 a.m.:
Pulmonary and mediastinal vascular engorgement are new and
although heart size
is normal and pleural effusions are small if any, the
interstitial abnormality
in the lungs is most likely mild edema. Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] paged.
.
#CXR [**2185-1-27**] (prelim): no acute process. Improved from [**1-21**]'s
chest x-ray.
Brief Hospital Course:
80 year-old female with chronic anemia, prior MRSA UTI, and
recent admission for RLL pneumonia admitted to MICU [**2185-1-21**] with
[**Last Name (un) **], hypotension, leukocytosis/bandemia in context of recent
nausea, poor PO intake, diarrhea, UTI.
MICU COURSE
In the MICU ([**Date range (1) 110500**]), she required fluid resuscitation and
1 unit pRBCs for hypotension. She was treated for candidal UTI
with fluconazole (initially cefepime, linezolid until culture
data returned). Initially also received vancomycin PO given
concern for colitis based on symptoms and finding of bowel wall
thickening on CT abdomen/pelvis on preliminary read; symptoms
resolved, C. difficile toxin was negative, and final read
changed to no evidence of colitis. Creatinine (baseline 0.6)
improved from 4.0 to 3.0 with fluid resuscitation; etiology
suspected to be ATN and component of prerenal azotemia.
Patient on admission wished to be DNR/DNI. Due to issues with
delirium, her healthcare proxy, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 110499**]
was contact[**Name (NI) **]. [**Name2 (NI) 227**] persistent agitation/delirium, psychiatry
was consulted and recommend haloperidol 0.5mg PO Q4-6HR PRN
agitation and 0.5mg PO HS.
She was transferred [**2185-1-25**] from MICU to medical service for
further care.
HOSPITIAL FLOOR COURSE
1. Sepsis/Hypotension. Patient was afebrile, off fluids and
hemodynamically stable on transfer to the floor. She remained
afebrile, without leukocytosis, hemodynamically stable
throughout her course, with blood pressures in the 110-120s
systolic. The source of the sepsis was not fully ascertained.
Although her admission urine culture grew out fungus and she
clinically improved on fluconazole in the MICU, it seemed
unlikely that fungal UTI was responsible for her sepsis (blood
cultures showed no fungus growth, patient was non-toxic
appearing). Her foley was discontinued, and a repeat UA was
obtained, which was negative except for trace leukocytes and an
additional urine culture was sent. With all of these findings,
her fluconazole was discontinued. At the time of discharge, the
patient remained afebrile, hemodynamically stable and all of her
culture data was with no growth to date. We continued to hold
all her anti-hypertensive medications, and her blood pressures
were not elevated.
2. Acute Kidney Injury. The presented initially with a Cr of
4.0, very [**Known lastname **] UOP and urinary sediment that was consistent with
ATN. The etiology of the ATN was thought to be secondary to
hypotension (sepsis, ongoing diarrhea, decreased PO intake) as
well as nephrotoxic tubular injury (Vancomycin level of 40 in
rehab). Per her MICU course above, she was fluid-resusictated
with some improvement of the Cr to 3.0. On the floor, her urine
output improved and her phosphorus came down to normal range.
However, her Cr. rose slightly to 3.3. Nephrology recommended
conservative management with no IV fluids, renally dosed
medications, and expected her recovery from ATN to be slow and
perhaps incomplete given her age and the severity of the insult.
She should follow up with her PCP regarding this issue.
3. Diarrhea. The patient had been experiencing 2-3 days of
non-bloody diarrhea during the initial onset of her symptoms in
rehab. A stool c-diff was sent on admission and returned
negative. No stool cultures were obtained. The diarrhea resolved
on the floor without treatment and the patient reported that her
stools were more formed at the time of discharge.
4. Agitation/Psych. As mentioned in above MICU course, patient
was seen by psych for persistent agitation/delirium. Etiology
thought to represent mixture of personality style, background of
dementia with superimposed delirium in setting of hypotension
and sepsis. Her citalopram was discontinued, and she was started
on mirtazapine 7.5 mg QHS. She was taken off of her prn valium
which had been given at her rehab and started on both PRN and
standing PM haldol 1 mg QHS. QTc was obtained prior to each
haldol administration and was consistently normal. Her behavior
was more appropriate on this regimen. Per psychiatric consult's
recommendation, patient was discharged on mirtazapine, and
Haldol as needed at bedtime, her valium and citalopram remained
discontinued. She was counseled to follow up with her primary
care physician regarding the management of these medications.
5. Normocytic Anemia. Her hematocrit was found to be [**Known lastname **] at 24
on admission, and she was transfused 1U PRBC in the MICU, but
this Hct value was reportedly around her baseline in the setting
of myelodysplasia. She was guiac negative on admission and was
mantained on GI prophylaxis. Her hematocrit remained stable
throughout her time on the floor until the time of discharge.
Medications on Admission:
Milk of magnesia PRN
Zantac 100mg PO BID
Albuterol - d/c [**2185-1-17**]
Atenolol 25mg PO daily
HCTZ 25mg PO daily - d/c [**2185-1-19**]
Lisinopril 5mg PO QHS - d/c [**2185-1-20**]
D5 1/2NS at 60cc/hour (500cc, then 1000cc, [**2185-1-19**])
Compazine 10mg PO Q6 hours PRN nausea
Ertapenem 1 gram IV Q24 hours [**Date range (1) 110501**]
Vancomycin 1 gram IV BID [**Date range (1) 110502**]
Duonebs TID
Valium 2.5mg PO Q6 hours PRN anxiety
Oxycodone 5mg PO Q6 hours PRN pan
Citalopram 5mg PO daily
Vitamin D 50,000 units Qweekly
Levothyroxine 75mcg PO daily
Lipitor 40mg PO daily
ASA 325mg PO daily
Mirapex 0.125mg PO daily
Colace 100mg PO BID
Flovent 110mcg PO BID
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for Shortness of breath, wheezing.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for Constipation.
11. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
sepsis, hypotension, urinary tract infection (yeast), kidney
damage (acute tubular necrosis)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **]
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for [**Known lastname **] blood pressure,
sepsis, and kidney damage. You were initially admitted to the
intensive care unit, where you received fluids and were started
on IV antibiotics, and you improved. Your urine culture grew out
yeast and your IV antibiotics were changed to oral antifungals
and you continued to improve.
.
Your kidneys were damaged by the [**Known lastname **] blood pressure and IV
antibiotics you were taking prior to your admission. Once we
stabilized your blood pressure, your kidneys began to show signs
of improvement, althought we believe that recovery of function
might take some time. You should be sure to follow up with your
primary care doctor about this issue closely.
.
You also had some of your psychiatric medications changed during
your hospitalization (see below) and you should follow up with
your primary care physician and be referred to a psychiatrist as
needed regarding the use of these medications.
.
We made the following adjustments to your medications:
STOPPED Valium 2.5mg PO every 6 hours as needed anxiety
STOPPED Citalopram 5mg by mouth at night
STARTED Mirtazipine 7.5 mg oral at night
STARTED Haloperidol 1 mg PO at night as needed for agitation
.
As a reminder, the following medications were discontinued at
your rehabilitation facility due to [**Known lastname **] blood pressure. We
continued to hold your blood pressure because your blood
pressure was not elevated. You should follow up with your
primary care physician about these medication.
STOPPED HCTZ 25mg by mouth daily
STOPPED Lisinopril 5mg by mouth at night
STOPPED Albuterol inhaler
STOPPED Mirapex 0.125mg PO daily
.
Your follow-up information is below.
Followup Instructions:
Please schedule an appointment with your primary care physician
[**Name Initial (PRE) 176**] 1 week for this hospitalization (sepsis, hypotension,
urinary tract infection (yeast), acute tubular necrosis, and
psychiatric medication adjustment.
Completed by:[**2185-1-28**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
19281, 19411
|
12526, 17322
|
395, 416
|
19548, 19548
|
4576, 4576
|
21511, 21785
|
2860, 2878
|
18038, 19258
|
19432, 19527
|
17348, 18015
|
19699, 21488
|
3878, 4557
|
3863, 3863
|
305, 357
|
444, 2009
|
4592, 12503
|
19563, 19675
|
2031, 2303
|
2319, 2844
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,192
| 128,007
|
24530
|
Discharge summary
|
report
|
Admission Date: [**2153-7-27**] Discharge Date: [**2153-7-30**]
Date of Birth: [**2075-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath, ascites, fluid overload.
Major Surgical or Invasive Procedure:
paracentesis x 2
History of Present Illness:
78 yo male with frequent admssion for heart failure and anemia
returns again from rehab for dyspnea, anemia, and subjective
cough and chest pain. DC'd from hospital 1 week ago on PO
regiment of diuretics, now returns with swollen scrotum,
ascites, fluid overload.
Past Medical History:
-HTN
-CAD: CABG [**2140**], cath [**2151**] with patent lima-lad, occluded
svg-om, near occluded svg-rca
-CHF: TTE [**7-5**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR
-Afib
-Cardiac cirrhosis: Requiring repeat sx paracenteses
-Chronic GIB [**3-2**] AVMs
-Colon polyps
-HBV
-CRI: cr 1.5-1.8
-Hypothyroidism
-OA
Social History:
Originally from [**Country 3397**]. Previously living with wife in [**Name (NI) 3146**],
but has been at rehab since recent hospitalization. Quit smoking
15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but
used to work as a machinist. Unable to walk. Needs
wheelchair/walker to get around his house.
Family History:
Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no
FH of cancer
Physical Exam:
PE:
Vitals -t 97.3; BP 94-105/47-53, 90-93% ra
General - frail, elderly male, no respiratory distress, sleeping
comfortably
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP, poor dentition
Neck: supple, + JVD
Pulmonary: crackles bilaterally at bases, very wheezy
Cardiac: RRR, nl. S1S2, holosystolic murmur RUSB
Abdomen: soft, NT, slightly distended, normoactive bowel sounds,
no masses or organomegaly noted. large umbilical hernia, scrotal
edema.
Extremities: 1+ edema to hips. + scrotal edema. Erythema on
shins b/l.
Pertinent Results:
[**2153-7-26**]
WBC-8.6 RBC-2.48* Hgb-7.2* Hct-23.1* MCV-93 MCH-29.2 MCHC-31.2
RDW-18.7* Plt Ct-379
Neuts-88.5* Bands-0 Lymphs-4.6* Monos-4.4 Eos-2.0 Baso-0.5
PT-11.9 PTT-29.1 INR(PT)-1.0
Glucose-131* UreaN-92* Creat-2.0* Na-131* K-5.5* Cl-97 HCO3-24
AnGap-16
CK(CPK)-119
CK-MB-13* MB Indx-10.9* cTropnT-0.20*
Calcium-7.5* Phos-4.7* Mg-3.1*
Digoxin-1.0
.
[**2153-7-27**]
WBC-8.3 RBC-2.88* Hgb-8.7* Hct-25.3* MCV-88 MCH-30.3 MCHC-34.6
RDW-18.6* Plt Ct-292
CK(CPK)-108
CK(CPK)-118
TropnT-0.20*
TropnT-0.20*
.
[**2153-7-28**] WBC-7.6 RBC-2.97* Hgb-8.8* Hct-27.0* MCV-91 MCH-29.5
MCHC-32.4 RDW-18.5* Plt Ct-346
.
[**2153-7-30**] WBC-10.5 RBC-3.01* Hgb-9.0* Hct-27.9* MCV-93 MCH-29.9
MCHC-32.3 RDW-18.3* Plt Ct-435
Glucose-124* UreaN-69* Creat-1.5* Na-132* K-5.0 Cl-100 HCO3-23
AnGap-14
.
[**2153-7-26**] ECG:Atrial fibrillation with a moderate ventricular
response. Right bundle-branch block. Loss of R waves in the
anteroseptal leads suggests old anteroseptal myocardial
infarction. Generalized low QRS voltage. Compared to the
previous tracing of [**2153-7-17**] no significant diagnostic change.
.
[**2153-7-26**] PORTABLE AP CHEST: Comparison is made to [**2153-7-17**].
Lung volumes remain low with worsening retrocardiac opacity. A
small left pleural effusion may be present. There is no evidence
of pneumothorax.
Patient is status post median sternotomy and CABG with an
unchanged enlarged cardiac silhouette. Pulmonary vascularity
appears stable and there is no evidence of overt edema. A
Port-A- Cath is in stable course and position.
.
IMPRESSION: Worsening retrocardiac opacity may represent
atelectasis however focal infectious consolidation cannot be
excluded. When clinically feasible, PA and lateral views would
help further evaluate.
.
[**2153-7-27**] 6:26 pm PERITONEAL FLUID PERITONEAL FLUID .
GRAM STAIN (Final [**2153-7-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2153-7-30**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
78M with CHF and longstanding cardiac cirrhosis presented with
repeated exacerbation of cardiac cirrhosis. Admitted to MICU for
paracentesis and hemodynamic monitoring, subsequently
transferred to floor for follow-up care. Pt presented on [**7-26**]
with exacerbated ascites severe enough to cause shortness of
breath and dyspnea. On [**7-27**] he underwent paracentesis with
removal of 4.3 liters of fluid (negative for SBP). His symptoms
drastically improved. On admission his diuretics were briefly
held for concern of renal failure, but were restarted on
transfer to the floor [**7-28**]. However, given his renal failure and
relative hyponatremia, his lasix dose was decreased and should
be titrated upwards with care. Urine output was acceptable
throughout. On [**7-30**] patient underwent regularly scheduled
paracentesis and was discharged back to his rehab facility.
.
With regards to his CHF, his digoxin level was 1.0 on admission.
Dig was held initially but restarted on the floor.
.
With regards to his DYSPNEA, his oxygen saturations have
remained normal off of supplemental oxygen. He denies SOB and
now speaks in complete sentences without breathlessness. His
crackles at lungh bases may represent transudative effusions
passing via diaphragm.
.
With regards to his ACUTE ON CHRONIC RENAL FAILURE, his baseline
is variable and fluctuates between 1 and 2. On admission, his
creatinine was 2.0, and on discharge it was 1.5. As mentioned,
he was never oliguric. His lasix and aldactone were restarted,
but lasix was continued at a lower dose than on admission.
.
With regards to his ANASARCA/EDEMA, he underwent 2 paracenteses,
on [**7-27**] and [**7-30**]. His perionteal fluid showed no evidence of SBP.
.
With regards to his ANEMIA, he received 2 units PRBCs in the
MICU with appropriate bump in Hct. His baseline Hct 24-28, and
on discharge it was stable at 27.9.
.
With regards to his HYPOTHYROIDISM, we continued his
levothyroxine 150 mcg po qd thoughout his stay.
.
With regards to his A-FIB, his rate was well controlled
throughout his stay. As with previous admissions, the decision
was made not to anticoagulate him based on his history of GI
bleeding from colonic AVMs.
.
With regards to his DELIRIUM, he briefly exhibited confused and
aggressive behavior in the MICU, and was placed on Abilify qd.
However, on transfer to the floor, no such behavior was noted,
and the medication will be d/c'ed on discharge.
.
He ate a regular diet, and minimal IVF was given for fear of
developing more ascites.
.
Prophylactically, he complained of constipation despite being on
Senna/Colace. We added bisacodyl 10mg po/pr qd and milk of
magnesia, with good effect. We continued his PPI. He was not
anticoagulated as mentioned above.
.
He continues to be DNR/DNI code status.
Medications on Admission:
Levothyroxine 150 mcg po daily
Spironolactone 50mg po daily
Furosemide 120mg po bid
Digoxin 125 mcg po q Mo/We/Fr
Albuterol/atrovent nebs
Senna 8.6 mg po bid
Docusate 100mg po bid
acetaminophen 325mg po q4-6 prn
Discharge Medications:
1. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-7**]
MLs PO Q6H (every 6 hours) as needed for cough.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Maalox/Diphenhydramine/Lidocaine Sig: Five (5) mL three
times a day as needed for cough.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Nebulizer Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
Cardiac Cirrhosis with chronic ascites
.
Other diagnoses:
-Coronary Artery Disease: 3 vessel bypass [**2140**], cath [**2151**] with
patent lima-lad, occluded
svg-om, near occluded svg-rca
-Congestive heart failure: echo [**7-5**] with ejection fraction 35%,
mild left vent hypertrophy, 2+ mitral regurg, 4+ tricuspid
regurg
-hypertension
-Atrial fibrillation - not on anticoag [**3-2**] prior gastrointesinal
bleeding
-Cardiac cirrhosis: Requiring repeat sx paracenteses
-Chronic Gastrointestinal bleeding [**3-2**] colonic angiodysplasias
-Colon polyps
-Lipids
-HBV positive
-Chronic Renal Insufficiency: creatinine 1.5-1.8
-Hypothyroidism - on T4
-osteoarthritis
Discharge Condition:
Improved, Stable
Discharge Instructions:
You were admitted to the hospital with swelling, fluid overload,
and shortness of breath. After your discharge, please continue
to take all your medicines as prescribed. If you experience any
difficulty breathing, abdominal pain, fevers, or other symptoms
that concern you, please call your doctor or go to the nearest
emergency room.
.
Weigh yourself every morning, call doctor if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please follow-up with your doctor in [**1-30**] weeks.
|
[
"V45.81",
"571.5",
"427.31",
"244.9",
"585.9",
"428.0",
"414.01",
"285.21",
"070.32",
"403.90",
"789.5",
"276.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8853, 8939
|
4255, 7042
|
360, 378
|
9649, 9668
|
2036, 4183
|
10141, 10199
|
1349, 1428
|
7305, 8830
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8960, 9628
|
7068, 7282
|
9692, 10118
|
1443, 2017
|
275, 322
|
406, 671
|
4219, 4232
|
693, 1006
|
1022, 1333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,706
| 179,428
|
24088
|
Discharge summary
|
report
|
Admission Date: [**2172-12-18**] Discharge Date: [**2173-1-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
Altered mental status, admitted to MICU for hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o woman with pmh of anemia, PUD, presents to the ED with
several days of poor po intake, somnolence, and altered mental
status. per ED notes and patient's family in USO until
approximately 1 week ago, when family members noticed she was
more withdrawn, not recognizing people, and needing encouragment
to take PO. Reports low urine output. Family denies fevers,
changes in bowel function, or nausea/vomitting. Other ROS unable
to be obtained as patient unresponsive.
Past Medical History:
-anemia, on iron supplementation
-peptic ulcer disase, history of perforated gastric ulcer four
years PTA with repair (?[**Location (un) **] patch placement)
Social History:
The pt. is originally from [**Country 2045**]. Pt. lives with her niece who
is her health care proxy. [**Name (NI) **] history of tobacco, alcohol or
illicit drug use.
No recent history of travel. She had been fully functional in
all of her ADLs per her niece.
Family History:
Noncontributory.
Physical Exam:
Vitals- T 98.0, BP 118/72, HR 76, RR 22, O2sat 96% RA
General- elderly woman lying in bed, responding to name,
initially not responding to questions, but began to respond
after asking repeatedly, following minor commands
HEENT- NCAT, sclerae muddy but anicteric, moist MM, patient not
opening mouth to command
Neck- no JVD seen
Pulm- + crackles 2/3 up R, + crackles at L base
CV- RRR, 2/6 SEM at [**Doctor Last Name **]/LLSB
Abd- + BS, mildly distended but soft, patient not guarding or
grimacing to deep palpation
Extrem- trace ankle edema b/l, no response to calf palpation, no
palpable cords
Neuro- somnolent but arousable to name, oriented to name and
"hospital", following simple commands, moving 4 extremities but
not cooperative with neuro exam
.
Brief Hospital Course:
Pt. was hypotensive (50's over 30's), hypothermic (96.0) and so
was admitted to [**Hospital Unit Name 153**].
In the [**Hospital Unit Name 153**], a right IJ was placed emergently and aggressive
fluid resusitation was begun. Dopamine was also started
peripherally while central line was placed. Her BP responded
well and she was changed to levophed after central line placed.
Broad spectrum antibiotics were started. She was weaned from
pressors the following day and continued to have good oxygen
saturations and BP. She in fact becamse hypertensive and her
metoprolol was restarted with good effect. Her mental status
recovered somewhat in that she opened her eyes to voice,
occasionally interacted with staff, and was able to speak a few
words. Per her family she did not yet appear at her MS [**Hospital Unit Name 5348**].
She failed a speech and swallow and it was recomended that she
be NPO and placed on NGT feeds. She was transfered to the floor
hemodynamically stable, tolerating her tube feeds, and sating
97-100% on 1-2L NC.
.
On transfer to the floor, her course was as follows:
# fever:
Patient was initially afebrile, completed vancomycin and
ceftriaxone for 14 days for pneumonia and was stable off
antibiotics. However, she began spiking fever on [**1-2**]. Repeat
urinalysis on [**1-2**] was c/w UTI. Her CXR still show right sided
consolidation but patient did not have sputum production. She
also had clinical evidence of aspiration per nursing staff.
Given that lung and urine was her potential infectious source,
she was started on vanco/zosyn [**1-3**], flagyl [**1-4**] and added
fluconazole [**1-4**] for yeast in urine. Fever seem get better with
addition of fluconazole. vanco/zosyn/flagyl were d/c'd that week
given improvement in respiratory symptoms and fever.
Fluconazole was given to compelete a 10 day course. Blood and
urine cultures remained negative except for >100K yeast in
urine.
Pt remained afebrile for the rest of her hospital course.
# acute renal failure
[**Month/Year (2) **] Cr was 0.8-0.9; creatinine began to rise on [**12-27**] and
continued to rise progressively to a peak of 3.7 on [**1-5**]. Renal
U/S was negative for any obstruction. Renal was consulted, felt
that ATN seemed most likely etiology in the setting of prior
hypotension. IVF were given initially, but then were limited by
pt's respiratory status. By [**1-6**], Cr began to decline and pt
began to diurese without any pharmacologic help. By time of
discharge, patients creatinine had nearly returned to [**Month/Year (2) 5348**]
and was continuing to improve.
# Pulmonary edema:
Patient was hydrated with IVF for acute renal failure as above
and shortly thereafter began to have worsening respiratory
distress. On exam, she had significant rales and some pulmonary
edema. She had been ruled out for MI by enzymes on [**12-21**] and
there were no obvious complain of chest pain. She was gently
diuresed with IV lasix and showed rapid improvement in
respiratory status, with improved oxygenation and decreased work
of breathing. For the remainder of her hospital stay, IVF were
more limited and patient continued to improve.
.
# Altered MS/agitation:
Pt's mental status worsened transiently in setting of renal
failure and worsening pulmonary edema, then began to improve
again as these issues resolved. By the time of discharge,
patient was more alert, able to answer some questions and follow
simple commands.
# Anemia:
Per PCP, [**Name10 (NameIs) 5348**] Hct is 30-33. Pt's hct had continued to drift
slowly downward and ultimately required transfusion of 1unit
PRBC on [**12-27**]. Hct responded appropriately, but continued to
drift slowly downwards, and patient ultimately required a second
transfusion on [**1-8**]. No clear etiology on CT abdomen, but
patient had some brown guaic-positive stools on [**1-8**],
[**1-11**]. Likely has slow GI bleed causing her anemia. Had been on
PPI, but given poor PO intake, new finding of heme-positive
stools, IV PPI was started on [**1-9**]. Overall, patient was
stable, and did not seem to have symptoms or physiologic
distress [**2-12**] anemia.
Will need to be intermittently followed by Dr. [**First Name (STitle) **].
.
# nutrition
Patient initially had NGT but pulled it out numerous times. Had
failed speech and swallow. Family has said that they want to
avoid PEG, NG, would like to continue to feed her orally and
they understand the risk of aspiration(nectar thickened soft
food). Pt. given some PPN on floor to improve nutritional status
and bridge pt to PO's while waiting for her mental status to
improve. By time of discharge, pt was taking some PO's but not
adequately to ensure good hydration, so was discharged with IVF
to rehab per Dr.[**Name (NI) 61245**] request.
.
# communication.
[**First Name9 (NamePattern2) **] [**Last Name (un) **] [**Telephone/Fax (1) 61246**] or [**Telephone/Fax (1) 61247**]. Staff had
contact[**Name (NI) **] and communicated with her family on multiple
occassion. They agree with plan of some IV hydration, continued
PO's despite some aspiration risk, no enteral feeding tube.
Patient will remain DNR/DNI.
Medications on Admission:
ASA 81 mg daily
Metoprolol 25 mg [**Hospital1 **]
Iron 325 mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed
for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID PRN
as needed for constipation.
Disp:*30 * Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer tx
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs nebulizer tx* Refills:*0*
4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*qs ML(s)* Refills:*2*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh
Inhalation every six (6) hours.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): [**Month (only) 116**] change to PO PPI when
taking PO's.
Disp:*30 Recon Soln(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
9. IV fluids
Please give D5W at 50ml/hr through peripheral IV
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Pneumonia
Altered mental status
Urinary tract infection
Acute renal failure
Pulmonary edema
Discharge Condition:
Good. Respiratory status improved, pt's mental status gradually
improving. Renal function improving.
Discharge Instructions:
Return to the hospital or call Dr [**First Name (STitle) **] immediately for:
-Worsening shortness of breath or more trouble breathing
-Poor urine output
-Worsening mental status
-Fevers >102 degrees
-Any other concerning symptoms
Followup Instructions:
Please call Dr.[**Name (NI) 61245**] office this week to arrange a follow-up
appointment.
Completed by:[**2173-1-13**]
|
[
"486",
"276.0",
"427.31",
"293.0",
"428.0",
"785.52",
"518.82",
"276.2",
"038.9",
"584.5",
"112.2",
"599.0",
"995.92",
"578.9",
"280.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"00.17",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8450, 8523
|
2135, 7267
|
320, 327
|
8659, 8762
|
9042, 9163
|
1323, 1341
|
7385, 8427
|
8544, 8638
|
7293, 7362
|
8786, 9019
|
1356, 2112
|
225, 282
|
355, 845
|
867, 1026
|
1042, 1307
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,136
| 192,248
|
1528
|
Discharge summary
|
report
|
Admission Date: [**2199-9-9**] Discharge Date: [**2199-10-7**]
Service: VSURG
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
synptomatic carotid stenosis
Major Surgical or Invasive Procedure:
right carotid endarectomy with introperative angiogram [**2199-9-9**]
History of Present Illness:
87y/o male with history of reucrrent transinet ischemic attacks.
The first occured [**2186**] after motor vehicle accident with
resulting left sided weakness for one hour. Second episode
occured [**2188**] and presented as left uppper and lower extremity
weakness for thirty minuets. The third occured [**2195**] occured
while getting out of bed and presented with montery left hand
weakness. The fourth occured [**2199-8-9**] with left hand weakness
which lasted for thirty minuets. When he saw his neurologist, on
exam left handed weakness was noted. Ultra sound of carotids
show 60-79% stenosis on the right internal artery .MRA confirms
small stroke and reveals significant disease at the arch of
right carotid artery. Patient now admitted for and elective
carotid endartectomy.
Past Medical History:
hyperthyroisism
squamous cell cancer
detached tetnia, s/p repair
begnin prostatic hypertrophy
Social History:
retired
lives with spouse
Denies alcohol or smoking
Family History:
unknown
Physical Exam:
Remarkable for right carotid bruit.
Remaing exam unremarkable.
Pertinent Results:
[**2199-9-9**] 10:30PM WBC-15.0*# RBC-3.33* HGB-10.0* HCT-30.0*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.3
[**2199-9-9**] 10:30PM PLT COUNT-228
[**2199-9-9**] 10:30PM PT-14.8* PTT-69.3* INR(PT)-1.4
[**2199-9-9**] 09:29PM TYPE-ART O2-50 PO2-230* PCO2-45 PH-7.37 TOTAL
CO2-27 BASE XS-0 INTUBATED-INTUBATED
[**2199-9-9**] 09:29PM freeCa-1.19
[**2199-9-9**] 09:21PM GLUCOSE-131* UREA N-22* CREAT-0.9 SODIUM-144
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15
[**2199-9-9**] 09:21PM PHOSPHATE-5.1* MAGNESIUM-1.5*
[**2199-9-9**] 05:44PM TYPE-ART RATES-/10 PEEP-5 O2-100 PO2-318*
PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 AADO2-372 REQ O2-65
INTUBATED-INTUBATED VENT-IMV
Brief Hospital Course:
[**2199-9-9**] s/p right carotid endartectomy.Transfered to PSACU
stable and neurologically intact. About 2300 resident was call
for activity suggestive of a seizure. Ct head obtained without
acute changes.blood gsases shwed patient ventilating and
oxygenating adequately. Neuro was consulted.FElt symptoms [**Last Name (un) 8966**]
secondary to embolic etology or ( but less likely) re expression
of old deficits. in the setting of bradycardia and hypotension.
Maintain systolic blood pressure greater than 130. continue
antiplatlet thearphy moniter neruro status. optmize glycemic
control.CT head obtained no bleed or or developing ischemia.
Dilantin load and dosing began. Patient transferd to ICU.
[**2199-9-10**] POD#1 nonresponsive to verable stimuli.clinical
findings not consistant with stroke. labateolol drip for blood
pressure control. Dopoff feeding tube placed .Remains in ICU
[**2199-9-11**] POD#2right neck hematoma stable. Remains somulent.tube
feed insututed.
[**Date range (1) 8967**] POD# [**2-8**] no changes neurologically. failed weaning
trial. EEG negative for seizure activity.Levofloxcin started for
temperaature of 102. sputum cultures pending. Weaning
began.Remain in ICU .MSSA pneumonia by cultures. tolerating tube
feeds.
[**Date range (1) 8968**] POD# [**3-14**] weaning continued. hypernatremia corrected
with free water. Neck heamtoma stable.mores responsive today.
[**2199-9-18**] POD#9 Repeat MRI consistant with posterior occupital
infract and reperfusion of post parietal of fetal circulation of
PCA.Patient made DNR.Free water repalcement for hypernatremia.
(157).REsponds to verbal stimuli. No motor activity. Remains
intubated. Antibiotics continued for MSSA pneumonia. Tube feed
held for stooling.Remains in SICU.REpeat EEG remains negative
for seizure activity.Neuro felt mental status changes secondary
to metabilic encelopathy.
[**2199-9-19**] POD# 10 placed on pressure support ventilations.
hypernatremia corrected.(140) antibiotic coverage brodend. Fever
workup. Continued on pressure support. Family does not want peg
or trachectomy. Episode of hypotension requiring fluid boluses
with good response.continues to be intubated. Remainas in SICU.
[**Date range (1) 8969**] POD#[**10-22**] New onset Af converted with lopressor.
Cdiff cultures negative x3. Vanco started for GPC in blood
cultures.
transfused one unit PRBC"S for hct of 25.Tube feed a goal rate.
Attemped vent weaning restarted.Extubated [**2199-9-24**] on face mask.
postransfusionHCT. 34.7.
[**2199-9-25**] POD#12 requested bedside swallowing sutdy. study
defered secondary as patient not awake enought to participate in
study.VAncomycin d/c'd A line d/c'd.
[**2199-9-26**] POD# 13 Transfered to VICU.Bed side swallowing done
patient failed. to remain NPO.REcommendations to repat study in
[**4-12**] days.
[**2199-9-27**] POD#14 beganing to vocalize more.Physical thearphy
continues to work with patient.
10/23-28/04 POD#15-20 Patient self discontinued feeding tube.
Repeat speech and swallowing evaluation done [**2199-9-30**]
demonstrated overt signs of aspiration with thin and tick
liquids. and significant orapharyngeal dysphagia. Continue tube
feed and
maintain NPO.. Will require speech thearphy at rehab facility to
address dysphagia and dysarthria, and likely right hemisphere
cognitive-linguistic defecits.GI service conslulted.Endoscopic
PEG placed. [**2199-10-2**]. Seen by OT and recommend rehablitittion
would be benefical . has not met goals set by them on first
visit [**9-26**].
[**Date range (1) 8970**] POD# 21-24Peg feeds began.Epidose of somulance
over the weekend. repeat MRI of head done.no new changes.
Improved mental status to baseline. Tube feed slowly progressed
@ time of discharge promote with fiber [**2-7**] strnght @ 70 cc/hr.
Check residuals q4h if <100cc increase tube feed to 75cc and in
eight hours to 80cc if residule <100cc. Patient then will be at
goal rate.Patient tolerating feeds.
Transfered to rehabiltation in stable contintion.
Medications on Admission:
detrol 2mgm
flomax 0.4mgmqd
celebrex 200mgm
couomadin 2mgm qd
asa 81mgm qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen
(14) units Subcutaneous twice a day: breakfast
dinner.
7. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection every six (6) hours: regular insulin slidig scale:
glucoses<120/none
glucoses 121-140/4u
glucoses 141-160/7u
glucoses 161-180/10u
glucoses 181-200/13u
glucoses 201-220/16u
glucoses 221-240/19u
glucoses 241-260/22u
glucoses 261-280/25u
glucoses 281-300/28u
glucoses >300 [**Name8 (MD) 138**] Md.
8. Acetaminophen 160 mg/5 mL Elixir Sig: 650mgm mgm PO Q4-6H
(every 4 to 6 hours) as needed.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**])
- [**Location (un) 8973**]
Discharge Diagnosis:
symptomatic carotid stenosis
hyperthyroidism
bph
squamous cell ca
postoperative right hemespheric stroke
[**Hospital 8974**] hospital acquired pneumonia
metabolic encelopathy
postoperative seizure, started on dilantin
blood loss anemia, transfused corrected.
hypernatremia, corrected
Discharge Condition:
stable
Discharge Instructions:
DNR
Followup Instructions:
4 weeks. Dr. [**Last Name (STitle) 1391**]. call for appointment. [**Telephone/Fax (1) 1393**]
Completed by:[**2199-10-7**]
|
[
"433.10",
"434.11",
"600.00",
"998.12",
"E879.8",
"482.41",
"997.02",
"780.39",
"427.31",
"V64.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.41",
"96.72",
"38.12",
"89.14",
"96.04",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
7440, 7561
|
2138, 6127
|
244, 316
|
7889, 7897
|
1438, 2115
|
7949, 8075
|
1331, 1340
|
6252, 7417
|
7582, 7868
|
6153, 6229
|
7921, 7926
|
1355, 1419
|
176, 206
|
344, 1129
|
1151, 1246
|
1262, 1315
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,564
| 140,759
|
53167
|
Discharge summary
|
report
|
Admission Date: [**2149-8-6**] Discharge Date: [**2149-8-15**]
Date of Birth: [**2068-2-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
difficulty breathing / new onset Atrial fibrillation
Major Surgical or Invasive Procedure:
Left internal jugular central line catheter placement, w/ swan
ganz catheter
History of Present Illness:
81 yo female with DM2, PVD, hyperlipidemia, and 50 py tobacco
abuse hx presents with new onset atrial fibrillation (dx by PCP
[**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **]), increasing LE edema, DOE, PND. At ED tachycardic
to 140s and given IV diltiazem, and PO metoprolol. Patient then
experienced episode of bradycardia to the 40s, hypoxia w/
saturation 70-80% on RA, and hypotension to the low 90's
systolic. She was diuresed w/ lasix drip since she was
considered to be in florid CHF.
Past Medical History:
DM type II
hypercholesterolemia
PVD
Mitral regurgitation
Macular degeneration, legally blind
Rheumatoid arthritis
Hypothyroidism
Depression
Carotid stenosis s/p ?
Cardiac Risk Factors: Diabetes, Dyslipidemia
Social History:
[**12-31**] ppd x > 50 y tobaccco hx
denies etoh, ivda
Family History:
Family history is significant for CAD in her father, and her
paternal grandfather had stomach cancer. Her father also had
lung cancer. Mother had diabetes and [**Name (NI) 13483**] thyroiditis.
Physical Exam:
VS - T:95.0 BP:108/82 HR: 58 RR: 22 O2: 100% on Face Mask
-> 88% on room air
.
General: Patient is a thin, pale, frail appearing elderly
female, appears tired, in mild to moderate respiratory distress,
wheezing intermittently
HEENT: NCAT, Sclera anicteric. EOMI
Neck: Thin, JVP up to ear sitting upright, +hepatojugular reflex
CV: Irregular, normal S1/S2 without obvious murmurs or gallops
although limited secondary to lung sounds
Chest: Mildly tachypneic, diffuse wheezes and rhonchi with
moderate air movement, prolonged expiratory phase.
Abdomen: Mildly distended, tympanitic but non-tender to
palpation. Bowel sounds present but hypoactive. No rebound, no
guarding
Rectal: Dark brown stool in rectal vault, guaiac negative
Extremity: feet cool bilaterally. 1+ pitting edema
Pertinent Results:
[**2149-8-6**] 12:00PM BLOOD WBC-6.6 RBC-3.21* Hgb-9.8*# Hct-29.7*#
MCV-92# MCH-30.6 MCHC-33.1 RDW-14.2 Plt Ct-349
[**2149-8-6**] 12:00PM BLOOD Neuts-77.2* Lymphs-17.3* Monos-3.5
Eos-1.7 Baso-0.3
[**2149-8-7**] 01:33PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Burr-2+
[**2149-8-6**] 12:00PM BLOOD Glucose-194* UreaN-17 Creat-1.1 Na-132*
K-5.1 Cl-99 HCO3-24 AnGap-14
[**2149-8-8**] 01:30AM BLOOD Glucose-219* UreaN-34* Creat-2.0* Na-132*
K-5.0 Cl-101 HCO3-17* AnGap-19
[**2149-8-12**] 06:55AM BLOOD Glucose-105 UreaN-23* Creat-1.0 Na-140
K-3.8 Cl-106 HCO3-24 AnGap-14
[**2149-8-7**] 06:30AM BLOOD ALT-352* AST-416* LD(LDH)-680* CK(CPK)-59
AlkPhos-131* TotBili-0.7
[**2149-8-7**] 04:04PM BLOOD ALT-2399* AST-3918* LD(LDH)-3310*
AlkPhos-113 Amylase-35 TotBili-0.4
[**2149-8-8**] 01:30AM BLOOD ALT-3547* AST-6027* LD(LDH)-3920*
AlkPhos-103 TotBili-0.3
[**2149-8-11**] 03:45AM BLOOD ALT-1087* AST-355* LD(LDH)-253*
AlkPhos-77 TotBili-0.6
[**2149-8-6**] 06:45PM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-3778*
[**2149-8-7**] 01:00AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2149-8-7**] 10:04AM BLOOD Glucose-150* Lactate-3.9* Na-130* K-6.7*
Cl-107
[**2149-8-7**] 11:27AM BLOOD Lactate-4.4* K-5.0
Brief Hospital Course:
Patient is a 81 yo female with hx type 2 DM, hyperlipidemia, +50
pack year tobacco abuse history, PVD who presented with dyspnea,
new onset afib and decompensated systolic CHF.
#PUMP
Patient initially presented w/ CHF symtoms and was diuresed as
well as rate controlled for new onset atrial fibrillation. Rate
control was likely overzealous, and given low ejection fraction
in setting of structural heart disease, patient experienced
hypotension and systemic hypoperfusion. Echo in setting of
decompensation on revealed severely depressed EF (10-20%) with
global hypokinesis and relative akinesis of the septum and basal
inferior walls as well as 4+ TR and 2+ MR. She was transferred
to the CCU for management of CHF in setting of renal failure,
and rising liver function tests. The initial differential in
the CCU included sepsis (broad spectrum antibiotics were
initiated), CHF (lasix was given), viral / other hepatitis
(supportive care given). A swan ganz catheter was placed in the
CCU and revealed a low-normal cardiac index and normal SVR.
Patient was observed and nodal agents were witheld; gentle
diuresis was also continued for overloaded state. Diagnosis of
ARF and shock liver were made given sustained hypotension and
bradycardia in setting of systemic decompensation. Renal
function and LFT's returned toward baseline as SBP's and HR
increased. Broad spectrum antiobotics were discontinued.
Digoxin 0.0625 mg and lisinopril 20 mg daily were started for
CHF. Lisinopril was increased to 40mg daily. Metoprolol was
also given, however this was discontinued since it was thought
to contribute to impaired respiratory status / wheezing. Patient
was put back on her home lotensin for discharge.
#. Rhythm -
Patient presented with atrial fibrillation and subsequently was
converted to sinus bradycardia with nodal agents. Beta blockade
was initially used for rate control however was discontinued
given respiratory status. It was restarted on the day prior to
discharge at low dose. Heparin was initiated for paroxysmal afib
and used to bridge coumadin until INR was >2. The patient will
continue coumadin with INR checks as outpatient. PT also noted
to have prolonged QT interval, stable, was recommended to
continue to follow as an outpatient.
#. CAD / Ischemia - Patient has not had a "known" MI, however
presents with EKG findings such as inferior and lateral q's on
EKG as well as ventricular hypokinesis on echo which signify
likely CAD. ASA was initiated as well as beta blockade; the BB
was stopped for above mentioned reasons and restarted.
#Transaminitis
As mentioned LFTs began to increase on hospital day 2 and peaked
in the thousands on hospital day 3. Subsequently they trended
down. Hepatitis serologies were sent and were negative except
for HAV IgG positivity. HAV IgM was negative. The transaminitis
was considered secondary to prolonged hypotension in setting of
acute decompensation.
#. Dyspnea/Hypoxia
Patient became quite hypoxic initially. In the CCU patient was
considered to have a COPD flare (despite lack of hx of COPD,
extensive smoking abuse and exam suggested otherwise) as well as
cardiogenic wheezing from failure. Diuresis was performed as
mentioned. For suspected COPD flare the patient was initiated
on levofloxacin and a prednisone taper starting at 60 mg daily.
Levofloxacin was changed to doxycycline given risks of QT
prolongation. The patient was restarted on lasix 20mg po daily
prior to discharge. Patient will need to complete 3 additional
days of 20mg PO prednisone at home.
#. ARF / Hyperkalemia
Patient had an increasing creatinine (max 2.0, baseline 1.0)
level during decompensation which was also considered [**1-31**]
hypotension and pre-renal causes. Renal ultrasound was
negative. Creatinine trended down as heart function improved.
Patient initially experienced hyperkalemia (up to max 7.3,
without ekg changes) and was treated appropriately. As renal
function improved along with diuresis, K returned to [**Location 213**] and
occasionally required supplementation.
#. DM
Initially patient had poorly controlled BS in setting of
decompensation (BS > 400). An insulin gtts was initiated and
then converted to lantus / humalog sliding scale with good
control. She later developed hypoglycemia and her dose of lantus
was decreased to 18UQHS. We are discharging her on 10U of lantus
as she will be completing her prednisone taper.
#. Hypothyroidism
Home synthroid was continued.
#. Anemia
Stable normocytic anemia; outpatient f/u is appropriate.
#. Depression
Home meds of Lexapro, Seroquel, Lithium were withheld initially
during decompensation. Psychiatry was consulted and recommended
restarting lithium at home dose as well as seroquel at 12.5mg
QHS. Home seroquel dose was lowered to due prolonged QT
interval. Lithium level on admission was WNL. Also, per psych,
as an outpatient, when patient is stabilized on regimen, can
consider restarting lexapro.
#. Code: DNR but not DNI (discussed with son on admission)
Code status was discussed w/ one son at admission as well as
patient; it was decided that patient's wishes were most
consistent with brief intubation for reversible causes otherwise
she would prefer DNR / DNI.
Medications on Admission:
LOTENSIN 20 MG TAB (BENAZEPRIL HCL) one po qday
GLUCOPHAGE 1000 MG TAB (METFORMIN HCL) TID
SYNTHROID 125 MCG TABS (LEVOTHYROXINE SODIUM) 1 PO QDay
ASPIRIN TAB 81MG EC (ASPIRIN) 1 QDay
COENZYME Q10 CAP (COENZYME Q10) one po qday
MULTIVITAMIN CAP (MULTIPLE VITAMIN) one po qday
AMBIEN TABS 10 MG (ZOLPIDEM TARTRATE) one po qhs prn sleep
LIPITOR 10 MG TAB (ATORVASTATIN CALCIUM) 1 PO QDay
FOLIC ACID TAB 1MG (FOLIC ACID) 1 PO QDay
LEXAPRO 20 MG TAB (ESCITALOPRAM OXALATE) 1 PO QDay
LITHIUM CARBONATE 150 MG CAP (LITHIUM CARBONATE) [**Hospital1 **]
SEROQUEL 25 MG TAB (QUETIAPINE FUMARATE) one po qd
PLAVIX TABS 75 MG (CLOPIDOGREL BISULFATE) 1 PO QDay
VITAMIN B-12 1000 MCG TAB (CYANOCOBALAMIN) 1 PO daily
ACTONEL 35mg Qweek
INSULIN 10U once daily
FLEXERIL 10mg PO QD prn
TYLENO PRN, no more than 8 tabs in 24 hr period
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) for 1 weeks.
Disp:*1 QS* Refills:*0*
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
Disp:*15 Tablet(s)* Refills:*0*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
11. PredniSONE 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for 3 days ([**Date range (1) **]).
Disp:*3 Tablet(s)* Refills:*0*
12. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. Flexeril 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
14. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
16. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Lotensin 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
19. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: With meals.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnoses:
- atrial fibrillation
- congestive heart failure, systolic dysfunction
- tricuscpid regurgitation
- ischemic "shock" hepatitis
Secondary diagnoses:
- Hyperlipidemia
- Diabetes, type 2
- peripheral vascular disease
- Carotid stensosis
- rheumatoid arthritis
- hypothyroidism
- depression
- macular degeneration, legally blind
Discharge Condition:
Stable, Home with services
Discharge Instructions:
You were admitted to the hospital for congestive heart failure
and a fast heart rate (atrial fibrillation). During the
hospitalization your blood pressure was low and heart rate was
slow, which likely caused damage to your liver (ischemic
hepatitis). We discovered that you were infected in the past
with hepatitis A.
.
You should follow up with your primary care doctor and
cardiologist regarding your care. You should maintain a diet
low in salt (less than 2 grams daily). You should weigh
yourself daily; if you gain more than 3 pounds in a week you
should contact your doctor.
.
Also, please follow up with Dr. [**Last Name (STitle) **] regarding your diabetes
regimen. Your visiting nurse will help you follow your blood
sugars closely and adjust your insulin accordingly. Also,
please follow up with Dr. [**Last Name (STitle) **], your cardiologist at the
appointment scheduled below.
.
You were started on these new medications:
- prednisone 20mg daily for 3 days
- lasix 20mg daily
- coumadin 5mg daily (you need to check your INR blood levels at
your appointment with Dr. [**Last Name (STitle) **] to adjust your levels)
- fluticasone
.
These medications were adjusted or stopped:
- stop taking your plavix, lexapro, and ambien
- decrease your seroquel from 25mg to 12.5mg daily (half a pill)
- decrease your metformin from 1000mg three times a day to two
times a day
- take 10units of glargine insulin once a day
.
Please take all medications as directed and do not change or
stop taking any medications without talking to your primary care
doctor. Please call your doctor or return to the hospital if you
have any chest pain, shortness of breath, dizziness, fainting,
or any other worrisome symptoms.
Followup Instructions:
Please maintain your follow up appointment with Dr. [**Last Name (STitle) **] on
Wednesday [**2149-8-20**] at 1:00pm. At this appointment, you need to
recheck your INR blood levels. [**Telephone/Fax (1) 1408**]
.
You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.
Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2149-9-3**] at 3:20
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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[
[]
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324, 403
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11841, 11870
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2281, 3541
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11894, 13612
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1477, 2262
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232, 286
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431, 946
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968, 1178
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1194, 1251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,497
| 104,564
|
992
|
Discharge summary
|
report
|
Admission Date: [**2155-7-16**] Discharge Date: [**2155-7-22**]
Date of Birth: [**2071-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 YO M w AF/FLUT (not anticoagulated), bioprosthetic AVR for
AS, prior colon Ca s/p hemicolectomy presenting from [**Hospital 745**]
Health Center Rehab with increased confusion, lethargy and
cloudy urine. The patient is a very poor historian so his
history was obtained largely from his daughter and HCP. She
reports that the patient was largely independant prior to a [**Month (only) 116**]
admission to [**Hospital1 18**] for MRSA bacteremia. He was treated with 4
weeks of abx and discharged to rehab. While at rehab he was
doing well until approximately 2 weeks ago. He began to develop
some mild confusion and had a fall. He reportedly did not have
any sequelae after the fall and it is not clear if the patient
had any secondary trauma although his changes in mental status
have also occurred over the past couple of weeks. Over the past
week, he has become more fatigued and lethargic, not getting out
of bed as he usually does. At one point, he did pull out his
foley. Over the past day, the patient's confusion became much
more severe. He developed some diarrhea and his family was
concerned that his confusion was [**3-4**] a UTI. His rehab noted that
the patient had a leukocytosis and so he was brought into the ED
for further evaluation.
.
Upon presentation to the ED, his initial VS were: 101.8 110
105/47 18 95%. Shortly after arrival his SBP decreased to 84.
Exam was reportably notable for mild confusion (normally
oriented times 3, but not oriented to time in the ED) a LUSB
ejection murmur and cloudy urine. Labs were notable for a
leukocytosis with left shift but no bands, a lactate of 1.4 and
a u/a with >50 WBCs and positive leuks. EKG was notable for new
ST segment depressions in V4-V6 with a rate of 117. Two 18g PIVs
were placed and less than 1L NS were given. Blood and urine
cultures were sent and the patient was given cefepime 2g,
levoflox 750mg IV once and APAP 325mg. VS prior to transfer
were: 107 22 97/52 95%.
.
Upon arrival to the floor, the patient reports recent confusion
and possibly some chest pain within the past few days although
he denies active chest pain and is unable to provide any
additional information.
.
Review of sytems:
(+) Per HPI, otherwise patient unable to provide
.
Past Medical History:
* severe AS, s/p valvuloplasty [**3-8**], then AVR [**4-5**] (19 mm
[**Last Name (un) 3843**]-[**Known firstname **] bovine pericardial prosthesis), repair [**5-6**].
* CHF [**3-4**] AS EF 45-50%
* atrial fibrillation/atrial flutter
* colon adenoCA s/p R colectomy [**3-8**]
* Chronic indwelling foley with several UTIs
* Zenkers diverticulum s/p surgical repair [**4-3**]
* h/o splenomegaly and thrombocytosis
* Anemia iron deficiency
* pulmonary asbestosis diagnosed by CT scan in [**2142**]
* jejunal microperforation diagnosed by barium swallow in [**2144**]
* manic depression/anxiety
* b/l inguinal hernia repair, right inguinal hernia [**2146**]
* decreased hearing
* esophageal stenosis
* left rotator cuff partial tear
* C diff [**2151**]
Social History:
Was living with family but was recently discharged to an
extended care facility after hospitalization for bacteremia. No
tobacco or alcohol use. Patient walks with a cane or walker.
Family History:
unable to obtain
Physical Exam:
Vitals: 96.8 119/69 16 98 2L
Gen: NAD, Oriented to hospital, person, not date.
HEENT: Mouth open, dry MM
Neck: JVP flat
Cardiovascular: Irregularly irregular no murmurs, rubs or
gallops
Respiratory: Clear to auscultation anteriorly. Scant rales at
right base.
Abd: Soft, non-tender, non distended, no heptosplenomegally,
bowel sounds present.
Extremities: No edema
Pertinent Results:
[**2155-7-16**] 05:30PM WBC-18.2*# RBC-3.75* HGB-11.2* HCT-34.2*
MCV-91 MCH-29.8 MCHC-32.7 RDW-15.8*
[**2155-7-16**] 05:30PM CK(CPK)-44*
[**2155-7-16**] 05:30PM CK-MB-2
[**2155-7-16**] 05:30PM cTropnT-0.04*
[**2155-7-16**] 05:30PM GLUCOSE-126* UREA N-32* CREAT-0.9 SODIUM-137
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-29 ANION GAP-15
[**2155-7-16**] 05:55PM URINE RBC-[**4-4**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2155-7-16**] 05:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2155-7-16**] 11:45PM TYPE-ART PO2-70* PCO2-41 PH-7.41 TOTAL CO2-27
BASE XS-0
MICRO:
[**2155-7-16**] Blood and Urine Culture: PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2155-7-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2155-7-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2155-7-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2155-7-17**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2155-7-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2155-7-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2155-7-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2155-7-16**] CXR: Left basal scarring of the lung; no acute
cardiopulmonary
process.
[**2155-7-22**] 05:10AM BLOOD WBC-5.6 RBC-3.56* Hgb-10.3* Hct-32.3*
MCV-91 MCH-29.0 MCHC-31.9 RDW-15.6* Plt Ct-398
[**2155-7-18**] 03:39AM BLOOD PT-13.6* PTT-36.4* INR(PT)-1.2*
[**2155-7-22**] 05:10AM BLOOD Glucose-87 UreaN-23* Creat-0.4* Na-144
K-4.5 Cl-104 HCO3-33* AnGap-12
[**2155-7-16**] 05:30PM BLOOD CK(CPK)-44*
[**2155-7-17**] 05:57AM BLOOD CK(CPK)-19*
[**2155-7-16**] 05:30PM BLOOD CK-MB-2
[**2155-7-16**] 05:30PM BLOOD cTropnT-0.04*
[**2155-7-17**] 05:57AM BLOOD CK-MB-2 cTropnT-0.04*
[**2155-7-22**] 05:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] is an 83 YO M with CHF EF 45-50%, aortic stenosis s/p
biprosthetic AVR, prior colon CA s/p hemicolectomy, chronic
indwelling foley for urinary retention and recent
hospitalization for MRSA bacteremia admitted with septicemia
from urinary source with pansensitive proteus mirabilis on blood
and urine cultures.
# Sepsis secondary to ascending urinary tract infection
Blood and urine cultures from admission with pan-sensitive
proteus mirabilis. Presented with pyuria, fevers, altered mental
status and leukocytosis to 18.2. Became hypotensive and
tachycardic shortly after arrival, which improved with fluid
boluses. Initially treated with vancomycin, cefepime and
ciprofloxacin. Changed to meropenem/ciprofloxacin. Narrowed to
ciprofloxacin alone once sensitivities available. Fevers, pyuria
and leukocytosis resolved within a couple days, and his mental
status slowly cleared to his baseline. He was discharged to
complete 14 day course of ciprofloxacin and he will follow up in
[**Hospital 159**] clinic.
# Altered mental status
Acute delirium in the setting of dementia. Most likely secondary
to infectious process. He came in mildly confused and
persistently did not know why he was brought to the hospital.
His confusion slowly improved; he became more coherent and
interactive over the course of his stay. He became mildly
agitated at times but could be reoriented. No focal neurologic
signs or symptoms. On discharge he was alert, oriented to
person and place. He was able to count from 10 to 1 backward.
He was at his baseline on discharge.
# EKG changes
When he became tachycardic to 117 in the setting of sepsis, he
had new ST segment depressions V4-V6. Improved when his heart
rate normalized with fluid resuscitation. Negative cardiac
enzymes and lack of chest pain or symptoms suggestive of anginal
equivalent. EKG changes were likely secondary to demand with
tachycardia.
# Hypernatremia
On the day prior to discharge, he became mildly hypernatremic
(146), likely from poor PO intake and restarting his home dose
of 10 mg Lasix. His lasix was held on discharge to be restarted
at rehab once back to baseline oral intake.
# Urinary retention
He chronically has in indwelling foley catheter for his urinary
retention. Likely source of his proteus urosepsis. He had pulled
out his prior foley, and a new foley was placed on admission.
He was continued on his home dose of tamulsulosin. He has been
discharged with a foley and he will follow up with Dr. [**Last Name (STitle) 770**]
in urology clinic.
#Loose Stools - during his admission he had several loose stools
per day with small amount of urgency and fecal incontinence. He
was tested for C. difficile which was negative x2. On the day
of discharge he was placed on a lactose free diet to see if this
would improve his symptoms and his bowel regimen was held.
# CHF
He showed no signs or symptoms of acute CHF. His home dose of
Lasix (10 mg daily) was stopped on admission in the setting of
sepsis. It was held during his hospitalization given decreased
po intake. His intake and weights should be monitored with
lasix restarted for weight gain or signs of fluid accumulation.
# Atrial fibrillation/flutter
Irregularly irregular rhythm, but rate is well-controlled.
Treated with 325 mg aspirin daily. On review of note from his
cardiologist Dr. [**Last Name (STitle) 1016**] he is not on coumadin due to increased
fall risk.
# Dementia - stable. Continued outpatient donepezil.
Medications on Admission:
Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID prn
Cholecalciferol (Vitamin D3) 800mg daily
Calcium Carbonate 500 mg Tablet, Chewable TID
Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS
Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID
Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
Ferrous Sulfate 325 mg Tablet daily
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Heparin (Porcine) 5,000 unit/mL TID
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID
Acetaminophen 1000 mg Tablet Q6H
Tamsulosin 0.4 mg PO daily
Furosemide 10 mg (half-tab of 20mg) PO daily
Vitamin B12 100 mcg PO daily
Lidoderm patch 5% to bilateral knee 12 hours on 12 hours off
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 10 days: Last doses on [**7-30**].
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Primary diagnoses:
UTI c/b bacteremia (pan-sensitive Proteus Mirabilis)
Orthostasis
Secondary diagnoses:
Atrial fibrillation/flutter
Dementia
Hypocalcemia
s/p aortic valve replacement
CHF
Discharge Condition:
Mental Status: Oriented to person. Occasionally oriented to
place. Not oriented to date. Able to count backward from 10 to
1. Delirium mostly resolved prior to discharge.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) due to high fall risk.
Discharge Instructions:
You were admitted because you had an infection in your urinary
tract and blood that gave you fevers, lowered your blood
pressure and made you more confused. We treated your infection
with antibiotics, and we treated your low blood pressures by
giving you IV fluids. Your fevers resolved, your blood pressures
stabilized and your mental status became more clear. Please
complete your full 14 day course of ciprofloxacin, which is the
antibiotic that treats your infection. Your foley catheter was
changed during your hospitalization.
Changes to your medications:
-ciprofloxacin 500mg PO twice daily (last day [**7-30**])
-HOLD furosemide, can be restarted by rehab when no longer
hypernatremic.
Otherwise no changes were made to your medications.
Please take all medications as prescribed.
Please follow up with all of your appointments.
It was a pleasure taking care of you, Mr. [**Known lastname **].
Followup Instructions:
1. You have an appointment to follow up in [**Hospital 159**] clinic given
your recurrent urine infections and foley catheter. You will
be seeing one of the nurse practitioners that works with Dr.
[**Last Name (STitle) 770**].
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2155-8-7**] at 1:30 PM
With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2. You have an appointment scheduled to see Dr.[**Name (NI) 3733**] who
is the cardiologist that is taking over your care from Dr.
[**Last Name (STitle) 6558**] since he is retiring. You will have an echocardiogram
at 9:00 am prior to your appointment with Dr.[**Doctor Last Name 3733**].
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-10-31**] 9:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-11-18**]
9:20
3. Please follow up with your primary care doctor within two
weeks of discharge from rehab.
|
[
"275.41",
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"294.8",
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"428.22",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11634, 11698
|
6305, 9796
|
336, 342
|
11931, 11931
|
4007, 6282
|
13206, 14293
|
3588, 3606
|
10525, 11611
|
11719, 11804
|
9822, 10502
|
12276, 12811
|
3621, 3988
|
11825, 11910
|
12840, 13183
|
275, 298
|
2548, 2601
|
370, 2530
|
11946, 12252
|
2623, 3373
|
3389, 3572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,313
| 124,991
|
103
|
Discharge summary
|
report
|
Admission Date: [**2191-4-24**] Discharge Date: [**2191-4-27**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with HTN, Dyslipidemia and Admission to [**Hospital1 882**] in [**2190-8-23**]
for acute pulmonary edema, presents from [**Hospital **] rehab c/o sob.
Pt lasix was noted to have been discontinued on end of [**3-16**]
to the fact that she had no peripheral edema. Around 1am she
was found to be short of breath and O2 sat of 82% on Room air
and diaphoretic. Other vital signs were 98.4 107 136/74. She
was placed on 2L NC, given albuterol and lasix 20mg PO. Her O2
sats increased to 88% and she put out 300cc of urine while en
route to [**Hospital1 18**] ED.
.
In the ED, T:99.8, HR: 108, BP 147/87, RR: 32, 91%NRB. Pt was
unable to speak in full sentences and T wave inversions in V4-6,
trop 0.18 and proBNP: [**Numeric Identifier 1168**]. Placed on BIPAP and given
kayexalate 30mg PO for K of 6.0, aspirin 325mg PO x1 and lasix
20mg IV x1. Vancomycin 1gm an cefepime 2gm, Nitro gtt started.
Pt diuresed 350cc of lasix in the ED. No effusion on bedside
(ED) echo. CXR showed vascular congestion and bilateral pleural
effusions. Most Recent VS: 96, 164/84, 23, 96% NRB
.
On review of systems, She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. Denies chest
pain, nausea, vomiting, diarrhea, change in urnary habits, URI
symptoms. All of the other review of systems were negative.
.
Positive for cough for last month. Non-productive, similar
during the day as well as at night, could not tell us if
anything makes it better or worse.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Osteoarthritis.
Low back pain in the past.
? TIA [**2173**]
S/P TAH, BSO
Mild inferior wall ischemia on echocardiogram.
R ICH s/p MVA [**2176**]
ruptured appendix s/p appendectomy
Mild Anemia
Hx of breast CA s/p left mastectomy
Social History:
She currently lives at a rehab center, but previously she lived
alone in an apartment. She had several friends in the area.
Grandson [**Name (NI) 1169**] is her power of attorney.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T=98.7 BP=141/74 HR=100 RR=25 O2 sat=96% NRB 12L
GENERAL: Mild respiratory distress Oriented x2. confused
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to earlobes.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Breathing quickly on NRB, poor inspiratory effort,
diminished breath sounds at the bases and crackles heard in the
mid lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing or cyanosis, 1+ edema No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 1+ Peripheral pulses
.
On Discharge:
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 75 (68 - 91) bpm
BP: 135/51(74) {102/28(41) - 155/65(87)} mmHg
RR: 23 (16 - 26) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 49.6 kg (admission): 52.5 kg
GENERAL: Mild respiratory distress Oriented x2. confused
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to mid neck.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, distant heart sounds, normal S1, S2. faint
holosystolic murmur with S3.
LUNGS: Breathing quickly on NRB, poor inspiratory effort,
crackles heard at the bases bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing or cyanosis, 1+ edema No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars
PULSES: Trace edema
Pertinent Results:
CBC:
[**2191-4-24**] 08:45AM BLOOD WBC-9.7 RBC-3.77* Hgb-11.9*# Hct-35.5*
MCV-94 MCH-31.5# MCHC-33.4 RDW-15.1 Plt Ct-189
[**2191-4-26**] 08:20AM BLOOD WBC-10.5 RBC-3.41* Hgb-10.9* Hct-32.0*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.6 Plt Ct-175
[**2191-4-27**] 04:20AM BLOOD WBC-6.2 RBC-3.27* Hgb-10.3* Hct-30.3*
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.7 Plt Ct-188
.
COAGS:
[**2191-4-26**] 08:20AM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.0
[**2191-4-27**] 04:20AM BLOOD PT-11.8 PTT-28.0 INR(PT)-1.0
.
CMP:
[**2191-4-24**] 08:45AM BLOOD Glucose-161* UreaN-43* Creat-1.4* Na-141
K-6.0* Cl-108 HCO3-22 AnGap-17
[**2191-4-25**] 04:21AM BLOOD Glucose-125* UreaN-43* Creat-1.6* Na-145
K-3.5 Cl-106 HCO3-26 AnGap-17
[**2191-4-26**] 08:20AM BLOOD Glucose-126* UreaN-51* Creat-1.7* Na-147*
K-3.5 Cl-107 HCO3-28 AnGap-16
[**2191-4-27**] 04:20AM BLOOD Glucose-94 UreaN-52* Creat-1.5* Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
[**2191-4-24**] 08:45AM BLOOD Calcium-9.4 Phos-5.0*# Mg-1.9
[**2191-4-25**] 04:21AM BLOOD Calcium-8.6 Phos-6.7* Mg-2.4
[**2191-4-26**] 08:20AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.2
[**2191-4-27**] 04:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.2
.
TROPONIN AND BNP:
[**2191-4-24**] 08:45AM BLOOD cTropnT-0.18*
[**2191-4-24**] 05:40PM BLOOD CK-MB-8 cTropnT-0.33*
[**2191-4-25**] 04:21AM BLOOD CK-MB-6 cTropnT-0.33*
[**2191-4-25**] 04:50PM BLOOD CK-MB-4 cTropnT-0.33*
[**2191-4-24**] 08:45AM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 1168**]*
###################################################
Microbiology: ([**2191-4-24**])
URINE CULTURE: NO GROWTH
BLOOD CULTURE: PENDING
###################################################
IMAGING:
ECHO [**2191-4-25**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with
aneurysm/near akinesis of the distal 1/3rd of the ventricle.
Basal segments are relatively preserved (LVEF 30%). No masses or
thrombi are seen. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-16**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with moderate
regional systolic dysfunction c/w CAD (mid LAD wrap-around
distribution). Mild-moderate mitral regurgitation. Pulmonary
artery systolic hypertension.
.
CXR [**2191-4-24**]:
CHEST, AP UPRIGHT: There is severe CHF with pulmonary edema,
cardiomegaly
bilateral layering pleural effusions. There is no pneumothorax.
The bones are diffusely demineralized, with multiple old and
partially
displaced rib fractures resulting in marked thoracic deformity.
There is
moderate thoracolumbar dextroscoliosis, with multilevel
compression
deformities better evaluated on chest CT from [**2188-11-3**].
IMPRESSION:
1. Congestive heart failure.
2. Diffuse skeletal demineralization, with multiple old rib and
vertebral
fractures, better evaluated on prior chest CT.
Brief Hospital Course:
ASSESSMENT AND PLAN: [**Age over 90 **] yo woman with history of hypertension
and dyslipidemia who presents with acute onset of shortness of
breath and pulmonary edema with troponin
.
# CHF: Pt with known diastolic heart failure on previous ECHO
(EF 65%) presents with acute onset of shortness of breath.
Initially, she was thought to be in diastolic heart failure and
treated with diuresis and discontinuing her amlodipine 10mg,
labetolol 200mg PO Daily, holding her Imdur 60mg PO Daily in the
setting of a nitro gtt. She was started on carvedilol 6.25mg PO
BID and her lisinopril was continued. A repeat ECHO showed an
EF of 30%, LV apical aneurysm and moderate regional left
ventricular systolic dysfunction with aneurysm/near akinesis of
the distal 1/3rd of the ventricle. It was believed that she had
an old infarct and she now has a systolic component to her heart
failure as well. She was properly diuresed and weaned off her
O2. She was restarted on her home dose of lasix 20mg PO daily.
She is on aspirin 325mg PO daily and we will continue that for
prevention of thrombus in the LV aneurysm. Given her new
finding of apical anuerysm there was long discussion about
whether to anticoagulate or not. Given that there is no
evidence of thrombus in the aneurysm and that the event was
likely old the data does not show a strong indication for
anticoagulation. Given her age and risk of bleeding it was
decided to continue her on aspirin 325mg PO Daily, but not to
start plavix or warfarin at this time. This was discussed with
her grandson [**Name (NI) 1169**] and was in agreement with the plan. She
should be monitored closely at [**Hospital **] Rehab and if she is
gaining weight her lasix should be increased. If her BP is
elevated her lisinopril or carvedilol should be uptitrated.
.
# RHYTHM: patient was in atrial bigemeny at time of admission to
the ICU with a rate of 89. She had not taken any of her
medications this am and so will give her her BB as prescribed.
Goal HR <80 for her in order to maximize filling time. She
remained in atrial bigeminy throughout the course of her
hospital stay and there were no other arrhythmias noted.
.
# CAD: Pt has no history of cardiac cath on record, nor did she
report ever having a catheterization. Has elevated troponin of
0.18, but MB was flat at 8. In previous hospitalizations she
also had increase in troponins in the setting of CHF
exacerbation and given her symptoms and history ACS is less
likely. Her troponin peaked at 0.33, but MB remained flat.
Repeat ECHO showed focal wall motion abnormalities and apical
ballooning of the left ventricle indicating an ischemic event at
some point between this admission and [**2189**] at the time of her
last ECHO at [**Hospital1 882**] which showed symmetric LVH and EF of 60%.
Given her new finding of apical anuerysm there was long
discussion about whether to anticoagulate or not. Given that
there is no evidence of thrombus in the aneurysm and that the
event was likely old the data does not show a strong indication
for anticoagulation. Given her age and risk of bleeding it was
decided to continue her on aspirin 325mg PO Daily, but not to
start plavix or warfarin at this time. This was discussed with
her grandson [**Name (NI) 1169**] and was in agreement with the plan.
.
# HTN: Pt presented with hypertension and systolics in the 150s
in the setting of not taking her medications this morning. She
was placed on a nitro drip in the ED to reduce afterload and
help with forward flow. She was intially continued on her home
medications lisinopril 5mg PO Daily, labetolol 200mg PO Daily,
Imdur 60mg PO Daily, amlodipine 5mg PO Daily. Given her heart
disease her amlodipine and labetolol were discontinued and she
was started on carvedilol 6.25mg PO Daily and continued on
lisinopril. Her nitro drip was stopped on Day 2 of admission.
She was also eventually started on her old home dose of lasix
20mg PO daily that should be continued in the outpatient setting
given her EF of 30%. Her BP were stable while in the hospital
and if she becomes hypertensive, her lisinpril or beta blocker
should be titrated up.
.
# Fevers: Pt had low grade temp of 99.8 in the ED and was given
vancomycin and cefepime. She had no white count, BP are stable,
U/A negative and CXR is indeterminate given pulmonary edema.
She has been endorsing a cough for the past month that is
non-productive. Likely not secondary to an infectious process.
She has a history of aspiration PNA and while she could have
aspirated overnight cannot distinguish between pneumonitis and
PNA at this time. We will held off on antibiotics and she
remained afebril and hemodynamically stable. She did not
exhibit any signs of infection and her urine culture was
negative. Her blood cultures are still pending and need to be
followed up on. A repeat CXR was not performed because of low
suspicion for pneumonia.
.
# Chronic Kidney Disease Stage III (GFR = 35): Pt creatinine on
admission 1.4 in the setting of fluid overload and a baseline of
1.2. During active diuresis her creatinine trended up to 1.7,
but on the day of discharge was back down to 1.5. This was
likely in the setting of diuresis and her creatinine should
trend down back to baseline. Her creatinine should be
monitored on routine screening in the future.
.
# s/p ICH on the [**2170**]'s: Pt is on Keppra and no clear reason
other than previous ICH. No history of seizures noted. She was
continued on her Keppra dose during her hospital stay, but she
should have neurology follow up in the outpatient setting to see
whether she requires continued administration of keppra. Given
her age she would benefit from reducing her medication burden.
.
INACTIVE ISSUES:
.
# GERD: Pt was asymptomatic throughout the course of her
hospital stay. We Continued Omeprazole 20mg PO Daily
.
# Adjustment disorder: Unclear if this is the underlying reason
the patient is taking venlafaxine. We continued venlafaxine XR
37.5mg PO Daily
Keppra 250mg PO BID
.
# Asthma: Currently stable, no wheezing and the patient did not
require any inhalers.
.
DNR/Ok to intubate for respiratory issues
.
TRANSITIONAL ISSUES:
- She was continued on her Keppra dose during her hospital stay,
but she should have neurology follow up in the outpatient
setting to see whether she requires continued administration of
keppra. Given her age she would benefit from reducing her
medication burden.
.
- If patient is hypertensive please uptitrate her lisinopril and
carvedilol prior to adding new medications.
.
- Follow up blood cultures
Medications on Admission:
Aspirin 325mg PO Daily
Omeprazole 20mg PO Daily
lisinopril 5mg PO Daily
venlafaxine XR 37.5mg PO Daily
Imdur 60mg PO Daily
Keppra 250mg PO BID
AMlodipine 10mg PO Daily
Labetolol 200mg PO Daily
Albuterol PRN
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-16**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Diagnosis:
Systolic heart Failure (EF 30%) with Diastolic dysfunction
.
Secondary Diagnosis:
Dyslipidemia
Hypertension
Osteoarthritis.
Low back pain in the past.
? TIA [**2173**]
R ICH s/p MVA [**2176**]
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 are being discharged from [**Hospital1 1170**]. You were admitted because you were Short of Breath in
the middle of the night and required oxygen. You chest X-ray
showed that you had extra fluid in your lungs and you were given
medication to help take some of the fluid off. We repeated an
Ultrasound of your heart an it showed that your heart was not
pumping as well as it used to and you have some ballooning of
the heart. We will monitor this for now, but you do not need
more therapy than aspirin daily. We also changed around your
medications so you are on the best therapy for Heart Failure.
.
The Following medications were STARTED:
Carvedilol 6.25mg by mouth twice a day
atorvastatin 40mg by mouth at night
Lasix 20mg by mouth Daily
.
The Following medications were STOPPED:
Amlodipine 10mg by mouth Daily
Labetolol 200mg by mouth Daily
Imdur 60mg PO Daily
.
Please take your other medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs as you may need to increase your water pill.
Followup Instructions:
Please have the patient evaluated by a neurologist for risk of
seizure given that she is on Keppra and there was no clear
indication in her history other than distant ICH s/p MVA many
years prior.
.
If patient is hypertensive and requires BP medications please
uptitrate lisinopril first and then carvedilol as she should not
be on a calcium channel blocker in the setting of her heart
failure.
.
Please follow up Blood cultures
.
IF gaining more than 3 lbs please evluate fluid status and
consider increasing lasix dose.
|
[
"272.4",
"585.3",
"493.90",
"309.9",
"530.81",
"403.90",
"428.43",
"780.60",
"V49.86",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15300, 15365
|
7610, 13328
|
267, 274
|
15623, 15623
|
4441, 7587
|
16890, 17414
|
2643, 2760
|
14446, 15277
|
15386, 15386
|
14215, 14423
|
15806, 16867
|
2775, 2775
|
2092, 2169
|
3538, 4422
|
13781, 14189
|
220, 229
|
302, 1982
|
15487, 15602
|
13345, 13760
|
15405, 15466
|
2789, 3524
|
15638, 15782
|
2200, 2430
|
2004, 2072
|
2446, 2627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,713
| 135,239
|
49431+59179
|
Discharge summary
|
report+addendum
|
Admission Date: [**2151-7-25**] Discharge Date: [**2151-8-10**]
Date of Birth: [**2102-6-16**] Sex: M
Service: MEDICINE
Allergies:
Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
Diagnostic paracentesis.
Therapeutic paracentesis
History of Present Illness:
49M w/ polysubstance abuse, HCV, HBV, AIDS, autonomic
dysfunction, and cirrhosis admitted after being found down at
the T stop. At the scene he was felt to have falled down the
stairs and was brought to the ED. Here he was hypothermic with
an elevated lactate and SPB ~70 and started on vancomycin/zosyn
for presumed sepsis. Diagnostic tap of his ascites was negative.
CT showed a small SAH (later thought to be artifact on repeat)
and he was dilantin/keppra loaded. A L1/2 compression fx was
seen and orthopedics evaluated him as well. His initial labs
were significant for a coagulopathy w/ INR=1.8 and plt=53 and he
was given 1u plt, 2u RBC, and 1u FFP and sent to the MICU for
further w/u. Of note, he was recently admitted to [**Hospital1 18**] in [**5-31**]
for progressive ascites and had a therapeutic tap there and was
diuresed with lasix/aldactone.
.
In the MICU, his BP was stable in a normal range and he had a
CXR showing a probable infiltrate along w/ ? R rib fractures and
his antibiotics were switched to levaquin/flagyl. His mental
status was slightly impaired on arrival (AAOx2) and this was
felt to be secondary to intoxication and chronic liver failure.
His labs were initially thought to be c/w a picture of DIC (low
haptoglobin, low plt, low fibrinogen) but his OSH labs were
eventually obtained and showed a chronic picture of liver
failure (alt 71, ast 130, alp 719, tbili 1.2, alb 2.1, INR 1.6)
along w/ pancytopenia (HCT 24.8 and plt 53). Given this
information, his hematologic abnormalities were thought to be
close to his baseline and he was called out to the floor.
Past Medical History:
1. Polysubstance abuse (etoh, cocaine, heroin)
2. Hep B
3. Hep C
4. HIV/AIDs with h/o PCP [**Name Initial (PRE) 1064**] (CD4-23, VL 140K on [**5-1**];
[**9-30**] on viracept/combavir changed to truvata/reyataz/norovir
[**1-31**] then to atrepla [**5-1**])
5. EtOH cirrhosis
6. Recurrent retropharyngeal abscess w/ GBS bacteremia and
sepsis
7. Autonomic dysfx requiring wheelchair use
8. Cachexia
9. Recurrent pancreatitis
Social History:
Homelessness, ETOH abuse. Followed at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] [**Hospital 103475**]
healthcare for the homeless, and [**Hospital1 2177**].
Physical Exam:
PE: 97.6, 141/73, 92, 20, 98% (50% blowby mask), 5138/1237
Gen: Sedated but arousable to voice and cooperative w/ exam
HEENT: MM dry, O/P w/ hard palate patches of erythema, pupils
reactive to light
CV: RRR, no M/R/G
Lungs: L basilar crackles but otherwise CTA
Abd: Distended and moderately tense. Mild diffuse tenderness but
no rebound or guarding
Ext: 2+ LE edema to thighs, scrotal edema, erythema of R ankle
shin w/out evident skin breakdown
Neuro: Oriented to self, city, year, and president. Cooperative
w/ exam and answers questions appropriately. Moving all
extremities spontaneously. Pupils reactive at 2.5mm.
Pertinent Results:
[**2151-7-25**] 03:55AM BLOOD WBC-6.9 RBC-2.41* Hgb-9.2* Hct-27.8*
MCV-115* MCH-38.1* MCHC-33.0 RDW-17.3* Plt Ct-52*#
[**2151-7-30**] 05:22AM BLOOD WBC-5.8 RBC-2.77* Hgb-9.8* Hct-30.0*
MCV-108* MCH-35.3* MCHC-32.6 RDW-17.2* Plt Ct-41*
[**2151-7-27**] 06:55AM BLOOD PT-18.7* PTT-36.3* INR(PT)-1.8*
[**2151-7-26**] 04:12AM BLOOD WBC-7.5 Lymph-8* Abs [**Last Name (un) **]-600 CD3%-87 Abs
CD3-524* CD4%-13 Abs CD4-79* CD8%-69 Abs CD8-412 CD4/CD8-0.2*
[**2151-7-25**] 03:55AM BLOOD UreaN-19 Creat-1.5*
[**2151-7-25**] 11:15AM BLOOD Glucose-157* UreaN-17 Creat-1.1 Na-138
K-4.5 Cl-111* HCO3-14* AnGap-18
[**2151-7-27**] 06:55AM BLOOD Glucose-83 UreaN-13 Creat-0.7 Na-135
K-3.8 Cl-110* HCO3-19* AnGap-10
[**2151-7-30**] 05:22AM BLOOD Glucose-120* UreaN-21* Creat-1.3* Na-131*
K-3.5 Cl-107 HCO3-19* AnGap-9
[**2151-7-25**] 03:55AM BLOOD ALT-101* AST-266* LD(LDH)-777*
CK(CPK)-126 AlkPhos-606* Amylase-193* TotBili-1.2
[**2151-7-30**] 05:22AM BLOOD ALT-27 AST-50* LD(LDH)-267* AlkPhos-305*
TotBili-1.6*
[**2151-7-25**] 02:42PM BLOOD Calcium-7.6* Phos-3.7 Mg-1.4*
[**2151-7-27**] 06:55AM BLOOD Albumin-2.1* Calcium-7.7* Phos-1.9*
Mg-1.7
[**2151-7-25**] 02:42PM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2151-7-25**] 03:55AM BLOOD ASA-NEG Ethanol-176* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2151-7-25**] 02:42PM BLOOD HCV Ab-POSITIVE
[**2151-7-26**] 11:57AM BLOOD Type-ART Temp-35.7 pO2-71* pCO2-27*
pH-7.48* calTCO2-21 Base XS--1
[**7-27**] MRI C-Spine Findings: Alignment of the cervical spine is
normal. There are degenerative changes with intervertebral
osteophyte formation at C4-5. This causes severe narrowing of
the spinal canal and flattening of the spinal cord.
Uncovertebral osteophytes narrow the neural foramina bilaterally
at this level. The involvement is more severe on the right and
left.
Small osteophytes at C5-6 narrow the spinal canal and produce
mild narrowing of the neural foramina. The signal intensity of
the spinal cord appears normal.
[**7-27**] Rib X-Ray Nondisplaced fractures of the right posterolateral
eighth, ninth, and tenth ribs with callous formation. The
findings represent subacute versus remote injury. No
pneumothorax.
Interval worsening of bilateral airspace opacities, worse in the
left mid lung. Diagnostic considerations include pneumonia
CT head [**2151-7-25**]:
Likely a small focus of subarachnoid blood in the left parietal
occipital lobe. Scalp hematoma of the left scalp. No evidence
for skull fracture.
.
CT spine [**2151-7-25**]:
No evidence for cervical spine fracture or malalignment.
Degenerative changes at C4-5
.
CT abd/pelvis:
1. Large volume of ascites throughout the abdomen and pelvis.
Small liver and few small varices suggest liver disease.
2. Distended gallbladder without gallbladder wall thickening or
gallstones.
3. Distended stomach containing solid and liquid material.
4. Pancreatic calcifications suggest prior pancreatitis. No
pancreatic inflammation or peripancreatic fluid collections.
5. Anasarca.
6. Probe/instrument within the rectum.
7. Compression deformity of L1 vertebral body of indeterminate
age.
.
CXR ([**2151-8-3**]): 1. Stable multifocal consolidations, most
consistent with pneumonia. 2. Stable appearance of right-sided
rib fractures without evidence for pneumothorax.
KUB ([**2151-8-3**]): 1) Mild gaseous distention to loops of small
bowel, with probable large bowel ileus affecting transverse
colon. 2) Re-identification of known ascites.
KUB ([**2151-8-4**]): Slightly decreased distention to loops of small
bowel with unchanged dilatation of the transverse colon
measuring up to 8 cm suggestive of an ileus. No evidence of
obstruction.
KUB ([**2151-8-5**]):Dilated transverse colon with interval development
of a single loop of dilated small bowel within the left lower
quadrant. These findings are again most suggestive of an ileus.
Continued radiographic surveillance is recommended.
[**2151-7-26**] 11:41 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2151-7-28**]**
GRAM STAIN (Final [**2151-7-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2151-7-28**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
YEAST. MODERATE GROWTH.
Brief Hospital Course:
On arrival to the floor on [**7-27**], the patient was complaining of
breathing difficulty and increased back, chest pain. His blood
pressure ranged from 95-110, and he had minimal urine output.
Imaging had previously revealed right rib and L1 fractures.
Lidocaine patchs were placed on the patient's right chest, and
lumbar spine, and he was administered oxycodone. Ortho saw the
patient, and recommended TLSO as soon as the patient could
ambulate out of bed. neurosurgery was consulted regarding the
patient's neck CT showing possible spinal cord compression.
They felt the compression was a result of chronic degenerative
changes, and that the patient's only clinical manifestation was
mild proximal weakness. They recommended a soft collar and
outpatient follow-up. hepatology consulted on the patient, and
they recommended increased diuretic administration. On [**7-29**], a
therapeutic paracentesis was performed, draining 4800cc of
fluid. The patient was administered 37.5g albumin after the
paracentesis. On [**7-30**], the patient was reporting improved
breathing and pain, however, he experienced further diminished
urine output and his blood pressure dropped to 90-100. His
creatinine also increased from .7 to 1.3, from [**Date range (1) 69675**].
hepatology initially diagnosed him with hepatorenal syndrome and
recommended to discontinue the diuretics, and to add 25g of 25%
albunmin [**Hospital1 **]. Since pt responded so well with IVFs and
discontinuation of diuretics, the diagnosis was later changed to
renal failure. On [**7-31**] the patient's chemistries portrayed a
picture of possible DIC. In addition, his left arm was found to
be cyanotic, with nonpalpable radial pulse and poor capillary
refill. IV fluida at 125cc/ hour were administered. Vascular
surgery consulted on the patient several hours later, and by
then the patient's arm was no longer cyanotic appearing and he
had a palpable radial pulse. No intervention was suggested
atthis time. Later in the day the patient triggered with a
temperature of 94.0, down from his baseline of 96-97. He was
given a warming blanket, and had blood cultures drawn. Heme/Onc
was cnsulted and they were not certain if the patient had DIC or
HIT, reporting the patient's chemistries are difficult to
interpret because he received blood products in the MICU prior
to arrival on the floor, and the recent trends in coagulation
studies may simply be the patient's return to his baseline
values as opposed to a consumptive coagulopathy. In addition,
they observed only few schistocytes on the smear. Eventually it
was decided this was most likely merely a manifestation of
trending down to his baseline and but DIC to some extent and not
HIT. ID was also consulted regarding the role for HAART. The
patient was not on HAART on presentation to the hospital, and
was instead begun without ID approval by a different medicine
team. They recommended discontinuing HAART and adding Zosyn (to
Vancomycin), given the fact that the patient just triggered with
hypothermia and may be septic. As pt developed a lower
extremity rash zosyn was discontinued and aztreonam and flagyl
was used instead.
.
From this point on the patients renal, and respiratory function
steadily improved, was not requring oxygen, and diuretics was
added on [**8-3**] with good effect. However, on [**8-3**] pt was found
to have a possible ileus on a KUB (done b/c had mild epigartic
pain). Patient was temporarily placed NPO but had BM and was
passing gas without nausea and vomiting; therefore his diet was
advanced while ambulation was ecouraged. On [**8-6**] patient looked
great and was able to eat regular meals, ambulating with a
walker in his brace and was ready for placement; however no beds
were found for him in rehab. In addition, his amylase and
lipase started to rise despite not having any s/s of
pancreatitis (no abd pain, no nausea, vomiting). The thinking
was that this was a drug-induced biochemical pancreatitis. The
patient had no s/s of pancreatits (no abd. pain, nausea,
vomiting etc). The most likely culprit initially was robutussin
which was d/c'd on [**8-6**]. On [**8-7**] vancomycin and aztreonam were
also d/c'd after ID had ok'd this from their perspective. On
[**8-9**], the amylase and lipase increase had begun to taper and the
patient was ambulating, taking adequate po, voiding on own. He
was discharged on [**8-9**] with close follow-up with ortho,
hepatolgy follow-ups as well as an appt with Dr. [**Last Name (STitle) **] for his
HIV/AIDS case as well as his general medical care.
Medications on Admission:
mvi
thiamine
folate
bactrim ds qd
spironolactone 100qd
lasix 80 [**Hospital1 **]
azithromycin qwk
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Renal Failure
MRSA pneumonia
L1 compression fracture
cervical stenossi with cord compression
cirrhosis
Hep A
Hep B
Hep C
HIV/AIDS
Polysubstance abuse
Discharge Condition:
Stable
Discharge Instructions:
- If you develop a fever >38.5 C, intractible nausea and
vomiting, blood in your vomitus, bleeding per rectum, severe
abdominal swelling (ascites), fatigue, severe abdominal pain, or
if you at any time become concerned about your medical condition
please contact [**Hospital1 18**] at [**Telephone/Fax (1) 91249**], Dr. [**Last Name (STitle) **] or present at
the nearest hospital.
- Please go to your scheduled follow-up visits with Dr. [**Last Name (STitle) **],
orthopedic surgery and hepatology.
Followup Instructions:
- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Monday [**2151-8-16**] at 9:30 am for your
HIV/AIDS and general medical care
- [**2151-9-16**], 01:30p [**Last Name (LF) **],[**First Name3 (LF) **] (LIVER CENTER), LM [**Hospital Unit Name **], [**Location (un) **] LIVER CENTER (SB). Pt needs to start
antiretroviral therapy for Hepatitis B once amylase and lipase
have normalized.
- [**2151-8-18**], 12:30p [**Doctor Last Name **],ORTHO [**Doctor First Name 147**] SPEC, [**Hospital6 29**],
[**Location (un) **] [**Hospital **] CLINIC (SB)
- [**2151-8-18**], 12:10p X-RAY ORTHO SCC2, [**Hospital6 29**], [**Location (un) **], X-RAY ORTHO SCC2
-Important contact info: [**Name (NI) 86**] Healthcare for the Homeless.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA [**Telephone/Fax (1) 14428**] (pager) PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Doctor Last Name **]
Health Group, [**Telephone/Fax (1) 14428**]; [**Telephone/Fax (1) 103476**]; fax [**Telephone/Fax (1) 103477**]
- Pt needs to start antiretroviral therapy for Hepatitis B once
amylase and lipase have normalized.
- Pt needs to have potassium monitored in the close follow-up
with his PCP since he is on a high dose of spironolactone which
may cause hyperkalemia
- Pt may need to be re-stared on HIV/AIS antiretroviral therapy
Name: [**Known lastname **],[**Known firstname 63**] Unit No: [**Numeric Identifier 16773**]
Admission Date: [**2151-7-25**] Discharge Date: [**2151-8-10**]
Date of Birth: [**2102-6-16**] Sex: M
Service: MEDICINE
Allergies:
Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 342**]
Addendum:
Pt was kept overnight to [**8-10**] since [**Hospital1 1238**] were not able to
accept the patient after 3 pm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 347**] MD [**MD Number(1) 348**]
Completed by:[**2151-8-9**]
|
[
"560.1",
"807.04",
"E930.0",
"571.1",
"284.1",
"789.5",
"584.9",
"805.2",
"571.5",
"995.91",
"920",
"070.32",
"V60.0",
"482.41",
"577.0",
"337.9",
"721.1",
"042",
"070.54",
"693.0",
"E880.9",
"263.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"54.91",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15505, 15732
|
8087, 12669
|
302, 353
|
13083, 13091
|
3282, 8064
|
13640, 15482
|
12911, 13062
|
12695, 12794
|
13115, 13617
|
2642, 3263
|
252, 264
|
381, 1979
|
2001, 2425
|
2441, 2627
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,519
| 102,703
|
22605
|
Discharge summary
|
report
|
Admission Date: [**2109-8-15**] Discharge Date: [**2109-9-17**]
Service: [**Doctor First Name 147**]
Allergies:
Sulfa (Sulfonamides) / Sulfamethoxazole
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
occult gastrointestinal bleeding and duodenal adenoma
Major Surgical or Invasive Procedure:
[**2109-8-15**] Pylorus preserving pancreaticoduodenectomy and open
cholecystectomy
[**2109-8-16**] 1. Reopening of recent laparotomy.
2. Evacuation of intraperitoneal blood and hematoma.
3. Reappraisal of hepaticojejunostomy with afferent external
biliary drainage catheter placement.
4. Combined feeding jejunostomy and draining gastrostomy tube
placement.
History of Present Illness:
Mrs. [**Known lastname 58620**] is an 85 year old woman with a history of chronic
blood loss anemia who endoscopically has been found to have a
circumferential duodenal adenoma that is friable and bleeding.
She is also on coumadin for atrial fibrillation.
Past Medical History:
Her surgical history is significant for an appendectomy,
tonsillitis, a bladder operation, and a uterine cancer in the
past. Her medical history is significant for arthritis, anemia,
atrial fibrillation, and subacute bacterial endocarditis many
many years ago. She has had no sequelae to that long-term. She
also has congestive heart failure.
Social History:
1 alcoholic drink per day, she stopped smoking in [**2092**].
Physical Exam:
On discharge patient is afebrile with stable vital signs. Her
abdomen is soft, nontender and nondistended. Her surgical
incision is healing well with pink granulation tissue. The small
incisions where 2 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drains had been placed are
closed and healing well. She has a T-tube which is capped and a
j-feeding tube which is in place. Her heart remains in sinus
rythym. Her lungs are clear except for crackles that improve
with cough bilaterally.
Brief Hospital Course:
1. GI- Patient went to the operating room for a whipple
procedure on [**2109-8-15**]. During the first 24 hours
postoperatively, she had clinical indications of slow, sustained
bleeding in the abdomen necessatated transfusion. She was taken
back to the operating room for revision and removal of blood
clots on [**8-16**]. She was transferred to the intensive care
unit postoperatively and remained intubated. 2 jp drains were
placed near the anastomoses, a drain was placed in the common
hepatic duct across the anastomosis and a combined MIC draining
gastrostomy and feeding jejunostomy tube were also placed.
2. Cardiovascular- rapid atrial fibrillation: treated with IV
lopressor and diltiazem drip intially and eventally
electrocardioverted late in her hospital course. Patient was
also initially on digoxin early in her hospital course, but
showed signs of digoxin toxicity per ECG and was discontined
soon after being transferred to the floor. Patient was started
back on coumadin the last few days of hospitalization and was
not therapeutic the day of discharge.
2. Pulmonary- While the intensive care unit, patient was
intubated and treated with gentamycyin and zosyn for
pseudomaonas found in her sputum. Patient was difficult to wean
of the ventalator and a pleural effusion was drained
percutaneously with ultrasound guidance. She was successfully
extubated on post operative day 16. Patient also had an episode
of shortness of breath early in the morning of the last day of
hospitalization. The symptoms responded to diuresis with lasix
and patient was started back on her home dose of lasix.
3. endocrine- Patient was covered on a insulin sliding scale
throughout her hospital course. While in the intensive care
unit, one of the jp drains had an amylase of over 3000.
Approximately 2 weeks later, the output decreased and amylase
was retested and was low.
4. heme- transfusion of 1 unit while in intensive care unit for
a hct of 27, in addition to the transfusion between the two
operations.
5. nutrition- Patient began tube feedings soon after 2nd
procedure through j tube. Late in her hospital course she was
transitioned to regular diet and tube feeds were decreased.
6. GU- Patient spike a fever late in her hospital course and a
UTI was diagnosed. Patient was started on cipro and transition
to ampilcillian based on culture data.
7. Physical therapy was consulted while patient was being weaned
from the vent and continued to see throughout rest of hospital
course.
Medications on Admission:
coumadin- 20mg weekly
cozaar 50mg qd
lasix 80mg qd
digoxin 125mcg qd
? 2nd heart medication
premarin 0.3mg qd
fergon 2 qd
prilosec
vit. C
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Circumferential duodenal adenoma with bleeding
Right apical lung nodule
urinary tract infection
atrial fibrillation
congestive heart failure
anemia
arthritis
Discharge Condition:
good
Discharge Instructions:
Continue tube feedings until patient is able to take in adequate
nutrition.
Keep t-tube in until patient follows up with Dr. [**Last Name (STitle) 468**] in
clinic.
Followup Instructions:
Patient is to follow up with primary care provider.
[**Name10 (NameIs) **] up CT for right apical lung nodule.
Patient with follow up with Dr. [**Last Name (STitle) 468**] by phone.
|
[
"599.0",
"280.0",
"575.11",
"578.9",
"V58.61",
"511.9",
"211.2",
"E878.6",
"285.1",
"427.31",
"998.11",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"96.6",
"96.04",
"99.62",
"52.7",
"34.91",
"51.43",
"46.39",
"99.04",
"54.12",
"96.72",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
4642, 4700
|
1959, 4454
|
320, 682
|
4902, 4908
|
5121, 5306
|
4721, 4881
|
4480, 4619
|
4932, 5098
|
1429, 1936
|
226, 282
|
710, 967
|
989, 1334
|
1350, 1414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,648
| 104,686
|
32304
|
Discharge summary
|
report
|
Admission Date: [**2199-9-25**] Discharge Date: [**2199-10-2**]
Date of Birth: [**2130-3-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Patient is a 63 yo woman with PMH of HTN, DM, morbid obesity,
hemorrhagic stroke 2 yrs ago, afib off coumadin who presents
after episode of seizure vs. syncope with family. She and her
husband are in town from CT visiting son and had just gone to a
performance. Following this they went to a restaurant to get a
late night meal, and en route there noted her to be normal in
the car. Once they got to the restaurant, the patient ordered
her meal correctly, but hortly thereafter was not making sense
with her speech. This was around 11 PM. She was speaking actual
words and was not dysarthric but her peech didn't make sense.
They recall that one phrase was something about "ice cream" and
much of her speech was about food. Her son seemed to notice a
slight facial droop around this time and pointed it out to the
patient's husband. This non-sensical speech went on or about 45
minutes without any improvement and the patient seemed ompletely
unconcerned about this. The son asked his father if this sort of
behavior occured frequently with her. They tried asking her if
she had a headache and once she said yes, and another time said
o. Then, suddenly, she threw her head and body back in the
chair, onvulsed at the arms for seconds to a minute, and then
fell to the left. Her husband was able to break her fall and she
did not strike her head. Once on the ground she continued to
convulse briefly and then stopped. At this point she was
gurgling, and not moving. She was not speaking or following
commands.
.
She did have a seizure in the context of her ICH. Her son noted
an event over a year ago where on the phone she suddenly had
non-sensical speech similar to today's. That event resolved
spontaneously.
.
In the ED she was found to have persitent altered mental status
and wasintubated for airway protection. She was evaluated by the
neurology consult service who felt that the symptoms were
concerning for left sided stroke. The evalution was notable for
+UA for UTI. A chest Xray showed concern for widenen mediastinum
which prompted a CTA chest which was negative for dissection. A
CT head was negative for hemorrhage or mass effect. No MRI was
obtained
.
Pt was loaded with dilantin (1g IV x 1) although neuro suggested
1.5g. Pt got pre and post Ct hydration with bicarbonate.
.
ROS: patient cannot offer
Past Medical History:
1. Hemorrhagic stroke 2 yrs ago. Patient had headache and went
to bed. Woke confused and en route to hospital became aphasic.
While there at the hospital coded according to husband and had
to
be intubated. He doesn't know it it was a cardiac vs.
respiratory failure. Following the stroke, she was noted to be
slightly weaker right than left.
2. DM, recent diagnosis
3. Morbid Obesity
4. afib off coumadin
5. OSA on CPAP
6. Depression
7. Diastolic heart failure
8. Hypertension
Social History:
Retired RN. Remote Tobacco. no ETOH. Lives with husband.
Family History:
mother had [**Name2 (NI) **] in late life and lived to 92.
Physical Exam:
VS: T 98.6 BP 130/80 P 50 100% on AC 500x14, peep 5, FiO2 60%
Gen: intubated and sedated
HEENT: left eye echymosis. Pupils 3-4 mm and equally reactive to
light. Thickened right cornea and injected sclera bilaterally
R>L. MMM.
Neck: unable to assess for JVD given size of neck and intubation
Chest: ctab anteriorly without w/c
CV: bradycardic and irregularly irregular, no m/r/g
Abd: obese, s/nd/hypoactive bowel sounds. no appreciable
organomegaly
Ext: no c/c/e. pedal pulses 1+ and equal bilaterally
Skin: no rashes
Neuro: withdraws all four limbs to pain, shifts body with
sternal rub. reflexes 2+ RUE, 1+LUE, 1+ LE bilaterally. + gag
reflex, brain-stem reflexes intact. with propofol weaned was
interactive trying to speak over ventilator, moved all
extremities to command
Pertinent Results:
Urinalysis 21-50 whites, many bacteria, LE, N neg
.
Studies:
CXR - Apparent widening of the upper mediastinum. An aortic
injury cannot be excluded. Consider CT as indicated. Enlarged
cardiac silohuette with evidence of pulmonary edema as
described. ETT tube positioned low (1.3 cm above carina)
.
CT c-spine - Cervical spondylosis with anterior osteophytes are
most prominent at C5/6. no fracture or dislocation identified.
.
CTA chest - No aortic dissection, huge cardiomegaly with
coronary calcifications, Rt pleural effusion, bronchial
thickening with basilar consolidation versus atelectasis, some
diffuse ground glass pattern.
.
MRI/A head/neck: No evidence of hemorrhage, masses, mass effect,
edema or midline shift. Bilateral periventricular white matter
demonstrates hyperintensity on FLAIR and T2-weighted imaging
suggestive of chronic microangiopathic ischemic disease. The
sulci and the ventricles appear normal in caliber,
configuration, and morphology. No hydrocephalus is noted. No
diffusion abnormalities are noted. No areas of abnormal
contrast enhancement are seen. Bilateral sphenoid sinus
demonstrates air-fluid levels suggestive of sinusitis. Mucus
retention cysts are noted in bilateral maxillary sinuses. The
osseous, soft tissue structures and visualized portions of the
orbits are unremarkable.
.
EKG afib with bradycardia (rate 49), normal axis, QTc 540.
diffuse TWI.
.
Bedside EEG: This is an abnormal portable EEG in the waking and
drowsy
states due to intermittent mixed frequency slowing noted broadly
over
the right hemisphere suggesting an underlying area of
subcortical
dysfunction in that region. In addition, the background was
mildly
slowed and disorganized, consistent with a mild encephalopathy,
suggesting bilateral subcortical or deep midline dysfunction.
Medications, metabolic disturbances, and infections are among
the common causes of encephalopathy. There were no epileptiform
features and no electrographic seizures were noted.
.
[**2199-9-25**] 04:07PM GLUCOSE-101 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-2.8* CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2199-9-25**] 04:07PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-1.8
Brief Hospital Course:
69 year old woman with history of L-sided hemorrhagic stroke,
DM2, atrial fibrillation, and obesity presenting with acute
altered mental status.
.
#Seizure: Pt admitted with seizure in the setting of presumed
[**Month/Day/Year **]. Symptoms of aphasia/werneke's type speech make L-sided
temporal [**Month/Day/Year **] likely with resultant seizure. The patient was
intubated in the ED due to concern over airway protection and
loaded with dilantin. MRI without stroke. Upon arrival to the
ICU she had full motor strength and was attempting to
communicate over the ventilator which suggested against a large
territory stroke. The patient had an MRI on HD 2 which did not
show stroke, and she was subsequently extubated. Her dilantin
was changed to keppra for ease of administration. Because of
her atrial fibrillation, the [**Month/Day/Year **] was presumed to be a result of
not being anticoagulated. The patient was advised by the
neurology team that she should be on coumadin but the patient
declined and wanted to discuss this with her PCP first, she was
started instead on a full dose aspirin.
With regards to her seizure activity, this was felt to be [**12-21**]
[**Month/Day (2) **] or possibly due to her UTI causing a lowered seizure
threshold. She was started on dilantin, which was changed to
keppra and she was treated with 3 days of augmentin. Carotid
ultrasound was without significant stenosis b/l.
Follow up scheduled with her primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] of [**Last Name (un) 3407**] to discuss course of Keppra and to determine
driving restrictions.
.
# Cardiac: Atrial fibrillation with mild bradycardia likely from
atenolol. And after recovery from stroke, hr was stable in
60-80s on atenolol. She also ruled out for MIwith 3x cardiac
enzymes
.
# Pulmonary - Inititally, intubated for airway protection in
setting of change in mental status. Sucessfully extubated
without complication. However, she did have desaturations to 88%
while on NC 2-4L concerning for hypoventilation vs COPD. Chest
CT abnormal with suggestion of possible pulmonary edema and
atelectasis vs RLL infiltrate. Hypozia resolved with gentle
diuresis though she does at times require low level of oxygen
with aggressive physical therapy. She should have an outpatient
chest CT in [**1-20**] months to evaluate for resolution and may need
work up for COPD with PFT's if she has persistent resting
desaturations.
.
# Diabetes Mellitus - New dx previously treated with diet and
exercise. Continue insulin sliding scale with plan deferred to
[**Name8 (MD) 1501**] MD regarding starting oral hypoglycemics.
#OSA: Continue CPAP at 12cm/h2o
.
# UTI: may be responsible for seizure, fully treated with
augmenting.
# Prophy - SQ heparin, PPI
# Code - full
Medications on Admission:
atenolol 50 mg po daily
fluoxetine 20mg po daily
lasix 20mg po daily
prilosec 20mg po daily
lisinopril 5mg po daily
simvastatin 20mg po daily
folate 1g po daily
KCl 10 mEQ po daily
Discharge Disposition:
Extended Care
Facility:
Montowese skilled nursing facility
Discharge Diagnosis:
seizure
[**Name8 (MD) **]
CHF exacerbation
Discharge Condition:
stable
Discharge Instructions:
Please continue physical therapy and be sure to follow up with
your neurologist re: whether to start coumadin. Return to ER
with seizure, weakness or other concerning symptoms.
Followup Instructions:
Chest CT in [**1-20**] months to ensure that infiltrates have resolved.
Please follow up with your primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] [**2199-10-9**] at 10:45am at the [**Location (un) 75500**], [**Location (un) **],
[**State 2748**] Phone: ([**Telephone/Fax (1) 75501**]. If family wants to change
appt to the [**Last Name (un) 3407**] office of Dr. [**Last Name (STitle) 75499**] they cal call
[**Telephone/Fax (1) 75502**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2199-10-2**]
|
[
"780.39",
"428.0",
"401.9",
"278.01",
"V12.54",
"599.0",
"427.31",
"428.32",
"276.0",
"327.23",
"435.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9349, 9410
|
6299, 9117
|
281, 293
|
9497, 9506
|
4105, 6276
|
9732, 10374
|
3232, 3293
|
9431, 9476
|
9143, 9326
|
9530, 9709
|
3308, 4086
|
234, 243
|
321, 2640
|
2662, 3141
|
3157, 3216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,003
| 179,032
|
32580
|
Discharge summary
|
report
|
Admission Date: [**2108-12-14**] Discharge Date: [**2108-12-18**]
Date of Birth: [**2076-1-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Pericardiocentesis
History of Present Illness:
32 M with pericarditis (dx 2 days pta) presents with worsening
CP with radiation to the back, diaphoresis, N/V nad abd pain. BP
intially 70s/50s. Bedside U/S by ED showed pericardial effusion
with some RV invagination. He received 4L NS with resolution of
BP. He had CTA of Torso which showed effusion and evidence of
RHF.
.
The patient reports having similar symptoms last year when he
was diagnosed with pericarditis as well. He has had 3 prior
episodes of similar symptoms, all with diagnosis of
pericarditis, but each time the duration of symptoms has
increased. He reports being admitted to St. [**Hospital 11042**] Hospital
in [**Location (un) 1468**], MA last year, and was apparently diagnosed with
autoimmune mediated pericarditis. At the time of this note,
these records were unavailable. He reports having negative TB
skin tests in the past, as well as negative HIV test in the last
8 months.
.
On review of symptoms, he reports having diarrhea the last 2
days with some nausea. He had multiple episodes of vomiting
today. 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 significant for chest pain, but
absent for dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
history of Pericarditis x3
Cardiac Risk Factors: none
Social History:
Social history is significant for occasional tobacco and
occasional marijuana use. He admits to cocaine use in the past,
but not in the past 5 years. He denies IVDU. He occasionally
drinks ETOH.
Family History:
There is no family history of pericarditis. He has a first
cousin with a diagnosis of lupus, otherwise no other
rheumatological diseases.
Physical Exam:
VS: T 97.5, BP 118/75 , HR 86, RR 25 , O2 95% on 4L Pulsus=8
Gen: WDWN athletic appearing black male, in mild to moderate
respiratory distress with difficulty speaking in complete
sentences. Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. Dry mucous membranes
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. no friction rub ausculated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored and tachypneic. Decreased BS in the bases,
but no crackles, wheeze, or rhonchi.
Abd: mild to moderate tenderness in RUQ/RLQ with voluntary
guarding. difficult to determine liver size given guarding.
tenderness to percussion with some dullness in RUQ.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; 2+ DP/PT
Pertinent Results:
[**2108-12-18**] 06:30AM BLOOD WBC-7.4 RBC-4.09* Hgb-11.6* Hct-35.7*
MCV-87 MCH-28.3 MCHC-32.4 RDW-13.1 Plt Ct-575*
[**2108-12-13**] 08:40PM BLOOD Neuts-82.4* Lymphs-10.3* Monos-6.1
Eos-0.9 Baso-0.3
[**2108-12-13**] 09:07PM BLOOD PT-12.3 PTT-29.4 INR(PT)-1.1
[**2108-12-15**] 03:49AM BLOOD ESR-55*
[**2108-12-17**] 06:07AM BLOOD Lupus-NEG
[**2108-12-18**] 06:30AM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-136 K-3.8
Cl-100 HCO3-25 AnGap-15
[**2108-12-13**] 08:40PM BLOOD ALT-34 AST-40 LD(LDH)-136 CK(CPK)-69
AlkPhos-98 TotBili-1.4
[**2108-12-15**] 03:49AM BLOOD ALT-74* AST-72* AlkPhos-100 Amylase-32
TotBili-1.2
[**2108-12-15**] 03:49AM BLOOD Lipase-16
[**2108-12-13**] 08:40PM BLOOD cTropnT-0.04*
[**2108-12-17**] 06:07AM BLOOD TotProt-5.7* Calcium-8.7 Phos-4.7* Mg-2.0
[**2108-12-15**] 03:49AM BLOOD TotProt-6.2* Albumin-3.0* Globuln-3.2
[**2108-12-13**] 08:40PM BLOOD TSH-1.2
[**2108-12-17**] 06:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2108-12-15**] 03:55PM BLOOD dsDNA-NEGATIVE
[**2108-12-15**] 03:49AM BLOOD CRP-271.1*
[**2108-12-14**] 06:45PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2108-12-14**] 06:45PM BLOOD RheuFac-25*
[**2108-12-15**] 03:55PM BLOOD C3-156 C4-27
[**2108-12-14**] 06:45PM BLOOD HIV Ab-NEGATIVE
[**2108-12-17**] 06:07AM BLOOD HCV Ab-NEGATIVE
[**2108-12-13**] 08:55PM BLOOD Lactate-1.8
[**2108-12-16**] 09:48PM URINE Color-AMBER Appear-Clear Sp [**Last Name (un) **]-1.010
[**2108-12-16**] 09:48PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2108-12-16**] 09:48PM URINE U-PEP-NO PROTEIN
[**2108-12-17**] 11:15AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG marijua-PRESUMPTIV
[**2108-12-15**] 01:50PM OTHER BODY FLUID WBC-2300* RBC-[**Numeric Identifier 75954**]*
Polys-82* Lymphs-2* Monos-15* Eos-1*
[**2108-12-15**] 01:50PM OTHER BODY FLUID TotProt-5.0 Glucose-95
LD(LDH)-840 Amylase-21 Albumin-2.6
.
Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS.
.
.
[**2108-12-13**] ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal/small cavity size and
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
No mitral regurgitation is seen. There is a small to moderate
sized (1.0-1.5cm) circumferential pericardial effusion without
right atrial or right ventricular diastolic collapse.
.
IMPRESSION: Small-moderate sized circumferential pericardial
effusion without evidence for hemodynamic compromise.
Clinical correlation and serial evaluation are suggested.
.
[**2108-12-13**] CTA
IMPRESSION:
1. Large pericardial effusion, heterogeneous perfusion of the
liver with
periportal edema, gallbladder wall edema, enlarged IVC and
interval
development of ascites (between initial and 20-minute delayed
imaging) all
suggest impaired venous return to the heart (early tampanade
physiology?) and
hepatic congestion.
.
2. No evidence of aortic dissection or pulmonary embolism.
.
[**2108-12-15**] C. Cath
COMMENTS: 1. Succesful pericardiocentesis. Pericardial drain
placed
with initial CI 2.46 up to 3.01 l/min/m2 and RA pressure 18 down
to 10
mmHg. The uncomplete normalization of RA pressure may suggest
constrictive physiology.
.
FINAL DIAGNOSIS:
1. Succesful pericardiocentesis.
2. Possible effusive constrictive physiology.
.
[**2108-12-17**] ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
There is abnormal septal motion suggestive of pericardial
constriction. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. There is a
trivial/physiologic pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There are no echocardiographic signs of tamponade.
.
[**2108-12-17**] Cardiac MRI
Impression:
1. Areas of focal pericardial thickening with circumferential
pericardial
late-gadolinium enhancement suggestive of pericardial
inflammation.
Pericardial tethering on tagged images is consistent with, but
not diagnostic of pericardial constriction.
2. Normal left ventricular cavity size with normal regional left
ventricular systolic function. The LVEF was normal at 56%. The
effective forward LVEF was borderline-normal at 54%. No MR
evidence of prior myocardial scarring/infarction.
3. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 55%.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly increased.
5. Mild right and moderate left atrial enlargement.
6. Moderate bilateral pleural effusions.
.
Findings are consistent with acute on chronic pericarditis with
possible
pericardial constriction.
.
Brief Hospital Course:
32 M without significant PMHx with acute pericarditis and
tamponade and also has RUQ pain with nausea and vomiting
.
# Pericarditis/Tamponade: The patient was found to have his 4th
episode of pericarditis over the last few years. His previous
episodes were managed at an outside hospital. He has never had
a diagnosis of tamponade before this hospitalization. On
admission, the patient had an Echocardiogram that was suggestive
of tamponade but he was hemodynamically stable with IV fluids.
Repeat Echo also showed probable tamponade physiology, and the
patient was then taken to the cath lab for further evaluation.
He had equalization of pressures, consistent with tamponade, and
a pericardial drain was placed with removal of pericardial
fluid. During this hospitalization, a complete workup was done
for the cause of the recurrent pericarditis, and now tamponade.
A rheumatology consult was called, and the patient will follow
with them in clinic as well.
The patient had a slight elevation in his LFTs, but
hepatitis serologies were negative. HIV test was negative.
Rheumatoid factor was slightly elevated, but [**Doctor First Name **], dsDNA were
both negative with normal C3/C4 levels. The patient also had
CH50, anti-LAC, anti-ro, anti-[**Doctor Last Name **], anti-CL sent which were all
pending at discharge. The patient's TB test was also negative
during this admission. The pericardial fluid was negative by
cultures, AFB, and negative for malignant cells on cytology.
Viral cultures were also pending at discharge.
The patient has made a PCP appointment at [**Name9 (PRE) 191**], and will also
followup in cardiology and rheumatology clinics as well. He
will continue indomethacin, colchicine, and percocet prn for
pain. At discharge, his symptoms of dyspnea and chest pain had
improved and the patient was able to tolerate activity without
difficulty.
A cardiac MRI was done prior to discharge as well. It showed
evidence of pericardial thickening, and likely pericardial
constriction which is consistent with his recurrent
pericarditis.
.
# RUQ pain/nausea/vomiting: The patient presented with RUQ pain,
slightly elevated LFTs, but negative hepatitis serologies. The
patient had a RUQ ultrasound which showed gall bladder wall
edema, but no evidence of cholecystitis. This was likely due to
backflow of venous pressures from the tamponade physiology.
Prior to discharge, the patient's symptoms had improved and he
was eating without difficulty.
Medications on Admission:
Ibuprofen PRN
Discharge Medications:
1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 2 weeks.
Disp:*42 Capsule(s)* Refills:*1*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*1*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pericardial Effusion with Tamponade
Secondary Diagnosis: Pleural Effusion
Discharge Condition:
Good, afebrile. Symptoms improved
Discharge Instructions:
You were admitted for chest pain. You were found to have
inflammation around your heart, and you were found to have fluid
around your heart as well. The fluid caused decreased function
of your heart and therefore you had a procedure performed to
remove the fluid. Your symptoms markedly improved prior to
discharge.
You were seen by the rheumatology consult as well. You will
need to followup with them in clinic to followup on your lab
results that are pending at the time of discharge.
Please take all medications as prescribed. Please make all
appointments scheduled.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: worsening chest pain, shortness
of breath, fevers, chills, cough, or weakness.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2109-1-11**] 9:00
Provider: [**Name10 (NameIs) 39063**] [**Last Name (NamePattern4) 39064**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2109-2-13**] 1:30
You will receive a phone call from the [**Hospital 2225**] Clinic at
[**Hospital6 **] to schedule an appointment with Dr.
[**Last Name (STitle) 75955**]. Please call them at [**Telephone/Fax (1) 75956**] with any questions.
Your Rheumatologist will followup the pending lab results during
your appointment.
Your Cardiologist, Dr [**First Name (STitle) **], [**First Name3 (LF) **] discuss the Cardiac MRI
results with you at your appointment.
|
[
"423.3",
"423.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
11599, 11605
|
8407, 10891
|
327, 372
|
11742, 11779
|
3477, 6878
|
12580, 13326
|
2264, 2403
|
10955, 11576
|
11626, 11626
|
10917, 10932
|
6895, 8384
|
11803, 12557
|
2418, 3458
|
277, 289
|
400, 1955
|
11702, 11721
|
11645, 11681
|
1977, 2033
|
2049, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,963
| 132,887
|
9150
|
Discharge summary
|
report
|
Admission Date: [**2183-5-30**] Discharge Date: [**2183-6-1**]
Date of Birth: [**2133-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Melenic stools admitted to MICU for observation
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
49 y/o male with PMHx of HIV, HCV, multiple GI bleeds who had
varices banding 1 month ago who presents with 3 black tarry
stools. Was banded [**5-8**], 2 band at lower esophagus for grade
II-III varices. He also 5 bands in [**4-7**] for grade III varices.
Reported NG lavage negative in ED. Patient Hct 28 in ED,
baseline approximately 30. Denies any hematemesis or BRBPR.
Denies any abdominal pain. NO CP, SOB, LH.
ROS: unremarkable, no HA, dysuria, weakness
Past Medical History:
1. HIV/AIDS-(Dx [**2163**]. H/o thrush and zoster, never had PCP, h/o
positive toxo IgG in [**2180**], hx of positive CMV IgG in [**2180**], hx of
negative RPR in [**2180**]. HIV VL 175, CD4 119 [**2183-5-19**]
2. H/O osteomylitis 10 yrs ago (from IVDA) in left foot, left
knee, left MTP joints
3. Gout (dx age 18; hx of tophi removal; on allopurinol in the
past. Was seen in [**Hospital **] Clinic [**2182-3-5**].)
4. Hepatitis C. dx [**2166**]; Genotype 4a. No hx of jaundice,
ascites, or encephalopathy;
5. Substance abuse -- heroin IV almost daily, occasional
methadone (has been in methadone programs in his past; has also
tried inpatient detox programs without success, also hx of
cocaine, klonopin
6. Chronic knee pain from degenerative joint disease
Social History:
Pt lives alone and is unemployed. 2 PPD x 20 yrs. No current
ETOH use (last use 15 yrs ago). Polysubtance abuse - daily
heroin, occasional methadone, cocaine, and benzos; currently
does not use heroin while on methadone. Contracted HIV and Hep C
from IVDA.
Family History:
Non-contributory
Physical Exam:
T HR 57 BP 93/60 RR 10 O2Sat 94% RA
Gen: NAD
Heent: R>L pupil both reactive, EOMI, OP clear, sclera white
Neck: supple
Lungs: CTA B/L
Cardiac: RRR S1/S2 no murmurs
Abdomen: distended, soft, + splenomegaly; per ED stool: guiac
postive
Ext: no edema, multiple scars in LE b/l
Neuro: AAOx3 grossly intact
Pertinent Results:
RENAL U.S. [**2183-5-29**] 2:05 PM
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with HIV/AIDS, Hep C, portal vein thrombosis
with new acute renal failure. Please evaluate kidney size and
for any obstructing lesion. Please also do *renal dopplers* to
evaluate for vascular obstruction. Thank you.
REASON FOR THIS EXAMINATION:
kidney size and obstructing lesion to explain new acute renal
failure. please also do *renal dopplers* to evaluate vasculature
to/from kidneys. Thank you.
RENAL ULTRASOUND AND DOPPLER
The right kidney measures 10.3 cm in length and the left kidney
11.6 cm. The left kidney is deformed in its proximal one-third
by an enlarged spleen, but otherwise both kidneys are normal in
echogenicity and architecture. There are no renal masses, stones
or any signs of hydronephrosis.
Color flow and pulse Doppler interrogation of the kidneys was
then performed demonstrating normal and symmetric flow
throughout both kidneys with normal venous drainage. Pulse
Doppler waveforms show normal acceleration times and normal
resistive indices bilaterally.
The bladder is unremarkable and the prostate does not appear
enlarged.
CONCLUSION: Normal renal ultrasound and Doppler. Marked
splenomegaly causing some flattening of the upper pole of the
left kidney which is otherwise normal.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2183-5-30**] 8:04 AM
.
EGD [**2183-5-31**]
Erythema with overlying whitish exudates. in the lower third of
the esophagus compatible with candidal esophagitis. Varices at
the lower third of the esophagus. Varices at the fundus.
Erythema and mosaic appearance in the fundus and stomach body
compatible with portal gastropathy. Otherwise normal EGD to
second part of the duodenum.
Brief Hospital Course:
49 y/o M with HIV, HepC, hx of multiple GI bleed s/p esophageal
banding who present with 3 melanic stools.
.
1. GI Bleed - On admission suspected UGIB given melanic stool
and previous hx of esophageal varices from HepC; NGL in ED
negative. Seen by GI, with EGD on [**2183-5-31**] that showed varices in
lower [**2-4**] of esophagus & fundus, [**Female First Name (un) **] esophagitis, and portal
gastropathy (see full report in OMR). Maintained on [**Hospital1 **] PPI,
octreotide gtt with serial hct and slow advancement of diet
after EGD. Pt did not require blood tranfusion. He will be seen
by GI in 2 weeks for a repeat EGD. He was sent home on [**Hospital1 **] PPI,
sucralfate and nadolol (tolerated nadolol well while in ICU). Pt
requested d/c home when stable and did not want to wait another
day for observation; he understood need to return immediately
for any bleeding, lightheadedness or other concerns.
.
2. HIV - Patient most recent CD4 count 119. Continued
HAART/dapsone. Needs 2 week treatment of fluconazole for
esophageal candidiasis.
.
3. Gout - Continued allopurinol and prednisone.
.
4. Substance Abuse - Continued methadone 70mg daily
.
5. CRI - Cre baseline 1.1-1.2, most likely secondary to HIV
nephropathy. No obstruction on US.
.
6. Code - Full
Medications on Admission:
Tenofovir 300mg qd
Kaletera 200-50mg daily
Epzicome (ABC/3TZ) 600-300mg daily
Dapsone
Allopurinol 300mg daily
Paxil 10mg daily
Prednisone 5mg
Methadone 70mg daily
Allergies: Penicillin/Bactrim, had mild rash with vancomycin but
tolerated vancomycin and ceftriaxone recently
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
[**Female First Name (un) 564**] esophagitis
Esophageal and fundal varices
Portal gastropathy
HIV/AIDs
Gout
CRI
Discharge Condition:
Good
Discharge Instructions:
Take all medications as directed. Continue taking your old
medications as previously directed; your new medications are
fluconazole, protonix, sucralfate and nadolol.
Call a doctor or return to the ER immediately for:
* chest pain or difficulty breathing
* black or bloody stool
* vomiting blood
* confusion or lightheadedness, or feeling like you might pass
out
* any other concerns
Followup Instructions:
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2183-6-17**] 8:00
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-6-13**]
9:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2183-6-3**] 11:30
|
[
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"042",
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"070.70",
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"572.3",
"585.9",
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icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5691, 5697
|
4093, 5365
|
328, 345
|
5868, 5875
|
2268, 2304
|
6308, 6701
|
1913, 1931
|
2341, 2573
|
5718, 5847
|
5391, 5668
|
5899, 6285
|
1946, 2249
|
241, 290
|
2602, 4070
|
373, 841
|
863, 1622
|
1638, 1897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,414
| 195,547
|
4262
|
Discharge summary
|
report
|
1
1
1
R
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 18500**]
Admission Date: [**2196-7-19**] Discharge Date: [**2196-7-25**]
Date of Birth: [**2124-6-9**] Sex: F
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
woman who was admitted for planned cardiac catheterization
with intervention on her left circumflex. The patient had an
aborted intervention on [**2196-6-23**], due to subintimal wire
entry of the saphenous vein graft to the obtuse marginal
graft as well as a groin hematoma with hypotension. The
patient had two episodes of chest pain prior to admission to
the [**Hospital 1474**] Hospital back in [**Month (only) **] with negative enzymes. A
Persantine MIBI at the outside hospital showed a reversible
defect in the lateral wall with mild septal hypokinesis and
the patient was transferred to Catheterization at [**Hospital1 346**] where she was found to have a left
main 60% stenosis, left circumflex 80%, diagonal 2 80%,
saphenous vein graft to obtuse marginal 1 with a patent left
internal mammary artery to left anterior descending and
saphenous vein graft to patent ductus arteriosus 20 to 30%.
On the day of admission, on [**2196-7-19**], the patient was taken
to the Catheterization Laboratory directly and while on the
table, she had a vasovagal episode after the intervention
whereby her heart rte fell into the 40s and her systolic
blood pressure was unable to be found due to the large size
of her arms and she was given 1.5 mg of Atropine with good
response. The systolic blood pressure rose back to 118 with
a pulse of 78. An echocardiogram was ordered to rule out
tamponade and this was negative.
During the catheterization, the LMCA had an occlusion of 80%,
left anterior descending totally occluded, left circumflex a
non-dominant vessel with a mid segment 80% and obtuse
marginal 2 of 90% lesion. At the TV of the previous
saphenous vein graft, the left main was stented with zero
residual and normal flow and subsequently the mid segment of
the left circumflex and the obtuse marginal 2 was stented.
The vasovagal episode spoken of previously actually happened
during the sheath pull.
The patient remained on the floor without chest pain or
shortness of breath and developed a drop in hematocrit. The
hematocrit was 35 on admission, 29 after catheterization and
24.7 on the morning after catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2184**]; grafts of left internal mammary artery
to left anterior descending; saphenous vein graft to obtuse
marginal 1; saphenous vein graft to patent ductus arteriosus.
3. Obesity.
4. Chronic obstructive pulmonary disease.
5. Hypertension.
6. Small cell lung cancer status post chemotherapy and
radiation therapy.
7. Dementia: Difficulty with short term memory.
8. History of paroxysmal atrial fibrillation.
9. Hypothyroidism.
10. Diabetes mellitus type 2.
11. History of colon cancer.
12. Parkinson's.
MEDICATIONS ON ADMISSION:
1. Glyburide 5 mg q. day.
2. Lasix 40 mg q. day.
3. K-Dur 20 mEq q. day.
4. Amiodarone 100 mg q. day.
5. Cogentin 1 mg q. day.
6. Synthroid 0.125 mg twice a day.
7. Prednisone 7.5 mg q. day.
8. Reglan 10 mg three times a day.
9. Naprosyn 500 mg twice a day.
PHYSICAL EXAMINATION: Temperature 97.8 F.; blood pressure
125/60; heart rate 92 and respiratory rate 18. The patient
was in no acute distress, appears to be in mild discomfort on
admission. The lungs were clear to auscultation anteriorly
bilaterally. Heart regular rate and rhythm with a positive
systolic murmur at the right upper sternal border. Abdomen
soft, nontender, nondistended, with positive bowel sounds.
Guaiac examination on admission revealed no stool in the
vault. Guaiac positive when the patient finally had a bowel
movement. Extremities: Obese; minimal edema bilaterally
lower extremities. No hematoma, bruit or bleeding at the
groin site.
LABORATORY: Labs on [**2196-7-24**], were as follows: White
blood cell count 5.2, hemoglobin 10.9, hematocrit 31.8,
platelet count 127. Sodium 142, potassium 3.4, chloride 110,
bicarbonate 25, BUN 24, creatinine 0.8, glucose 75, magnesium
1.9.
HOSPITAL COURSE: The patient had this falling hematocrit
post catheterization and the hematocrit was followed and the
patient received three units of blood on the floor. She had
a CT scan of her abdomen, pelvis and lower thighs which
showed no retroperitoneal bleeds and was negative for any
acute bleeds. An ultrasound of the groin revealed no
hematoma and no bleeds and an ultrasound was negative for
tamponade.
Thereafter, GI was consulted for a possible gastrointestinal
bleed. GI believed that the patient should be transferred to
the Coronary Care Unit for stabilization and evaluation of a
possible bleed.
In the Coronary Care Unit, the patient required two more
units of packed red blood cells. The first
esophagogastroduodenoscopy showed red blood at the GE
junction. There was retained solid food in the stomach, not
allowing visualization of the duodenum. The next
esophagogastroduodenoscopy revealed small sized hiatal hernia
as well as evidence of gastritis and three non-bleeding
ulcers in the stomach body along the greater curve of the GE
junction.
The patient was injected during the examination with
epinephrine. GI recommended that the patient be placed on
high dose proton pump inhibitors twice a day and to avoid
NSAIDS as well as aspirin. The patient was continued on her
Plavix and aspirin secondary to the left main stent which was
placed during the catheterization.
After one day in the Coronary Care Unit, the patient was
transferred back to the floor, stabilized, with no further
blood loss and without chest pain or shortness of breath and
without fevers, chills or abdominal pain.
The patient was advanced to a p.o. diet after a day and a
half of the n.p.o. with intravenous maintenance fluids and
tolerated it nicely but has not yet had another bowel
movement. When she has another bowel movement, the plan is
to check for continued blood.
The patient was placed on stress dose steroids in the
Coronary Care Unit. The plan is a rapid taper of this
Prednisone as the patient is doing well at this point.
The events to discharge will be added in an Addendum per the
next intern.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern1) 18501**]
MEDQUIST36
D: [**2196-7-24**] 13:15
T: [**2196-7-24**] 19:50
JOB#: [**Job Number 18502**]
|
[
"496",
"250.00",
"427.31",
"285.1",
"531.40",
"998.11",
"414.01",
"458.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"36.06",
"37.22",
"99.20",
"36.05",
"38.93",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
3116, 3384
|
4320, 6683
|
3408, 4300
|
314, 2480
|
2502, 3090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 115,687
|
50313
|
Discharge summary
|
report
|
Admission Date: [**2148-6-11**] Discharge Date: [**2148-6-15**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Hypoxia.
Major Surgical or Invasive Procedure:
Right femoral central venous line placement ([**6-11**]).
PICC line placement ([**6-13**]).
History of Present Illness:
Patient is a 51 y/o woman with PMHx of T1-T2 paraplegia
following MVC [**1-4**], COPD and recent admission for PNA on
[**5-29**]-4/30 who presented to her PCP today with hypoxia, lethargy,
cough and increased work of breathing. Of note, she was
discharged on [**5-31**] after a two day hospital stay for PNA and
COPD exacerbation. She was treated with a short course of
Levofloxacin and steroid taper. Per husband, pt has been doing
well for the last week and has been out socializing and feeling
well. However, she was notably tachypneic, satting in the 80s
and requiring increased NC oxygen this morning. He brought her
in for evaluation in [**Company 191**] and they referred her into the ED for
further evaluation.
In the ED, initial vs were: T 97.9 P 110 BP 109/84 R 24 O2 sat
97% on NRB. Pt underwent CXR which showed bilateral hazy
opacities at bases, essentially unchanged from prior film on
[**5-30**]. CTA was performed for hypoxia but did not show any PE,
there was bilateral atelectasis with RLL consolidations. Blood &
Urine Cx were sent and pt had right femoral line placed before
she was given 1L NS, Vanc and Zosyn for possible PNA. Per [**Name (NI) **], pt
became more somnolent with ABG showing pH 7.34 pCO2 64 pO2 62.
She was given Solumedrol 125mg IV, alb/atrovent and was placed
on BIPAP to treat a component of COPD exacerbation and CO2
retention.
On arrival to the ICU, pt was wearing BIPAP and complaining
about the discomfort of the mask. Overall, she was still
somnolent and husband provided most of the history.
Review of systems: as above, provided by husband. Denies fevers,
chills, nausea, vomiting, diarrhea, chest pain, med changes,
rash, cough. Husband did note increased somnolence while eating
and snoring while asleep.
Past Medical History:
1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]
Social History:
- Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking after last
hospitalization
- etOH: Denies
- Illicits: Denies
Family History:
No history of lung disease.
Physical Exam:
Vitals: BP 114/70 HR 80 Sats 99% on Face tent and 2L NC
General: NAD, sleepy but easily arousable
HEENT: Sclera anicteric, MMM, PERRLA
Lungs: CTAB, no wheezes, occaisional RLL rhonchi
CV: RRR no murmurs, rubs, gallops
Abdomen: soft, NT/ND/NABS, no rebound tenderness or guarding
Ext: warm, 2+ pulses, trace edema bilaterally
Neuro: following commands, symmetric facial movement, squeezing
hands bilaterally
Pertinent Results:
Labs at Admission:
[**2148-6-11**] 02:45PM BLOOD WBC-18.3*# RBC-4.00* Hgb-10.7* Hct-35.0*
MCV-88 MCH-26.7* MCHC-30.4* RDW-15.5 Plt Ct-223
[**2148-6-11**] 02:45PM BLOOD Neuts-93.6* Lymphs-3.5* Monos-1.7*
Eos-1.0 Baso-0.3
[**2148-6-11**] 02:45PM BLOOD PT-12.2 PTT-27.4 INR(PT)-1.0
[**2148-6-11**] 02:45PM BLOOD Glucose-123* UreaN-11 Creat-0.3* Na-142
K-4.9 Cl-101 HCO3-32 AnGap-14
[**2148-6-11**] 02:45PM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Lactate:
[**2148-6-11**] 03:10PM BLOOD Lactate-2.1* K-4.1
[**2148-6-11**] 11:40PM BLOOD Lactate-1.9
[**2148-6-12**] 02:47PM BLOOD Lactate-3.0*
Micro Data:
[**2148-6-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE- negative
[**2148-6-11**] URINE URINE CULTURE- negative
[**2148-6-11**] BLOOD CULTURE Blood Culture, Routine-
negative
[**2148-6-11**] BLOOD CULTURE Blood Culture, Routine-
negative
CTA chest ([**2148-6-11**]):
1. Assessment for pulmonary embolism within the segmental and
subsegmental pulmonary arterial branches is limited due to
suboptimal bolus timing. No
evidence of pulmonary embolism in the main pulmonary arteries.
2. Moderate-to-severe bibasilar atelectasis, predominately
within the right
lower lobe. A more consolidative element within the right lower
lobe along
with a new lingular patchy opacity may reflect an infectious
process.
3. Paraseptal emphysema.
4. Unchanged chronic rib cage deformities.
Brief Hospital Course:
51 y/o woman with PMHx of T1-T2 paraplegia, COPD and recurrent
PNAs who presents after recent discharge with respiratory
distress and somnolence, concern for new RLL infiltrate.
# Respiratory Distress: Mixed hypoxic/hypercarbic resp failure.
Pt with COPD and recurrent PNAs who developped tachypnea,
increased O2 requirement, cough and lethargy acutely this
morning. She was referred into the ED by her PCP and underwent [**Name Initial (PRE) **]
CTA that was negative for PE but revealed RLL consolidation,
unclear if new or resolving from prior admission. Pt became
increasingly somnolent in the ED with pCO2 in 60s. In the ED she
got steroids, alb/atrov and BIPAP, with improved mental status
and minimal O2 requirement. Given increased WBC and possible
consolidation and recent hospital admission, she was treated for
HAP with cefepime and vancomycin. A PICC line was placed so that
she could complete a 7-day course of antibiotics. There was
concern of recurrent aspiration. Patient underwent a speech and
swallow eval and passed. Her diet was restarted. Her initial
PICC placed at the bedside went up the right IJ, so it was
removed and replaced by interventional radiology. [**2148-6-12**] she
had hypotension and a low-grade fever to 100.7 at 1am. She was
given fluids and looked well clinically. Her CXR was unchanged,
U/A was negative and blood cultures had no growth at the time of
discharge. Her vancomycin was originally dosed 1250mg Q24 hours,
but a trough level was 3.8, so the dosing was changed to 1000mg
Q12 hours for the remainder of the course.
# T1-T2 Paraplegia with chronic pain: pt is maintained on
multiple sedating drugs for spasms and pain. She presented with
respiratory distress and progressive somnolence and hypercarbia.
Suspect a component of obesity hypoventilation with possible
aspiration PNA. During this admission, her clonazpeam,
pregabalin, and trazodone were initially held. Baclofen was
decreased to 5 mg tid. Methadone and oxybutynin were continued
at outpatient doses. Her pregabalin and trazodone were added
back on, but her Baclofen was continued at 5mg TID with some
minor leg spasticity, but adequate pain control. She was
switched to Ultram for breakthrough pain, but did not find this
effective, so she was switched back to Oxycodone. She was
discharged, finally, on the same doses of methadone and
oxycodone, a reduced dose of baclofen, and off of Klonopin. She
was given 2 weeks of methadone and oxycodone to last until she
can see Dr. [**Last Name (STitle) 665**] because she was supposed to get refills the
day of her admission but ended up being transferred to the ED.
.
# Possible UTI: Urine Cx from [**5-29**] grew out +enterococcus
>100,000 and this was not treated, possibly thought to be
contaminant. Repeat UAs appeared bland without WBCs and she
remained asymptomatic, so any possible UTI was probably treated
with vanco/cefepime.
.
# Access: She originally had a right femoral CVL, which was
pulled once she was stabilized.
Medications on Admission:
- albuterol nebs q4-6h prn
- baclofen 10 mg up to 5 tabs daily
- citalopram 40 mg daily
- clonazepam 2mg qhs (occaisionally during the day for pain)
- Combivent 2 puffs tid
- levothyroxine 75 mcg qday
- lidocaine patch qday
- methadone 5 mg tid
- omeprazole 20 mg prn
- oxybutynin 5 mg up to five tabs daily
- pregabalin 150 mg tid
- sucralfate 1 g qid
- trazodone 200 mg qhs
- calcium carbonate 500 mg [**Hospital1 **]
- loratadine 10 mg daily prn
- nicotine patch 21 mg daily
- polyethylene glycol prn
Discharge Medications:
1. Cefepime 2 gram Recon Soln [**Hospital1 **]: Two (2) grams Intravenous
every twelve (12) hours for 3 days.
Disp:*12 grams* Refills:*0*
2. Vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) gram
Intravenous Q 12H (Every 12 Hours).
Disp:*6 gram* Refills:*0*
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheeze.
4. Baclofen 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day).
5. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
6. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
7. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
9. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
10. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
11. Pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a
day.
12. Trazodone 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
13. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. Nicotine 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
16. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
packet PO DAILY (Daily).
17. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily) as needed for heartburn.
18. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
19. Percocet 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for pain: For breakthrough pain. Take
methadone as prescriped.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aspiration pneumonia
Respiratory failure
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 were having difficulty breathing.
We think that you had some contents from your stomach go into
your lungs because you were oversedated by your medications.
You went to the intensive care unit overnight, but your
breathing has now improved and we think you are safe to go home.
We cut back on your medications to try to avoid having this
happen again.
.
- You should get 3 more days of antibiotics. A visiting nurse
will come to give you the antibiotics through your PICC line.
- Please STOP taking Klonopin for at this time.
- Please DECREASE your Baclofen dose to 5mg every 8 hours. 5mg
is half of a 10mg dose.
- Please continue using methadone for pain control and percocet
for breakthrough pain.
- Please use ranitidine instead of omeprazole as needed for
heartburn.
- You can use colace and Miralax for constipation. You should
take them every day unless you are having diarrhea.
Followup Instructions:
Please call Dr.[**Name (NI) 666**] office at [**Telephone/Fax (1) 250**] on Monday
morning to make an appointment for later next week or the week
after.
You had this appointment already made for you:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2148-9-2**] at 3:30 PM
With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2148-6-16**]
|
[
"507.0",
"070.70",
"300.00",
"787.22",
"244.9",
"V12.51",
"344.1",
"535.10",
"276.2",
"491.21",
"518.0",
"285.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10307, 10362
|
4734, 7731
|
325, 418
|
10446, 10446
|
3342, 4711
|
11563, 12063
|
2870, 2899
|
8285, 10284
|
10383, 10425
|
7757, 8262
|
10621, 11540
|
2914, 3323
|
2007, 2205
|
277, 287
|
446, 1988
|
10461, 10597
|
2227, 2678
|
2694, 2854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,317
| 118,602
|
7967
|
Discharge summary
|
report
|
Admission Date: [**2181-2-5**] Discharge Date: [**2181-2-13**]
Date of Birth: [**2095-7-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Wheezing and back pain.
Major Surgical or Invasive Procedure:
Non Invasive Positive Pressure Ventilation
History of Present Illness:
85 yo woman with PMHx sig. for afib on coumadin, CAD s/p MI
([**2178**]), sCHF (EF 30-35% TTE [**2178**]), OA and remote hx of GIB
([**2178**]) and anxiety who preseted to [**Hospital1 **] ED in setting of new
onset of dyspnea and b/l infrascapular back pain.
.
Pt. was in USOH until the night prior to admission, when she
developed sudden onset upper back pain, bilateral in nature,
sharp [**7-30**] w/o radiation. She tried to move around to make
herself feel better but unable to do so. Around the same time,
she developed SOB. This was a rest, she had difficult time
taking a deep breath felt to be due to pain in her back. Given
these symptoms, she called for help and EMS was called (lives at
ALF).
.
Of note, she reports symptoms of congestion, HA and intermittent
cough productive of clear sputum. Pt. treated these with
decongestants with mild relief. She denies fever, chills,
sweats. She denies PND, orthopnea, or frank CP, n/v,
diaphoresis. Notes no recent dietary changes. She does report
increasing hip pain for which she took endocet. No other
medication changes.
.
Initial VS in the ED BP 231/89 98.7 77 24 100% 15L nrb. Was
treated with Nitro gtt (now at 0.07) with resultant BP 150/60
but continued to have increase WOB. Labs were notable for
leukocytosis to 14K, HCT 32% and 2.4 INR, bicarb of 25.
CXR showed bibasilar opacities and given recent prodrome, she
was treated with Levofloxacin 750mg IV, Duonebs and NTG gtt as
above. She was started on Bipap given persistent hypoxemia
(6LNC) and incr. WOB. UOP was 1600cc, thus no lasix was give.
BiPAP 40% and PS 10 PEEP .
.
On arrival to the MICU, SBPs in 220s and O2 sat 94 on NRB. Pt.
appeared tachypneic, with increased WOB, unable to speak full
sentences. ABG showed 7.51/37/87 on NRB. Noted to have b/l
crackles, + JVD. Treated with Nitro gtt, lasix 20mg IV,
duonebs, methylprednisone of 125mg IV and placed on BiPAP 5/5 w/
ABG 2hrs later showing 7.55/34/89. Pt. was c/o of subscapular,
b/l pain [**5-29**] and arthritis pain in her b/l hips.
.
Review of systems:
(+) Per HPI, as per HPI, otherwise
(-) Denies fever, chills, night sweats, uncertain of weight
changes. Denies headache, sinus tenderness. Denies cough or
wheezing. Denies chest pain, chest pressure. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
rashes or skin changes.
Past Medical History:
1. A fib on coumadin, s/p previous attempted cardioversion x2
2. Systolic heart failure thought to be ischemic from echo
showing anterior and inferior akinesis. EF 30-35%
3. Coronary artery disease based on coronary artery
calcifications and echo findings.
4. Hypertension
5. Hypercholesterolemia
6. s/p tonsillectomy
Social History:
Lives in Compass ALF x 15mo. Retired from working at a
cosmetics counter. Ambulates w/ walker, no recent falls.
-Tobacco history: never smoker.
-ETOH: denies
-Illicit drugs: denies
Family History:
Father with history of A fib. Mother had [**Name (NI) 5895**].
Physical Exam:
Physical Exam in Discharge:
See HPI.
General: Alert, oriented, anxious, some accessory m. use
HEENT: Sclera anicteric, R eye ptosis (chronic), MMM, oropharynx
clear
Neck: supple, JVP 12
CV: [**Last Name (un) 3526**]/[**Last Name (un) 3526**], normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-tender, multiple bruises
GU: foley
MSK: reproducible paraspinal pain in upper thoracic region
Ext: warm, well perfused, nonpitting edema, 2+ pulses
Neuro: alert, awake, following commands, attentive.
CNII-XII: [**Name (NI) 3899**], ptosis on left, no miosis, symmetric face,
palate midline and tongue midline.
5/5 strength upper extremities, LE antigravity.
Normal tone.
Physical Exam on Discharge:
Vitals:T97.9, BP160/70, HR67, RR20, O2sat:94%RA
General: no accessory muscle use
Neck: no elevated JVP
Exam otherwise unchanged from admission
Pertinent Results:
Labs on admission:
[**2181-2-5**] 06:17AM BLOOD WBC-14.5* RBC-3.50* Hgb-10.1* Hct-32.6*
MCV-93 MCH-29.0 MCHC-31.1 RDW-14.5 Plt Ct-336
[**2181-2-8**] 03:01AM BLOOD WBC-9.7 RBC-3.32* Hgb-9.4* Hct-30.2*
MCV-91 MCH-28.4 MCHC-31.2 RDW-14.8 Plt Ct-290
[**2181-2-5**] 06:17AM BLOOD Neuts-83.5* Lymphs-10.8* Monos-4.5
Eos-0.4 Baso-0.8
[**2181-2-5**] 06:17AM BLOOD PT-25.3* PTT-38.3* INR(PT)-2.4*
[**2181-2-8**] 03:01AM BLOOD PT-24.6* PTT-30.8 INR(PT)-2.4*
[**2181-2-5**] 06:17AM BLOOD Glucose-153* UreaN-18 Creat-0.8 Na-130*
K-4.2 Cl-93* HCO3-25 AnGap-16
[**2181-2-7**] 03:06AM BLOOD Glucose-134* UreaN-22* Creat-0.7 Na-129*
K-4.1 Cl-88* HCO3-29 AnGap-16
[**2181-2-8**] 03:01AM BLOOD Glucose-153* UreaN-33* Creat-1.0 Na-128*
K-3.8 Cl-88* HCO3-30 AnGap-14
[**2181-2-5**] 06:17AM BLOOD ALT-48* AST-39 LD(LDH)-338* CK(CPK)-95
AlkPhos-99 TotBili-0.5
[**2181-2-5**] 06:17AM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-<5
[**2181-2-5**] 02:12PM BLOOD CK-MB-4 cTropnT-<0.01
[**2181-2-5**] 08:38PM BLOOD cTropnT-<0.01
[**2181-2-5**] 06:17AM BLOOD Lipase-24
[**2181-2-5**] 06:17AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
[**2181-2-5**] 02:12PM BLOOD Albumin-4.3
[**2181-2-7**] 03:06AM BLOOD Digoxin-0.9
[**2181-2-5**] 02:12PM BLOOD Digoxin-0.7*
[**2181-2-5**] 06:31AM BLOOD Lactate-2.0
Imaging:
CXR on admission:
IMPRESSION: Bibasilar opacities, right greater than left, may
indicate
developing infectious process.
CXR [**2-7**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild interstitial edema. Moderate cardiomegaly. No
pleural
effusions. No evidence of pneumonia.
CTA chest [**2-5**]:
IMPRESSION:
1. No acute aortic pathology or central pulmonary embolism.
2. Cardiomegaly with biatrial enlargement. Reflux of contrast in
the IVC,
suggestive of right heart failure.
3. Prominent mediastinal lymph nodes are nonspecific, but can be
seen in CHF;
these are larger and more numerous than on the prior study.
4. Wedge compression deformity in the mid thoracic spine is
increased since
[**2178**], although the exact acuity is unknown.
TTE:
The left atrium is markedly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of Moderate (2+) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2179-6-3**], left ventricular systolic function is
significantly improved.
Radiology Report CHEST (PA & LAT) Study Date of [**2181-2-11**] 2:25 PM
FINDINGS: In comparison with the study of [**2-7**], the patient has
taken a
somewhat better inspiration. There is continued enlargement of
the cardiac silhouette without vascular congestion or acute
pneumonia. Streaks of atelectasis are seen at the right base.
There is substantial wedging of a mid to lower thoracic vertebra
that was not well appreciated on the study of [**2179-6-18**].
Cardiovascular Report ECG Study Date of [**2181-2-9**] 11:48:22 PM
Atrial fibrillation with a controlled ventricular response. Left
axis deviation consistent with left anterior fascicular block.
Voltage criteria for left ventricular hypertrophy. Compared to
the previous tracing of [**2181-2-5**] no diagnostic interval change
other than slowing of the ventricular response.
Microbiology:
__________________________________________________________
[**2181-2-13**] 6:07 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final [**2181-2-13**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
__________________________________________________________
[**2181-2-7**] 10:34 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2181-2-7**]**
Respiratory Viral Culture (Final [**2181-2-7**]):
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final [**2181-2-7**]):
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final [**2181-2-7**]):
POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV).
Viral antigen identified by immunofluorescence.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2181-2-7**] 1315.
__________________________________________________________
[**2181-2-6**] 4:52 am URINE Source: Catheter.
**FINAL REPORT [**2181-2-7**]**
URINE CULTURE (Final [**2181-2-7**]): NO GROWTH.
__________________________________________________________
[**2181-2-5**] 2:30 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2181-2-11**]**
Blood Culture, Routine (Final [**2181-2-11**]): NO GROWTH.
__________________________________________________________
[**2181-2-5**] 2:20 pm BLOOD CULTURE SOURCE: VENIPUNCTURE #1.
**FINAL REPORT [**2181-2-11**]**
Blood Culture, Routine (Final [**2181-2-11**]): NO GROWTH.
__________________________________________________________
[**2181-2-5**] 10:04 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2181-2-7**]**
MRSA SCREEN (Final [**2181-2-7**]): No MRSA isolated.
__________________________________________________________
[**2181-2-5**] 6:29 am BLOOD CULTURE
**FINAL REPORT [**2181-2-12**]**
Blood Culture, Routine (Final [**2181-2-12**]): NO GROWTH.
__________________________________________________________
[**2181-2-5**] 6:17 am BLOOD CULTURE
**FINAL REPORT [**2181-2-11**]**
Blood Culture, Routine (Final [**2181-2-11**]): NO GROWTH.
Lab Results on Discharge:
[**2181-2-13**] 07:50AM BLOOD WBC-14.9* RBC-3.38* Hgb-9.5* Hct-31.9*
MCV-95 MCH-28.2 MCHC-29.9* RDW-14.4 Plt Ct-377
[**2181-2-13**] 07:50AM BLOOD Neuts-70 Bands-1 Lymphs-19 Monos-9 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2181-2-13**] 07:50AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2181-2-12**] 05:35AM BLOOD PT-29.5* INR(PT)-2.8*
[**2181-2-12**] 05:35AM BLOOD Glucose-93 UreaN-26* Creat-0.9 Na-135
K-4.6 Cl-94* HCO3-33* AnGap-13
[**2181-2-5**] 02:12PM BLOOD ALT-39 AST-30 CK(CPK)-112 AlkPhos-90
TotBili-0.6
[**2181-2-12**] 05:35AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.3
[**2181-2-7**] 01:20AM BLOOD Type-ART pO2-114* pCO2-41 pH-7.52*
calTCO2-35* Base XS-10
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is an 85 yo woman
with PMHx sig. for afib on coumadin, CAD s/p MI ([**2178**]), sCHF (EF
30-35% TTE [**2178**]), OA and remote hx of GIB ([**2178**]) and anxiety who
preseted to [**Hospital1 **] ED in setting of new onset of dyspnea and b/l
infrascapular back pain and hypoxic respiratory distress. She
was found to have a vertebral wedge fracture and RSV infection
with exacerbation of chronic diastolic heart failure. She was
diuresed fluid, received steroids and bronchidilators for RSV,
and lidocaine patch for pain control. She was discharged home
with better oxygenation and adequate pain control.
.
ACUTE CARE
1. Hypoxemic respiratory distress. Initially felt to be
combination of b/l CAP and CHF in setting severe pain from
compression fracture and flash pulmonary edema with SBPs to
220s. Patient was treated with NTG, diuresis, pain control,
standing duonebs and anxiolytics, with transient improvement in
her respiratory distress (accessory muscle use), however
required use of BIPAP on HD2,3. Given persistent distress and
b/l scapular pain, CTA was performed, no PE or dissection was
found. Diuresis was continued w/ [**Location 10226**]6.7L in the MICU. Given
exposure to URI at [**Hospital3 **] facility and no significant
improvement in oxygenation w/ ABx and diuresis, viral screen was
sent. Pt. found to be positive for RSV. She was started on IV
solumedrol and transitioned to PO prednisone on [**2-7**]. ROMI was
completed and TTE was performed showing normalization of EF and
no significant valvular abnormality and TR gradient of 46 mmHg.
Pt was transferred to regular medicine floor on HD#4, where she
was placed on home dose lasix and continued on steroid and
bronchodilator treatment. She completed a course of steroids and
was discharged home on home bnebulizers when oxygenation
improved.
.
2. Scapular pain. Most concerning for dissection on admission,
but CTA negative. Likely due to compression fracture (this is
of unknown duration). Pt was treated with narcotics and
lidocaine patch with near resolution of her pain.
.
3. CHF, acute on chronic diastolic: Likely due to diastolic
dysfunction in setting of acute illness and hypertension leading
to flash pulmonary edema. Repeat TTE showed noramlization of
EF. LOS fluid balance as above. Pt was restarted on home
diuretic dose, continued on BB (increased to 75mg), ACEi.
.
CHRONIC ISSUES:
1. CAD hx: Asx. D/w OP cardiologist who that ASA could be
started if indicated, however was not convinced that she had
CAD. Given her age and being on coumadin, initiation of ASA was
deferred to OP setting and discussion of risks and benefits.
Continued on BB and statin.
.
2. OA: Hip pain at this time mostly, chronic. Continued on
narcotics prn and started lidocaine patch.
.
3. Afib. Pt was rate controlled. Initially due to HR in 120s
intermittently, increased BB to 75mg daily and continued on home
digoxin. Patient became bradycardic at night on that dosing,
but with dose adjusted to 25mg of metoprolol daily she had
adequate HR control to 60's and 70's range. Coumadin dose was
adjusted given increasing INR in the setting of levofloxacin
use. She was discharged on 2mg coumadin daily.
.
TRANSITIONAL ISSUES
# CODE STATUS: DNI
# PENDING STUDIES AT DISCHARGE: final culture of repiratory
viruses, but screen negative for antigen indicating resolution
# MEDICATION CHANGES:
1. CHANGE your dose of metoprolol succinate to be 25mg daily at
night with the 25mg tabs. (STOP taking 50 mg tablets)
2. Your warfarin dosing will be 2mg daily on discharge. Please
follow up with your coumadin clinic regarding titrating the
dosing.
3. START ipratropium bromide nebulizer treatments. 1 neb inhaled
every 6 hours. bring this down in frequency as tolerated over
the next 2 weeks.
4. START albuterol nebulizer treatments. Take 1 neb inhaled
every 4 hours as needed for shortness of breath or wheeze. Bring
this down in frequency as tolerated over the next 2 weeks.
5. START lidocaine patches. Place one patch over affected areas
on back and hips daily. Leave it on for 12 hours and have the
area patch-free for 12 hours.
6. START guaifenesin 50 mg/5 mL Liquid take Five (5) mL by mouth
every six (6) hours as needed for cough.
7. START benzonatate 100mg by mouth three times daily as needed
for cough.
8. START saline nasal spray. Use one spray each nostril as
needed for congestion.
9. START fluticasone nasal spray. Take 2 nasal sprays daily for
four weeks for nasal congestion and seasonal allergies
- There are no further changes in your medication
#Follow-up:
Department: GERONTOLOGY
When: FRIDAY [**2181-2-23**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2181-4-2**] at 1:20 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
Department: MEDICAL SPECIALTIES
When: MONDAY [**2181-4-2**] at 2:40 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Patient will have PT/INR drawn Friday post discharge.
LABS: PAtient is to have PT/INR drawn on Friday and sent to her
coumadin clinic
Medications on Admission:
lasix 20mg po
digoxin 0.125mg daily
lipitor 20mg daily
lisinopril 20mg daily
metoprolol ER 50mg nightly
Omeprazole 20mg daily
senna/colace/tums
Vitamin d 800 U
Ativan 0.5mg prn
endocet 10/325mg Q4h prn
coumadin 2.5mg daily
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. sennosides-docusate sodium 8.6-50 mg Tablet Sig: Two (2)
Tablet PO at bedtime.
9. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
10. Vitamin D3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
11. Endocet 10-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: do not drive or operate machinery
while taking this medication.
12. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
titrate this dosing under the direction of your coumadin clinic.
Disp:*30 Tablet(s)* Refills:*2*
13. ipratropium bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) for 2 weeks.
Disp:*56 dose* Refills:*0*
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) dose Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing for 2 weeks:
gradually taper off as breathing improves.
Disp:*60 doses* Refills:*0*
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: apply to affected areas. 12 hours on and 12
hours off.
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
16. guaifenesin 50 mg/5 mL Liquid Sig: Five (5) mL PO every six
(6) hours as needed for cough.
Disp:*300 mL* Refills:*2*
17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*2*
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-20**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
Disp:*2 bottles* Refills:*3*
19. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily) as needed for nasal congestion.
Disp:*2 bottles* Refills:*3*
20. nebulizers Kit Sig: One (1) kit Miscellaneous once:
please dispense one nebulizer machine with accessories.
Disp:*1 unit* Refills:*0*
21. Outpatient Lab Work
Please draw PT, PTT, INR on Friday, [**2181-2-13**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Respiratory syncytial virus
Secondary diagnosis:
- atrial fibrillation
- acute on chronic diastolic heart failure
- vertebral compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 9449**],
You came to our hospital for shortness of breath and cough along
with back pain. After arrival in the ED, you were found to have
respiratory distress, and were transferred to the intensive care
unit for respiratory support. We found that you had a viral
infection of your airway called respiratory syncytial virus.
This condition is typically self-limited. We gave you
medication to remove excess fluid around the lung and breathing
treatment to prevent tightened airways. Your breathing improved
and you were discharged home. Your back pain was found to be a
compression fracture of a bone in the spinal column and you
should follow-up with your PCP regarding this issue, but
continue with the pain control medication we have initiated with
you.
.
Please note the following changes in your medication
1. CHANGE your dose of metoprolol succinate to be 25mg daily at
night with the 25mg tabs.
2. Your warfarin dosing will be 2mg daily on discharge. Please
follow up with your coumadin clinic regarding titrating the
dosing.
3. START ipratropium bromide nebulizer treatments. 1 neb inhaled
every 6 hours. bring this down in frequency as tolerated over
the next 2 weeks.
4. START albuterol nebulizer treatments. Take 1 neb inhaled
every 4 hours as needed for shortness of breath or wheeze. Bring
this down in frequency as tolerated over the next 2 weeks.
5. START lidocaine patches. Place one patch over affected areas
on back and hips daily. Leave it on for 12 hours and have the
area patch-free for 12 hours.
6. START guaifenesin 50 mg/5 mL Liquid take Five (5) mL by
mouth every six (6) hours as needed for cough.
7. START benzonatate 100mg by mouth three times daily as needed
for cough
8. START saline nasal spray. Use one spray each nostril as
needed for cough
9. START fluticasone nasal spray. Take 2 nasal sprays daily as
needed for nasal congestion.
- There are no further changes in your medication
.
We have made the following appointments for you (see below).
After leaving the hospital, please weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery
Followup Instructions:
Department: GERONTOLOGY
When: FRIDAY [**2181-2-23**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2181-4-2**] at 1:20 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
Department: MEDICAL SPECIALTIES
When: MONDAY [**2181-4-2**] at 2:40 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"480.1",
"401.9",
"397.0",
"251.2",
"300.00",
"412",
"424.0",
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"733.13",
"428.0",
"427.89",
"799.02",
"425.4",
"E849.7",
"272.0",
"276.1",
"416.8",
"E942.6",
"428.33",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20640, 20697
|
12189, 14601
|
327, 371
|
20920, 20920
|
4395, 4400
|
23334, 24201
|
3372, 3438
|
18042, 20617
|
20718, 20718
|
17794, 18019
|
21071, 23311
|
3453, 4204
|
4232, 4376
|
15490, 15583
|
11404, 12166
|
2450, 2814
|
15603, 17768
|
264, 289
|
399, 2431
|
20792, 20899
|
20739, 20769
|
5687, 11390
|
20935, 21047
|
14617, 15476
|
2836, 3156
|
3172, 3356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,531
| 112,561
|
41156+58424
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-5-18**] Discharge Date: [**2160-5-29**]
Date of Birth: [**2088-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
tibial plateau fracture, [**First Name3 (LF) 8813**] stenosis
Major Surgical or Invasive Procedure:
[**2160-5-23**]
1. [**Month/Day/Year **] valve replacement with a 23-mm Biocor Epic tissue
valve.
2. Coronary artery bypass grafting x2: Left internal
mammary artery graft to left anterior descending;
reverse saphenous vein graft to diagonal branch.
History of Present Illness:
71 year old woman with a medical history of A-fib on coumadin
and sotalol and [**Month/Day/Year 8813**] stenosis. She was told by a doctor
(presumably her cardiologist or cardiac surgeon) that she needed
to have her [**Month/Day/Year 8813**] valve replaced. She
was told this two months ago and because she is scared of the
surgery has not scheduled a date for the surgery. She was
walking and stepped on her left foot oddly, this caused her to
stumble and fall on her left knee. Her daugher who lives with
her was able to help her up and bring her to the ED at [**Hospital 39437**]. She is unable to walk across the room without getting
short of breath. She does not get shortness of breath at rest,
but consistently becomes short of breath with minimal exertion.
She is now being referred to cardiac surgery for evaluation of
an [**Hospital 8813**] vavle repelacment.
Past Medical History:
[**Hospital **] Stenosis
Coronary Artery Disease
PMH:
A-fib
Hypertension
Hyperlipidemia
[**Hospital **] Valve stenosis
Mitral Valve problem
Hypothyroidism
Past Surgical History:
s/p Left ankle fracture 10 years ago repaired with "10 screws
and
a bar"
s/p Surgery for PUD causing gastric outlet obstruction
s/p Tonsillectomy as child
Social History:
No Tob ever
No EtOH
No illicits
Patient lives with daughter and granddaughter
Family History:
Obesity
Heart problems, pt not sure what kind
Half sister had [**Hospital 8813**] valve repalcement at the age of 43
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
Admission:
VS: afebrile 87/62 145 96% RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: difficult to assess due to body habitus.
CARDIAC: RR, normal S1, soft S2, 3/6 systolic murmur
crescendo-decrescendo heard throughout precordium, No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2160-5-28**] 04:13AM BLOOD WBC-8.9 RBC-3.18* Hgb-10.0* Hct-28.9*
MCV-91 MCH-31.4 MCHC-34.7 RDW-17.0* Plt Ct-220
[**2160-5-27**] 07:48AM BLOOD Hct-24.0*
[**2160-5-27**] 04:43AM BLOOD WBC-9.7 RBC-2.57* Hgb-8.4* Hct-23.8*
MCV-93 MCH-32.6* MCHC-35.2* RDW-16.4* Plt Ct-196
[**2160-5-29**] 06:08AM BLOOD PT-26.6* INR(PT)-2.5*
[**2160-5-28**] 04:13AM BLOOD PT-17.9* INR(PT)-1.6*
[**2160-5-27**] 04:43AM BLOOD PT-14.9* INR(PT)-1.3*
[**2160-5-26**] 05:55AM BLOOD PT-14.0* INR(PT)-1.2*
[**2160-5-25**] 12:59PM BLOOD PT-14.2* INR(PT)-1.2*
[**2160-5-24**] 01:36AM BLOOD PT-14.6* PTT-27.1 INR(PT)-1.3*
[**2160-5-23**] 04:00PM BLOOD PT-15.6* PTT-35.2* INR(PT)-1.4*
[**2160-5-23**] 02:05PM BLOOD PT-15.9* PTT-32.7 INR(PT)-1.4*
[**2160-5-23**] 07:05AM BLOOD PT-14.6* PTT-67.7* INR(PT)-1.3*
[**2160-5-22**] 02:50AM BLOOD PT-13.5* PTT-50.5* INR(PT)-1.2*
[**2160-5-21**] 07:30AM BLOOD PT-15.3* PTT-71.6* INR(PT)-1.3*
[**2160-5-28**] 04:13AM BLOOD Glucose-109* UreaN-27* Creat-0.8 Na-133
K-4.2 Cl-95* HCO3-34* AnGap-8
[**2160-5-27**] 04:43AM BLOOD Glucose-124* UreaN-29* Creat-0.8 Na-131*
K-4.4 Cl-94* HCO3-31 AnGap-10
CT L Lower ext [**2160-5-18**]:
FINDINGS: There is a comminuted slightly depressed fracture of
the left
tibial plateau which involves the articular surface. The largest
fracture
fragment involves the medial tibial plateau with 4 mm lateral
displacement of the distal tibia. A large anterior fracture
fragment arising from the lateral tibial plateau also
demonstrates slight displacement. Finally, there is a comminuted
fracture of the lateral aspect of the proximal fibula. There is
no evidence of femoral or patellar fracture. Bones are
demineralized. There is a large lipohemarthrosis in the
suprapatellar region and a small [**Hospital Ward Name 4675**] cyst. There is soft
tissue edema. There is atrophy of the muscles, particularly the
semimembranosis. The remainder of the soft tissues are normal.
IMPRESSION: Comminuted tibial and fibular fractures as above.
TTE [**2160-5-19**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>65%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The [**Month/Day/Year 8813**] valve leaflets (?#) are moderately
thickened. There is severe [**Month/Day/Year 8813**] valve stenosis. Mild to
moderate ([**2-17**]+) [**Month/Day (2) 8813**] regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is a minimally increased
gradient consistent with trivial mitral stenosis. Moderate to
severe (3+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate to severe
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and normal
regional excellent global systolic function. Severe [**Month/Day (2) 8813**] valve
stenosis. At least moderate to severe mitral regurgitation.
Pulmonary artery systolic hypertension. Dilated ascending aorta.
Cardiac cath [**2160-5-20**]:
1. Selective coronary angiography of this left-dominant system
demonstrated 1 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
80%
mid-vessel stenosis and there was 70% stenosis at the origin of
a large
diagonal. The LCx had no significant disease. The RCA had 50%
mid-vessel stenosis in a non-dominant vessel.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
Intra-op TEE [**2160-5-23**]
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is 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.
There are simple atheroma in the descending thoracic aorta. The
[**Month/Day/Year 8813**] valve leaflets are severely thickened/deformed. There is
critical [**Month/Day/Year 8813**] valve stenosis (valve area <0.8cm2). Moderate
(2+) [**Month/Day/Year 8813**] regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation
is seen. There is no pericardial effusion. There is severe
mitral annular calcification. Calcium chunks were also seen on
the atrial aspect of the P2 scallop of anterior mitral leaflelt
probably leading to increased transmitral gradient and mod
mitral stenosis.
Dr. [**Last Name (STitle) **] was notified in person of the results on this
patient before surgical incision.
POST-BYPASS:
Normal biventircular systolic function. LVEF 55%. Post bypass
MVA still shows 1.2 cm2. Mild to Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 8813**] valve
bioprosthesis is stable, functioning well, no leaks, transaortic
mean gradient of 11 mm of Hg. Intact thoracic aorta.
Minimal TR.
Brief Hospital Course:
Ms.[**Known lastname 1683**] was brought to the operating room on [**2160-5-23**] where the
patient underwent [**Date Range **] valve replacement with a 23-mm Biocor
Epic tissue valve/ Coronary artery bypass grafting x2(Left
internal mammary artery graft to left anterior descending;
reverse saphenous vein graft to diagonal branch) with Dr.
[**Last Name (STitle) **]. Please refer to operative report for further surgical
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, alert and oriented and breathing comfortably.
She was neurologically intact and hemo- dynamically stable,
weaned from inotropic and vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. Postoperatively, Orthopeadics followed up
on her left tibial plateau fracture immobilization brace.
Coumadin was resumed for atrial fibrillation. Subcutaneous
heparin was administered for DVT prophylaxis. 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. She remained non-weight
bearing on the left lower extremity per ortho recommendations.
By the time of discharge on POD#6 Ms.[**Known lastname 1683**] was cleared by
Dr.[**Last Name (STitle) **] for discharge to [**Hospital1 756**] Manor Nursing and
Rehabilitation for further increase in strength and mobility.
All follow up appointments were advised.
Medications on Admission:
vitamin D 50,000 units once a week
zestoretic daily
levothyroxine 100 mcg daily
lipitor 20 mg daily
coumadin 5 mg daily
sotalol AF 80 mg [**Hospital1 **]
fish oil 1 gm [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever/HA.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation .
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
[**Location (un) **] Stenosis
Coronary Artery Disease
PMH:
A-fib
Hypertension
Hyperlipidemia
[**Location (un) **] Valve stenosis
Mitral Valve problem
Hypothyroidism
Past Surgical History:
s/p Left ankle fracture 10 years ago repaired with "10 screws
and
a bar"
s/p Surgery for PUD causing gastric outlet obstruction
s/p Tonsillectomy as child
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Left lower extremity: Non weight bearing
Left lower extremity brace: [**Doctor Last Name 6587**] lockis 20 degree extension
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **]: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2160-6-19**] at
1:30
Cardiologist Dr. [**Last Name (STitle) 77919**], [**Last Name (un) 83355**] on [**7-11**] at 12:15pm
Please call to schedule the following:
Dr [**Last Name (STitle) 1005**] in 1 week [**Telephone/Fax (1) 9769**]
Primary Care Dr. [**Last Name (STitle) **],[**Last Name (un) 75760**] A. [**Telephone/Fax (1) 75761**] in [**5-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for a-fib
Goal INR 2-2.5
First draw day after discharge on [**2160-5-30**]
Then please do daily INR checks with Coumadin dosing [**Name8 (MD) **] MD.
Completed by:[**2160-5-29**] Name: [**Known lastname **],[**Known firstname 2868**] Unit No: [**Numeric Identifier 14201**]
Admission Date: [**2160-5-18**] Discharge Date: [**2160-5-29**]
Date of Birth: [**2088-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
The discharge summary should reflect that the patient was
admitted with systolic congestive heart failure likeley due to
severe aortic stenosis. She was treated preoperatively with
diuretics and ultimately had an aortic valve replacement.
The discharge diagnosis list should be:
Discharge Diagnosis:
Aortic Stenosis -s/p AVR
Coronary Artery Disease -s/p CABG x2
PMH:
A-fib
Acute systolic congestive heart failure
Hypertension
Hyperlipidemia
Aortic Valve stenosis
Mitral Valve problem
Hypothyroidism
Past Surgical History:
s/p Left ankle fracture 10 years ago repaired with "10 screws
and a bar"
s/p Surgery for PUD causing gastric outlet obstruction
s/p Tonsillectomy as child
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Manor Nursing & Rehab Center - [**Location (un) 6451**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2160-6-24**]
|
[
"427.31",
"424.1",
"272.4",
"428.21",
"V49.86",
"823.00",
"401.9",
"285.9",
"707.09",
"244.9",
"E927.0",
"707.21",
"414.01",
"V58.61",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.11",
"35.21",
"36.15",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
15391, 15613
|
8506, 10187
|
372, 637
|
12277, 12448
|
3064, 8483
|
13447, 14968
|
2005, 2236
|
10422, 11765
|
14989, 15188
|
10213, 10399
|
12472, 13424
|
15211, 15368
|
2251, 3045
|
271, 334
|
665, 1537
|
1559, 1714
|
1910, 1989
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,087
| 121,880
|
13566
|
Discharge summary
|
report
|
Admission Date: [**2125-5-30**] Discharge Date: [**2125-6-9**]
Date of Birth: [**2055-6-2**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10544**] is a 69-year-old man
with a history of CAD, status post RCA stenting in [**2124-3-12**], who is admitted for a repeat cardiac catheterization.
He has a history of lower extremity edema and had a positive
exercise tolerance test which showed an enlarged fixed
anterior defect with an EF of 39%. He had a CYPHER stent of
the RCA in [**2124-9-10**] and had a positive exercise
tolerance test in [**2125-4-10**]. An echo done in [**2125-4-10**] showed an EF of 45% with inferior hypokinesis and mild-
to-moderate MR, along with a mildly dilated left atrium. He
also complains of fatigue over the past 2 to 4 weeks. Cardiac
cath done on [**2125-5-14**] showed normal LV wall motion with
no MR. [**First Name (Titles) 6**] [**Last Name (Titles) **] of 60%. Left main was normal. LAD with diffuse
disease, 50% to 60% proximal. Left circumflex with 70%
stenosis at OM1. RCA with 100% mid in-stent restenosis. He
was referred to cardiac surgery for coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Significant for CAD, hyperlipidemia,
diabetes mellitus type 2, lower extremity claudication with
occlusive disease of the femoral/popliteal outflow tract as
well as possible tibial disease, hypertension, status post
removal of a squamous papilla on the larynx, history of
alcohol use (4 to 5 beers per day and 2 to 3 glasses of wine
per day), and status post T&A.
MEDICATIONS ON ADMISSION: Include glyburide 5 mg in the
morning and 2.5 mg at bedtime, Plavix 75 mg daily, aspirin
325 mg daily, metformin 1000 mg b.i.d., Lopressor 50 mg
b.i.d., Lopid 600 mg b.i.d., lisinopril 40 mg daily, Prilosec
40 mg daily, Lasix 40 mg daily, Oxytrol 3.9-mg patch 2 times
per week, Flomax 0.4 mg at bedtime, gabapentin 300 mg daily,
Lipitor 10 mg daily.
ALLERGIES: The patient states no known drug allergies.
SOCIAL HISTORY: Positive tobacco; smoked 1 pack per day x 30
years; quit about 3 years ago. Alcohol as stated previously;
4 to 5 beers per day and 2 to 3 glasses of wine per day. He
lives with his wife. [**Name (NI) **] works in real estate.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Positive urinary frequency and positive
right lower extremity claudication; otherwise unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: In general, an elderly
man in no acute distress. Vital signs reveal a heart rate in
the 80s, blood pressure of 168/44 on the right and 175/55 on
the left, respiratory rate of 20, height of 5 feet 9 inches,
weight of 200 pounds. HEENT reveals the pupils are equally,
round and reactive to light. Extraocular movements are
intact, anicteric, noninjected. The oropharynx is benign. The
neck is supple. No lymphadenopathy or thyromegaly. The
carotids are 1+ without bruits. The lungs are clear.
Cardiovascular reveals a regular rate and rhythm. No murmur.
Normal S1 and S2. The abdomen is obese, soft, nontender,
without masses or hepatosplenomegaly. Extremities without
clubbing, cyanosis, or edema. Pulses reveal radial 2+
bilaterally, brachial 2+ bilaterally, popliteal and dorsalis
pedis are trace bilaterally. Neurologically, a nonfocal exam.
HOSPITAL COURSE: The patient is a postoperative admission
following coronary artery bypass grafting. Admitted directly
into the operating room. Please see the OR report for full
details. In summary, the patient had coronary artery bypass
grafting x 3 with a LIMA to the LAD, a saphenous vein graft
to the OM1, and saphenous vein graft to the PDA. His bypass
time was 74 minutes with a cross-clamp time of 44 minutes. He
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 Neo-Synephrine at 0.8
mcg/kg/min and propofol at 40 mcg/kg/min. The patient did
well in the immediate postoperative period. After a short
stabilization period, his anesthesia was reversed. He was
weaned from the ventilator and successfully extubated.
On postoperative day #1, the patient remained hemodynamically
stable. He was weaned from his Neo-Synephrine infusion. His
Swan-Ganz catheter was removed. His chest tubes were removed.
He was begun on beta blockade and transferred form the
cardiothoracic intensive care unit to [**Hospital Ward Name 121**] Two for continuing
postoperative care and cardiac rehabilitation.
On postoperative day 2, the patient was noted to have periods
of rapid atrial fibrillation which was successfully treated
initially with IV Lopressor. However, after several doses of
IV Lopressor the patient was somewhat hypotensive, and he was
transferred back to the cardiothoracic intensive care unit to
be placed on a Neo-Synephrine drip. Additionally, the patient
was begun on amiodarone orally. During the course of
postoperative day 2, the patient converted to a normal sinus
rhythm.
On postoperative day 3, the patient remained in a normal
sinus rhythm. His beta blockade was gradually increased, and
it was felt that the patient was stable and ready to be
transferred back to the floor. However, there were no floor
beds available.
Finally, on postoperative day 5, the patient was transferred
back to the floor. He remained hemodynamically stable
throughout this time. His activity level was increased with
the assistance of the nursing staff as well as physical
therapy. It was noted that the patient coughed with thin
liquids, and therefore a swallow evaluation was obtained.
Initially the evaluation showed that the patient aspirated
with think liquids but did have a normal functional swallow,
and therefore he was restricted to nectar thick liquids. The
patient had an uneventful postoperative course. His
swallowing was reevaluated on postoperative day 9, and at
that time his diet was advanced to thin liquids and regular
consistency for solids. At that time it was also determined
that the patient was stable and ready to be discharged to
home on the following morning.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged to home
with visiting nurses.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass grafting x 3 with a left internal mammary artery to
the left anterior descending, saphenous vein graft to
first obtuse marginal, and saphenous vein graft to
posterior descending artery.
2. Hypercholesterolemia.
3. Diabetes mellitus type 2.
4. Hypertension.
5. Ethanol use.
6. Removal of squamous papilla of the larynx.
DISCHARGE FOLLOWUP:
1. He is to have followup with Dr. [**Last Name (STitle) 40975**] in 3 to 4
weeks.
2. Followup with Dr. [**Last Name (STitle) 5874**] in 3 to 4 weeks.
3. Follow up with Dr. [**Last Name (STitle) 70**] in 6 weeks.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg daily x 10 days and then 20 mg daily x 10
days.
2. Colace 100 mg b.i.d.
3. Potassium chloride 20 mEq daily x 20 days.
4. Prilosec 40 mg daily.
5. Aspirin 81 mg daily.
6. Percocet 5/325 1 to 2 tablets q.4-6h. as needed (for
pain).
7. Lipitor 10 mg daily.
8. Plavix 75 mg daily.
9. Flomax 0.4 mg at bedtime.
10. Neurontin 300 mg at bedtime.
11. Gemfibrozil 600 mg b.i.d.
12. Glyburide 5 mg q.a.m. and 2.5 mg q.p.m.
13. Lopressor 50 mg t.i.d.
14. Fluconazole 100 mg daily x 5 days.
15. Amiodarone 400 mg b.i.d. x 1 week and then 400 mg
daily x 1 week and then 200 mg daily.
16. Lisinopril 10 mg daily.
17. Oxytrol 3.9-mg patch [**Hospital1 **]-weekly.
PHYSICAL EXAMINATION ON DISCHARGE: Neurologically, alert and
oriented. Moves all extremities. Follows commands. A nonfocal
exam. Pulmonary reveals clear to auscultation bilaterally.
Cardiac reveals a regular rate and rhythm, S1 and S2, with no
murmur. The sternum is stable. The incision with Steri-
Strips. No erythema or drainage. The abdomen is soft,
nontender, and nondistended with normal active bowel sounds.
The extremities are warm and well perfused with trace edema.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2125-6-8**] 16:39:20
T: [**2125-6-8**] 17:57:21
Job#: [**Job Number 40976**]
|
[
"401.9",
"682.6",
"427.31",
"458.29",
"414.01",
"996.72",
"440.21",
"788.41",
"787.2",
"303.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.72",
"00.17",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2252, 2267
|
6199, 6595
|
6859, 7595
|
1583, 1991
|
3287, 6062
|
7610, 8321
|
2287, 2409
|
6615, 6833
|
163, 1168
|
2424, 3269
|
1191, 1556
|
2008, 2235
|
6087, 6178
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,055
| 147,047
|
50428
|
Discharge summary
|
report
|
Admission Date: [**2120-12-20**] Discharge Date: [**2121-1-1**]
Date of Birth: [**2037-8-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
intubation for mental status in the emergency room
extubation [**12-22**]
Lumbar puncture
History of Present Illness:
This is a 83 year-old female with a history of hypertension,
anxiety, OCD and diabetes who presents from the ER after 911 was
called. Per ER, records, the patient called EMS this AM. When
EMS arrived, the patient was found to have altered mental status
and was febrile to approx 106.
Of note the patient's PCP had [**Name Initial (PRE) **] home visit on [**12-19**]. During that
visit the NP remarked that while she did not seem quite like her
normal self, she certainly didn't have any new or concerning
complaints or physical exam findings. She had persistent joint
page,
.
In the ED, the patient was found to be febrile to 103 with
hypertensive episodes to 210/64. Given that the patient had
altered mental status and fever, the patient was intubated for
CT head, abdomen/pelvis. (Patient's DNR/I status was not known).
As well the patient was given Vancomycin, Ceftriaxone 2 grams.
.
ROS: Was not obtained secondary to intubation.
Past Medical History:
Hypertension
Hyperlipidema
DJD
Anxiety
Abdominal cellulitis
Intertrigo
CHF
.
Social History:
Lives with sister, has multiple psych issues including Anxiety,
OCD and agoraphobia. Thus the patient rarely leaves the house.
Has a VNA as well as a friend [**Name (NI) 553**] [**Name (NI) 105080**] [**Telephone/Fax (1) 105081**].
Family History:
non obtained
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Multiple skin lesions in lower extremities that appear well
healed
Pertinent Results:
=========
Labs
=========
[**2120-12-20**] 6:30 am BLOOD CULTURE FROM LEFT LINE.
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = Sensitive AT <= 0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2120-12-20**] 6:30 am URINE Site: CATHETER
**FINAL REPORT [**2120-12-21**]**
URINE CULTURE (Final [**2120-12-21**]):
GRAM NEGATIVE ROD(S). ~1000/ML.
[**2120-12-21**] 03:38AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
Lymphs-63 Monos-35 Macroph-2
[**2120-12-21**] 03:38AM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-128
[**2120-12-24**] 03:07AM BLOOD WBC-7.2 RBC-3.85* Hgb-11.4* Hct-34.3*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.6* Plt Ct-226
[**2120-12-23**] 03:48AM BLOOD WBC-8.3 RBC-3.64* Hgb-11.0* Hct-33.0*
MCV-91 MCH-30.3 MCHC-33.4 RDW-16.0* Plt Ct-194
[**2120-12-22**] 03:11AM BLOOD WBC-11.0 RBC-3.80*# Hgb-11.4* Hct-34.5*#
MCV-91 MCH-30.0 MCHC-33.1 RDW-16.1* Plt Ct-206
[**2120-12-21**] 04:12AM BLOOD WBC-8.9 RBC-3.01* Hgb-9.2* Hct-27.3*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.1* Plt Ct-165
[**2120-12-20**] 06:30AM BLOOD WBC-13.6*# RBC-3.77* Hgb-11.4* Hct-34.0*
MCV-90 MCH-30.2 MCHC-33.5 RDW-16.2* Plt Ct-238
[**2120-12-24**] 03:07AM BLOOD Neuts-74.4* Lymphs-17.1* Monos-6.7
Eos-1.3 Baso-0.4
[**2120-12-20**] 06:30AM BLOOD Neuts-85.4* Lymphs-8.2* Monos-4.3 Eos-1.9
Baso-0.1
[**2120-12-24**] 03:07AM BLOOD Glucose-242* UreaN-16 Creat-0.7 Na-139
K-3.3 Cl-100 HCO3-29 AnGap-13
[**2120-12-23**] 03:48AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2120-12-22**] 03:11AM BLOOD Glucose-103 UreaN-12 Creat-0.9 Na-137
K-4.3 Cl-106 HCO3-23 AnGap-12
[**2120-12-21**] 04:12AM BLOOD Glucose-173* UreaN-12 Creat-0.8 Na-138
K-2.9* Cl-109* HCO3-21* AnGap-11
[**2120-12-20**] 06:30AM BLOOD Glucose-269* UreaN-20 Creat-1.0 Na-139
K-4.0 Cl-100 HCO3-27 AnGap-16
[**2120-12-20**] 06:30AM BLOOD ALT-14 AST-24 CK(CPK)-61 AlkPhos-114
TotBili-0.5
[**2120-12-24**] 03:07AM BLOOD Calcium-9.9 Phos-1.8* Mg-2.1
[**2120-12-23**] 03:48AM BLOOD Calcium-10.0 Phos-2.1* Mg-2.0
[**2120-12-22**] 03:11AM BLOOD Calcium-9.8 Phos-2.3* Mg-2.1
[**2120-12-21**] 04:12AM BLOOD Albumin-2.6* Calcium-8.0* Phos-1.7*
Mg-1.5*
[**2120-12-20**] 06:30AM BLOOD Albumin-4.2 Calcium-10.4* Phos-2.3*
Mg-1.8
[**2120-12-20**] 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2120-12-20**] 08:16AM BLOOD Lactate-1.4
[**2120-12-20**] 06:44AM BLOOD Lactate-1.9
=========
Radiology
=========
MR [**Name13 (STitle) 1093**] - IMPRESSION:
Limited study due to patient motion. No evidence for discitis,
osteomyelitis, or paraspinal abscess.
CXR [**12-20**]
Significantly limited radiograph without evidence of large
effusion or pneumothorax. Recommend repeat PA and lateral when
feasible.
Probable left lower lobe opacity suggesting aspiraton.
CXR [**12-24**]
In comparison with the study of [**12-22**], there is continued
enlargement of the cardiac silhouette with poor definition of
engorged
pulmonary vessels consistent with elevated pulmonary venous
pressure.
Probable bibasilar atelectatic change, though a lateral view
would be helpful for further evaluating this region. Nasogastric
tube extends well into the stomach. The
==========
Cardiology
==========
TTE [**12-23**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. with normal free wall contractility. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. There
is a focal thickening (non-mobile) at the tip of the
non-coronary cusp of the aortic valve with the appearance of
fibrocalcific change. No definite vegetations are seen on the
aortic valve. 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 ([**1-10**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
If clinically indicated, a TEE would be better to exclude
valvular vegetations.
Brief Hospital Course:
In brief, the patient is an 83 year old female with a history of
schizophrenia who lives at home with her sister who is
additionally noted to have cognitive delay and significant
psychiatric disease. On [**12-20**], the patient called EMS with a
chief complaint of severe back pain and fever with T = 106.0 on
EMS arrival. In the ED the patient was noted to confused,
agitated and febrile to 102 with vitals of 210/64, P116, 98% on
4L. The patient was reporting at that time severe back pain and
difficulty walking or sitting. The patient was intubated,
sedated and received ceftriaxone, Flagyl and propofol. The
patient was transferred to the ICU for further care. In the ICU
the patient was noted to have 1/2 bottles growing Group B Strep.
The patient had a CT Head that was without acute change,
Abdominal CT/Pelvis that revealed a number if incidental
findings (see below) but no evidence of active infection. The
patient has chest imaging with left lower lobe opacity that was
potentially concerning for aspiration. The patient additionally
underwent LP that was not consistent with bacterial or viral
meningitis. An MRI was performed which did not reveal any
evidence of osteomyelitis, discitis or epidural abscess. The
patient was initially covered broadly with CTX, Vancomycin,
Acyclovir, Ampicillin. The patient was seen by Infectious
Disease team and Vanc, Acyclovir and Amp discontinued with
ongoing therapy with CTX/Flagyl recommended for Group B Strep
bacteremia and possible aspiration in setting of poor dentition.
The patient underwent a TTE which did not reveal any
vegetations, presumed source of infection at this time is soft
tissue from lower extremities vs. oropharyngeal. Recommendation
was made to further pursue TEE although this was not pursued in
the ICU given report that murmur was known and clinical
improvement. The patient has been extubated. She was seen by
speech and swallow on [**2120-12-23**] and failed at that time for which
an NGT was placed for ongoing nutrition and med support.
.
The following is a summary of her course by problem:
.
# Fever/Group B strep Bacteremia/Aspiration Pneumonia: [**1-12**]
Blood Cultures grew pan sensitive GBS from admission.
Surveillance cxs negative. No evidence of epidural abscess,
osteomyelitis or discitis on MRI. Murmur on exam concerning for
endocarditis, but no peripheral manifestations of endocarditis.
TTE did not demonstrate vegetations. TTE was deemed to be an
adequate study to rule out vegetations, so a TEE was not
pursued. Other possible sources included skin entry, but
although skin lesions looked bad, there was no areas that looked
acutely cellulitic. Fever diminished and leukocytosis resolved
after admission. LP on admission to MICU WNL, and antibiotic
coverage for meningitis was stopped. CTX and Flagyl were
continued for aspiration and CAP, as well as coverage of GBS
bacteremia for a two week course. An ID consult was obtained and
agreed with this plan of action. Urine growing out Gram negative
rods, but under 1000 and UA clear so treatment was not pursed
for UTI. She finished all her antibiotic treatment today at the
time of discharge.
.
# Altered mental status/Psych: Most likely secondary to
infection as outlined above. Her mental status slowly improved.
.
#Observed Aspiration: Aspiration is likely in part secondary to
inability to attend to basic operations of swallowing. Failed S
and S evaluation [**12-23**] [**2-10**] to poor mental status. An NGT was
placed for tube feeding. Repeat speech and swallow eval showed
no aspiration, so NGT was pulled and pt was started on a pureed
diet with crushed pills and 1:1 supervision.
.
# Hypertension: The patient remained hypertensive on enalapril
20 po bid, HCTZ 25 po daily, metoprolol 50 tid and Valsartan 160
mg po tid in the ICU. We increased the dose of enalapril and
Valsartan to the max. Clonidine was added at time of transfer
from ICU to the floor, and her metoprolol was changed to
labetalol. These changes brought her SBP down from 180s-190s to
a range from 130 to 160. HCTZ was discontinued because of
hypercalcemia. Lasix, low dose of 20 MG PO, was used to target
both hypercalcemia and hypervolemia resulting from the use of
[**Last Name (un) **]/ACEIs. Diuretics are needed in this resistant hypertension.
However, her creatinine and her oral intake of fluids should be
monitored. Lasix can be held if she develop dehydration.
Secondary causes of hypertension were not pursued after
discussion with her NP and HCP.
.
# Urinary Retention: After her urinary catheter was d/c's upon
transfer from ICU to floor, she was noted to have PVR up to 900
cc x 2. Per her HCP, she may have had urinary retention at home
and no one new about it. On exam, there was stool in the rectal
vault, but mostly soft. She was started on lactulose TID until
several bowel movements to ensure impaction is not an issue. She
did have several bowel movements but continued to retain.
Straight cath were performed every 8 hours for 2 days, until
finally a Foley was replaced. UA was checked and was not
consistent with a UTI. In addition, the pt has been on Mellaril
for years, but per her current NP she has had no psychosis for
years. In agreement with her NP and given that Mellaril can
cause urinary retention, it was stopped (Celexa started). This
still did not help her retention. Bladder ultrasound showed
large fibroid tumor with no hydronephrosis. Most likely the pt
has diabetic cytopathy. fibroid tumor could be contributing as
well. She needs a urology follow up in the out patient. We will
attempt a voiding trial again before her final discharge. If she
fails, we will reinsert the Foley cath again. She had MRI of
spine to r/o out lesions with unremarkable results.
.
# Back pain: MRI of spine was negative for infection, and her
back pain resolved while she was here.
.
# Pancreatic lesions: 2 lesions noted on CT Torso that should be
followed up with MRI to r/o cystic tumor vs. pseudocyst. This
could be done in the out patient. Patient has
hyperparathyroidism. She may have pancreatic islet cell tumors
as well. This all could be part of MEN syndrome (MULTIPLE
ENDOCRINE NEOPLASMS).
.
# Fungal infection: Chronic candidal infection being treated as
outpatient. Topical antifungals were continued, and there was no
suspicion for disseminated fungemia because fevers resolved on
admission.
.
# Diabetes: On NPH and glipizide at home. Continued NPH and SSI
here. NPH was titrated based on insulin needs and altering po
intake.
.
# Metabolic Alkalosis: Her bicarb rose to 38 from 21. ABG
7.45/53/75, consistent with respiratory compensation for met.
alkalosis. She was given IVF in the case this was contraction
alkalosis and this improved. Her alkalosis may be related to
hypercalcemia as well. Primary hyperaldosteronism can cause
alkalosis and uncontrolled HTN.
.
# Psychiatric: Pt has diagnosis of schizophrenia. [**Name6 (MD) **] her NP,
[**Name (NI) 4457**] [**Name (NI) 10686**], pt has not had any psychosis over past several
years, but instead mostly OCD/anxiety. Given her urinary
retention and the fact that her Mellaril dose is not even an
antipsychotic dose (10 mg [**Hospital1 **]), it was stopped. Celexa was
started for her anxiety and OCD symptoms.
.
# Hyperparathyroidism/hypophosphatemia: Given her
hypophosphatemia, PTH level was checked. PTH was elevated at 88
with Ca in normal to high range. This is consistent with
Hyperparathyroidism. She had Vit D deficiency as well with low
VIT D level. She was given Vit D 50,000 U x1 and then started on
repletion. Elevated calcium levels may be due a thiazide as
well. This was stopped and she was placed on Lasix. Her PTH,
Phos, and calcium levels should be followed by her PCP. [**Name10 (NameIs) **]
Calcium on discharge was WNL. Sensipar can be used if she
develops progressive hypercalcemia.
.
# Hypothyroid: Continued home dose Levothyroxine
.
# Hyperlipidemia: Continued home Atorvastatin 40 mg PO DAILY
.
.
.
.
total discharge time 67 minutes.
Medications on Admission:
Lovastatin 40 mg q day
Metoprolol 50mg [**Hospital1 **]
Humulin 70/30 28 U [**Name (NI) 4962**], unclear PM dose
HCTZ 25 mg QDAY
Levoxyl 88 mcg QDAY
Diovan 160 mg daily
Naphcon 2 drops qday
ASA 81 mg once daily
Fentanyl patch 25 mg q72
Atractane
Flonase 1 spray once daily
Enalapril 20 mg daily
Tylenol 1 gram q 6
Gabapentin 100 mg [**Hospital1 **]
Prilosec 20 mg dialy
Glipizide 20 mg [**Hospital1 **]
Mellaril 10 mg [**Hospital1 **]
Ureasin
Clotrimazole to affected areas
Protonix 40 mg once a day
Nizatidine 150 mg [**Hospital1 **]
Oxycodone 5 mg TID prn
Discharge Medications:
1. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Naphazoline-Pheniramine 0.025-0.3 % Drops [**Hospital1 **]: Two (2) Drop
Ophthalmic DAILY (Daily).
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
4. Atorvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
7. Gabapentin 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Enalapril Maleate 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
10. Valsartan 80 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
11. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
12. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
13. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
14. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO TID (3 times a day).
15. Citalopram 20 mg Tablet [**Age over 90 **]: 0.5 Tablet PO DAILY (Daily).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Age over 90 **]: Three (3)
Tablet PO DAILY (Daily).
17. Clonidine 0.3 mg/24 hr Patch Weekly [**Age over 90 **]: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
18. Labetalol 200 mg Tablet [**Age over 90 **]: One (1) Tablet PO TID (3 times
a day).
19. Oxycodone 5 mg Tablet [**Age over 90 **]: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
20. Oxycodone 5 mg Tablet [**Age over 90 **]: 0.5 Tablet PO HS (at bedtime).
21. Furosemide 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
22. Insulin NPH Human Recomb 100 unit/mL Suspension [**Age over 90 **]: One (1)
36 units in AM and 34 units in PM. Subcutaneous twice a day: 36
units in AM and 34 units in PM. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Group B strep bacteremia
Hyperglycemia; Diabetes Mellitus Type II, uncontrolled
Aspiration Pneumonia
Urinary Retention
Hyperparathyroidism
Vitamin D defeciency
Discharge Condition:
stable
Discharge Instructions:
You were admitted with fever and altered mental status. You were
found to have a bacteria growing in your blood called group
strep B. You were also intubated initially in the intensive care
unit. A lumbar puncture showed no signs of meningitis. MRI of
your back showed no infections in your spine. An echocardiogram
(picture of your heart) was done and showed no evidence of
infection. You were treated with IV antibiotics for the bacteria
that had been growing in your blood.
.
.
Your blood pressure was very high while you were here. Some of
your blood pressure medications have been increased. You were
also started on 2 new blood pressure medications called
clonidine and labetolol.
.
You were found to have urinary retention. The reson is unclear
but we found mass in the uterus that is a large fibroid tumor.
you need to see a urologist at some point. The staff at the
rehab can attempt to discontinue the foley cath again for a
trial of urination. you have failed this trial here.
.
we found high calcium level related to HCTZ and
hyperparathyroidism. we also found Vitamin D defeceincy.
.
Call your doctor or return to the ER for any fevers, confusion,
chest pain, shortness of breath, or any other concerning
symptoms.
Followup Instructions:
She needs follow up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] or her NP [**First Name8 (NamePattern2) 4457**]
[**Last Name (NamePattern1) 10686**] of [**Hospital3 4262**].
.
have your PCP arrange [**Name Initial (PRE) **] urologist appointment if you continue to
require foley cath.
|
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icd9cm
|
[
[
[]
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[
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] |
icd9pcs
|
[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,237
| 169,162
|
37344
|
Discharge summary
|
report
|
Admission Date: [**2153-12-21**] Discharge Date: [**2153-12-24**]
Date of Birth: [**2073-7-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M s/p mechanical fall down 15 stairs. Pt stated it was dark in
the middle of the night and turned the wrong way and fell down
the stairs. Denies syncope/dizziness/chest pain at time of fall.
No LOC. Injuries found: right-sided flail ribs [**4-30**] with small
hemothorax.
.
Past Medical History:
HTN, CAD, hyperlipidemia, OA, glaucoma, cataracts
PSH: CAD stent, eye operations, hernia repair x 2
Family History:
Noncontributory
Pertinent Results:
[**2153-12-21**] 08:20PM GLUCOSE-135* UREA N-25* CREAT-1.0 SODIUM-139
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
[**2153-12-21**] 08:20PM CALCIUM-9.2 PHOSPHATE-4.4 MAGNESIUM-2.1
[**2153-12-21**] 08:20PM WBC-12.7* RBC-4.31* HGB-13.6* HCT-40.0 MCV-93
MCH-31.5 MCHC-33.9 RDW-13.8
[**2153-12-21**] 08:20PM NEUTS-86.4* LYMPHS-9.1* MONOS-4.1 EOS-0.3
BASOS-0.1
[**2153-12-21**] 08:20PM PLT COUNT-221
[**2153-12-21**] 08:20PM PT-12.3 PTT-28.0 INR(PT)-1.0
IMAGING:
[**12-21**] CXR: Left basilar atelectasis. Small b/l pleural
effusions.
Right anterior sixth rib fracture with adjacent subcutaneous
emphysema.
[**12-21**] CT Head: No acute intracranial injury. Prominent
extra-axial CSF space in the left frontotemporal region. Mild
chronic microvascular ischemic disease.
[**12-21**] CT C-spine: No acute cervical fx or malalignment.
[**12-21**] CT Chest/Abd/Pelv: R 4th, 5th rib segmental fx. R 6th rib
simple fx. [**Name (NI) **] PTX. [**Name (NI) **] pneumomediastinum. Mild SQ emphysema.
Moderate R hemothorax. No vascular injury or solid organ injury.
[**12-21**] Right Wrist/Forearm Xray: No acute fracture or
dislocation. Extensive degenerative changes within the first CMC
and triscaphe joint.
[**12-22**] CXR: Slight interval evolution of R ptx.
Brief Hospital Course:
He was admitted to the trauma service for respiratory monitoring
and pain management related to his rib fractures. He was
monitored in the Trauma ICU for 24 hours and transferred to the
regular nursing unit once deemed hemodynamically stable. Serial
chest xrays were followed and his last film on day of discharge
showed interval improvement of right pneumothorax.
His pain was controlled with Toradol, oral Dilaudid and Tylenol;
his home meds including ASA and prednisone (2.5) were restarted.
He was advanced to a regular diet for which he was able tolerate
and his Foley was removed.
Physical therapy was consulted and made recommendations for home
with services. He was discharged to home on hospital day 4 with
instructions for follow up.
Medications on Admission:
ASA 81, Atenolol 25', simvastatin 80', prednisone 2.5',
lisinopril 20', HCTZ 12.5'
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
QAM (once a day (in the morning)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
s/p Fall
Right rib fractures [**4-30**] with flail
Right hemo/pneumonthorax
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, ambulating
independently, pain adequately controlled, room air saturations
stable.
Discharge Instructions:
You were hospitalized following a fall where you sustained rib
fractures and an area of collapse on the right side of your lung
called a pneumothorax. These injuries did not require any
operations. You remained in the hospital for several days so
that we could monitor your breathing and oxygen saturations more
closely. These have all remained stable.
It is important that you continue to cough, deep breathe and use
the incentive spirometer 10x every hour that you are awake in
order to prevent developing pneumonia which is commonly
associated with rib fractures.
Return to the Emergency room if you develop any fevers, chills,
productive cough, shortness of breath, chest pain, nausea,
vomting, diarrhea and/or any other symptoms that are concerning
to you.
Resume your home medications prescribed to you by your primary
care providers.
Followup Instructions:
Follow up next week in clinic with Dr. [**Last Name (STitle) **], Trauma Surgery for
evaluation of your chest injuries. You will need a standing AP
end expirotory chest xray for this appointment. Call
[**Telephone/Fax (1) 2359**] for an appointment.
Follow up with your primary care doctor in the next 2 weeks; you
will need to call for an appointment.
Completed by:[**2154-5-8**]
|
[
"807.03",
"V45.82",
"414.01",
"733.00",
"401.9",
"E880.9",
"365.9",
"366.8",
"860.0",
"272.0",
"913.0",
"715.90",
"714.0",
"807.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3806, 3865
|
2107, 2854
|
324, 330
|
3984, 4119
|
812, 1447
|
5011, 5394
|
776, 793
|
2987, 3783
|
3886, 3963
|
2880, 2964
|
4143, 4988
|
276, 286
|
358, 636
|
1456, 2084
|
658, 760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,749
| 186,743
|
44591+58732+58738
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2175-8-7**] Discharge Date: [**2175-9-1**]
Date of Birth: [**2119-3-9**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 56-year-old
female who has a history of atrial fibrillation and is status
post mitral valve replacement with a mechanical valve
secondary to rheumatic heart disease and is on Coumadin. She
does have a history of multiple strokes including an old
frontal infarct and an old watershed infarct on the left side
with hemorrhage. She was admitted in [**2174-12-25**] with a
few days of severe headache but no aneurysm was found by
angiogram and she did have a history of a third nerve palsy.
Over the last six months, she has become increasingly
depressed and unable to participate in her physical therapy
and occupational therapy and was also noted to be
incontinent. She does have minimal ability to do activities
of daily living. She is unconcerned and speaks very little
at a time. She was started on Zoloft and Ritalin without
good effect.
A head CT done on [**2175-7-21**] showed an increase in size of
her ventricles. She is now admitted to the Neurology Service
for evaluation of possible hydrocephalus.
PAST MEDICAL HISTORY:
1. Status post mechanical mitral valve replacement for
rheumatic heart disease.
2. Atrial fibrillation.
3. Osteoporosis.
4. Possible seizure disorder.
5. History of strokes with no residual deficits.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Synthroid.
2. Lanoxin.
3. Lisinopril.
4. Methylphenidate.
5. Coreg.
6. Zoloft.
7. Tums.
8. Coumadin as needed to maintain an INR greater than 2.5.
9. Ditropan.
SOCIAL HISTORY: She lives with her husband in [**Name (NI) 3146**]. She
is Italian and immigrated to the United States over 30 years
ago and formerly worked as a medical assistant.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.4, heart rate 60, blood pressure 110/64, respirations 20,
02 saturation of 95% on room air. General: The patient was
a middle-aged woman sitting in a wheelchair in no apparent
distress. HEENT: PEERL, EOMI, and anicteric sclerae.
Lungs: Clear to auscultation bilaterally. Heart:
Irregularly/irregular. She has a soft grade II systolic
murmur at the base. Abdomen: Soft, nontender, nondistended
with positive bowel sounds. Extremities: No edema.
HOSPITAL COURSE: The patient was admitted and because her
INR was greater than 1.5 she remained in the hospital for
three days before her INR was less than 1.5 and a lumbar
puncture was able to be performed. Following her lumbar
puncture, she did have slight improvement in her symptoms,
specifically that her speech was greater quantity and she
seems to be quicker in her movements. She is also more
descriptive in her speech. It was felt that with this
improvement she may need to have a VP shunt placed and
Neurosurgery was consulted.
The Neurosurgical Team saw her and felt that a VP shunt would
likely be helpful; however, they did feel that she would be
at risk of significant problems given her need for
anticoagulation in lieu of her mechanical valve. The
decision was then made to proceed with the VP shunt. On
[**2175-8-12**], a right VP shunt was placed. The patient tolerated
the procedure and was transferred back to [**Hospital Ward Name 121**] II after
normal recovery in the PACU.
The patient continued to recover normally from her VP shunt
placement until the morning of [**2175-8-14**] when she
experienced worsening shortness of breath with a rapid heart
rate. A Cardiology consult was called and they felt that if
the chest x-ray was consistent with CHF she should be
diuresed with Lasix and possibly she could be started on IV
Diltiazem if her heart rate did not slow. At the time, her
heart rate was in the 120s, irregular. It was also suggested
that she be restarted on her heparin and Coumadin not only
for her mechanical valve but also for the atrial
fibrillation.
In light of her respiratory status and rapid rate, she was
transferred to the Medical Intensive Care Unit because of her
atrial fibrillation and rate increase to 140 with a blood
pressure drop to 80/palpable with a saturation of 90% on 100%
nonrebreather. A transthoracic echocardiogram was performed
which showed a left thrombus in the left atrium and no valve
motion. The patient was then transferred to the PACU where
she was intubated and a central line and arterial line were
placed.
She was then brought to the Operating Room for an urgent
procedure including a left atrial thrombectomy and a redo
sternotomy with a redo mitral valve replacement with a #25
Carbomedics mechanical valve. She was transferred to the
CRSU on dobutamine, milrinone, Levophed, Neo-Synephrine. She
was intubated, sedated, and had an intra-aortic balloon pump.
Throughout the operative night, she was weaned off her
propofol drip and remained calm and followed commands
appropriately. She did stay in a tachy-atrial fibrillation
with frequent ventricular ectopy in the overnight period.
Her balloon pump remained in place and she maintained a
cardiac index on milrinone of greater than 2.8 with a mixed
venous gas of 74% or greater.
Later on postoperative day number one, she was weaned from
her dobutamine and continued on the milrinone. She was noted
to have a decreasing platelet count and HIT antibody screen
was sent off. She was kept intubated during the stay partly
for small amounts of thick yellow secretions. She also was
started on an Amiodarone drip to help with her ventricular
ectopy and atrial fibrillation.
On her second postoperative day, she did remain intubated and
more of her drips were weaned off. By postoperative day
number three, she was extubated and her intra-aortic balloon
pump was discontinued without incident. It was noted that
her platelet count did continue to decrease and another HIT
screen was sent and she was found to have HIT antibody
positive. Therefore, her heparin drip was discontinued and
she was started on Argatroban as per the Hematology Service.
On the following day, [**2175-8-19**], her INR was elevated to
4.7 and this was thought to be secondary to the Argatroban
and this drip was held. A transthoracic echocardiogram was
performed and she was noted to have a functioning valve with
decreased biventricular dysfunction which was unchanged from
preoperatively.
On the evening of [**2175-8-20**], she was noted to have a
decrease in her level of consciousness and was noted to be
disoriented. She was sent for a CT scan of her head and was
found to have a small right frontal subdural hematoma. At
the same time, LFTs were sent and these were noted to be
elevated. At this point, her Argatroban was discontinued
completely and for anticoagulation, she was started on
.................... per Hematology Service.
On the following day, [**2175-8-21**], she received a GI
consult for her elevated LFTs. It was felt that this could
possibly be due to coincidence with the Argatroban but as
many of the medications that are cleared hepatically that
were stopped were. Also, at this point, she had a
self-limited run of V-fib and an EP consult was called for an
AICD placement secondary to a run of V-fib in lieu of her low
ejection fraction.
On [**2175-8-22**], she received a repeat head CT to evaluate
her subdural hematoma which showed no changes. At this
point, she remained stable and she remained in the CRSU while
awaiting AICD placement. The delay in this placement was
secondary to elevated INR for which on [**2175-8-27**], she
received 1 mg of vitamin K. By [**2175-8-28**], her INR was
less than 1.5 and she was able to go to the Electrophysiology
Laboratory for AICD placement.
She did receive a dose of Coumadin the night of [**2175-8-28**] and was started back on her .................... drip on
the morning of [**2175-8-29**]. Also, it was felt that her
Amiodarone would not be needed anymore and this was
discontinued. Following her AICD placement, she was
transferred to [**Hospital Ward Name 121**] II and started on Ancef for 48 hours and
then Keflex for 72 hours.
Following this, she was encouraged to increase her p.o.
intake. She worked aggressively with physical therapy and
continued to improve slowly. She did have her pacing wires
discontinued by having them cut at the skin and be left in
place.
On [**2175-8-31**], her INR was 2.7 and her
.................... drip was able to be discontinued. She
will receive 1 mg of Coumadin on the night prior to discharge
and if her INR continues to be greater than 2.5 and less than
3.5 on the morning of discharge then she will be able to be
discharged to a rehabilitation facility.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Stable with a
temperature of 97.9, heart rate 105, blood pressure 104/60,
respirations 18, room air saturation 96%. She appears in no
apparent distress. Heart: Irregularly/irregular. Lungs:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended. Extremities: No clubbing, cyanosis
or edema. Her sternal incision was clean, dry, and intact
and her sternum was stable. Her other wounds were clean,
dry, and intact and healing well.
DISCHARGE MEDICATIONS:
1. Percocet one to two tablets q. four to six hours p.r.n.
pain.
2. Aspirin 325 mg p.o. q.d.
3. Levothyroxine 88 micrograms one tablet p.o. q.d.
4. Zoloft 50 mg p.o. b.i.d.
5. Levetiracetam 500 mg p.o. b.i.d.
6. Diphenhydramine, 25 mg p.o. q.h.s. p.r.n.
7. Keflex 500 mg p.o. q. six hours times 48 hours.
8. Lopressor 25 mg p.o. b.i.d.
9. Captopril 6.25 mg p.o. t.i.d.
DISPOSITION: She will be discharged in good condition.
DISCHARGE DIAGNOSIS:
1. Status post VP shunt on [**2175-8-12**].
2. Status post redo mitral valve replacement with a #25
Carbomedics mechanical valve on [**2175-8-15**].
3. Heparin-induced thrombocytopenia.
4. Subdural hematoma on the right.
5. Status post AICD placement on [**2175-8-28**].
6. Atrial fibrillation.
7. Rheumatic heart disease.
8. Possible seizure disorder.
9. Status post cerebrovascular accidents without residuals.
10. Osteoporosis.
FOLLOW-UP: She should follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one week, with Dr. [**Last Name (STitle) **] in one to
two weeks and with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 95479**]
MEDQUIST36
D: [**2175-8-31**] 04:47
T: [**2175-8-31**] 17:04
JOB#: [**Job Number 95480**]
Name: [**Known lastname 6833**], [**Known firstname **] Unit No: [**Numeric Identifier 15125**]
Admission Date: [**2175-8-7**] Discharge Date: [**2175-9-12**]
Date of Birth: [**2119-3-9**] Sex: F
Service: CARDIOTHORACIC SURGERY
ADDENDUM: The addendum covers the period from [**2175-9-1**]
through [**2175-9-9**].
On the period of [**2175-9-1**] through [**2175-9-8**], the patient
continued to improve slowly. The issues during that period
included nutrition for which the patient was seen on a daily
basis from the Nutrition Service. Her regular diet was
supplemented with shakes and she was encouraged to eat small
frequent meals. By the end of this period, the Nutrition
Service was estimating that the patient was receiving 82% of
her protein and 100% of her caloric needs on a daily basis.
Additional issues included anticoagulation. The patient's
anticoagulation status during that period was adjusted to her
INR of 2.5 to 3.5. On several occasions, the patient's INR
dipped below 2.5. During these periods, she was maintained
on a Lepra infusion with a PTT greater than 60.
Over the period, the patient's Coumadin dose was titrated
from 1.5 to 3 mg on a daily basis. Four days prior to
discharge, the patient received 2 mg on [**2175-9-5**] and 3 mg on
[**2175-9-6**], 3 mg on [**2175-9-7**], and 2 mg on [**2175-9-8**]. Again, her
goal INR is 2.5 to 3.5.
The patient was also seen by the Heart Failure Service during
that time for persistent tachycardia. Recommendations
included beginning the patient on digoxin, discontinuing the
metoprolol, replacing this with carvedilol. She was begun
and titrated up to 12.5 mg of carvedilol b.i.d. Her digoxin
was 1.25 mg q.d. The captopril was also discontinued and
Zestril started at 2.5 mg p.o. q.h.s.
The final issue was increasing the patient's activity level.
She was seen by Physical Therapy on a daily basis and with
the assistance of physical therapy and the nursing staff, she
was able to walk over 400 feet three times a day.
Anemia: The patient's hematocrit on the day prior to
discharge was 25.2. At that point, she was transfused with 2
units of packed red blood cells.
DISCHARGE MEDICATIONS:
1. Coumadin 1.5 to 3 mg titrated to a goal INR of 2.5 to
3.5.
2. Levothyroxine 88 micrograms q.d.
3. Sertraline 50 mg b.i.d.
4. Levetiracetam 500 mg b.i.d.
5. Digoxin 0.125 mg q.d.
6. Carvedilol 12.5 mg b.i.d.
7. Zestril 2.5 mg q.d.
8. Percocet 5/325 one tablet q. six hours p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Status post ventriculoperitoneal shunt on [**2175-8-12**].
2. Status post re-do mitral valve replacement with a #25
Carbomedics mechanical valve on [**2175-8-15**].
3. Heparin-induced thrombocytopenia.
4. Subdural hematoma on the right.
5. Status post AICD placement on [**2175-8-28**].
6. Atrial fibrillation.
7. Rheumatic heart disease.
8. Possible seizure disorder.
9. Status post cerebrovascular accident without residuals.
10. Osteoporosis.
11. Anemia.
12. Heart failure with an estimated ejection fraction between
10-20%.
DISPOSITION: The patient is to be discharged to home with
visiting nurses. The patient is to have follow-up with Dr.
[**Last Name (STitle) **] in four weeks. The patient is to follow-up with Dr.
[**Last Name (STitle) **] in one to two weeks. The patient is to follow-up with
Dr. [**Last Name (STitle) **] in one to two weeks. Additionally, the patient
is to have her INR drawn by the VNA on [**Last Name (LF) 7290**], [**2175-9-10**] with the VNA to call Dr.[**Name (NI) 15126**] office to get a
Coumadin dose for [**Name (NI) 7290**]. The VNA will also check PT/INR per
instructions per Dr.[**Name (NI) 15126**] office following the draw on
[**Name (NI) 7290**] and call the results into Dr.[**Name (NI) 15126**] office
thereafter. Finally, the patient's PT/INR will be checked on
the day of discharge here at [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]
prior to discharge with Coumadin dose for Saturday, [**2175-9-9**] to be decided by the house staff and passed along to
the patient and family upon discharge.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Name8 (MD) 3027**]
MEDQUIST36
D: [**2175-9-8**] 05:34
T: [**2175-9-8**] 20:27
JOB#: [**Job Number 15127**]
Name: [**Known lastname 6833**], [**Known firstname **] Unit No: [**Numeric Identifier 15125**]
Admission Date: [**2175-8-7**] Discharge Date: [**2175-9-12**]
Date of Birth: [**2119-3-9**] Sex: F
Service:
ADDENDUM: The patient remained in the hospital through
[**2175-9-12**] secondary to elevated INR. On the morning of
her projected date of discharge, [**2175-9-9**], she had an
INR of 4.0 which peaked on [**2175-9-10**] at 4.2 and on the
day of discharge, [**2175-9-12**], her INR was 3.1. She will
be discharged home and instructed to take 1 mg of Coumadin on
the night of discharge and to have the Visiting Nurse
Services draw her PT/INR the following day with the results
to be called in to Dr.[**Name (NI) 15126**] office.
PHYSICAL EXAMINATION ON DISCHARGE: The lungs are clear to
auscultation with minimal bibasilar crackles. Heart:
Regular rate and rhythm. Abdomen: Soft, nontender,
nondistended. She has no peripheral edema. Her wounds are
healing well.
LABORATORY/RADIOLOGIC DATA: Discharge white count 6.3,
hematocrit 32.9%. Discharge INR is 3.1. Her sodium was 139,
potassium 4.0, chloride 104, C02 29, BUN 16, creatinine 0.7,
blood glucose of 110.
A chest x-ray done on [**2175-9-11**] showed small bilateral
pleural effusions with persistent mild left heart failure.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 188**], M.D. [**MD Number(1) 7588**]
Dictated By:[**Last Name (NamePattern4) 9828**]
MEDQUIST36
D: [**2175-9-12**] 12:00
T: [**2175-9-12**] 12:06
JOB#: [**Job Number 15138**]
|
[
"427.41",
"427.1",
"427.31",
"E878.1",
"996.61",
"428.0",
"331.3",
"287.4",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"38.91",
"96.71",
"37.61",
"38.93",
"03.31",
"37.94",
"02.34",
"35.24",
"39.61",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12901, 13192
|
13245, 15906
|
2418, 8732
|
1522, 1695
|
8755, 9229
|
15921, 16757
|
1915, 2400
|
1239, 1499
|
1712, 1900
|
13217, 13224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,107
| 154,877
|
24699
|
Discharge summary
|
report
|
Admission Date: [**2152-2-7**] Discharge Date: [**2152-2-16**]
Service: CARDIOTHORACIC
Allergies:
Furosemide
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain and dyspnea
Major Surgical or Invasive Procedure:
AVR/cabg x2 on [**2-8**] (21 mm CE pericardial valve, LIMA to LAD,
SVG to PDA)
History of Present Illness:
88 yo female with history of chest pain and increasing dyspnea
on exertion. Cath done in [**10-10**] showed 90% LAD, 85% RCA, 40 %
PDA, 40% CX , severe AS. Referred for surgery to Dr. [**Last Name (STitle) 1290**].
Past Medical History:
aortic stenosis
Hypercholesterolemia
Venous stasis changes with chr. LE edema
HTN
s/p bladder suspension
s/p colon resection secondary to cancer
Congestive heart failure
Urinary tract infection
Social History:
Lives alone. Never smoked. Rare alcohol use.
Family History:
Father with MI, child with CAD
Physical Exam:
NAD, Alert and oriented x3, anicteric
PERRL, EOMI, no LAD
S1 S2 RRR 3-4/6 SEM
CTAB
abd soft, NT, ND, + BS, no HSM
1+ BLE edema
no focal neuro deficits
RR 20 HR 62 124/46 T 97.9 RA sat 96%
147# (66.6 kg) 5'5"
Pertinent Results:
[**2152-2-7**] 07:25PM BLOOD PT-12.4 INR(PT)-1.0
[**2152-2-7**] 07:25PM BLOOD Plt Ct-261
[**2152-2-7**] 07:25PM BLOOD WBC-8.7 RBC-4.05* Hgb-13.1 Hct-35.9*
MCV-89 MCH-32.3* MCHC-36.3* RDW-13.2 Plt Ct-261
[**2152-2-7**] 07:25PM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-137
K-3.4 Cl-96 HCO3-30 AnGap-14
[**2152-2-7**] 07:25PM BLOOD ALT-33 AST-29 LD(LDH)-221 AlkPhos-101
TotBili-0.6
[**2152-2-7**] 07:25PM BLOOD Albumin-4.5
[**2152-2-7**] 07:25PM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE
CXR [**2152-2-7**] - No acute cardiopulmonary process
CXR [**2152-2-10**] - There are small bilateral pleural effusions and
bibasilar linear/discoid atelectases. No pneumothorax.
[**2152-2-8**] EKG - Sinus rhythm. The P-R interval is 0.18. Left
bundle-branch block. Compared to the previous tracing of [**2152-2-8**]
atrial ectopy is no longer recorded.
[**Last Name (NamePattern4) 4125**]ospital Course:
Ms. [**Known lastname 1726**] was admitted to the [**Hospital1 18**] on [**2152-2-7**] for surgical
management of her aortic stenosis and her coronary artery
disease. On [**2152-2-8**], she was taken to the operating room where
she underwent coronary artery bypass grafting to two vessels and
an aortic valve replacement utilizing a 21mm [**Last Name (un) **] [**Doctor Last Name **]
pericardial valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Ms. [**Known lastname 1726**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta
blockade and aspirin were resumed. On postoperative day two, she
was transferred to the cardiac surgical step down unit for
further recovery. Ms. [**Known lastname 1726**] was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
Acyclovir was started for a shingles flare. She was transfused
with a unit of packed red blood cells for postoperative anemia.
Iron and vitamin C supplement were also added. Ms. [**Known lastname 1726**]
continued to make steady progress and was discharged to
rehabilitation on postoperative day seven. She will follow-up
with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care
physician as an outpatient.
Medications on Admission:
ASA 81 mg daily
lovenox 70 mg [**Hospital1 **]
lipitor 20 mg daily
zantac 150 mg daily
HCTZ 50 mg daily
lopressor 75 mg QAM, 50 mg QPM
Discharge Medications:
1. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO twice a day for
5 days: Take for 5 days or until reach preoperative weight of
152. Then diuretic per cardiologist. .
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 1 days: Last dose [**2152-2-16**]. Capsule(s)
13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days: Take with bumex and stop when bumex
stopped. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25499**] Manor - [**Location (un) 47**]
Discharge Diagnosis:
s/p AVR/cabg x2
CHF
BLE varicosities
chr, LE edema/ stasis
colon CA/colectomy
hx of ? femoral pseudoaneurysm
HTN
Discharge Condition:
stable
Discharge Instructions:
1) [**Month (only) 116**] shower and pat wound dry.
2) No lotions, creams or powders to incisions until it has
healed.
3) No driving for one month.
4) No lifting greater than 10 pounds for 10 weeks.
5) Call for fevers greater then 100.5, redness or drainage from
wound.
6) Call if you gain more then 2 punds in 24 hours or 5 pounds in
1 week.
7) Take bumex and potassium for 5 days or until reach
preoperative weight of 147. Then take as instructed by
cardiologist.
8) Call with any questions or concerns.
Followup Instructions:
see Dr. [**Last Name (STitle) **] (primary care physician) in 2 weeks
see Dr. [**Last Name (STitle) 20222**] (cardiologist) in [**2-7**] weeks
see Dr. [**Last Name (STitle) 1290**] in the office in 4 weeks [**Telephone/Fax (1) 170**]
Call all providers for appointments
Completed by:[**2152-2-15**]
|
[
"272.4",
"396.8",
"V10.05",
"454.9",
"285.1",
"414.01",
"053.9",
"398.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"88.72",
"39.61",
"99.04",
"36.15",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
4932, 5010
|
246, 328
|
5166, 5175
|
1151, 1992
|
5729, 6030
|
869, 901
|
3593, 4909
|
5031, 5145
|
3433, 3570
|
5199, 5706
|
916, 1132
|
2043, 3407
|
184, 208
|
356, 572
|
594, 790
|
806, 853
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,431
| 177,037
|
724
|
Discharge summary
|
report
|
Admission Date: [**2148-4-8**] Discharge Date: [**2148-4-8**]
Date of Birth: [**2070-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia, s/p PEA arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 male nursing home resident, 2 admissions in past month, sent
to the ED from his NH with hypoxia and worsening L sided PNA.
He was found to have an O2 sat in the 70's while receiving 100%
oxygen by non-rebreather face mask. He had some ectopy for
which he received 75 mg of amiodraone. He was intubated and his
oxygen saturations remained low in the 60's, with PAO2 in the
40's on vent settings of AC 500 x 15, 10 peep. His CXR showed
worsened PNA with white out of the L lung and his labs returned
with + UTI and elevated lactate. He was started on Vanc and
Zosyn. He had a PEA arrest in the ED requiring CPR and an amp
of epinephrine. A spontaneous pulse returned. His blood
pressure was opiginally in the 90's, which is his [**Last Name (NamePattern1) 5348**], and
then improved to the low 100's after the epinephrine. His heart
rate was in the 120's. He was transferred to the MICU for
further care.
.
On arrival to the floor patient was persistantly hypoxic and was
noted to go in and out of V tach. His legal guardian was called
and was not available. His PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] was called
and it was established that the patient has recently had a legal
guardian appointed but that the legal guardian had not yet met
the patient. Per the PCP, [**Name10 (NameIs) **] was a plan in motion to go to
court to obtain a DNR/DNI order later this month. The patient
remained hypoxic and bradycardiac despite vent changes and
positioning manuvers. He received 4 mg and then 2 mg of
morphine to treat his respiratory distress. It was determined
that CPR was not indicated and the patient again had a PEA
arrest. He became asystolic and was pronounced dead at 12:55
PM. The medical examiner was called and they declined the case.
Past Medical History:
Recent hospitalization for hypoxia, hypotension of unknown
etiology
TIA in [**3-5**]
Schizophrenia, per PCP, [**Name Initial (NameIs) 5348**] AAOx1, verbally abusive
Depression
HTN
Dementia
R eye cataract
CAD, s/p CABG
Social History:
Nursing Home patient. Legal Guardian is [**Name (NI) 3608**] [**Name (NI) 4334**]. Patient
has a new guardian
Family History:
Non-contributory
Brief Hospital Course:
See HPI
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Urinary Tract Infection
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"427.1",
"294.8",
"507.0",
"112.2",
"799.02",
"401.9",
"366.9",
"427.89",
"V45.81",
"V12.54",
"414.00",
"311",
"427.5",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
2675, 2684
|
2643, 2652
|
344, 351
|
2762, 2772
|
2828, 2839
|
2602, 2620
|
2705, 2741
|
2796, 2805
|
281, 306
|
379, 2215
|
2237, 2457
|
2473, 2586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,727
| 156,979
|
47889
|
Discharge summary
|
report
|
Admission Date: [**2113-4-5**] Discharge Date: [**2113-4-17**]
Date of Birth: [**2056-6-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Iodine; Iodine Containing / Levofloxacin
Attending:[**Doctor First Name 16571**]
Chief Complaint:
Bilateral lower extremity and abdominal petechiae/ecchymoses,
recent onset right low back pain, and increasing weakness.
Major Surgical or Invasive Procedure:
Central line placement.
History of Present Illness:
The pt. is a 56 year-old female with metastatic breast cancer
who presented with bilateral lower extremity and abdominal
petechiae/ecchymoses, recent onset right low back pain, and
increasing weakness. The patient stated that she began to
develop low back pain on the right approximately seven days PTA.
She described the pain as dull in quality, constantly present,
and has not increased in severity since the time of onset.
There is no history of trauma to the area. She also noted
petechiae over her abdomen and lower extremities for the past
two days PTA. She has never experienced this in the past.
The pt. also complained of increasing weakness for the past week
PTA. She stated that she has found it difficult to get out of
bed and is able to walk without assistance. She noted that the
weakness has been progressive since onset. She added that the
weakness is generalized. The patient was seen by VNA who noticed
petechiae and advised the patient to see her oncologist who sent
her to the ED.
On review of systems, the patient denied recent fever, chills,
shortness of breath, chest pain or pressure, N/V/D,
constipation, abdominal pain, BRBPR, hematuria, dysuria,
arthralgias, or myalgias. She denied headache, visual changes,
sensory disturbances, imbalance. She did admit to diffuse
weakness, but not in any one particular area. She has had no
recent change in her appetite. She did admit to one episode of
lightheadedness on the morning of admission after urinating.
She did not experience LOC or fall. This has not recurred.
In the ED, the patient was found to have a low hematocrit and
platelet count. She received one liter of normal saline. In
addition, the patient was discovered to be hypoxemic to 89% on
room air. A V/Q scan was performed, as was a CT of the torso.
Oncologic Hx:
The pt. was first diagnosed with breast cancer in [**2101**] status
post right mastectomy, chemotherapy, radiation, autologous [**Year (4 digits) 500**]
marrow transplant in [**2104**]. She has metastatic lesions to [**Year (4 digits) 500**],
liver, and lungs. She has recently discontinued from Zometa
because of elevated creatinine, metastasis to the [**Year (4 digits) 500**], liver,
and lung. Hospitalized in [**2112-12-24**], with dizziness for five
days and slurred speech. MRI showed cerebellar and pituitary
lesions, which were felt to be metastasis from her breast
primary. Neurosurgery felt that given the patient's poor
prognosis, aggressive measures were not indicated. The patient
was started on Temodar with whole brain radiation. She did whole
brain radiation from [**2112-12-29**] to [**2113-1-18**].
Recently tapered down on her Decadron over concern for
developing myopathy. Repeat MRI on [**2113-3-13**] showed substantial
but incomplete regression of cerebellar and pituitary metastases
with leptomeningeal enhancement.
Past Medical History:
1. Metastatic breast cancer first diagnosed in [**2101**] status post
R mastectomy, chemotherapy, radiation, auto [**Year (4 digits) 500**] marrow
transplant in [**2104**], metastatic to [**Last Name (LF) 500**], [**First Name3 (LF) **], liver, and lungs.
s/p Xeloda toxicity, was recently stopped from Zometa [**1-25**]
elevated creatinine.
2. Anemia of chronic disease, baseline Hct in mid-30's
3. Status post TRAM flap
4. H/O LUE DVT in setting of PICC line, was not anticoagulated
5. VT arrest, felt [**1-25**] prolonged QT in setting of Levaquin
6. Herpes zoster
7. Polio: as child, no residual neurologic deficits
Social History:
She lives alone in [**Location (un) 538**], has part-time aid. She is a
graphic designer. Nonsmoker, occasional alcohol use, no other
drug use.
Family History:
Grandmother with breast cancer. Father with Parkinson's disease
and a stroke.
Physical Exam:
Vitals: T: 98.9F P: 103 R: 20 BP: 123/65 SaO2: 89% RA -> 94% on
3L NC
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic, RR, nl. S1S2, no M/R/G noted
Abdomen: soft, mimimal tenderness in LLQ without rebound or
guarding, normoactive bowel sounds, no masses or organomegaly
noted.
Back: No spinal or CVA tenderness, no Grey-[**Doctor Last Name **] sign
bilaterally
Extremities: Trace pitting edema of LE bilaterally, 2+ radial,
DP and PT pulses b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: scattered petechiae over abdomen and LE with small
ecchymoses located over LE bilaterally.
Rectal: guaiac negative per ED note
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk and tone throughout. No abnormal movements
noted.
Strength delt. [**Hospital1 **] tri wr ext io ip quad ham TA [**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
R: 5 5 5 5 5 4+ 5 5 5 5 5
L: 5 5 5 5 5 4 4 4 5 5 5
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, dysdiadochokinesia noted.
FNF and HKS WNL with subtle dysmetria bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was equivocal
bilaterally.
Pertinent Results:
Labs on Admission:
[**2113-4-5**] 12:40PM WBC-2.3* RBC-1.61*# HGB-5.8*# HCT-18.4*#
MCV-114*# MCH-36.2*# MCHC-31.7 RDW-19.2*
[**2113-4-5**] 12:40PM PLT SMR-VERY LOW PLT COUNT-44*
[**2113-4-5**] 12:40PM NEUTS-81* BANDS-4 LYMPHS-5* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-27*
[**2113-4-5**] 12:40PM PT-13.2 PTT-21.5* INR(PT)-1.1
[**2113-4-5**] 12:40PM GLUCOSE-87 UREA N-19 CREAT-1.1 SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2113-4-5**] 12:40PM D-DIMER-6812*
[**2113-4-5**] 03:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2113-4-5**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Micro data:
[**4-5**] blood cx 4/4 bottles no growth
[**4-9**] urine cx mixed flora
[**4-9**] blood cx 4/4 bottles positive MSSA
[**4-10**] blood cx 2/4 bottles positive MSSA
[**4-10**] fungal pending and one with MSSA
[**4-11**] blood cx 4/4 bottles no growth
[**4-12**] blood cx 4/4 bottles no growth
CT torso [**2113-4-5**]:
IMPRESSION:
1) Small scattered bilateral pulmonary nodules, which are less
prominent than in [**2109**].
2) Bilateral pleural effusions, greater on the right.
3) Innumerable hepatic metastasis.
4) Prominent retroperitoneal lymph nodes. No evidence of
retroperitoneal hematoma.
5) Likely right renal cyst.
6) Diffuse osseous metastatic disease.
V/Q scan [**2113-4-5**]:
Matched abnormalities at the right lung base are compatible with
the chest X-ray findings. Although there are no findings
particularly
suggestive of pulmonary embolism; pulmonary embolism in this
location cannot beruled out.
CXR [**2113-4-5**]:
1. Small bilateral pleural effusions.
2. Diffuse osseous metastatic disease
LE dopplers [**2113-4-9**]:
1. Occlusive thrombus in the right popliteal vein and
nonocclusive eccentric thrombus in the right superficial femoral
vein.
2. Findings suggestive of a nonocclusive thrombus in the left
superficial femoral vein. Left popliteal vein not evaluated.
CT abdomen/pelvis [**2113-4-10**]:
1) No evidence of functional bowel obstruction or perforation.
2) Unchanged appearance of innumerable hepatic metastases,
retroperitoneal lymph node enlargement, and stranding at the
root of the mesentery.
3) Diffuse subcutaneous edema and new small amounts of
indeterminant fluid in the pelvis, and thickening of the
gallbladder wall without focal inflammatory change. The
gallbladder is not overly distended, and there is no definite
evidence of acute cholecystitis. The findings are likely due to
fluid overload/third spacing, possibly secondary to
hypoalbunemia given the patient's underlying hepatic metastases.
4) Worsening bilateral lower lobe consolidations.
Echo [**2113-4-10**]:
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.
RUQ US [**2113-4-11**]: No evidence for cholecystitis, or intrahepatic
or extrahepatic biliary ductal dilatation.
CXR [**2113-4-12**]: Unchanged appearance of the chest with extensive
predominantly basilar opacities with probable bilateral pleural
effusions.
Brief Hospital Course:
56 year-old female with metastatic breast cancer who initially
presented on [**2113-4-5**] with c/o bilateral lower extremity and
abdominal petechiae/ecchymoses, about 7 day h/o right low back
pain, and increasing weakness. In the ED, the patient was found
to have a low hematocrit and platelet count. She received one
liter of normal saline. In addition, the patient was hypoxemic
with oxygen sats to 89% on room air. A V/Q scan was performed
and was indeterminate. CT of the torso showed progression of
metastatic disease in liver, RP, and abdomen. Her lower back
pain was thought to be associated with malignancy. Patient also
noted to have pancytopenia ( presumably related to BM
suppression/infiltration of [**Date Range 500**] marrow by mets). She was given
2 units pRBCs for HCT 20. On [**4-9**] she was noted to have
left-sided pleuritic CP. EKG showed sinus tachycardia. Cardiac
enzymes were negative. LENIs (patient with dye allergy) showed R
popliteal occlusive DVT, R SFV non-occlusive DVT and L SFV
non-occlusive DVT. Anti-coagulation was held in setting of brain
metastases and thrombocytopenia. Later that evening, she spiked
to 101.6. She also complained of increased abdominal pain and
was noted to have abdominal distension. KUB showed probable pSBO
with distended loops of small bowel. NGT was placed. At 9pm,
patient noted to have SBP 60-80's. She was given 2 L IVF (NS)
boluses and sent to MICU for further care. From 2pm on, patient
in sinus tachy 120-130's. Also UOP decreased to 100cc over 6hrs.
MICU course ([**4-10**] - [**4-11**]): Blood cultures 4/17 and [**4-10**] returned
+ for G+ cocci (6/6 bottles). The source of bacteremia was not
clear. Urine culture with mixed flora. The patient was started
on Vancomycin and Zosyn. When the cultures returned with G+
cocci Zosyn was discontinued. CXR did not show new infiltrate.
The patient had RIJ line but was bacteremic before line was
placed. Line was removed on [**2113-4-11**]. CT abd/pelvis were done and
did not confirm obstruction. Per discussion with attending, the
patient's code status was changed to DNR, DNI and the patient
was transferred back to the floor on [**4-11**].
The patient was continued on Vancomycin which was then changed
to Oxacillin when the sensitivities results came back. The
patient had an episode of acute onset of shortness of breath
associated with tachycardia, increased oxygen requirements that
was followed by anxiety/agitation that was controlled with
Ativan. Diagnostic investigations were limited by patient having
a h/o allergy to contrast. However, given clinical scenario and
known LE DVT, it was felt that the patient likely did have a PE.
Given the patient's poor prognosis, limited life expectancy,
known brain mets and pancytopenia, the goal of care were
readdressed with the family. The goals of care were changed to
comfort care only. The patient was started on Morphine drip and
Ativan for comfort. She was initially continued on her other
medications to increase the chance for her family to get in
town. While her cousins and other family members arrived,
antibiotics and other medications were discontinued. The patient
expired on [**2113-4-17**]. The family declined autopsy.
Medications on Admission:
-synthroid 75 mcg alt with 50 mcg daily
-DDAVP 50 mcg every other day
-Colace 100mg po tid
-Decadron 2 mg po bid
-Senna 2tabs po bid
-Protonix 40mg po bid
-reglan 40mg po bid
-dapsone 100mg po daily
-glipizide 2.5mg po once daily
-MVI 1tab po daily
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Metastatic breast cancer
2. Bacteremia
3. Deep vein thrombosis
Discharge Condition:
Expired
Completed by:[**2113-4-22**]
|
[
"284.8",
"V42.81",
"511.9",
"253.5",
"453.8",
"197.0",
"198.5",
"593.9",
"197.7",
"V10.3",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12617, 12632
|
9105, 12317
|
438, 463
|
12742, 12780
|
5876, 5881
|
4171, 4251
|
12653, 12721
|
12343, 12594
|
5242, 5857
|
4266, 5145
|
278, 400
|
491, 3349
|
5896, 9082
|
5160, 5225
|
3371, 3993
|
4009, 4155
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,481
| 114,544
|
48172
|
Discharge summary
|
report
|
Admission Date: [**2196-12-8**] Discharge Date: [**2196-12-14**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
cardiac catherization complicated by femoral artery bleed
Major Surgical or Invasive Procedure:
cardiac catherization
History of Present Illness:
89 yo female with history of severe CAD including CABG (SVG->OM,
SVG->RCA, LIMA->LAD) followed by artherectomy for SVG total
occlusion and recent cath ([**2196-11-21**]) for accelerating anigina
resulting in stent to 95% ostial LMCA lesion who as transferred
to [**Hospital1 18**] from [**Hospital **] hospital for recurrent chest burning times
2 days without ECG changes or +CE's. Decison made for repeat
diagnostic catherization to assess patency of LMCA stent; wich
showed patent stent however procedure complicated by commonn
femoral artery aneursym and brisk retroperitoneal bleed. Pt was
able to be succesfully [**Hospital 79818**] tamponade just proximal to the
aneurysm. During which Pt recieved two units PRBC and started
on dopamine gtt. Upon arrival to the CCU, Pt c/o left abd pain
and nausea. Denies any chest discomfort or anginal equivalent.
Past Medical History:
1) coronary artery disease
2) hypertension
3) dyslipidemia
4) hypothyroidism
5) dejenerative joint disease
6) h/o spinal stenosis - treated with epidural injections
7) COPD
8) hiatal hernia
9) s/p cholecystectomy
[**02**]) chronic renal insufficiency (crn. baseline 1.8)
Social History:
Quit smoking 30yrs ago. No alcohol. Lives alone in senior
houing. Ambulates with cane.
Family History:
mother - ca
father - MI at age 60
Physical Exam:
VS: 95.2, 69, 130/60 (MAP 80) on dopa 10
PE:
Lying in bed, comfortable
Anicteric, MMM, OP wnl
supple, JVP not appreciable
RRR, nl S1/S2, [**2-9**] SM
anteriorly CTA-B
obese, significant LLQ tendernes, ND, no rebound/guarding,
Hypoactive BS
stable left groin hematoma, FEM 2+
Ext without edema, warm and perfused, DP 1+ with R>L
A&O
Pertinent Results:
[**2196-12-9**] 12:33AM BLOOD Hct-37.3 Plt Ct-219
[**2196-12-9**] 04:09AM BLOOD WBC-16.1*# RBC-3.62* Hgb-11.5* Hct-34.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.2 Plt Ct-188
[**2196-12-9**] 09:30AM BLOOD Hct-26.2*
[**2196-12-9**] 09:29PM BLOOD Hct-28.9*
[**2196-12-10**] 06:00AM BLOOD WBC-7.5# RBC-3.17* Hgb-10.1* Hct-28.9*
MCV-91 MCH-31.9 MCHC-34.9 RDW-15.5 Plt Ct-133*
[**2196-12-10**] 12:48PM BLOOD Hct-34.0*
[**2196-12-10**] 05:29PM BLOOD Hct-34.7*
[**2196-12-11**] 05:30PM BLOOD WBC-8.3 RBC-3.59* Hgb-11.3* Hct-33.6*
MCV-94 MCH-31.5 MCHC-33.6 RDW-14.8 Plt Ct-129*
[**2196-12-9**] 12:33AM BLOOD Plt Ct-219
[**2196-12-10**] 06:00AM BLOOD Plt Ct-133*
[**2196-12-11**] 06:50AM BLOOD Plt Ct-113*
[**2196-12-11**] 05:30PM BLOOD Plt Ct-129*
[**2196-12-9**] 04:09AM BLOOD Glucose-170* UreaN-29* Creat-1.2* Na-142
K-4.3 Cl-112* HCO3-24 AnGap-10
[**2196-12-10**] 06:00AM BLOOD Glucose-76 UreaN-26* Creat-1.2* Na-144
K-3.9 Cl-112* HCO3-25 AnGap-11
[**2196-12-11**] 06:50AM BLOOD Glucose-79 UreaN-23* Creat-1.1 Na-141
K-3.9 Cl-111* HCO3-26 AnGap-8
[**2196-12-9**] 04:09AM BLOOD CK(CPK)-190*
[**2196-12-10**] 11:11PM BLOOD CK(CPK)-158*
[**2196-12-9**] 04:09AM BLOOD CK-MB-4 cTropnT-<0.01
[**2196-12-10**] 11:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2196-12-9**] 04:09AM BLOOD Calcium-7.4* Phos-3.2 Mg-1.8
[**2196-12-10**] 06:00AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8
[**2196-12-11**] 06:50AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.9
ECHO
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The aortic valve leaflets (3) are mildly thickened.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension
CCath
Brief Hospital Course:
89 yo female with extensive CAD s/p CABG and TO SVG and recent
95% LM lesion stented. Pt with recurrent angina like symptoms,
resulting in repeat diagnostic cath c/b FA bleed and aneurysm
requiring multiple blood transfusions and pressors.
1) CAD: Pt with extensive CAD s/p CABG and recent LMCA stent
who presented for repeat diagnostic catherization that showed
patent stent but complicated by common femoral artery bleed.
Given Pt's HD instability post-procedure, Pt was only continued
on [**Last Name (LF) **], [**First Name3 (LF) **] and Plavix; while holding BB. After
stabilization Pt was restarted on a BB. Pt will continue to be
managed medically. [**Hospital **] medical regimen consisting of
atenolol 12.5 mg qd (to be titrated up as outpatient as
tolerated), [**Hospital **] 325 qd, Plavix 75 mg qd times 9 months,
Simvastatin 10 mg qd. On transfer Pt recieving Cozaar 50 mg qd,
which was held during hospital stay due to HD instability; it
should be added back on as an outpatient when seen next week by
PCP if Pt continues to be stable.
2) Vascular: As above, Pt's catherization complicated by CFA
aneurysm and bleed. Initial external pressure unsuccesful in
stopping the bleed. Attempt to asses artery from the other
femoral artery unsuccessful given extensive artherosclerosis.
However, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 79818**] [**Last Name (un) **] from a the same FA was able to be
advanced to the aneursym with succesful tamponade. CT confirmed
significant retroperitoneal bleed. Pt did require 2 emergent
units of PRBC and the initiation of dopamine gtt given
hypotension. Pt aggresively hydrated overnight, with serial
Hcts being stable. Hct then began to trend down requiring an
additional 4 units of PRBC the following day. Hemodynamically
Pt improved and was weaned off dopamine. Vascular surgery
followed throughout and was integral in her management. Hct
stabilized once again; not requiring further transfusions or
exploratory surgery.
3) Pump: A p-MIBI earlier in the year with evidence of EF 72%.
Pt without history of CHF or LV dysfunction. Pt hypovelemic
secondary to RP bleed and was aggresively hydrated during
initial hospital days. [**Last Name (un) **] held due to this instability and BB
started at a lower dose. Out Pt cardiac regimen as above and
weill be titrated to maximum effect as outpatient given Pt's
ability to tolerate.
4) CRI: Pt with known CRI with a reported baseline Cr 1.8 prior
to admission. Initial Cr 2.1 however remaining Cr ranged from
1.2 - 1.1. Pt managed with mucomyst prior to and proceeding
catherization as well as receiving D5 with NaBicarb. No
evidence of renal failure or insufficiency during hospital stay.
Pt to be followed up as outpatient.
Medications on Admission:
[**Last Name (un) **] 81
Plavix 75
Cozaar 50
Indur 30
Zocor 30
Levoxyl 0.25
Iron
Protonix 40
Procrit times one
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 9 months.
Disp:*30 Tablet(s)* Refills:*6*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
5. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*6*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
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. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for indigestion.
13. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD with patent LMA stent
common femeral artery bleed
Discharge Condition:
good
Discharge Instructions:
please attend all follow up appointments as scheduled below. If
you are unable to, please call and reschedule as soon as
possible.
call your PCP or return to ED if persistent fever greater than
101.4, chest discomfort typical of your angina, abrupt shortness
of breath, persistent nausea and vomitting, inability to
tolerate food or liquid, severe weight gain, severe leg or
abdominal pain.
Followup Instructions:
please follow up with PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 133**])
Friday [**2196-12-23**] at 3:00, if unable to make please call and
rechedule.
Please make a follow up appointment to be seen by a cardiologist
of either Dr[**Initials (NamePattern4) 15012**] [**Last Name (NamePattern4) 7027**] or with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
can be reached at [**Telephone/Fax (1) 5003**].
|
[
"442.3",
"496",
"997.2",
"E879.0",
"998.11",
"401.9",
"584.9",
"414.01",
"V45.81",
"244.9",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"37.23",
"99.04",
"88.52",
"88.56",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
8346, 8418
|
3813, 6580
|
274, 297
|
8516, 8522
|
2008, 3790
|
8963, 9476
|
1604, 1639
|
6741, 8323
|
8439, 8495
|
6606, 6718
|
8546, 8940
|
1654, 1989
|
177, 236
|
325, 1189
|
1211, 1483
|
1499, 1588
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
907
| 149,649
|
43048+58582
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-8-12**] Discharge Date: [**2155-10-18**]
Date of Birth: [**2107-6-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Left leg wound
Major Surgical or Invasive Procedure:
Multiple debridements of left thigh ([**8-12**], [**8-19**], [**8-26**], [**9-3**])
Tracheostomy ([**8-19**])
Split thickness skin graft ([**10-6**])
History of Present Illness:
48yo Chinese F presented to ED with extensive necrotic L thigh
wound. Pain & rash started 2wks prior to admission as red dots
on leg. Pt treated with a topical compound made up from
centipedes & cow gallbladder. Leg subsequently became more
painful, edematous & weeping fluid. Pt very dizzy &
orthostatic, +chills.
Past Medical History:
type IV lupus nephritis
HTN
anemia
Social History:
Social History: Cantonese speaker who is a homemaker and lives
with husband and 2 children of 9 and 14 years. She denies
cigarrettes, drugs, alcohol.
Family History:
FH: sister with lupus and mother with HTN. No CAD, CA
Physical Exam:
VS - bp 61/36, hr 77, rr 22, sat 88% RA
Thin, pale, toxic-appearing, Asian female, oriented x 3, limited
English-speaking
HEENT - PERRLA/EOMI, facial rash
Chest - decreased breath sounds throughout
CV - tachy, RR, no murmur
Abd - soft, NT, ND
Ext - L thigh with sloughed skin & tense/weeping bullae, foul
odor, 1+ femoral pulse, 2+ peripheral edema, DP pulse
non-palpable but biphasic on u/s
Pertinent Results:
[**2155-8-12**] 01:56PM BLOOD WBC-4.6 RBC-2.06*# Hgb-6.1*# Hct-17.5*#
MCV-85 MCH-29.3 MCHC-34.6 RDW-16.7* Plt Ct-83*#
[**2155-8-12**] 01:56PM BLOOD Neuts-74* Bands-23* Lymphs-2* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2155-8-12**] 01:56PM BLOOD PT-11.8 PTT-89.1* INR(PT)-0.9
[**2155-8-12**] 04:50PM BLOOD Fibrino-104*#
[**2155-8-12**] 01:56PM BLOOD ESR-13
[**2155-8-12**] 01:56PM BLOOD Glucose-128* UreaN-115* Creat-5.9*#
Na-113* K-6.7* Cl-91* HCO3-12* AnGap-17
[**2155-8-12**] 01:56PM BLOOD ALT-14 AST-13 CK(CPK)-53 AlkPhos-43
Amylase-80 TotBili-0.4
[**2155-8-12**] 01:56PM BLOOD Lipase-137*
[**2155-8-12**] 05:49PM BLOOD CK-MB-3 cTropnT-<0.01
[**2155-8-12**] 01:56PM BLOOD Albumin-1.9* Calcium-9.7 Phos-7.2*#
Mg-2.5
[**2155-8-12**] 04:37PM BLOOD Type-ART pO2-216* pCO2-34* pH-7.03*
calHCO3-10* Base XS--21
[**2155-8-12**] 05:01PM BLOOD Glucose-153* Lactate-4.5* Na-129* K-4.9
Cl-105
[**2155-8-12**] 02:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2155-8-12**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Pt admitted to [**Hospital1 18**] via ED for sepsis & suspected necrotizing
fasciitis, taken to ED for debridement, transferred to SICU
intubated & on pressors. Consults placed to
dermatology/hematology/nephrology. Diagnosed with zoster &
started on acyclovir. Multiple antibiotics for superinfection of
L thigh wound. Pt was extubated on [**8-14**], but reintubated on [**8-15**]
for worsening respiratory distress & hypoxia. Pt developing
thrombocytopenia (requiring platelet transfusions), anemia
(requiring multiple transfusions), acute renal failure, melena.
TEE performed on [**8-15**] - no vegetations. Transferred to MICU
service on [**8-15**]. Pt underwent repeat debridement & tracheostomy
on [**8-19**], after which she returned to SICU. Pt diagnosed with CMV
viremia on [**8-20**] & started on ganciclovir. Pt started on GCSF
for leukopenia. Plastics consulted regarding future skin
grafting of wound & took pt to OR for debridement of wound and
placement of VAC dressing. Ophthamology consulted & noted no
evidence of retinitis. Transferred from SICU to floor on [**9-2**].
Pt taken to OR on [**9-3**] for planned split-thickness skin graft,
but decided intraoperatively that tissue was not ready for
grafting; debrided wound & placed VAC drain. Pt transferred
back to SICU on [**9-4**] due to profound anemia due to blood loss
from thigh with a confirmed hct of 8.4, hypotension - received
transfusion of 9 units PRBC plus FFP & platelets. Pt started on
Amicar upon recommendation of heme for ? bleeding dyscrasia,
although extensive work-up has failed to demonstrate a known
bleeding disorder - pt responded to amicar with significantly
decreased bleeding from wounds. Pt stabilized & returned to
floor. Chronic pain service consulted for L leg pain. Pt
developed a LLL pneumonia (Klebsiella) & ileus on [**9-23**], tx'd
with antibiotics. Pt noted to have significant metabolic
acidosis on [**9-24**], transferred back to SICU for monitoring -
placed on bicarb. Work-up resulted in diagnosis of renal
tubular acidosis, pt stabilized on bicarb infusion &
transitioned to PO bicitrate, returned to the floor on [**9-25**].
Pt to OR on [**10-6**] for a split thickness skin graft to her left
thigh from donor sites on right thigh & abdomen - surgery went
well w/o complication. Pt noted to have a UTI post-operatively
& tx'd with course of antibiotics. Trach d/c'd on [**10-13**]. Pt's
STSG with 70-80% take, continue dressing changes, cultures sent
from wound with ? of colonization - no signs of cellulitis or
systemic infection. Pt to rehab for continuing wound care until
fully healed & PT/OT to treat her severe deconditioning
following a 2 month hospitalization with multiple stays in the
ICU. D/C to rehab on [**2155-10-18**].
Medications on Admission:
Nifedipine, Atenolol, MVI, Lasix, Phoslo, Ferosol, Prednisone,
Cellcept, Zaroxylyn, Feosol
Discharge Medications:
1. Tizanidine HCl 2 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for muscle spasms.
Disp:*60 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*1 vial* Refills:*2*
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
Disp:*1800 ML(s)* Refills:*2*
10. Aminocaproic Acid 500 mg Tablet Sig: Eight (8) Tablet PO Q4H
(every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Chemical burn left thigh, s/p multiple debridements & skin
graft.
Renal tubular acidosis.
Lupus nephritis.
Urinary tract infection.
Bleeding dyscrasia, unspecified.
Blood loss anemia.
Disseminated varicella zoster.
CMV viremia.
Hypertension.
Discharge Condition:
Good, stable.
Discharge Instructions:
-[**Hospital1 **] dressing changes
-Daily physical therapy
-Medications per attached sheet
-Follow-up with Trauma Clnic in 2 weeks
-Follow-up with Nephrology in 2 weeks
-Needs electrolytes drawn at least twice weekly
Followup Instructions:
Follow-up in the Trauma Clinic in [**1-7**] weeks, call ([**Telephone/Fax (1) 376**]
for appointment & directions.
Follow-up with Nephrology, Dr. [**Last Name (STitle) 1366**], in 2 weeks, call ([**Telephone/Fax (1) 26815**] for appointment.
If any questions regarding hematology issues, please call Dr.
[**Last Name (STitle) 6160**] @ ([**Telephone/Fax (1) 31457**].
Name: [**Known lastname **],[**Known firstname **] [**Doctor Last Name **] Unit No: [**Numeric Identifier 14612**]
Admission Date: [**2155-8-12**] Discharge Date: [**2155-10-18**]
Date of Birth: [**2107-6-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 3524**]
Chief Complaint:
as noted before
Major Surgical or Invasive Procedure:
as noted before
Brief Hospital Course:
pt is being discharged on cipro for minor pseudomonal infection
of graft site
final sensitivities are not yet available; please contact [**Hospital1 **]
to obtain final sensitivities to tailor antibiosis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
as noted before
Discharge Condition:
as noted before
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2155-10-18**]
|
[
"948.00",
"289.9",
"286.9",
"996.69",
"560.1",
"482.0",
"958.4",
"V58.65",
"958.3",
"078.5",
"052.1",
"518.5",
"401.9",
"E924.1",
"285.1",
"584.5",
"710.0",
"945.36",
"583.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"86.69",
"00.11",
"96.72",
"88.72",
"99.05",
"96.6",
"99.07",
"99.15",
"86.22",
"99.04",
"38.93",
"31.1",
"38.91",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
8548, 8618
|
8320, 8525
|
8280, 8297
|
8677, 8852
|
1525, 2636
|
7470, 8208
|
1042, 1097
|
5563, 6811
|
8639, 8656
|
5448, 5540
|
7229, 7447
|
1112, 1506
|
8225, 8242
|
477, 797
|
819, 859
|
891, 1026
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,946
| 163,928
|
22629
|
Discharge summary
|
report
|
Admission Date: [**2122-1-29**] Discharge Date: [**2122-2-7**]
Date of Birth: [**2047-7-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Right ulna/radius fracture ORIF
2. Dual chamber ICD placement
History of Present Illness:
74-year-old male patient transferred from an OSH for a motor
vehicle collision. Patient was restrained driver who struck a
tree after ?LOC. Presents with diagnosis of RUE comminuted
fracture and left mandibular condyle fracture. Arrived in ED in
stable condition with GCS 15, splint to RUE. Patient had repeat
CT and xrays. RUE fracture was reduced by ortho under conscious
sedation. The patient was admitted to the trauma service for
further management.
Past Medical History:
1. CAD s/p CABG '[**11**]
2. St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**]
3. Hypothyroidism
4. Atrial fibrillation
5. Hypertension
Social History:
1. Wife in nursing home
2. Denies EtOH, tobacco abuse
Family History:
NC
Physical Exam:
On arrival
VS: T 101 BP 143/90 HR 82 RR 20 sat 100 RA
GEN: NAD, GCS 15
HEENT: PERLA, EOMI, L ear and nostril blood, OP clear, c-spine
non-tender, trachea midline, no JVD
CARDIO: S1S2, RRR
PULM: CTAB, no crepitus
[**Last Name (un) **]: soft, NT/ND, rectal: nl tone, guaiac neg
PELVIS: stable
ORTHO: RUE: obvious mid-forearm deformity, no tenting or open
wound, radial pulse palpable, TLS spine non-tender/no
deformities.
Pertinent Results:
[**2122-1-29**] 07:20PM WBC-12.5* RBC-3.58* HGB-11.3* HCT-33.4*
MCV-93 MCH-31.5 MCHC-33.7 RDW-15.4
[**2122-1-29**] 07:20PM PLT COUNT-164
[**2122-1-29**] 07:20PM [**Year/Month/Day **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-1-29**] 07:32PM GLUCOSE-130* LACTATE-1.6 NA+-138 K+-4.3
CL--101 TCO2-28
[**2122-1-29**] 07:20PM UREA N-36* CREAT-0.8
[**2122-1-29**] 07:20PM AMYLASE-68
[**2122-1-29**] 07:20PM CALCIUM-9.6 PHOSPHATE-3.0 MAGNESIUM-1.8
##
RUE xray [**2122-1-29**]:
RIGHT FOREARM, 2 VIEWS: Overlying cast obscures fine osseous
detail. Comminuted fractures through the midshafts of the right
radius and ulna are identified with anterior displacement of the
distal fracture fragments and approximately 1.5 cm of overlap
between the fracture fragments. Additionally, a comminuted
fracture through the distal radius is identified which is
minimally displaced. Possible fracture through the base of the
ulnar styloid is also likely present which is minimally
displaced.
##
CT face [**2122-1-29**]:
1) Fracture/dislocation of the left mandibular condyle.
2) Fracture of the anterior wall of the external auditory canal.
The bone fragments from this wall of the temporal bone are
located within the external auditory canal causing obstruction
of this canal.
##
Echo [**2122-1-30**]:
1. The left atrium is moderately dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed, EF 30%. Resting regional wall
motion abnormalities include inferior and inferolateral
akinesis.
4. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
5.The aortic root is mildly dilated. The ascending aorta is
moderately
dilated.
6. A bileaflet aortic valve prosthesis is present. The aortic
prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular
gradients.
7.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
8.There is no pericardial effusion.
##
CT head [**2122-1-30**]:
1) Small subarachnoid hemorrhage in the left temporal
lobe/sylvian fissure.
2) Increased soft tissue swelling over the left temporal region.
Brief Hospital Course:
NEURO: Mr. [**Known lastname **] was admitted to the TSICU for close observation
and hourly neurological checks. A repeat head CT performed on
[**2122-1-30**] revealed a small left insular SAH which remained stable.
He remained neurologically stable throughout his stay. The
neurosurgery team recommended tight BP control. This was
achieved with iv metoprolol and labetolol. No further issues or
concerns.
##
CARDIO: A cardiology consult was requested to assess for a
potential cardiac cause for the patient's MVC in light of the
frequent atrial and ventricular ectopies observed on telemetry
and his cardiac history. Also an echocardiogram revealed an EF
of 30% with severe global LV HK attributed to previous ischemia.
The patient received blood transfusions for a falling hematocrit
below 28. His coumadin was initially held. This was reinstituted
with a heparin drip immediately after his second orthopedic
procedure. On [**2-4**] the coumadin was held for placement of an ICD
which was done on [**2-5**]. The patient will follow up at the [**Hospital **]
clinic one week after the placement. The patient coumadin was
restarted the evening following the ICD placement. He had no
cardiac events and his hematocrit remained stable throughout. He
was discharged on toprol 50 qd, lisinopril 20 [**Last Name (LF) **], [**First Name3 (LF) **], coumadin
5 qd.
##
ORTHO: The patient's comminuted fracture of the right ulna and
radius was surgically corrected by the orthopedic surgeons on
HD#2. Secondary closure was preferred due to concerns for
compartment syndrome. He underwent fasciotomy closure on [**2122-2-3**].
The patient's arm was placed in a cast with recommendations for
non-weight bearing for three weeks. He will follow up in the
orthopedic clinic with Dr. [**Last Name (STitle) **] two weeks after discharge.
##
ORL: The patient's left mandibular condyle fracture was assessed
by the ENT service and recommendations were made to treat
conservatively with prophylactic antibiotic ear drops. The
patient had minor complaints of jaw movement limitations. He
initially failed a swallow test for reasons which could not be
identified and subsequently passed it and had no problems
feeding. Recommendations were also made to follow up with Dr.
[**Last Name (STitle) **] at the [**Hospital **] clinic. This issue remained stable and no
further concerns were identified. He was discharged on a soft
diet for 5 weeks.
##
DISPO: Physical therapy has been following the patient and
recommended transition to a rehabilitation facility. The patient
was transferred to an extended care facility in stable
condition.
Medications on Admission:
1. Atenolol 25
2. Coumadin 5
3. Lisinopril 20
4. [**Hospital **] 81
5. Synthroid 0.75
Discharge Medications:
1. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic TID
(3 times a day) for 3 days.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO 1X/WEEK
([**Doctor First Name **]).
Discharge Disposition:
Extended Care
Facility:
Seaview
Discharge Diagnosis:
1. Right ulna/radius fractures
2. Left mandibular condyle fracture
3. External auditory canal fracture
4. Cardiac dysrhythmia
Discharge Condition:
Good
Discharge Instructions:
you were hospitalized for a broken right forearm and a right
facial fracture. your broken arm was surgically repaired by the
orthopedic surgery team. your facial bone will heal and does not
require any surgery at this time. it is likely that your
accident was due to an irregular heart beat. a pacemaker was
placed in your chest to prevent against any further events.
please take your medications as prescribed. please call the
trauma clinic to schedule a follow up visit in [**6-7**] days
[**Telephone/Fax (1) 2359**]. also, call Dr. [**Last Name (STitle) **] at the [**Hospital **] clinic for a
follow up visit in [**11-30**] weeks [**Telephone/Fax (1) 41**]. you also have a
follow up appointment at the pacemaker clinic on [**2122-2-12**] at
11:30. please call the neurosurgery clinic to schedule a follow
up appointment in [**11-30**] weeks [**Telephone/Fax (1) 1669**].
Followup Instructions:
1. Trauma clinic in [**6-7**] days
2. [**Hospital **] clinic with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 41**] in [**11-30**]
weeksProvider: 3. DEVICE CLINIC Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2122-2-12**] 11:30
4. [**Hospital **] clinic in 2 weeks with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5499**]
5. [**Hospital 4695**] clinic in [**11-30**] weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2122-2-7**]
|
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"801.22",
"958.8",
"790.92",
"244.9",
"802.21",
"813.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"83.09",
"83.44",
"79.02",
"38.91",
"37.94",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
7566, 7600
|
3970, 6585
|
333, 399
|
7770, 7776
|
1614, 3947
|
8701, 9290
|
1154, 1158
|
6721, 7543
|
7621, 7749
|
6611, 6698
|
7800, 8678
|
1173, 1595
|
274, 295
|
427, 883
|
905, 1067
|
1083, 1138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,752
| 180,863
|
11008
|
Discharge summary
|
report
|
Admission Date: [**2104-11-6**] Discharge Date: [**2104-11-12**]
Date of Birth: [**2024-12-26**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Staph aureus bacteremia
Major Surgical or Invasive Procedure:
Placement of PICC line
History of Present Illness:
Mr. [**Known lastname 4643**] is a 79 yo male with hx of CAD, CHF, Afib, AS s/p
[**Known lastname 1291**], DM2 who presents from [**Hospital 100**] Rehab with staph bacteremia
[**11-4**] and [**11-5**] in need of a TEE. Patient was discharged from
[**Hospital1 18**] on [**2104-10-23**]. He was admitted at that time for increasing
dependence on the vent and was thought to have a VAP and
questionable CHF exacerbation. He was diuresed daily and treated
with levaquin for stenotrophomonas pna. Patient was also able to
be weaned from the vent and was discharged on trach mask with
50% FIO2. Patient then went to [**Hospital 100**] Rehab and during his
course there developed a klebsiella UTI and pna and is being
treated with cefaclor per sensitivities. Start date of cefaclor
appears to be [**11-1**]. On [**11-3**], patient spiked a fever to 101
rectally and blood cultures were drawn. He has been afebrile
since then. He also had a rising white count from 8-->13 noted
on [**11-4**] with diarrhea and was started on po vanco empirically.
Blood cultures from [**11-4**] and [**11-5**] are growing out staph aureus
and patient was sent to [**Hospital1 18**] for TEE since he has recent
history of [**Hospital1 1291**]. Also has stage 4 pressure ulcer on right foot
which could also be causing the fever and bacteremia as there is
a question of osteomyelitis.
Past Medical History:
Past Medical History:
CAD s/p CABG (LIMA -> LAD, SVG ->OM)
CHF EF 50%, mod AI
DM2 with neuropathy and retinopathy
aortic stenosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1291**], [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) **]
PVD s/p left bkpop-at with left cephalic vein [**6-6**], s/p left
fem-pedal [**5-6**] failed
osteoarthritis-back l/s spine
AFib with embolic CVA
cataracts s/p repair bilaterally
inguinal hernia s/p repair
retinopathy s/p OD laser
HIT positive
s/p trach
s/p PEG tube
Social History:
retired, married, living in [**Hospital 100**] Rehab.
Family History:
NC
Physical Exam:
vitals: T 99.2 ax P 95 BP 113/50 R 25 O2 sat 98% on 35% cool
mist neb
general: sleepy but interactive, NAD
heent: NCAT , anicteric, no injections, MMM, no oral lesions
pulm: fine bibasilar crackles
cv: irreg, irreg no mgr
abd: + bs, soft, nt, nd, peg in place- no erythema at site
extr: no cce, pedal pulses dopplerable
neuro: moves all extrem except left arm which had previous
plexus injury
Pertinent Results:
[**2104-11-6**] 09:05PM LACTATE-1.0
[**2104-11-6**] 06:37PM GLUCOSE-188* UREA N-75* CREAT-1.4* SODIUM-144
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-27 ANION GAP-11
[**2104-11-6**] 06:37PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-3.0*
[**2104-11-6**] 06:37PM CRP-192.2*
[**2104-11-6**] 06:37PM WBC-18.2* RBC-3.15* HGB-9.6* HCT-29.6* MCV-94
MCH-30.5 MCHC-32.5 RDW-16.5*
[**2104-11-6**] 06:37PM NEUTS-80.9* LYMPHS-13.6* MONOS-3.5 EOS-1.6
BASOS-0.3
[**2104-11-6**] 06:37PM PLT COUNT-266#
[**2104-11-6**] 06:37PM PT-18.1* PTT-41.8* INR(PT)-1.7*
[**2104-11-6**] 06:37PM SED RATE-124*
[**2104-11-6**] 09:05PM LACTATE-1.0
[**2104-11-9**] 06:58PM BLOOD WBC-17.9* RBC-3.14* Hgb-9.3* Hct-29.2*
MCV-93 MCH-29.6 MCHC-31.9 RDW-15.7* Plt Ct-246
[**2104-11-9**] 04:00AM BLOOD PT-25.2* PTT-47.2* INR(PT)-2.5*
[**2104-11-9**] 06:58PM BLOOD Glucose-67* UreaN-42* Creat-1.0 Na-146*
K-4.3 Cl-114* HCO3-26 AnGap-10
[**2104-11-9**] 06:58PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.7*
.
Micro:
[**2104-11-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S), GRAM NEGATIVE ROD #2}
[**2104-11-7**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2104-11-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2104-11-6**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL
[**2104-11-6**] URINE URINE CULTURE-FINAL
[**2104-11-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
[**2104-11-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PRELIMINARY {STAPH AUREUS COAG +}
.
Imaging:
CHEST (PORTABLE AP) [**2104-11-6**] 6:16 PM
IMPRESSION: AP chest compared to [**10-19**] through 18:
Extensive infiltrative pulmonary abnormality has improved since
[**10-23**] and previous moderate bilateral pleural effusions
have decreased, consistent with improving pulmonary edema.
Residual abnormality could represent pneumonia to some degree.
Moderate-to-severe enlargement of the cardiac silhouette due to
cardiomegaly and/or pericardial effusion is unchanged.
Tracheostomy tube is in standard placement. No pneumothorax or
mediastinal widening.
.
FOOT 2 VIEWS PORT RIGHT [**2104-11-7**] 10:16 AM
IMPRESSION: No radiographic evidence of osteomyelitis.
.
TEE [**2104-11-7**]:
A small secundum atrial septal defect/stretched PFO is seen with
color Doppler (cine loop #60). The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. There is
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function appears preserved. There are simple atheroma
in the ascending aorta, arch and descending aorta. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis (but may be
slightly UNDERestimated on this study). No masses or vegetations
are seen on the aortic valve. A paravalvular jet of moderate
(2+) aortic regurgitation is seen. The jet emanates from the
posterolateral aspect of the aortic annulus, adjacent to the
left sinus of Valsalva. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen. Moderate paravalvular
prosthetic aortic regurgitation.
Brief Hospital Course:
A/P: 79 yo with CAD, CHF, DM2 who presents with bacteremia
growing staph.
.
#. Staph bacteremia- Patient had positive blood cultures with
coag + Staph at rehab and GPC in one BCx bottle at [**Hospital1 18**]. TEE
was negative for endocarditis. GS from foot decub showed coag
negative staph and diptheriae (likely contaminate). He continued
to have high white count despite treatment, though he was never
febrile during his stay. Surveillance blood cultures taken after
[**2104-11-6**] showed no growth several days after drawn. He was
continued on vancomycin IV throughout his stay. Sensitivities
of the original positive blood culture showed MRSA that was
sensitive to Bactrim. Per vascular, the decision was made to
treat the infection as if he has osteomyelitis. The plan is to
continue IV vancomycin for a total of 6 weeks to end, last day
[**2104-12-10**].
.
#. Klebsiella UTI- diagnosed at rehab and treated with cefaclor
for 7 days before admission. He was continued on ceftriaxone
(cefaclor is not formulary at [**Hospital1 18**], though sensitivies from
rehab showed that it was sensitive to ceftriaxone). Urine
culture from [**11-6**] negative. The plan is to continue the
ceftriaxone for a total of 14 days of cefaclor/ceftriaxone, last
day [**11-19**].
.
#. Afib: Patient has chronic afib and had periods of RVR on [**11-8**]
which were controlled with his usual scheduled dose of
metoprolol. Patient is anticoagulated with coumadin. Will check
coags on admission. His INR was therapeutic during his stay and
his rate was controlled with his home metoprolol dose. He was
monitored on telemetry.
.
#. Ulcer right foot- Patient has a stage 2 and stage 4 pressure
ulcer on right foot, one on his heel and the other on the sole
of his foot. Podiatry and vascular were consulted. GS from foot
sole decub grew coag negative staph and diptheriae (likely
contaminate). Foot xray showing no evidence of osteomyelitis,
but should be treated as if he has osteo per vascular for 6
weeks. Vasculary surgery also reccomended against chemical or
surgical debridement. He was continued on IV vancomycin and
micro data as above.
.
#. Positive sputum- patient appears to be colonized with
stenotrophomonas as he has previous sputum cultures showing
stenotrophomonas. His CXR was not worsening and he was afebrile.
He was not treated specifically for pna given the likelihood of
the stenotrophomonas being a colonizer.
.
#. Diarrhea- On empiric flagyl for c dif as patient is on
antibiotics and had diarrhea at OSH. C dif was pending at rehab
at the time of admission. Started on po vanco empirically as
well at rehab. This could also be the source of his rising WBC,
though he is currently without diarrhea. Here, he has had C.diff
negative x2. He was continued on Flagyl and po vanco
empirically. He should have 7 more days of both Flagyl and PO
Vanc, last day [**11-19**].
.
#. AoCRF- He had a small increase in his renal failure above
baseline. It improved during his stay.
.
#. CAD- stable. No current ischemic symptoms. Ekg is unchanged
from prior.
He was continued on asa, simvastatin, metoprolol
.
#. CHF: ECHO as above. Patient had EF of 50%. On exam, patient
appeared euvolemic. No further intervention was done.
.
#. DM2: He was continued on glargine and covered with humalog
sliding scale.
.
#. Hyperkalemia: He had a potassium level of 146 on [**11-9**] which
was treated by increasing his free water flushes in his tube
feeds.
.
#. FEN: He was given tube feeds- nutren renal at 35 cc/hr and
35g beneprotein with water flushes.
.
#. PPx: lansoprazole, no heparin products given history of HIT,
venodynes, bowel regimen
.
#. Code: He was determined to be DNR/DNI by family discussion
.
#. Access: He has very poor access. He was given a PICC by IR
on [**11-10**].
.
#. Communication: HCP is daughter [**Name (NI) **] [**Name (NI) 10132**] [**Telephone/Fax (1) 35665**] and
wife [**Name (NI) **] [**Name (NI) 4643**] at [**Telephone/Fax (1) 35666**]
Medications on Admission:
1. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Aspirin 81 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical 12 HOURS ON AND 12
HOURS OFF () as needed for to back.
5. Ferrous Sulfate 325 mg qd
6. Duonebs q6 hours
7. Prilosec 20 mg qd
9. Insulin Glargine 100 unit/mL Solution [**Telephone/Fax (1) **]: Fifty (50) units
Subcutaneous once a day.
10. Novolog insulin sliding scale as directed by rehab physican
11. Warfarin 2.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO HS (at
bedtime).
12. Hydralazine 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q6H (every 6
hours).
13. Quetiapine 50 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. Metoprolol Tartrate 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
three times a day.
15. Isosorbide Dinitrate 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
(3 times a day).
16. senna and colace
17. Mucomyst nebs q 8 hours
18. cefaclor 250 mg q8 hours started on [**11-1**]
19. vancomycin 250 mg po QID started [**11-4**]
20. vancomycin 1 g IV q24 started on [**11-5**]
21. pramiprexole 0.125 mg po qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Month/Day (4) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (4) **]:
One (1) Adhesive Patch, Medicated Topical QD (): do not leave on
for longer than 12 hours per day.
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (4) **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution [**Month/Day (4) **]: One (1) Inhalation
Q6H (every 6 hours).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
8. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2
times a day).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H
(every 8 hours).
12. Isosorbide Dinitrate 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
13. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
14. insulin
per previous regimen
15. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
16. oral vancomycin
Vancomycin Oral Liquid 125 mg PO Q6H
17. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID:PRN.
18. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Hospital1 **]:
One (1) Intravenous Q24H (every 24 hours).
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
Intravenous Q36H (every 36 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 102**] center
Discharge Diagnosis:
Primary:
MRSA bacteremia
stage 2 and 4 foot ulcers on his right foot
Secondary:
CAD s/p CABG (LIMA -> LAD, SVG ->OM)
CHF EF 50%, mod AI
DM2 with neuropathy and retinopathy
aortic stenosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1291**], [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) **]
PVD s/p left bkpop-at with left cephalic vein [**6-6**], s/p left
fem-pedal [**5-6**] failed
osteoarthritis-back l/s spine
AFib with embolic CVA
cataracts s/p repair bilaterally
inguinal hernia s/p repair
retinopathy s/p OD laser
HIT positive
s/p trach
s/p PEG tube
Discharge Condition:
good, afebrile
Discharge Instructions:
Mr. [**Known lastname 4643**] was treated at [**Hospital1 18**] for MRSA bacteremia and right
foot ulcers stage 2 and 4. He was started on a six week course
of IV vancomycin for the bacteremia on [**11-5**]. He had one
positive blood culture while here. He was seen by vascular and
podiatry and no debridement was undertaken, but it was felt that
he should be treated as if he had osteomyelitis (despite
negative foot xray) since the ulcer on the sole of his foot is
deep to bone. He also had a negative TEE to address the
possibility of endocarditis.
His vancomycin trough levels should be followed as his level was
too high on the morning of [**2104-11-11**] so his dosing was decreased
to 1g q 36 hours.
He was changed from cefoclor to ceftriaxone for his klebsiella
uti as cefoclor is not on the [**Hospital1 18**] formulary. He should get a
total of 14 days of treatment with the cefoclor/ceftriaxone.
He was continued on metoprolol for his afib, which other than
one brief episode of RVR which resolved with his regular dose of
metoprolol, he was well controlled.
He was continued on his PO vancomycin for cdiff coverage which
was started before he was admitted. We were unable to check him
for cdiff while in the ICU.
He should be returned to the ED if he becomes febrile or septic
or if he has any other concerning symptoms.
Followup Instructions:
He should follow up with his primary care physician in the next
7 to 10 days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"041.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13896, 13949
|
6434, 10401
|
308, 332
|
14619, 14636
|
2830, 6411
|
16028, 16245
|
2398, 2402
|
11906, 13873
|
13970, 14598
|
10427, 11883
|
14660, 16005
|
2417, 2811
|
245, 270
|
360, 1721
|
1765, 2311
|
2327, 2382
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,221
| 139,276
|
20169
|
Discharge summary
|
report
|
Admission Date: [**2136-10-30**] Discharge Date: [**2136-11-13**]
Date of Birth: [**2061-6-2**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
gentleman who seen for a screening physical examination where
he was found to have a carotid bruit.
Evaluation by carotid ultrasound revealed an 80% to 99% right
internal carotid artery stenosis and 60% to 79% left internal
carotid artery stenosis. The patient was referred for
carotid endarterectomy. As part of the preoperative workup,
the patient underwent an exercise tolerance test which was
markedly positive.
The patient subsequently underwent a cardiac catheterization
which showed a left ventricular ejection fraction of 70%, 70%
left anterior descending artery stenosis, 60% stenosis of the
first diagonal, 80% stenosis of the left posterior descending
artery, and 70% proximal stenosis of the right coronary
artery.
The patient was transferred to the [**Hospital1 190**] for coronary artery bypass grafting and
treatment of the significant right internal carotid artery
stenosis.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Hematuria.
MEDICATIONS ON ADMISSION: (Preoperative medications
included)
1. Atenolol 50 mg by mouth once per day.
2. Zocor 20 mg by mouth once per day.
3. Hydrochlorothiazide 25 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY:
PERTINENT LABORATORY VALUES ON PRESENTATION:
PERTINENT LABORATORY VALUES ON PRESENTATION:
CONCISE SUMMARY OF HOSPITAL COURSE: Neurology was consulted
on the patient for aide and management of the internal
carotid artery stenosis. They recommended repeating the
carotid ultrasound which showed right internal carotid artery
stenosis of 80% to 99% and left internal carotid artery
narrowing of 40% to 59%.
On [**11-1**], the patient underwent a repeat magnetic
resonance imaging/magnetic resonance angiography of his head
which showed no intracranial stenosis.
On [**11-2**], the patient underwent a percutaneous
transluminal coronary angioplasty to the right internal
carotid artery by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. Status post
procedure, the patient was transferred to the Coronary Care
Unit for blood pressure monitoring and frequent neurologic
checks. The patient required a Neo-Synephrine infusion to
maintain an adequate systolic blood pressure. The patient
required a Neo-Synephrine infusion as the patient's blood
pressure off the Neo-Synephrine was 90 systolically which was
not responsive to fluid boluses.
On [**11-6**], as the patient continued to require
Neo-Synephrine and his hematocrit was 27, he was transfused
two units of packed red blood cells. By the evening of
[**11-6**], the patient had been weaned off the
Neo-Synephrine.
The patient was taken to the operating room on [**11-7**]
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for a coronary artery bypass graft
times three with left internal mammary artery to left
anterior descending artery, saphenous vein graft to second
diagonal, and saphenous vein graft to third diagonal.
The patient was transferred to the Coronary Intensive Care
Unit in stable condition. The patient required a
Neo-Synephrine drip and propofol on admission to the
Intensive Care Unit. The patient was extubated from
mechanical ventilation on the morning on postoperative day
one. The patient required significant amounts of
Neo-Synephrine to maintain a systolic blood pressure of
greater than 120; which was the recommendation per Neurology.
Postoperatively, the patient was restarted on his Plavix. On
postoperative day two, the patient's chest tubes were
removed. The patient began ambulating in the Intensive Care
Unit with occasional complaints of orthostasis. The patient
continued to require Neo-Synephrine.
However, by postoperative day four, the Neo-Synephrine was
weaned off with adequate blood pressures. On postoperative
day five, the patient was transferred from the Intensive Care
Unit to the regular part of the hospital.
On postoperative day five, the patient continued to remain
hemodynamically stable. The patient worked with Physical
Therapy. By postoperative day six, the patient was able to
ambulate greater than 500 feet and climb one flight of stairs
while remaining hemodynamically stable and without requiring
oxygen. The patient was cleared for discharge to home.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's
temperature maximum was 98.7 degrees Fahrenheit, his heart
rate was 80 (in sinus rhythm), his blood pressure was 115/69,
his respiratory rate was 15, and his oxygen saturation was
94% on room air. The patient's weight on [**11-13**] was 69
kilograms. Preoperatively, the patient weighted 59
kilograms. Neurologically, the patient was alert, awake, and
oriented times three. Strength in the upper and lower
extremities were equal bilaterally. The patient's neurologic
examination was nonfocal. He was ambulating in the hallway
without difficulty. Cardiovascular examination revealed the
heart was regular in rate and rhythm. No murmurs or rubs.
Breath sounds were clear bilaterally; decreased at the bases.
Abdominal examination revealed positive bowel sounds. The
abdomen was soft, nontender, and nondistended. The patient
was tolerating a regular diet and had normal bowel movements.
The sternal incision revealed Steri-Strips were intact. The
wound was open to air. There was no erythema of drainage.
The sternum was stable. The right lower extremity vein
harvest site had 1+ pitting edema. The Steri-Strips were
intact. There was no erythema and no drainage. The left
lower extremity had trace edema. Both extremities were warm
and well perfused.
PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's
white blood cell count was 9.2, his hematocrit was 35.4, and
his platelet count was 230. Sodium was 137, potassium was
4.6, chloride was 102, bicarbonate was 28, blood urea
nitrogen was 19, creatinine was 0.9, and his blood glucose
was 95.
PERTINENT RADIOLOGY/IMAGING PRIOR TO DISCHARGE: A chest
x-ray on [**11-13**] revealed resolution of a previous
right-sided pleural effusion and left lower lobe atelectasis.
No pneumothorax. No infiltrate.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Significant right internal carotid artery stenosis.
4. Status post right internal carotid artery stent.
5. Hypertension.
6. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg by mouth once per day (times seven days).
2. Potassium chloride 20 mEq by mouth once per day (times
seven days).
3. Colace 100 mg by mouth twice per day.
4. Zantac 150 mg by mouth twice per day.
5. Enteric-coated aspirin 325 mg by mouth every day.
6. Percocet 5/325-mg tablets one to two tablets by mouth
q.6h. as needed.
7. Plavix 75 mg by mouth once per day (which the patient was
to continue for the rest of his life).
8. Lopressor 12.5 mg by mouth twice per day.
9. Zocor 20 mg by mouth once per day.
DISCHARGE STATUS: The patient's discharge status was to
home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in five to six weeks.
2. The patient was instructed to follow up with his
cardiologist (Dr. [**Last Name (STitle) 54223**] in one to two weeks.
3. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 54224**] in one to two weeks.
4. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **] on [**2137-2-12**] with an initial carotid
ultrasound appointment in the Department of Radiology
scheduled for 10 a.m. and an appointment with Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **] at noon.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2136-11-13**] 17:58
T: [**2136-11-13**] 18:26
JOB#: [**Job Number 54225**]
|
[
"414.01",
"401.9",
"458.29",
"272.0",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"36.12",
"36.15",
"39.50",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6370, 6599
|
6625, 7229
|
1216, 1466
|
7313, 8367
|
1612, 4544
|
7244, 7280
|
5885, 6349
|
181, 1107
|
1129, 1189
|
1483, 1583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,694
| 163,309
|
8913
|
Discharge summary
|
report
|
Admission Date: [**2174-6-25**] Discharge Date: [**2174-7-7**]
Date of Birth: [**2138-11-7**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2174-6-25**] Pediatric en bloc renal transplant,
right iliac fossa.
History of Present Illness:
35 M with h/o esrd of unknown etiology. He had a living donor
transplant in [**2158**] from his aunt at [**Name (NI) 112**] that was complicated by
early acute rejection and ultimately lost in three years due to
chronic rejection. He went back on dialysis in [**2161**] and had a AV
fistula placement and nephrectomy shortly thereafter both at
[**Hospital1 112**]. He has had 2 revisions of his avf with the most recent
occurring in [**2173-5-18**] by Dr. [**First Name (STitle) **] at [**Hospital1 18**] where a portion
of the fistula was resected and a graft was placed in his left
forearm. His last HD was yesterday and has no other lines for
HD. He is here today for cadaveric renal transplant.
Past Medical History:
PMH: ESRD, HTN
PSH: renal transplant [**2158**]
renal graft nephrectomy
avf [**2161**]
avg
[**2174-6-25**] Pediatric en bloc renal transplant,
right iliac fossa.
Social History:
runs a restaurant, lives with his daughter, her mother and her
other daughter. non-[**Name2 (NI) 1818**]. drinks rarely and no illegal drugs
Family History:
both parents have DM. His sisters are healthy and his aunt
(previous donor, recently had CA). Grandparents have DM.
Physical Exam:
97 78 137/87 18 95%RA wt 80.2, height 170 cm
A&O
lungs clear
cor RRR, no murmur
abd soft, nontender, non-distended with striae. well healed LLQ
scar from his transplant nephrectomy and no organomegaly
ext no edema, 2+ pulses. L arm avf with thrill.
Pertinent Results:
[**2174-7-7**] 06:00AM BLOOD WBC-6.4 RBC-3.33* Hgb-9.9* Hct-29.0*
MCV-87 MCH-29.8 MCHC-34.3 RDW-17.1* Plt Ct-186
[**2174-7-6**] 06:15AM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1
[**2174-7-7**] 06:00AM BLOOD Glucose-107* UreaN-50* Creat-5.8* Na-142
K-5.6* Cl-115* HCO3-16* AnGap-17
[**2174-6-27**] 05:21AM BLOOD ALT-6 AST-26 AlkPhos-74 Amylase-56
TotBili-0.1
[**2174-7-7**] 06:00AM BLOOD Calcium-10.4* Phos-5.3* Mg-1.6
[**2174-7-6**] 06:15AM BLOOD tacroFK-10.7
Brief Hospital Course:
On [**2174-6-25**], he underwent pediatric en bloc renal transplant,right
iliac fossa. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Induction
immunosuppession consisting of ATG,Solumedrol and cellcept was
given. The pediatric ureters were anastomosed side-to-side then
anastomosed to the ureter of the recipient over a 6-French
double-J stent. At the
completion of the procedure, kidneys were secured to the
sidewall allowing the peritoneal contents to secure the kidneys
without torsion. A 19 [**Doctor Last Name 406**]
drain was placed. The kidneys pinked up and made urine.
Ultrasound the next day showed normal vascular flow, no hydro
and no perinephric fluid collection. Ureters were not
identified, but there was no evidence of hydroureters. Postop,
urine output decreased some. Creatinine did not drop initially.
BP (180/110) was elevated requiring antihypertensives to keep BP
lower. His home meds were resumed in modified doses(minoxidil
2.5, amlodipine 10mg [**Hospital1 **]) and labetalol. BP improved. Urine
output increased. Dialysis was deferred.
JP drainage increased and fluid was sent for creatinine given
concern for possible urine leak. This showed the JP creatinine
of 18.9 with serum creatinine of 12.2. A repeat renal ultrasound
was done showing no hydronephrosis or perinephric fluid
collection. On postop day 3, his abdomen was distended. KUB
revealed generalized dilated loops of bowel with air-fluid
levels consistent with postoperative ileus. He was made NPO for
Ogilvies. He was transferred to the SICU for neostigmine. A
total of 3 doses were given with some improvemet. On postop day
5, repeat kub showed slight improvement of colonic distention
with maximum distension measured at 8.2 cm slightly improved
since the previous day from 9.3 cm. Distension resolved and diet
was slowly advanced and tolerated.
JP drainage decreased to 75-100 cc/day of yellow clear fluid.
Subsequent JP drain fluid creatinines were sent and trended down
(11.5, 8.3, 6.5, 6.2, and 5.6 [**7-6**]). Serum creatinine was 5.9 on
[**7-6**]. The incision remained clean, dry and intact. Compared to
baseline US [**2174-6-26**], resistive indices in both kidneys were
slightly elevated. He complained of pain over the RLQ transplant
incision and received dilaudid for this. Repeat ultrasound on
[**7-5**] demonstrated moderate hydronephrosis of the more medially
placed transplant kidney in the right lower quadrant. This
kidney demonstrated some mildly elevated resistive indices. No
renal stones or perinephric collections were seen. The more
laterally placed transplant kidney appeared
normal. Urinalysis and culture were sent on [**7-6**] for complaints
of pain over transplant site. U/A revealed [**7-27**] wbc, 0-2 epi,
few bacteria and trace leukocytes. Ciprofloxacin 500mg qd was
started on [**7-6**]. A two week course was recommended. Dysuria was
slightly better on [**7-7**]. Urine culture was negative to date.
Urine remained yellow with some scant intermittent visible
hematuria. Pain over his transplant was felt to be related to a
possible urine infection with possible colic.
Of note, he experienced hyperglycemia that was treated with a
regular insulin sliding scale. A total of 20 units of regular
insulin was required each day in increments for sugars in the
140 to 180 range. [**Last Name (un) **] was consulted and recommended starting
Amaryl 1mg po qd with 1 week f/u with [**Last Name (un) **] nurse [**Last Name (un) 30484**] and
given for metabolic acidosis.
Potassium was initially elevated immediately postop, but this
resolved. Potassium trended up on [**7-7**] with potassium of 5.6
likely related to elevetaed Prograf level of 13.7. He was
instructed to follow a 2gram potassium diet.
Immunosuppession consisted of a total of 5 doses of ATG 100mg,
steroid taper, cellcept 1 gram [**Hospital1 **] and prograf that was
initiated on postop day 1. Dose was increased to 12mg [**Hospital1 **], but
levels increased to the 15.9 range. Dose was decreased to 11mg
[**Hospital1 **] on [**7-4**] and subsequent trough levels trended down to 10.7.
He was discharged to home ambulating independently with stable
vital signs ( BP 117/73-125/83)and tolerating a regular diet. He
was instructed to get repeat labs on [**7-8**]([**Last Name (NamePattern1) 439**])
and [**7-9**] (Felberg Outpatient Clinic was notified). Script was
given for labs [**7-8**] and [**Hospital Ward Name 1826**] 7 Clinic requisition was fax'd.
Appointment scheduled with diabetes nurse [**Hospital Ward Name 30484**] ([**First Name5 (NamePattern1) 16883**]
[**Last Name (NamePattern1) 30988**]) [**7-12**] at 4pm, [**Location (un) **] [**Last Name (un) **].
Medications on Admission:
renagel, sensapar 120mg qd, amlodipine 10mg [**Hospital1 **], atenolol 100mg
[**Hospital1 **], minoxidil 2.5mg [**Hospital1 **]
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): may obtain over the counter.
14. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
16. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
17. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day: check glucose prior to meals and bedtime.
Disp:*1 box* Refills:*2*
18. Outpatient Lab Work
STAT Labs on Friday [**7-8**] and Sunday [**7-10**] for
chem 10, ua, trough prograf level
Call the Transplant Coordinator with results [**Telephone/Fax (1) 673**]
19. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ESRD
s/p 2 pediatric kidney transplants
ileus
small urine leak
hyperglycemia
UTI
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
increased drain output, worsening abdominal pain, incision
redness/bleeding/drainage
Labs Friday [**7-8**] am at [**Last Name (NamePattern1) 439**] and [**7-10**] 08:30 at [**Hospital Ward Name 5074**] [**Hospital Ward Name 1826**] 7 Outpatient Unit then
Labs every Monday and Thursday
Empty drain when [**2-18**] full and record outputs. Bring record of
drain outputs to next appointment
check blood sugar prior to meals and bedtime
No heavy lifting/driving
Followup Instructions:
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-7-12**] 8:20
[**First Name4 (NamePattern1) 16883**] [**Last Name (NamePattern1) 30988**], RN Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] [**Location (un) 551**] [**2174-7-12**] at 4pm
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2174-7-22**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-7-22**] 2:00
[**Last Name (un) **]
Completed by:[**2174-7-7**]
|
[
"997.4",
"V18.0",
"276.2",
"276.8",
"276.52",
"276.7",
"403.91",
"585.6",
"V45.87",
"584.9",
"997.5",
"E878.0",
"458.29",
"790.29",
"599.0",
"591",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
9147, 9205
|
2313, 7017
|
270, 343
|
9330, 9337
|
1836, 2290
|
9985, 10612
|
1431, 1548
|
7195, 9124
|
9226, 9309
|
7043, 7172
|
9361, 9962
|
1563, 1817
|
226, 232
|
371, 1071
|
1093, 1257
|
1273, 1415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,958
| 130,636
|
54628
|
Discharge summary
|
report
|
Admission Date: [**2155-6-12**] Discharge Date: [**2155-6-23**]
Date of Birth: [**2079-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Debridement of sacral decubitus ulcer
History of Present Illness:
76 y.o. man with Stage IV COPD CAD s/p CABG, CHF, and dense
lower extremity paralysis secondary to epidural abscess recently
discharged from our service following a 3+ week admission
complicated by episodes of bradycardia and 2 episodes of
respiratory faliure and intubation. Patient had been at rehab
where he had 2 days of increasing hallucinations and confusion.
His CO2 level was per report 40. EMS was called, brought
patient from [**Hospital1 **] to [**Hospital 84697**]Hospital and brought to
[**Hospital1 18**] as patient was "too sick" for hospital.
In the ED, initial vitals were 128/67, 90, 93% on 4L NC. No
temperatures were recorded in the ED. For a UA with
leukocytosis, patient was given 750mg levoquin. His stool was
guiac positive.
On arrival to the MICU, patient is combative, asking not to be
touched, but recognizes staff and is alert and oriented. He was
transferred back to his old room. He is in no acute distress,
denying dyspnea or chest pain.
Review of systems:
(+) Per HPI
(-) Patient does not comply with further review of symptoms.
Past Medical History:
CABG [**2147**] (4 vessle)
Systolic CHF EF - 35%
COPD on Home O2
Obstructive Sleep Apnea
Chronic Kidney Diease Stage 3 baseline Cr 1.7
Type 2 Diabetes (IDDM)
Hypothyroidism
Atrial Fibrillation
Heel Ulcers
BPH
Social History:
Lives in [**Hospital1 1501**]. 50 pack year hx of smoking, quit in [**2147**]. no EtOH
or drug use
Family History:
Family history unknown by patient
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, swinging around in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, but soft heart
sounds.
Lungs: Clear to auscultation bilaterally, but diminished at the
bases.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper extremities, 0/5
lower extremities. unable to feel below thighs.
Skin: large unstageable decubitus ulcer in back.
DISCHARGE EXAM
VS: 97.5/97.5 132/67 (110s-130s/50s-70s) 80 20 96%3L CPAP, FS:
183
General: Lying in bed, wearing CPAP
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not appreciated
CV: Regular rate and rhythm, normal S1 + S2, distant heart
sounds
Lungs: Clear to auscultation bilaterally, but diminished
throughout Abdomen: soft, non-tender, non-distended, bowel
sounds present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper extremities, 0/5
lower extremities. unable to feel below thighs
Skin: large unstageable decubitus ulcer in back
Pertinent Results:
Admission:
[**2155-6-12**] 09:09PM TYPE-[**Last Name (un) **] PO2-43* PCO2-56* PH-7.46* TOTAL
CO2-41* BASE XS-13 INTUBATED-NOT INTUBA
[**2155-6-12**] 09:09PM LACTATE-2.2*
[**2155-6-12**] 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2155-6-12**] 09:00PM URINE RBC-6* WBC-21* BACTERIA-FEW YEAST-OCC
EPI-<1
[**2155-6-12**] 08:50PM GLUCOSE-131* UREA N-20 CREAT-2.1* SODIUM-140
POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-37* ANION GAP-11
[**2155-6-12**] 08:50PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2155-6-12**] 08:50PM WBC-9.4# RBC-3.28* HGB-10.5* HCT-32.8*
MCV-100* MCH-32.0 MCHC-32.0 RDW-17.4*
[**2155-6-12**] 08:50PM NEUTS-59.4 LYMPHS-32.0 MONOS-7.6 EOS-0.2
BASOS-0.7
[**2155-6-12**] 08:50PM PLT COUNT-243
Discharge:
[**2155-6-23**] 07:05AM BLOOD WBC-9.8 RBC-3.45* Hgb-10.7* Hct-35.3*
MCV-102* MCH-30.9 MCHC-30.3* RDW-17.6* Plt Ct-396
[**2155-6-23**] 07:05AM BLOOD Glucose-122* UreaN-20 Creat-1.9* Na-140
K-4.1 Cl-101 HCO3-34* AnGap-9
Studies:
[**2155-6-17**] MR HEAD W/O CONTRAST
In the absence of IV contrast, evaluation for septic emboli is
limited. However, there is no evidence of edema, acute
infarction or blood
products to suggest septic emboli.
[**2155-6-16**] CHEST PORT. LINE PLACEM
New left-sided PICC line ends in upper atrium or cavoatrial
junction.
[**2155-6-12**] Radiology CHEST (PORTABLE AP)
Findings consistent with persistent substantial pleural
effusions
on limited examination.
Micro:
[**2155-6-18**] URINE URINE CULTURE-FINAL {STAPHYLOCOCCUS
SPECIES}
STAPHYLOCOCCUS SPECIES. ~4000/ML
[**2155-6-15**] STOOL C. difficile DNA amplification
assay-FINAL
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
[**2155-6-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
No growth
[**2155-6-12**] URINE URINE CULTURE-FINAL {YEAST} EMERGENCY
YEAST. 10,000-100,000 ORGANISMS/ML
[**2155-6-12**] BLOOD CULTURE Blood Culture, Routine-FINAL:
No growth
Brief Hospital Course:
76 year old man with Stage IV COPD CAD s/p CABG, CHF, and dense
lower extremity paralysis secondary to epidural abscess recently
discharged from the [**Hospital1 18**] following a 3+ week admission
complicated by episodes of bradycardia and 2 episodes of
respiratory faliure and intubation, now presents from rehab with
agitation and combativeness.
# Altered mental status:/Encephalopathy Likely delerium as it
was waxing and [**Doctor Last Name 688**] throughout admission. He was admitted from
rehab after combative behavior and intermittent confusion. This
was thought to be related to either not wearing CPAP at night or
from infection. He has many possible sources of infection. He
is being treated for T9 epidural abscess (below) with IV
ceftriaxone through [**7-7**]. He has a stage 3+ sacral
decubitus ulcer that is not healing well and that was debrided
during this hospitalization (below). He had a urine culture
positive for staph species. He was also having diarrhea but c.
diff was sent and was negative. Blood cultures were also
negative. Psych was consulted for delerium and recommended
frequent reorientation, discontinuation of seroquel, and
recommended starting haldol 1 mg IV/IM prn for agitation or
combativeness. He required several doses early in his
hospitalization, but did not requre any doses for several days
prior to discharge to rehab.
# Unstageable decubitus ulcer: Patient was seen by surgery who
took the patient to the OR on [**6-14**] for debridement of the sacral
ulcer and followed throughout the remainder of hospitalization
for regular wound checks and dressing changes. Wound care
nurses were also involved in caring for ulcer with collagenase
ointment and regular turning given paralysis (below). Surgery
recommended temporary diverting colostomy given chronic diarrhea
that was possibly contaminating wound. Patient decided against
this option, but will reconsider if wound fails to heal.
# Pleural effusions in setting likely volume overload in the
setting of Chronic systolic heart failure: From prior
hospitalization. His EF was 35% per report from [**2155-6-1**]. He
was initially on furosemide 80 mg QAM and furosemide 40 mg QPM
and this was titrated down as effusions improved and he began to
develop acute kidney injury (below). He was discharged on
furosemide 40 mg QAM and this should be further titrated down if
renal function worsens.
# Epidural abscess and T9 osteomyelitis s/p debridement and
fusion: From prior hospitalization. He was continued on
ceftriaxone 2 gm IV Q24H which he will continue through
[**2155-7-10**]. He was also continued on calcitriol, calcium
carbonate, and vitamin D. He should have follow up scheduled
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] of orthopedics.
# History of coronary artery disease s/p CABG and [**Last Name (NamePattern1) 7792**] on
previous admission. Patient was continued on aspirin,
atorvastatin, and clopidogrel. He did experience several
episodes of substernal chest pain during admission, though ECGs
were stable without new ischemic changes, troponins were
trending down (elevated to 0.26 from prior admission). Pain was
reproducible and was likely musculoskeletal in origin. ACEi was
held in the setting [**Last Name (un) **] restarting this medication should be
considered as renal function improves.
# Hypotension: Resolved from prior admission. SBPs were 110-150s
on the floor. We continued to hold his Fludrocortisone as he
was started on lasix (above). His midodrine was also held
initally but restarted prior to discharge. This should be
addressed as outpatient. Consider transitioning back to home
regimen as blood pressure tolerates.
# [**Last Name (un) **]: Creatinine elevated to peak of 2.4 and was likely
prerenal from agressive diuresis for pleural effusions (above).
Furosemide was titrated down and creatinine returned to baseline
of 1.9-2.2 from prior hospitalization.
# OSA: Patient requires CPAP at night and continued to use
throughout hospitalization with O2 saturations in the mid-high
90s.
# Complete AV Block / Tachycardia-Bradycardia syndrome: Per
cardiology and EP, a pacemaker is likely to be required after
his acute osteomyelitis has resolved and antibiotics course
completed. He had one episode of asymptomatic bradycardia to 30
which resolved within 60 seconds. ECG was normal and no
intervention was done. He should follow-up with his cardiologist
Dr. [**Last Name (STitle) 13310**] on [**7-7**] at which time a pacemaker should be
considered.
# Diarrhea: Reported to have loose bowel movements w/ c diff
odor. C diff negative.
# Hypothyroidism: On Levothyroxine Sodium 175 mcg daily. TSH
returned elevated at 20, but T4 and free T4 normal. Likely sick
euthyroid. This should be rechecked in a few months.
# Diabetes Mellitus: Stable. Was maintained on an insulin
sliding scale throughout hospitalization.
# COPD: Stable, continued home regimen of fluticasone and
tiotropium. Was given albuterol nebulizers as needed.
# Depression: Stable. Continued home regimen of fluoxetine.
# Prophylaxis: Subcutaneous heparin, colace, senna
# Access: peripherals, PICC
# Communication: HCP, nephew, [**Name (NI) 449**] [**Name (NI) **] [**Name (NI) 976**] ([**Telephone/Fax (1) 111744**]
# Code: Full code
# Transitional:
- Will need to have T4 and free T4 rechecked at rehab (were
normal here despite high TSH)
- He should follow-up with his cardiologist Dr. [**Last Name (STitle) 13310**] on [**7-7**]
at which time a pacemaker should be considered
- Given history of heart failure ACEi therapy should be
considered when renal function improves
- IV ceftriaxone through PICC line through [**2155-7-10**]
- Will need PCP follow up scheduled to review med changes in
hospital and transition back to stable home regimen
- Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, cough,
shortness of breath
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. CeftriaXONE 2 gm IV Q24H
6. Clopidogrel 75 mg PO DAILY
7. Collagenase Ointment 1 Appl TP DAILY
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. Quetiapine Fumarate 25 mg PO TID
11. Midodrine 7.5 mg PO TID
12. Vitamin D 1000 UNIT PO DAILY
13. Levothyroxine Sodium 175 mcg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Furosemide 80 mg PO QAM
16. Furosemide 40 mg PO QHS
17. Insulin SC
Sliding Scale
Fingerstick QID
Insulin SC Sliding Scale using REG Insulin
18. Senna 1 TAB PO BID:PRN constipation
19. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
20. Fluoxetine 20 mg PO DAILY
21. K-DUR *NF* 40 meq ORAL DAILY
22. Calcium Carbonate 1000 mg PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Heparin 5000 UNIT SC TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, cough,
shortness of breath
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 1000 mg PO DAILY
7. CeftriaXONE 2 gm IV Q24H Duration: 13 Days
daily Last day [**2155-7-6**]
8. Clopidogrel 75 mg PO DAILY
9. Collagenase Ointment 1 Appl TP DAILY
10. Docusate Sodium (Liquid) 100 mg PO BID
11. Fluoxetine 20 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
13. Furosemide 40 mg PO QHS
14. K-DUR *NF* 40 meq ORAL DAILY
15. Levothyroxine Sodium 175 mcg PO DAILY
16. Midodrine 7.5 mg PO TID
17. Senna 1 TAB PO BID:PRN constipation
18. Tiotropium Bromide 1 CAP IH DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. Haloperidol 1 mg IV TID:PRN agitation
Please check QTc 15 minutes after dose to look for prolongation
21. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Encephalopathy
Sacral decubitus ulcer
T9 epidural abscess with cord compression and dense paralysis
AV heart block
Acute renal failure
CAD, bypass graft
Chronic systolic CHF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound, due to dense T9 paralysis.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you were combative and
agitated at rehab. This may have been because you were not
wearing your CPAP at night. It is also possible that this was
due to an infection. We continued your IV antibiotics through
your PICC line and you wore your CPAP at night and your mental
status returned to baseline.
You also went to the operating room to have your back ulcer
cleaned and the wound nurses changed your dressing regularly to
help it heal.
It was a pleasure taking care of you.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2155-7-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Location (un) **] ORTHO ASSOCIATES
When: THURSDAY [**2155-7-10**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 89824**], MD [**Telephone/Fax (1) 3736**]
Building: [**Street Address(2) **] ([**Location (un) 5028**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: None
Department: INFECTIOUS DISEASE
When: THURSDAY [**2155-7-31**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 25076**]
Appointment: Monday [**2155-7-7**] 11:20am
Completed by:[**2155-6-23**]
|
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"707.07",
"584.9",
"344.1",
"244.9",
"V45.81",
"276.8",
"327.23",
"410.72",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
13084, 13184
|
5202, 5562
|
326, 366
|
13401, 13401
|
3176, 5179
|
14141, 15384
|
1833, 1868
|
12095, 13061
|
13205, 13380
|
11057, 12072
|
13565, 14118
|
1883, 3157
|
1392, 1467
|
264, 288
|
394, 1373
|
13416, 13541
|
1489, 1699
|
1715, 1817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,154
| 102,331
|
19765
|
Discharge summary
|
report
|
Admission Date: [**2140-2-25**] Discharge Date: [**2140-3-1**]
Date of Birth: [**2084-6-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 55 year old gentleman
known coronary artery disease who has had multiple PCIs in
the past. He just recently relocated to the [**Location (un) 86**] area and
had an exercise treadmill test as part of a workup with a new
cardiologist. The patient does not report any symptoms of
chest pain or shortness of breath. The exercise treadmill
test was positive and he was referred to [**Hospital6 1760**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1. Hypertension; 2.
Hypercholesterolemia; 3. Coronary artery disease; 4. Status
post collarbone surgery.
ALLERGIES: Altace which causes hyperkalemia.
PREOPERATIVE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Atenolol 50 mg p.o. q. day.
3. Zocor 40 mg p.o. q. day.
4. Niacin 1000 mg p.o. q. day.
HOSPITAL COURSE: The patient was transferred to Dr.
[**Last Name (STitle) 70**] for surgical treatment of his coronary artery
disease. His cardiac catheterization showed 80% ostial left
main stenosis and two patent stents in the right coronary
artery with 80% lesion proximal to the stent with a normal
left ventricular function. The patient was taken to the
Operating Room on [**2-25**] with Dr. [**Last Name (STitle) 70**] for a
coronary artery bypass graft times three with left internal
mammary artery to left anterior descending, vein graft to
right coronary artery and vein graft to diagonal, please see
operative note for further details. The patient was
transferred to the Intensive Care Unit in stable condition on
Propofol and Levophed. The patient was weaned and extubated
on his first postoperative day. On postoperative day #1 the
patient continues to require Levophed for maintaining
adequate blood pressure. The patient was seen by physical
therapy on postoperative day #2. By postoperative day #2 the
patient was able to walk 500 feet. While still in the
Intensive Care Unit the Levophed was weaned to off. Chest
tubes were removed without incident. On postoperative day
#4, the patient was able to complete a level 5 of physical
therapy ambulating 500 feet and climbing one flight of stairs
with no difficulty. The patient's pacing wires were removed
without incident and on postoperative day #5 the patient was
cleared for discharge to home.
CONDITION ON DISCHARGE: Temperature maximum 98.6, pulse 94
in sinus rhythm, blood pressure 116/62, respiratory rate 18,
room air oxygen saturation 97%. The patient's weight on
[**3-1**], is 74.7 kg. Preoperatively the patient was 74
kg. The patient is awake, alert and oriented times three,
nonfocal. Heart is regular rate and rhythm without rub or
murmur. Respiratory breath sounds are clear bilaterally.
Gastrointestinal, positive bowel sounds. Abdomen is flat,
nontender, nondistended. Extremities are warm and well
perfused with trace pedal edema. Sternal incision
Steri-Strips are intact. There is no erythema or drainage.
Sternum is stable. Left lower extremity vein prior site
Steri-Strips are intact and there is no erythema or drainage.
Laboratory data revealed white blood cell count 5.4,
hematocrit 22.8, platelet count 193, sodium 143, potassium
3.7, chloride 107, bicarbonate 31, BUN 14, creatinine 0.7,
glucose 90. The patient's hematocrit had been 22 and stable
for several days. The patient was asymptomatic with
hematocrit and it was felt the patient had not had any prior
blood transfusions and was asymptomatic with his anemia. The
patient will be discharged to home on iron and Vitamin C.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post urgent coronary artery bypass graft times
three.
3. Postoperative anemia.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. day times seven days.
2. Potassium chloride 20 mEq p.o. q. day times seven days.
3. Atenolol 50 mg p.o. q. day.
4. Enteric coated Aspirin 325 mg p.o. q. day.
5. Plavix 75 mg p.o. q. day.
6. Colace 100 mg p.o. b.i.d.
7. Percocet 5/325 one to two p.o. q. 4-6 hours prn.
8. Zantac 150 mg p.o. b.i.d.
9. Niferex 150 mg p.o. q. day.
10. Vitamin C 500 mg p.o. b.i.d.
11. Folate 1 mg p.o. q. day.
12. Simvastatin 40 mg p.o. q. day.
13. Niacin 1000 mg p.o. q. day.
DISCHARGE DISPOSITION: The patient is to be discharged to
home in stable condition.
FOLLOW UP: The patient is to follow up with Dr. [**First Name (STitle) 2031**] in
one to two weeks. The patient is to follow up with Dr.
[**Last Name (STitle) 22889**] in one to two weeks and the patient is to follow up
with Dr. [**Last Name (STitle) 70**] in five to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2140-3-1**] 12:42
T: [**2140-3-1**] 10:55
JOB#: [**Job Number 53441**]
|
[
"285.1",
"272.0",
"414.01",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"88.55",
"37.22",
"36.15",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4306, 4368
|
3792, 4282
|
3648, 3769
|
948, 2403
|
4380, 4951
|
804, 930
|
158, 599
|
622, 778
|
2428, 3627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,751
| 194,722
|
15399+56638
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-10**]
Date of Birth: [**2128-10-7**] Sex: M
Service: [**Company 191**]-MED
REASON FOR ADMISSION: This patient was a call-out from the
Intensive Care Unit after a TCA overdose who is now stable
but still needs monitoring and psychiatric follow-up.
HISTORY OF PRESENT ILLNESS: This is a 42 year old man with
a past medical history of HIV and depression, who
intentionally took approximately 16 Nortriptyline pills and
20 Klonopin pills on the day of admission, [**2170-11-5**].
He was originally admitted to the Intensive Care Unit for
care. He was in a coma with dilated pupils on presentation.
EMERGENCY ROOM COURSE: The patient was intubated and he
received three ampules of sodium bicarbonate in D5W at 250
cc. per hour. He was given 100 grams of activated charcoal
and admitted to the SICU. His EKG was notable for a
prolonged QRS.
INTENSIVE CARE UNIT COURSE, [**11-5**] until [**11-7**]: The patient
was seen by Psychiatry and given more bicarbonate, potassium
and magnesium. On [**11-7**], he spiked a temperature to 101.4 F.
He was extubated and the central line was discontinued on
[**11-7**]. He was started on Levofloxacin for a presumed
pneumonia and he was sent stable to the floor on [**2170-11-7**].
REVIEW OF SYSTEMS: Positive for productive cough, pleuritic
chest pain. No nausea, vomiting or abdominal pain.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus diagnosed in [**2156**]. The
patient was on HAART from [**2161**] until [**2165**]. He states that he
had two episodes of PCP [**Last Name (NamePattern4) **] [**2163**] and in [**2164**], when his CD4
count was approximately 50. He was restarted on his HAART in
[**2169**] and he self-discontinued his HAART in [**2170-5-23**] when
his CD4 count was 900. He is currently followed for his HIV
at the [**Hospital1 778**].
2. Depression.
3. History of substance abuse in the past with cocaine and
currently with Klonopin.
4. Chronic back pain.
5. Sleep disturbance.
SOCIAL HISTORY: The patient lives in [**Location (un) 44698**] which is a
group home for HIV males with substance abuse histories. He
admits to occasional alcohol use but denies intravenous drug
use at this time. He does smoke cigarettes.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. Levofloxacin 500 mg q. day started on [**11-7**].
2. Tylenol p.r.n.
OUTPATIENT MEDICINES:
1. Klonopin 3 mg q. h.s.
2. Motrin 400 mg three times a day.
3. Seroquel 75 mg q. h.s.
4. Combivir one tablet twice a day.
5. Nortriptyline 100 to 150 mg q. h.s.
6. Viramune 500 mg twice a day.
7. [**Doctor First Name **] D one tablet twice a day.
8. Tramadol 50 mg q. six hours p.r.n.
9. Chloral hydrate 500 mg q. h.s.
10. Kenalog 5 mg three times a day.
PHYSICAL EXAMINATION: Vital signs were heart rate 92;
saturation 96% on room air and otherwise stable. In general,
in no acute distress. HEENT: Mucous membranes are moist.
Pupils are equal, round and reactive to light. There is no
jugular venous distention. Chest: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm,
normal S1 and S2. No murmurs, rubs or gallops. Abdomen with
positive bowel sounds, soft, nontender, nondistended, obese.
Extremities with no cyanosis, clubbing or edema. Plus two
dorsalis pedis bilaterally. Neurological: Flat affect and
alert and oriented times three, non-focal.
LABORATORY: On transfer to the floor, hematocrit 37.6, white
count of 10.3, potassium of 3.2, magnesium of 1.4, TSH 1.6.
A urine toxicology screen on the day of admission was
positive for benzodiazepines. A serum toxicology screen on
the day of admission was positive for tricyclic
anti-depressants.
A chest x-ray on [**11-7**] showed right diaphragm elevated
and a right lower lobe atelectasis versus consolidation.
EKG on [**11-7**], sinus at a rate of 93; normal axis, PR
160, QRS of 110. QTC 412. No ST or T wave changes.
IMPRESSION: This is a 42 year old male call out from the
Intensive Care Unit after intentional TCA overdose, no
extubated and EKG abnormalities are resolving.
HOSPITAL COURSE (SINCE DISCHARGE FROM THE INTENSIVE CARE UNIT
TO THE FLOOR):
1. TOXICOLOGY: The QRS remained narrow on the floor for
over two days (QRS less than 100). There were no events on
Telemetry and it was discontinued on [**11-9**]. His
electrolytes were aggressively repleted and normalized by
[**11-9**]. From a cardiac standpoint he was stable for
discharge to a psychiatric facility on [**11-9**], however,
patient was unable to void, likely secondary to
anti-cholinergic side effects of his TCA overdose.
He was straight cathed on the night of [**11-8**] with a
total residual urine of 1,600 cc. At that time, his Foley
was replaced. On the morning of [**11-9**], the Foley was
removed and we began a trial of bethanechol, 10 mg q. one
hour times five until the patient voids. At the time of this
discharge summary, the patient had not yet voided and had
just received his third dose. Please see the discharge
addendum.
The patient was unable to transfer to Psychiatry from a
psychiatric standpoint until he voids, however, he is
medically stable for transfer.
2. HEMATOLOGIC: Deep vein thrombosis prophylaxis with
subcutaneous heparin.
3. INFECTIOUS DISEASE: A CD4 count was 355. Viral load was
pending at the time of this dictation. There was no need to
start HAART or prophylaxis at this time. [**Month (only) 116**] want to
consider starting HAART treatment in the future once the
acute psychiatric issues have resolved if the patient can
adhere to this treatment.
He received topical Kenalog for oral hairy leukoplakia.
Treatment was initiated with Levofloxacin for a fever, cough
and a question of a right lower lobe consolidation (on chest
x-ray, atelectasis versus consolidation) on [**11-7**]. The
patient improved by [**11-9**] on Levaquin and should
complete a seven day course for bronchitis versus question of
pneumonia.
4. PSYCHIATRIC: Psychiatry continued to follow the patient
on the floor for ongoing issues of depression, sleep
disturbance and status post overdose. He was restarted on
Prozac 10 q. a.m. and Seroquel 25 q. h.s. on [**11-8**]. The
one-to-one sitter was continued throughout this admission.
The patient is to be transferred to an inpatient psychiatric
unit from here.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: The patient is to be discharged to an
inpatient psychiatric facility.
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg q. day to complete a seven day course.
2. Tylenol p.r.n.
3. Prozac 10 mg q. a.m.
4. Motrin 400 to 800 q. six hours p.r.n. back pain.
5. Kenalog Topical Ointment q. six hours p.r.n.
6. Seroquel 25 mg q. h.s.
DISCHARGE DIAGNOSES:
1. Status post TCA (also Klonopin) overdose, suicide
attempt.
2. Human Immunodeficiency Virus.
3. Depression/sleep disturbance.
4. Substance abuse (recently with Klonopin and in the past
with cocaine).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2170-11-9**] 15:58
T: [**2170-11-9**] 22:51
JOB#: [**Job Number 44699**]
Name: [**Known lastname 8180**], [**Known firstname **] Unit No: [**Numeric Identifier 8181**]
Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-10**]
Date of Birth: [**2128-10-7**] Sex: M
Service: [**Company 112**] MEDICINE
CONTINUATION OF HOSPITAL COURSE: Mr. [**Known lastname **] was able to void
by [**2170-11-10**] after treatment with Bethanechol.
However, he still had a postvoid residual of 400 cc;
therefore, the Foley was put back in place and should remain
for two days. He was discharged to a psychiatric inpatient
hospital and in addition to his discharge medications he will
also be on Bethanechol 10 mg t.i.d. for a total of two days
until the Foley is removed. Then, he will need to have his
urine output monitored carefully.
Of note, there was an error in the discharge summary in that
the patient intentionally took 60 nortriptyline pills not 16.
Of note, the patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 8182**] at the [**Hospital1 8183**] and his psychiatrist is Dr. [**Last Name (STitle) 8184**].
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 290**], M.D. [**MD Number(1) 291**]
Dictated By:[**Name8 (MD) 6984**]
MEDQUIST36
D: [**2170-11-11**] 14:54
T: [**2170-11-11**] 15:21
JOB#: [**Job Number 8185**]
cc:[**Last Name (NamePattern4) 8186**]
|
[
"969.0",
"486",
"305.90",
"042",
"969.4",
"788.20",
"E950.3",
"296.34",
"780.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6807, 7571
|
6553, 6786
|
7589, 8749
|
2855, 6406
|
1327, 1421
|
359, 1307
|
1443, 2048
|
2066, 2831
|
6432, 6530
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,406
| 144,290
|
52244
|
Discharge summary
|
report
|
Admission Date: [**2139-7-20**] Discharge Date: [**2139-7-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
"My fistula wasn't flowing right."
Major Surgical or Invasive Procedure:
Left AV Venogram
Left AV Thrombectomy
History of Present Illness:
[**Age over 90 **]yom w/PMHx significant for CAD, CHF, CABG, HTN, Atrial
fibrilliation, Ventricular Brady-paced, Hyperlipidemia renal CA,
s/p left nephrectomy in ESRD, HD dependent who presented to the
[**Hospital1 18**] 24hrs prior via his dialysis clinic.
.
Daughter reports weakness of the extremities over the weekend
following Fri HD c/w previous episodes of hyperkalemia. He then
presented this Mon for regularly scheduled HD per MWF schedule
through left arm AV graft which was complicated my apparent clot
of the graft.
.
Pt was then sent to the [**Hospital1 18**] for HD. On arrival at the [**Hospital1 18**] pt
was noted to have hyperkalemia w/K of 8.1. He received calclium
gluconate, insulin and bicarbonate for correction of
hyperkalemia. Pt was admitted to the ICU and femoral access was
obtained for HD and was subsequently dialysed via the femoral
access. On hospital day two patient was taken to the
interventional suite and clot lysis was attempted without
apparent success. Pt was then evaluated by the vascular surgery
team and planned for transfer to medicine.
Past Medical History:
Past Medical History:
#. P-MIBI ([**3-4**]): new fixed small severe defect in the PDA
territory, new transient cavity dilation, and an old fixed small
moderate defect in the distal LAD territory
#. Cardiac catheterization [**5-4**] w/L main and 3 vessel dz w/
patent LIMA to LAD w/ 70% stenosis in distal LAD, patent SVG to
diagnoal ramus w/ 50% stenosis in native diagonal branch, patent
SVG to OM1/OM2 but occluded OM1 at touchdown. s/p unsuccessful
PTCA of LM, Moderate right and left ventricular diastolic
dysfunction
#. CHF: Echo ([**6-4**]) EF 30-35%, [**12-1**]+ MR, 2+ TR, moderate
pulmonary artery systolic HTN
#. HTN
#. Hypercholesterolemia
#. Reportedly small ASD on a TEE
#. ESRD, on HD (since [**2134**]) MWF evenings via left arm AV graft
(evening shift at [**Location (un) 4265**], [**Location (un) **])
#. Chronic anemia associated w/ renal failure
#. Renal cell carcinoma, s/p left nephrectomy
#. Gout w/flairs 1-2x/mo
#. s/p TURP for BPH
#. Bilateral cataracts
#. Left hydrocele w/ hydrocelectomy [**12/2130**]
#. Multiple episodes of SOB
.
PSHx:
#. Right common femoral artery thrombus s/p cath in [**5-4**]
#. Pacemaker placement Trahy-Brady syndrome [**3-/2128**], w/replacement
[**11-2**]
#. CAD s/p 5-vessel CABG [**2124**] (LIMA-LAD, SVG-D1, SVG-RI,
SVG-OM1, SVG-OM2)
#. Left CEA [**2127**] (s/p TIA)
#. Thrombectomy and revision of LUE AV graft [**2-1**] w/multiple
interventions to graft in the past.
Social History:
He lives alone in [**Location (un) 745**]. Recently retired fully from selling
furniture, pt had reduced from full time work to part time work
over the past year.
+ tob: cigar/pipe smoking, daily x20-25 years w/cessation 20yrs
prior
- EtOH
- Illicit/Recreational drug use
Family History:
Daughter with MI in mid-40s, had Type 1 DM, deceased 56y/o
Brother w/heart disease, ?MI. + hypertension, + diabetes
mellitus, Brother w/lymphoma, ? question liver ca
Physical Exam:
Vitals: T=96.1; HR=70; BP=90/48; RR=20; O2Sat=98% RA
General: A/O x 3. NAD.
HEENT: NC/AT, MMM, scar c/w previous CEA
CV: S1=S2, with Grade II/VI soft systolic murmur heard best at
apex, no rubs or gallops appreciated
Pulm: CTA bilaterally, no rhonchi, wheezes or crackles
Abd: Soft, NT/ND with normoactive BS.
Ext: No cyanosis, 2+ DP bilat, left arm bleed/dressing over AV
graft
Pertinent Results:
[**2139-7-20**] 07:30PM GLUCOSE-99 UREA N-94* CREAT-10.9*# SODIUM-138
POTASSIUM-8.0* CHLORIDE-99 TOTAL CO2-24 ANION GAP-23*
[**2139-7-20**] 07:30PM WBC-7.6 RBC-3.67* HGB-12.5* HCT-38.9*
MCV-106* MCH-34.1* MCHC-32.2 RDW-16.2*
[**2139-7-20**] 07:30PM CALCIUM-10.0 PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2139-7-20**] 07:30PM NEUTS-67.0 LYMPHS-21.3 MONOS-7.5 EOS-2.7
BASOS-1.4
[**2139-7-20**] 07:30PM PT-23.6* PTT-39.2* INR(PT)-2.4*
[**2139-7-20**] 07:30PM CK-MB-7 cTropnT-0.21*
[**2139-7-20**] 07:30PM CK(CPK)-79
[**2139-7-20**] 07:42PM K+-8.1*
[**2139-7-20**] 11:27PM POTASSIUM-6.6*
Brief Hospital Course:
#) Left Arm AV Graft Failure: Pt presented w/clot of left arm AV
graft and access for emergent HD right femoral access was
obtained and emplyed for HD. Pt was then taken to the IR suite
and thrombectomy of the left AV graft was attempted w/o success.
A venogram of the region was also obtained. Post intervention
the pt experienced a bleed of the left arm access site which was
monitored by IR overnight, pressure was applied though slow
leaking bleed persisted overnight the day of procedure. At the
time of procedure INR was 2.5 and coumadin was held and on post
intervention day one had decreased to 2.1 and the bleed stopped.
Based on the failed thrombectomy renal transplant surgery was
consulted for long term access for HD. Pt was planned for left
proximal AV fistula w/permcath placement in the interim. Pt
underwent repeat venogram of more proximal vessels in
preparation for surgery.
Pt was planned for routine HD via femoral cath. The day of IR
intervention, overnight the femoral cath was associated
w/proximal tenderness and local bleed externally which resolved
w/pressure and occlusive dressing, no signs/symptoms of
significant internal bleeding were noted. On the day prior to
discharge, the patient had a new AV fistula placed on his
proximal LUE. He also had a permacath placed on the Left side
(IJ). The patient was dialyzed through the permacath on the day
of discharge without incident. He developed slight oozing from
his new graft site after dialysis, thought to be related to
heparin given during HD. He was discharged with dressings and
instruction to return with any symptoms, such as
lightheadedness, CP.
.
#) Anemia: HCT as low as 26.4 though pt asymptomatic: w/o
orthostatic signs, lightheadedness, no feelings of fatigue,
AOx3. Drop in HCT from 30 is likely [**1-1**] bleed over the previous
24-48hrs following IR access. At that time RBC was noted to have
dropped w/o drop in HCT. I suspect the HCT did not change at
that time due to the acute nature of the bleed and at this time
his fluids have re-equilibrated and now the HCT reflects the
blood loss as well as the RBC. The patient received 1U PRBC
prior to graft surgery and permacath placement.
.
#) Hyperkalemia: Pt was noted on admission to have hyperkalemia
w/potassium of 8.1. Renal was consulted and pt received calcium
gluconate, bicarbonate and insulin and then sent for emergent
hemodialysis. Post HD potassium was noted to be 5.6. On the
second day of admission potassium was again elevated to 6.2 and
patient was taken to hemodialysis. It was determined to repeat
HD as this also would coincide w/regularly scheduled HD regimen
and avoid side effects of kayexolate. It was also decided to
discontinue ACEi as it was considered to be contributing to
hyperkalemia.
.
#) Cardiovascular: PMHx significant for CAD, CHF and
Hyperlipidemia. On presentation pt w/o SOB, CP, Dyspnea,
Syncope. On transfer from the MICU to the medicine floor exam
revealed BP 90s/40 pt reported baseline low pressures of 100s
systolic. Pressures low likely secondary to HD w/1kg taken off.
Pt w/o orthostatic signs and was asymptomatic. Over the next
24hrs pressures corrected and had increased to 110s/70s without
intervention.
.
#) ESRD: Pt w/hx of renal CA and left nephrectomy. ESRD w/HD
dependency. HD per HD team was maintained via femoral access
until alternative permanent access placed by the renal
transplant team. The patient left the hospital with a graft in
his L arm, a permacath on the L (IJ). The R fem line was
discontinued.
.
#) Atrial Fibrillation: Pt w/hx of afib and maintained on
coumadin 3mg qhs as oupt. The patient's coumadin was temporarily
held prior to surgery for graft placement. The patient was
discharged back on coumadin 3mg QHS.
Medications on Admission:
#. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY
#. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
#. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet PO DAILY
#. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO BID
#. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
#. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
#. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
#. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
#. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO WITH
BREAKFAST AND LUNCH
#. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO WITH
DINNER
#. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
#. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO every other day.
#. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
#. Digoxin 50 mcg/mL Solution Sig: One (1) mL PO every other
day.
#. Colchicine prn gout flair
Discharge Medications:
#. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY
#. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
#. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet PO DAILY
#. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO BID
#. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
#. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
#. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
#. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
#. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO WITH
BREAKFAST AND LUNCH
#. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO WITH
DINNER
#. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
#. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO every other day.
#. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
#. Digoxin 50 mcg/mL Solution Sig: One (1) mL PO every other
day.
#. Colchicine prn gout flair
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Left AV shunt stenosis
2) Hyperkalemia
Secondary:
1) ESRD
2) CHF
3) CAD
Discharge Condition:
Improved, VSS, afebrile
Discharge Instructions:
Take all medications as prescribed.
Attend all of your outpatient dialysis appointments.
Schedule a follow-up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] at [**Telephone/Fax (1) **].
Followup Instructions:
Schedule a follow-up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] at [**Telephone/Fax (1) **].
.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-8-6**]
10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"428.0",
"585.6",
"397.0",
"403.91",
"428.32",
"276.1",
"424.0",
"285.1",
"996.73",
"E878.2",
"274.9",
"V45.81",
"272.4",
"998.11",
"V10.52",
"427.31",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"39.95",
"99.04",
"39.49",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
10166, 10172
|
4406, 8140
|
297, 336
|
10300, 10326
|
3790, 4383
|
10621, 11031
|
3207, 3375
|
9166, 10143
|
10193, 10279
|
8166, 9143
|
10350, 10598
|
3390, 3771
|
222, 259
|
364, 1448
|
1492, 2901
|
2917, 3191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,478
| 102,221
|
45110
|
Discharge summary
|
report
|
Admission Date: [**2200-4-18**] Discharge Date: [**2200-4-21**]
Service: MEDICINE
Allergies:
Sulfonamides / Macrodantin / Bactrim
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
hypoxic respiratory distress
Major Surgical or Invasive Procedure:
BIPAP
History of Present Illness:
[**Age over 90 **]F with atrial fibrillation, severe tricuspid regurgitation,
moderate mitral regurgitation, and HTN, admitted to the MICU
from the ED with hypoxic respiratory distress. Ms. [**Known lastname 96416**] has
a long h/o chronic dyspnea, and has had extensive workup by
Cardiology and Pulmonary, including negative stress test, PFTs,
and CT chest. Her ambulatory sats have been normal. The etiology
has been felt to be most likely [**3-14**] a combination of diastolic
dysfunction, atrial fibrillation, and MR. However, she has
failed to improve on appropriate medical management of these
issues. Over the last 2 days, she has had symptoms similar to
past exacerbations. She states she has become intermittently
dyspneic with minimal exertion, worse in the morning. She has
had no associated chest pain, lightheadedness, diaphoresis,
palpitations, fever/chills, or cough. She has had no recent LE
edema, orthopnea, or PND. She states she has been compliant with
her medications. This afternoon, she was at her hairdresser and
had acutely worsening shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] she came into the
ED.
.
In the ED, her VS were T 96.8, HR 63, BP 150/70, RR 18, and
O2sat 100%RA. She was in no distress, but had scattered crackles
on lung exam. Her CXR showed no acute process. EKG showed
V-paced rhythm with no obvious abnormalities. Her BNP was mildly
elevated, as was her D-dimer. She was sent for CTA chest to r/o
PE. The CT showed no PE or other acute abnormality, however she
became acutely SOB and hypoxic to 85% on 6LNC upon returning.
She was 90% on NRB, and she was tried on nitro gtt, but became
hypotensive to 70s/40s. The nitro gtt was stopped and she
regained her BP. Her ABG on NRB was 7.51/26/55, and she was
started on BiPAP. She was subsequently given Lasix 40mg IV x 1
then 60mg x 1, to which she put out 1.25L. She was admitted to
the MICU for further management.
Past Medical History:
1. Chronic afib- s/p AVJ ablation ([**2-14**]) and PPM placement
([**4-13**])
2. Hypertension
3. hyperdynamic LV function in the absence of coronary disease
4. s/p breast reduction
5. History of post-herpetic neuralgia
Social History:
Walks with walker; lives alone at [**Hospital3 **]. Smoked for
one year [**73**] years ago; husband was a heavy smoker. Occasional
EtOH. She is an artist.
Family History:
Mother died of MI at 78
Father died of stroke at 84
Physical Exam:
PHYSICAL EXAM:
Vitals- T 96.6, HR 86, BP 108/80, RR 20, O2sat 96% 4LNC
General- very pleasant elderly woman in NAD, lying flat in bed
HEENT- NCAT, sclerae anicteric, dry MM
Neck- no JVD at 30 deg
Pulm- bibasilar crackles, good air movement
CV- RRR with 2/6 systolic murmur
Abd- +BS, soft, NT, ND
Extrem- no LE edema, DP pulses 2+ b/l
Pertinent Results:
[**2200-4-18**] 11:00PM GLUCOSE-141* UREA N-18 CREAT-0.7 SODIUM-133
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
[**2200-4-18**] 11:00PM CK(CPK)-71
[**2200-4-18**] 11:00PM CK-MB-NotDone
[**2200-4-18**] 11:00PM cTropnT-<0.01
[**2200-4-18**] 11:00PM MAGNESIUM-2.2
[**2200-4-18**] 09:11PM TYPE-ART PO2-55* PCO2-26* PH-7.51* TOTAL
CO2-21 BASE XS-0
[**2200-4-18**] 09:11PM HGB-15.8 calcHCT-47
[**2200-4-18**] 05:00PM GLUCOSE-112* UREA N-21* CREAT-0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-31 ANION GAP-13
[**2200-4-18**] 05:00PM estGFR-Using this
[**2200-4-18**] 05:00PM CK(CPK)-54
[**2200-4-18**] 05:00PM CK-MB-NotDone cTropnT-<0.01 proBNP-2143*
[**2200-4-18**] 05:00PM WBC-5.5 RBC-4.52 HGB-14.3 HCT-41.8 MCV-92
MCH-31.7 MCHC-34.3 RDW-15.3
[**2200-4-18**] 05:00PM NEUTS-73.8* LYMPHS-18.1 MONOS-7.0 EOS-0.6
BASOS-0.5
[**2200-4-18**] 05:00PM PLT COUNT-242
[**2200-4-18**] 05:00PM PT-28.3* PTT-32.7 INR(PT)-2.9*
[**2200-4-18**] 05:00PM D-DIMER-776*
.
Admission CXR
New convincing evidence of pulmonary edema in this radiograph.
The radiograph is of somewhat suboptimal quality
.
CTA Chest
1. No evidence of pulmonary embolism. Limited assessment of the
aorta demonstrates no aneurysmal dilatation.
2. Reflux of contrast into the inferior IVC likely secondary to
bolus rate, less likely right heart failure.
3. Stable CT appearance of 3-mm pulmonary nodules in the lingula
and left lower lobe from [**2198-11-3**].
.
Transesophageal echocardiogram
Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
There is no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior report (images
unavailable for review) of [**2198-11-5**], the findings are similar.
Brief Hospital Course:
This is a [**Age over 90 **]F with AF, TR/MR, and HTN, admitted with hypoxic
respiratory distress.
.
MICU Course: On admission to the MICU she was satting 100% on
BiPAP in NAD. She was weaned to 4LNC immediately and was
subsequently titrated down to RA again. She received IV lasix
and had good urine output to it. She is was then transferred
out to the floor. She denies chest pain, shortness of [**Age over 90 1440**],
lightheadedness, palpitation.
.
1. Hypoxic respiratory distress: SOB on presentation without
hypoxia. Decompensated after CT with hypoxia and respiratory
distress in setting of hypertension, likely [**3-14**] acute pulmonary
edema with IV contrast bolus. TTE is largely unchanged from [**2198**]
- shows mild-mod TR, mod MR. [**First Name (Titles) **] [**Last Name (Titles) 96417**] were flat, making
ACS unlikely.
She was transferred to the floor on room air, and her home dose
of lasix was restarted. Per Dr. [**Last Name (STitle) **], she should receive an
extra half dose for the next two days, and she should take this
extra dose prn shortness of [**Last Name (STitle) 1440**] or lower extremity edema.
.
2. Atrial fibrillation: s/p PPM placement and AVJ ablation. She
is followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] of
Cardiology. As above, she was continued Toprol XL for rate
control and coumadin.
.
3. HTN: On multiple meds as outpatient, reports compliance.
Continued Toprol XL, irbesartan, verapamil SR, HCTZ and lasix
.
4. FEN: Regular, heart-healthy/low-sodium diet
.
5. Ppx: PPI, coumadin
.
6. Code status: DNR/DNI, confirmed with patient
.
7. Communication: son, [**Name (NI) **] [**Name (NI) 96416**] ([**Telephone/Fax (1) 96418**],
([**Telephone/Fax (1) 96419**]
Medications on Admission:
Verapamil SR 120mg qd
Hydrochlorothiazide 25mg qd
Toprol-XL 37.5mg qd
Avapro 150 mg b.i.d.
Coumadin 2.5mg qhs
Lasix 10mg qd
Lipitor (unknown dose)
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Flash pulmonary edema
.
Secondary diagnosis:
Chronic afib- s/p AVJ ablation ([**2-14**]) and PPM placement ([**4-13**])
Hypertension
Hyperdynamic LV function in the absence of coronary disease
History of post-herpetic neuralgia
Discharge Condition:
Good
Discharge Instructions:
You were admitted for fluid in your lungs. You should resume
all of your home medications upon discharge.
.
Please take an extra half dose of lasix for the next two days,
or when you develop shortness of [**Month/Year (2) 1440**] or increased edema in
your lower legs.
.
Please call your doctor if you develop chest pain, shortness of
[**Month/Year (2) 1440**], fevers, chills, abdominal pain, nausea or vomiting.
Followup Instructions:
You have an appointment to follow up with your primary care
doctor, [**Location (un) **],[**Doctor First Name **] M. [**Telephone/Fax (1) 1713**]. On [**5-1**] at 1pm.
.
You have the following appointments already made:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2200-9-25**]
2:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2200-9-25**] 3:00
|
[
"V45.01",
"427.31",
"428.0",
"424.0",
"402.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8120, 8178
|
5555, 7346
|
272, 279
|
8469, 8476
|
3091, 5532
|
8939, 9400
|
2668, 2722
|
7543, 8097
|
8199, 8199
|
7372, 7520
|
8500, 8916
|
2752, 3072
|
204, 234
|
308, 2234
|
8263, 8448
|
8218, 8242
|
2256, 2476
|
2492, 2652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,251
| 150,426
|
2604
|
Discharge summary
|
report
|
Admission Date: [**2121-7-3**] Discharge Date: [**2121-7-15**]
Date of Birth: [**2050-2-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED [**2121-7-9**]:
Removal of vacuum-assisted closure device.
Irrigation and debridement.
Culture of deep tissue.
Revision arthrodesis with BMP-7, T11-L1.
PROCEDURES [**2121-7-7**]:
1. Removal of hardware.
2. Incision and debridement deep to bone.
3. Application of vacuum-assisted closure device on an open
wound to bone that measured approximately 12 cm x 5 cm.
PICC line placement
History of Present Illness:
71yo female patient with PMH of DM, CAD, PE who had an initial
laminectomy in [**2118**] and failed fusion in [**2120**], before Dr.
[**Last Name (STitle) 1352**] revised arthrodesis T9-L2 for pseudoarthrosis on
[**2121-6-6**]. She then discharged to [**Hospital 1319**] Rehab on [**2121-6-11**].
She was seen in ortho follow up by Dr. [**Last Name (STitle) 1352**] on [**2121-6-30**]
because of increasing pain and imaging with loosening of the
hardware (medial screw).
Current admission for revision of hardware secondary to pain.
She had fever before admission, was admitted to ortho for
revision. She was given a dose of vancomycin initially in the
ED, stopped per ID recommendations, then restarted on Vancomycin
on [**7-7**] around the time of surgery. She had hardware removed
yesterday without washout with tissue biopsy, showing GPCs on
gram stain. She then went to PACU afterwards secondary to
persistent hypotension to SBP 80s and monitored overnight. She
was given several boluses of fluids (SBP 80s --> 100s with IVF
and then drifting with 4.5 L total). This morning, she went to
ortho floor with blood pressure 100/50 and was triggered about
an hour later for BP 72/42. Medicine was consulted. She was
cultured and given 500cc NS on the floor as well as the 80cc/hr
(for total of 160cc) maintenance fluids with potassium. Pt
mentating well, denied any symptoms except thirst but was
diaphoretic. SBP 72/40. She is being bolused 1 L and unit of
pRBC. Output from wound vac was 450 cc. Urine output 600 cc
since midnight.
On the floor, patient reports feeling well. She is sleeping but
easy to arouse and conversational. She has soreness in her
lower back but not uncomfortable from pain. Denies shortness of
breath, fevers, chills, other pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough, shortness of breath, or wheezing. Denies
chest pain, chest pressure. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits.
Denies dysuria, frequency, or urgency.
Past Medical History:
- CAD, s/p MI
- Type II DM
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Hx of PE in [**2118**], IVC filter in place
- hyponatremia
- osteoporosis
- allergies
- spinal stenosis
- s/p laminectomy x2
- s/p appendectomy and cholecystectomy
- s/p TAH and oophorectomy
- s/p multiple hernia operations
- s/p B/L total knee replacements
- s/p tonsillectomy
Social History:
Patient lives with her husband and son in [**Name (NI) 4628**]. She has
three children and three grandchildren.
# Tobacco: smoked 2-3 packs/day for 15 years, quit 20+ years ago
# Alcohol: rare
Family History:
No family history of abnormal clotting. One brother died of an
MI in his early 50s. Father died of MI at 71, mother of leukemia
at 63.
Physical Exam:
see admission H+P
Brief Hospital Course:
Ms. [**Known lastname 13123**] is a 71 year old female with history of CAD, DM2,
HTN, spinal stenosis s/p several spinal surgeries who was
admitted for revision of spinal hardware in the settin of
infection.
# Hypotension-The patient presented for revision of spinal
hardware. Following surgery, she was noted to be hypotensive in
the PACU with SBPs in the 80s. Overnight in the PACU, she
received 4.5L of fluid with BP response to ~100 systolic.
Transferred to ortho floor. On the floor, the patient dropped
her pressures to around 70 systolic and was triggered. Medicine
was consulted and fluid resusitation begun with NS and blood
however pressures remained in the 70s. Thought was sepsis vs.
recent anesthesia or a combination thereof. Transferred to MICU
on vanc and clinda, patient was fluid resusitated and placed on
pressor support. Over the next days her antibiotics were
narrowed to Nafacillin given tissue culutre data and weaned from
pressors. Cortstim test showed a mild bump in cortisol after 30
minutes of 6.7-->11.7, suggesting adrenal insufficency though
stress dose steroids were not started as her blood pressures had
recovered. Antihypertensive medications were held. On transfer
to the Orthopedics service patient had systolic pressures in the
120s.
# Spinal Stenosis-The patient had a revised arthrodesis T9-L2
for pseudoarthrosis on [**2121-6-6**] and was discharged soon after.
Returned to orthopedist (Dr. [**Last Name (STitle) 1352**]) on [**2121-6-30**] with
increasing back pain thought to be [**1-22**] a loosening screw. Ms.
[**Known lastname 13123**] underwent repair on [**7-3**]. In the MICU, the patient c/o
back soreness but no significant pain. She was covered
emperically with vanc, clinda, cipro for a possible
polymicrobial infection. Patient was taken back to the OR on
[**7-9**] for a washout procedure and had vac dressing placed.
Tissue cultures grew MSSA and patient was successfully
desensitized to nafacillin in the MICU. Patient will need to be
treated for 4-6 weeks with IV nafacillin.
# PE History-The patient has a history of PE in the past and an
IVC filter is in place. Also on coumadin which is being held in
the setting of recent surgeries. GIven multiple trips to the OR
patient's heparin and coumadin were held and recived pneumoboots
for prophylaxis. The patient was placed on lovenox prior to
discharge.
# Diabetes Mellitus-No ative issues, put on insulin slidding
scale.
# CAD-Held antihypertensives in setting of hypotension and held
81mg aspirin tabs in setting of recent spinal surgery.
# Hypothyroidism-No active issues. Continued home dose
levothyroxine.
Medications on Admission:
see admission H+P
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
10. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for spasm.
11. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
15. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QHS (once a day (at bedtime)).
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3075**]
Discharge Diagnosis:
DIAGNOSES:
1. Pseudoarthrosis T6 to L3.
2. T12 compression fracture.
3. Severe osteoporosis.
4. Morbid obesity.
5. Postoperative infection, deep bone.
Discharge Condition:
stable
Alert and oriented
Ambulate as tolerated
Completed by:[**2121-7-15**]
|
[
"V12.51",
"733.00",
"733.13",
"278.01",
"V45.4",
"412",
"V43.61",
"255.41",
"V43.65",
"272.4",
"250.00",
"458.29",
"401.9",
"424.1",
"724.02",
"996.67",
"996.47",
"041.11",
"244.9",
"414.01",
"E878.1",
"998.59",
"599.0",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"38.93",
"78.69",
"77.69"
] |
icd9pcs
|
[
[
[]
]
] |
7925, 8021
|
3616, 6262
|
296, 705
|
8216, 8295
|
3422, 3559
|
6330, 7902
|
8042, 8195
|
6288, 6307
|
3574, 3593
|
2517, 2814
|
246, 258
|
733, 2498
|
2836, 3194
|
3210, 3406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,285
| 127,903
|
2131+55352
|
Discharge summary
|
report+addendum
|
Admission Date: [**2202-9-22**] Discharge Date: [**2202-10-2**]
Date of Birth: [**2142-3-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE/Pedal Edema
Major Surgical or Invasive Procedure:
[**2202-9-24**] - 1) Redo-Redo Sternotomy/AVR(21mm St. [**Male First Name (un) 923**] Tissue
valve)/ Ascending aorta replacement/Saphenous vein
(SVG)interposition graft between RIMA.
History of Present Illness:
Mrs. [**Known lastname 9907**] is a 60-year-old lady who in [**2195**] underwent an
ascending aortic tube graft replacement for an ascending aortic
aneurysm/dissection that was found to be circulytic in origin.
That was done with a 24-mm Gelweave graft at the time. In [**2196**],
she subsequently developed a pseudoaneurysm of the proximal
suture line and was re-operated on and the pseudoaneurysm was
resected and the
anastomosis at that point was repaired. She has been
experiencing worsening shortness of breath and was found to have
severe aortic insufficiency with 4+ aortic insufficiency and a
dilating left ventricle. The initial surgery mentioned the AV
suspension of the aortic valve. She also had a right internal
mammary artery graft at the time and underwent operation to the
distal right coronary artery that was transected and revised at
the time of the second operation. The preoperative
catheterization and imaging showed that the
right internal mammary artery crosses the midline and was in a
very tenuous location.
Past Medical History:
hypothyroidism
hypercholesterolemia
GERD
TIA
HTN
OA of the spine
s/p TAH
s/p aortic arch graft with CABG x1 complicated by superficial
wound infection in [**1-3**].
Social History:
Pt. lives with husband, and is retired. Quit smoking around the
time of her CABG. Minimal EtOH.
Family History:
Father died at age 67 of a ? aneurysm vs. MI. Mother is
deceased and had colon cancer & CAD s/p CABG.
Physical Exam:
64 SR 12 158/50 (R) 148/48 (L) 69" 200lbs
GEN: WDWN female in NAD
SKIN: Warm, dry, no C/C. Well healed sternotomy with some keloid
noted on scar.
HEENT: NCAT, PERRL, Anicteric sclera, OP benign. Teeth in good
repair.
NECK: Supple, no JVD
LUNGS: Clear
HEART: RRR, Nl S1-S2, I/VI Systolic and III/VI Diastolic murmur
ABD: S/NT/ND/NABS
EXT: TRace peripheral edema. Right groin incision well healed.
Pulses intact.
NEURO: Grossly intact
Pertinent Results:
[**2202-9-22**] 01:04PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2202-9-22**] 01:50PM WBC-7.8 RBC-4.65 HGB-13.5 HCT-40.3 MCV-87
MCH-29.0 MCHC-33.5 RDW-13.4
[**2202-9-22**] 01:50PM ALT(SGPT)-25 AST(SGOT)-25 LD(LDH)-208 ALK
PHOS-69 AMYLASE-85 TOT BILI-0.5
[**2202-9-22**] 01:50PM GLUCOSE-128* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-12
[**2202-9-22**] Carotid Ultrasound
Bilateral less than 40% ICA stenosis.
[**2202-9-22**] Cardiac Catheterization
1. Selective coronary angiography of this right-dominant system
revealed single-vessel coronary artery disease, patent
previously-placed
stents, and a patent single-vessel bypass graft. The LMCA had a
20%
distal stenosis. The LAD had a 30% proximal stenosis and a
widely
patent stent. The LCX had a 50% proximal stenosis and widely
patent
stents. The RCA was not injected as it is known to be
chronically
occluded. The RIMA-RPDA graft was without
angiographically-apparent
stenoses.
2. Resting hemodynamics revealed mildly elevated right- and
left-sided
filling pressures. Right-heart pressures included RA of
[**1-14**]/9, RV of
40/4 with RVEDP of 14, PA of 40/15/27, and PCWP of 18/16/15.
3. Supra-valvular aortography revealed severe aortic
regurgitation.
Aortic pressures were 142/42/81 and LV pressures were 142/8 with
an
LVEDP of 18.
4. LV-gram demonstrated diffuse hypokinesis with an estimated
LVEF of
47%.
[**2202-9-23**] CTA CHest
1. Patient is status post ascending aorta repair. No evidence of
aortic
dissection or pseudoaneurysm. Minimum calcification in the
aortic arch,
unchanged compared to prior study in [**2199-10-3**].
2. Marked emphysematous changes in the upper lobes, which
appears unchanged
compared to prior study in [**2199-10-3**].
3. 13-mm right hilar lymph node in creased in size from prior
study. Follow-up CT in 6 months is recommended to ensure
stability of this finding.
[**2202-9-24**] ECHO
Pre-CPB:
The left atrium and right atrium are normal in cavity size. No
mass/thrombus is seen in the left atrium or left atrial
appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
No masses or thrombi are seen in the left ventricle.
Overall left ventricular systolic function is mildly depressed .
The right ventricular cavity is mildly dilated with normal free
wall contractility.
The aortic root is moderately dilated at the sinus level. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
A bioprosthetic aortic valve prosthesis is present. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. Moderate to severe (3+) aortic regurgitation is
seen. The aortic regurgitation vena contracta is >0.6cm.
The mitral valve leaflets are moderately thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CBP:
The patient is AV-Paced on infusions of epinephrine and
milrinone.
An aortic tissue valve is well-seated with no leak and no AI.
R|V systolic fxn is moderately depressed.
LV systolic fxn is mildly depressed.
Aorta intact.
An aortic valve prothesis is visualized and is well seated
without central or paravalvular aortic regurgitation. There are
no other changes from the pre-CBP echocardiographic exam.
[**2202-9-26**] Lower Extremity U/S
No DVT in bilateral lower extremities. [**Hospital Ward Name **] cyst in the left
popliteal region.
Brief Hospital Course:
Mrs. [**Last Name (STitle) 11445**] was admitted to the [**Hospital1 18**] on [**2202-9-22**] for further
work-up in preparation of her redo-redo cardiac surgery. A
cardiac catheterization was performed which showed single vessel
disease and severe aortic regurgitation. A CT scan was performed
to evaluated her aorta in preparation for her surgery. As she
complained of a hoarse voice, the ENT service was consulted. No
significant abnormalities were found on fiberoptic exam and the
recommendation was to dose her proton pump inhibitor at a double
dose to promote laryngeal recovery from presumed regurgitation.
Lastly, in preparation for surgery, a carotid duplex ultrasound
was obtained which showed less then 40% internal artery stenosis
bilaterally. On [**2202-9-24**], Mrs. [**Known lastname 9907**] was taken to the operating
room where she underwent a redo-redo stenotomy with replacement
of her aortic valve using a tissue prosthesis, an ascending
aorta replacement and a saphenous vein interposition graft for
the right internal mammary artery graft. Please see operative
not for details. Postoperatively she was taken to the intensive
care unit for monitoring. Ciprofloxacin was started for
klebsiella which grew from urine culture. Diuresis was
initiated. She was slowly weaned form the ventilator and
extuubated on postoperative day three. Beta blockade was
initially held due to bradycardia. On postoperative day four,
she was transferred to the step down unit for further recovery.
She continued to be gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. She
complained of mild left upper extremity weakness however her
exam showed her strength to be [**6-7**] bilaterally. Her weakness
slowly resolved. Neurology consult was obtained for remaining
LUE fine motor deficit. It was recommended that the patient
continue aspirin and plavix and follow up as an outpatient for
MRI.
By the time of discharge to home on POD6 the patient was
ambulating freely, the wound was healing and the pain was
controlled with oral analgesics.
Medications on Admission:
asa 325', plavix 75'(last dose 8/18), lasix 20', valsartan 320',
HCTZ 25', lopressor 50''', crestor 40', zetia 10', amlodipine
10', synthroid 175, prn NTG, MVI, clonazepam 2 prn, estrace
Discharge Medications:
1. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
AI/MR s/p Redo-Redo AVR/Ascending aorta replecement/SVG jump
graft from RIMA to RIMA.
CHF
CAD
h/o aortic dissection
HTN
Prior TIA
Hypothyroid
Syphilitic aortitis
h/o colitis
anxiety
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.
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 Dr. [**First Name (STitle) 1395**] in [**3-7**] weeks. [**Telephone/Fax (1) 2205**]
Dr. [**Last Name (STitle) **] (stroke neurologist),([**Telephone/Fax (1) 11446**]
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2202-11-23**] 2:20
Completed by:[**2202-10-1**] Name: [**Known lastname 1610**],[**Known firstname 2**] G. Unit No: [**Numeric Identifier 1611**]
Admission Date: [**2202-9-22**] Discharge Date: [**2202-10-2**]
Date of Birth: [**2142-3-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 741**]
Addendum:
As per Neuro reccommendations: prior to discharge Mrs. [**Known lastname **]
went for a brain MRI to evaluate any acute events post op. As
discussed with neurology on day of discharge [**2202-10-2**], a
preliminary report or wet read indicates a right acute
subcortical infarct in the posterior/frontal region. Neuro
recommendations are to continue with antiplatlet agents and
allow blood pressure to autoregulate. This information was
discussed with Dr.[**Last Name (STitle) **] and he cleared the patient for
discharge on POD# 7. Occupational therapy has instructed
Mrs.[**Known lastname **] on exercises to perform with her left upper
extremity.
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 1612**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2202-10-2**]
|
[
"401.9",
"041.3",
"272.0",
"414.01",
"V12.54",
"434.91",
"093.1",
"V45.81",
"424.1",
"530.81",
"428.0",
"599.0",
"427.89",
"721.90",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.63",
"99.04",
"37.23",
"88.53",
"35.21",
"39.61",
"88.42",
"88.72",
"88.56",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12573, 12762
|
6108, 8251
|
290, 475
|
10311, 10318
|
2434, 6085
|
11060, 12550
|
1859, 1964
|
8488, 9997
|
10106, 10290
|
8277, 8465
|
10342, 11037
|
1979, 2415
|
235, 252
|
503, 1538
|
1560, 1727
|
1743, 1843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,529
| 139,934
|
36150
|
Discharge summary
|
report
|
Admission Date: [**2198-11-24**] Discharge Date: [**2198-11-29**]
Date of Birth: [**2125-2-2**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Visual disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Difficult to get the history, Mr [**Known lastname 81983**] is only alert and
oriented X2 at baseline. I tried calling his wife, with whom I
spoke to, unfortunately, she is deaf. However, from what little
I could piece together, she mentioned that her husband had a
headache, and that he had double vision around 15:30 h and kept
bumping into things on the right.
Past Medical History:
Hyperlipidemia
An MRI scan of the brain in [**2196**] (copy sent to the ED) showed
multiple hemorrhages, and he was diagnosed with amyloid
angiopathy - he had left occipital hemorrhages
Seizures
Residual left hemiparesis
Melanoma excision
Basal Cell cancer excision
Social History:
Lives with his wife, retired [**Name2 (NI) 31869**], they have a son. Habits not
known.
Family History:
not known
Physical Exam:
T-98.2 BP-134/84 HR-64 RR-16 O2Sat 100% on room air
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake, confused, cooperative with exam, kept
closing his eyes. Oriented to person, but not place or date.
Not attentive. Speech is fluent but makes many paraphrasic
errors. Cannot read, write. Registers [**2-26**], recalls 0/3 in 5
minutes. Neglects things on the right side of his vision.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Dense right temporal visual field deficit, also
appears to have difficulty seeing things in the left visual
field. Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. Arms and legs are
antigravity, but could not understand any of the commands for
motor testing.
Sensation: appears to have intact light touch, pinprick.
Reflexes:
+2 on the right and 2 on the left and symmetric throughout.
Toes upgoing bilaterally
Coordination: could not understand what to do.
Gait: not assessed under the circumstances.
Pertinent Results:
[**2198-11-23**] CThead
Large right occipital hemorrhage with local mass effect and
without midline shift. Extensive chronic microvascular disease.
No interval change in the CThead scan from [**11-24**]
[**2198-11-24**] 07:00PM BLOOD WBC-9.6 RBC-4.38* Hgb-13.2* Hct-37.0*
MCV-85 MCH-30.2 MCHC-35.7* RDW-13.1 Plt Ct-190
[**2198-11-24**] 07:00PM BLOOD Neuts-79.2* Lymphs-14.8* Monos-4.6
Eos-0.9 Baso-0.4
[**2198-11-24**] 07:00PM BLOOD PT-13.6* PTT-28.6 INR(PT)-1.2*
[**2198-11-24**] 07:00PM BLOOD Glucose-94 UreaN-17 Creat-1.4* Na-139
K-3.5 Cl-103 HCO3-27 AnGap-13
[**2198-11-24**] 07:00PM BLOOD CK(CPK)-74
[**2198-11-25**] 02:30AM BLOOD ALT-8 AST-17 CK(CPK)-57 AlkPhos-54
[**2198-11-25**] 12:22PM BLOOD CK(CPK)-61
[**2198-11-24**] 07:00PM BLOOD cTropnT-<0.01
[**2198-11-25**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-11-25**] 02:30AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8 Cholest-112
[**2198-11-24**] 07:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2198-11-24**] 07:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR
[**2198-11-24**] 07:20PM URINE RBC-0-2 WBC-[**11-15**]* Bacteri-FEW Yeast-RARE
Epi-0-2 TransE-0-2
UCx [**11-26**]: <10,000 orgs
BCx [**11-26**] & [**11-27**]: NGTD
Brief Hospital Course:
Mr [**Known lastname 81983**] was admitted overnight to the SICU, and he did not
require a drip containing antihypertensive medication. Serial
head CT's revealed his bleed to be stable. He was transferred to
the neuorlogy floor where his course was complicated by a
transient fever and elevated WBC count that was thought to be
due to a UTI as he had [**11-15**] WBC's/hpf in his urine. He was
started on Ceftriaxone, however a urine culture grew < 10,000
col/mL and therefore his Abx were discontinued. On transfer to
rehab, he continues to have left weakness in the 2-3 range
throughout and left neglect and poor attention in general.
His ICH was felt to be likely related to amyloid angiopathy
given the presence of multiple microbleeds on an earlier MRI of
the brain. However, we elected to schedule him for a repeat MRI
with gadolinium in [**4-1**] weeks to r/o the remote possibility of an
underlying mass given his history of melanoma.
Medications on Admission:
Allopurinol 100 daily
Keppra 1000 [**Hospital1 **]
Simvastatin 20 bedtime
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for T>100.4 or pain.
5. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed for seizures.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis:
Right occipito-parietal intracerebral hemorrhage, likely
secondary to amyloid angiopathy
Secondary diagnosis:
Hyperlipidemia
Seizures
Residual left hemiparesis
Melanoma excision
Basal Cell cancer excision
Discharge Condition:
Large right temporal field deficit, left hemiparesis
Discharge Instructions:
You have had another hemorrhagic stroke (R parietal occipital
lobe). You should go to your nearest emergency room should you
experience the following: further problems with your vision,
sudden onset weakness or speech/language difficulties.
Please refrain from taking aspirin or other anti-platelet agents
as you are prone to intracranial bleeds.
Please take medications as prescribed.
Please keep your follow-up appointments.
Followup Instructions:
[] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28528**], MD Phone: ([**Telephone/Fax (1) 81984**]
Date/Time: [**2198-12-5**] 11:30AM
[] Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 77121**], MD (Neurologist) Phone: [**Telephone/Fax (1) 81985**]
Please follow-up with your outpatient neurologist within [**2-27**]
weeks of discharge.
[] Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD ([**Hospital 18**] [**Hospital 4038**] Clinic) Phone:
[**Telephone/Fax (1) 2574**]
Date/Time: [**2199-1-29**] 2:30pm
Please call to update your information prior to your
appointment.
[] Follow-up MRI brain with and without contrast Phone:
[**Telephone/Fax (1) 327**]
Date/Time: Before [**2199-1-27**]
Call to schedule your MRI brain to be completed before [**1-26**], [**2198**].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2198-11-29**]
|
[
"431",
"342.90",
"272.4",
"277.30",
"345.90",
"V10.83",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5535, 5632
|
4035, 4981
|
336, 343
|
5902, 5957
|
2740, 4012
|
6435, 7418
|
1148, 1159
|
5105, 5512
|
5653, 5653
|
5007, 5082
|
5981, 6412
|
1174, 1530
|
278, 298
|
371, 737
|
1880, 2721
|
5784, 5881
|
5673, 5763
|
1569, 1864
|
1554, 1554
|
759, 1026
|
1042, 1132
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,740
| 178,624
|
33261
|
Discharge summary
|
report
|
Admission Date: [**2103-9-6**] Discharge Date: [**2103-9-10**]
Date of Birth: [**2026-4-10**] Sex: M
Service: MEDICINE
Allergies:
Zithromax / Erythromycin Base
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Melena and hypotension
Major Surgical or Invasive Procedure:
Upper Endoscopy
Duodenal ulcer biopsy and cauterization
History of Present Illness:
This is a 77 yo M with h/o DM II, dementia, HTN, COPD, and
recent admission for cellulitis on Levo/Flagyl/Bactrim who
presents from Nursing home with melena and hypotension. Patient
reports one episode of melena yesterday which he describes as
black loose stool. He denies any hematochezia, BRBPR, bloody or
coffee ground emesis, abdominal pain, fevers, or chills. He
does reports some nausea. Per report at his nursing home, BPs
were noted to be in the 70s along with decreased HCT so he was
transferred to [**Hospital1 18**].
In the ED: Temp 97.7, HR 83, BP 116/60. Patient was given 1u
PRBC, NG lavage showed coffee ground emesis which cleared with
200cc lavage.
On arrival to the SICU, patient denies diarrhea, melena,
abdominal pain, bloody emesis, coffee ground emesis.
Otherwise ROS negative.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Type 2 diabetes.
3. Chronic renal impairment.
4. Peripheral vascular disease s/p stent to left SFA, s/p
therectomy and PTA of the right
5. Atrial fibrillation.
6. Hyperlipidemia.
7. Chronic obstructive pulmonary disease.
8. [**Last Name (un) 309**] body dementia.
9. CAD s/p stents on Plavix
Social History:
Currently lives in Stone [**Hospital3 **] home. He continues to
smoke at least one pack of cigarettes a day. Denies etoh use,
h/o IVDU.
Family History:
Not obtained
Physical Exam:
VS: BP 115/69 HR 91 RR 12 95% RA
GEN: AAO X 3, lethargic, responds to verbal stimuli
HEENT: EOMI, PERRLA, dry mucous membranes, OP clear
NECK: Supple, no JVD appreciated
CV: normal S1, S2. irregularly irregular. no m/r/g appreciated
CHEST: +minor crackles at bilateral bases, +mild expiratory
wheezes
ABD: Soft, NT, ND, no HSM, normoactive BS
EXT: no peripheral edema, +1 distal pulses
SKIN: erythema noted over bilateral lower shins, warm to touch,
several overlying healing skin ulcers, no pus.
Rectal: +small amount black stool, guaiac +, +stage 2 ulcer of
superior buttocks
Pertinent Results:
STUDIES:
.
[**2103-8-31**] 4:19 pm SWAB Source: R anterior LE.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Please contact the Microbiology Laboratory ([**7-/2401**])immediately
if
sensitivity to clindamycin is required on this patient's
isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
alsoRESISTANT to other penicillins, cephalosporins,
carbacephems,carbapenems, and beta-lactamase inhibitor
combinations. Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
[**2103-9-6**] 01:25AM WBC-11.9* RBC-3.11* HGB-9.1*# HCT-29.1*
MCV-94 MCH-29.4 MCHC-31.4 RDW-14.0
[**2103-9-6**] 01:25AM NEUTS-74.7* LYMPHS-18.8 MONOS-5.4 EOS-0.8
BASOS-0.3
[**2103-9-6**] 01:25AM PLT COUNT-449*#
[**2103-9-6**] 01:25AM PT-15.6* PTT-25.6 INR(PT)-1.4*
[**2103-9-6**] 01:25AM ALT(SGPT)-23 AST(SGOT)-25 ALK PHOS-83 TOT
BILI-0.3
[**2103-9-6**] 01:25AM GLUCOSE-86 UREA N-51* CREAT-1.0 SODIUM-138
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-10
[**2103-9-6**] 01:31AM HGB-9.8* calcHCT-29
[**2103-9-6**] 05:45AM HGB-9.3* HCT-28.0*
[**2103-9-6**] 08:39AM HGB-10.0* calcHCT-30
Brief Hospital Course:
77 yo M with h/o CAD, DM II, PVD, COPD, cellulitis, who
presented with melena and hypotension, and underwent
embolization after duodenal ulcers were identified.
# Melena: Patient with melena x 1, along with hypotension at
nursing home and HCT drop from 37.3 on [**9-1**] to 29.1. GI was
consulted. GI performed an EGD on the morning of [**9-7**], which
showed 2 duodenal ulcers, cauterized. Pt was initially
transfused 1 unit PRBCs in emergency department. Hct was 28,
stable at 29.9-30 while on MICU service. Pt. was treated with
PPI IV BID. BP meds were held. After discussion with GI,
decision was made to continue plavix given pt's CAD s/p stents,
but ASA was decreased from 325 to 81 mg. Pt should discuss
resumption of full dose ASA with his PCP.
# Hypotension: Likely in setting of UGIB, was hemodynamically
stable in MICU. Hct stable as above. Did not require fluid
boluses while on MICU service or on floor. Generally maintained
good pressures 110-122 systolic while on floor. The patient was
discharged on Metoprolol Succinate 100 mg Tablet Sustained
Release one per day.
# Cellulitis: Patient with recent discharge for cellulits, on
Bactrim/Levo/Flagyl PO. These antibiotics were discontinued as
the wound culture showed resistance, and patient was started on
Vanco IV for 14 days first dose [**2103-9-6**].
# CAD s/p stents - Pt s/p PCI of LAD in [**6-/2103**] with 2 Bare Metal
Stents. Plavix continued and ASA decreased to 81 mg as above.
In the context of his hypotension on presentation, his home
ACEi, BB, and statin were initially held. Metoprolol was later
introduced. We advise that the patient's PCP consider
[**Name9 (PRE) 18290**] his ACE-I as outpatient if pressures remain stable.
# COPD: Patient lethargic on arrival, on O2. O2 stopped, ABG
taken, hypoxic to 89% transiently which improved immediately.
ABG 7.39/49/68. Lethargy likely [**2-24**] to lack of sleep. His
tiotropium was continued, and albuterol nebs were ordered.
# DM II - Pt continued on half dose NPH while NPO.
# Atrial fibrillation - Hx of afib, not on coumadin. Continued
on ASA 81mg as above. When patient was NPO, he was continued on
Digoxin IV and his digoxin level was checked. As above, his
beta blocker was held, and restarted at the end of his course
with good results. Patient should discuss restarting Coumadin
with PCP after GI tract has had some time to heal.
# PVD - History of SFA stent: Continued plavix, decreased ASA
dose as above.
# Dementia - Held aricept, paroxetine while NPO, these were
reintroduced at the end of his course.
# Sacral Ulcer: Pt was seen by wound care. Wound was dressed
with wet to dry dressings.
Medications on Admission:
Bactrim 80-400mg 2tabs PO BID
Levofloxacin 500mg daily
Flagyl 500mg TID
Insulin Sliding Scale
NPH 36u SQ [**Hospital1 **]
Furosemide 20mg daily
Digoxin 125mcg daily
Lisinopril 20mg daily
Toprol XL 150mg daily
MVI
Paroxetine 10mg qAM
Plavix 75mg daily
Spiriva 18mcg capsule daily
Thiamine 1 tab daily
Aricept 10mg daily
Simvastatin 40mg daily
Trazodone 37.5mg daily
ASA 325mg daily
Bisacodyl 10mg supp PRN
Simethicone 30mg q6h PRN
Milk of Magnesia 30mg daily PRN
Acetaminophen PRN
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-24**] Inhalation Q6H (every 6 hours) as needed.
Disp:*120 * Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
6. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. 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*
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*7 * Refills:*0*
15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous per sliding scale: According to sliding scale.
Disp:*30 * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Bleeding duodenal ulcer
Lower extremity ulcers and cellulitis
Chronic atrial fibrillation
Stable coronary artery disease
Chronic systolic heart failure
Diabetes type 2, controlled, with complications
Hyperlipidemia
Chronic obstructive pulmonary disease
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as prescribed. Please note that
you will need to complete a 7 day course of IV vancomycin
adminstered through the PICC line.
Please return for fever, chest pain, shortness of breath,
shaking chills, blood in urine or stool, non-healing wounds or
ulcers, or any other concerning symptom.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] at [**Telephone/Fax (1) 10688**] within 24
hours to make an appointment to take place withint the next
week. Please ask her to review your medications with you, as
well as follow-up on those issues addressed during this
hospitalization.
Please see Dr. [**Last Name (STitle) **] (Phone:[**Telephone/Fax (1) 62**]) on [**2103-9-18**] 9:30
Please see [**Doctor First Name **] [**Doctor Last Name **], DPM (Phone:[**Telephone/Fax (1) 543**]) on [**2103-11-22**]
10:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2103-9-9**]
|
[
"682.6",
"250.00",
"428.22",
"285.1",
"585.9",
"532.40",
"440.23",
"294.10",
"707.03",
"427.31",
"496",
"707.12",
"414.01",
"272.4",
"331.82",
"V45.82",
"403.90",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9106, 9175
|
3995, 6652
|
313, 371
|
9484, 9491
|
2370, 2442
|
9861, 10607
|
1739, 1753
|
7182, 9083
|
9196, 9463
|
6678, 7159
|
9515, 9838
|
1768, 2351
|
251, 275
|
2477, 3972
|
399, 1209
|
1253, 1567
|
1583, 1723
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,421
| 126,319
|
7684
|
Discharge summary
|
report
|
Admission Date: [**2167-8-19**] Discharge Date: [**2167-8-25**]
Date of Birth: [**2094-6-13**] Sex: M
Service: MEDICINE
Allergies:
Ancef
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
1. esophagogastroduodenoscopy (EGD)
2. colonoscopy
3. blood transfusion
History of Present Illness:
73 yr old male with hx of CAD s/p recent ant MI with stent [**5-12**],
CHF, EF of 35% and a hx of GIB in [**2162**] who presents to the ED
with BRBPR. During the night prior to admission, pt had three
liquid bowel movements consisting of dark liquid with some
bright red blood and blood noted on the toilet paper. He denies
chest pain, abd pain, nausea but does have mild dizziness. Of
note, pt had an anterior MI with stent placement in [**5-12**] and
thus has been on ASA and plavix. When pt had a GIB in [**2162**], his
ASA was d/c'd. EGD at that time showed a duodenal ulcer and some
erosions while a colonoscopy showed only diverticula.
.
In [**Last Name (LF) **], [**First Name3 (LF) **] NG lavage was done and was negative though no bile
return noted either. Pt had 3 large bloody bowel movements in
the ED but remained hemodynamically stable. His hct was 31 and
he was tranfused one unit of PRBCs. He was also given one liter
of NS. GI evaluated the patient and brought him the endoscopy
suite for an EGD. Nothing was seen on EGD but after more
hematochezia (last episode ~6 p.m.), it was determined that the
pt was too unstable for the floor given that the source of the
bleed was still unknown and he was admitted to the MICU. In MICU
had been transfused 2U PRBCs since admission [**8-19**], remained HD
stable, has started Golytely prep and is still not clear, so he
will go for colonoscopy [**8-21**].
Past Medical History:
1. CHF EF 15%
2. CAD s/p CABG and stent placement in [**5-12**]
3. HTN
4. h/o GIB in [**2162**]
Social History:
Lives with wife, denies current tobacco use, EtOH use or IVDU.
Family History:
NC
Physical Exam:
On transfer from MICU
.
Tc 97.1, pt o/w afebrile BP 150-160/70s HR 58-65 RR 20, Sats
99RA. I/O not recorded since last evaluation.
Gen: elderly male, NAD
HEENT: PERRL, EOMI, anicteric, pale conjunctiva, MMM, OP clear
Neck: JVP at 10 cm, neck supple, no cervical lymphadenopathy
CV: RRR, 2/6 systolic murmur at RUSB heard earlier but not
appreciated on this encounter
Chest: CTAB with no crackles or wheeze, good air movement
throughout.
Abd: Obese, +BS, soft, NT/ND, no HSM
Ext: trace edema, warm, no palpable DP/PT but dopplerable this
AM
Pertinent Results:
[**2167-8-19**] 11:49PM CK(CPK)-40
[**2167-8-19**] 11:49PM CK-MB-NotDone cTropnT-<0.01
[**2167-8-19**] 11:49PM HCT-29.4*
[**2167-8-19**] 08:09PM HCT-31.8*
[**2167-8-19**] 11:30AM GLUCOSE-94 UREA N-59* CREAT-1.9* SODIUM-144
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-25 ANION GAP-15
[**2167-8-19**] 11:30AM CK-MB-3 cTropnT-0.01
[**2167-8-19**] 11:30AM WBC-9.3 RBC-3.36* HGB-10.7* HCT-31.0* MCV-92
MCH-31.9 MCHC-34.6 RDW-15.1
Brief Hospital Course:
1. Gastrointestinal bleed, presumed small bowel: As detailed
predominantly in HPI.
In ED on admission, pt had an NG lavage which was negative,
though no bile return noted either. Pt had 3 large bloody bowel
movements in the ED but remained hemodynamically stable. His hct
was 31 and he was tranfused one unit of PRBCs. He was also given
one liter of NS. GI evaluated the patient and brought him the
endoscopy suite for an EGD. EGD unrevealing. Once transferred
from the MICU to the floor, colonscopy demonstrated colonic
diverticula that had been noted on a prior study, but was
otherwise unremarkable. Pt's hematocrit continued to slowly
fall, though he remained HD stable. Angiography performed
[**2167-8-21**] showed small blush of tracer activity in the right upper
quadrant which does not persist. It was unclear whether this
represents bleeding into the large bowel, in the region of the
hepatic flexure, or into the small bowel. It was interpreted as
"weakly positive", though there was no intervention deemed to be
necessary based on this study. The patient continued to have
some melenic stool with small hct drops, though was HD stable
throughout his hospitalization after transfer to the medicine
floor. He received multiple blood transfusions to maintain hct
>30. As pt had remained HD stable >4 days despite small hct
drop, and no intervention was indicated based on available data,
pt was discharged in good condition with instructions to follow
up for hct checks, as well as for possible further GI
intervention.
.
2. Diverticuli: Stable throughout admission.
.
3. Coronary artery disease: Stable throughout admission.
Decision was made by attending physician to hold ASA and Plavix
in light of continued bleeding. Pt was discharged with
instructions to hold Plavix until speaking again with PCP
[**Name Initial (PRE) **].
.
4. HTN: remained stable. Pt maintained on home regimen as BP
tolerated.
Medications on Admission:
LASIX 40MG--2 tabs in in the morning and [**2-8**] in eve
QUININE SULFATE 260MG--At bedtime
RANITIDINE HCL 150MG--Qd-[**Hospital1 **] as needed for upset stomach
ALLOPURINOL 100 mg--1 tablet(s) by mouth every other day
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
DIOVAN 80 mg--1 tablet(s) by mouth once a day
ISOSORBIDE DINITRATE 10 mg--1 tablet(s) by mouth three times a
day
LIPITOR 80 mg--1 tablet(s) by mouth once a day
PLAVIX 75 mg--1 tablet(s) by mouth once a day
TOPROL XL 25 mg--[**2-8**] tablet(s) by mouth once a day
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Pantoprazole Sodium 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*
6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet
Sustained Release 24HR PO once a day.
7. Lasix 40 mg Tablet Sig: Two (2) Tablet PO qAM.
8. Lasix 40 mg Tablet Sig: 1-2 Tablets PO qPM.
9. Outpatient Lab Work
[**9-1**]: Hct
Please have results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 771**], fax # is ([**Telephone/Fax (1) 16691**]. The phone
number is ([**Telephone/Fax (1) 1300**] if needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. gastrointestinal bleed, presumed small bowel
2. diverticuli
Secondary:
1. coronary artery disease
2. hypertension
Discharge Condition:
stable, tolerating po, stable hematocrit, no further BRBPR
Discharge Instructions:
To patient: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
.
If you notice more bright red blood in the stool, or if you feel
dizzy, lightheaded, or weak, call your primary care doctor or go
to the emergency room.
.
Your aspirin and Plavix have been stopped for now. Please do
not take these medications until you are instructed to restart
them. If your blood count is stable when tested next week, Dr.
[**First Name (STitle) **] may tell you to restart these medications.
Followup Instructions:
To patient: You need to have your blood drawn in 1 week. Please
have these results faxed to Dr.[**Name (NI) 17410**] office.
.
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-21**]
11:40
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2167-10-13**] 10:30
|
[
"V45.81",
"496",
"401.9",
"398.91",
"274.9",
"414.8",
"272.0",
"562.10",
"396.3",
"578.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6497, 6503
|
3044, 4960
|
271, 348
|
6677, 6737
|
2587, 3021
|
7339, 7919
|
2007, 2011
|
5540, 6474
|
6524, 6656
|
4986, 5517
|
6761, 7316
|
2026, 2568
|
226, 233
|
376, 1792
|
1814, 1911
|
1927, 1991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,222
| 168,766
|
54052
|
Discharge summary
|
report
|
Admission Date: [**2142-5-1**] Discharge Date: [**2142-5-2**]
Date of Birth: [**2113-10-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Collapse
Major Surgical or Invasive Procedure:
Endotracheal intubation and mechanical ventilation
History of Present Illness:
25 M who was reportedly drinking while he was at work when he
suddenly collapsed. EMS was called and the pt was found to be
unresponse in the field with normal vitals, normal FS. Initial
GCS 4 with some deviation of gaze to right, PERRL.
.
In the ED, was noted to have some diconjugate gaze so a head CT
was performed which was negative.
.
Vital sings in the ED: 85 115/70 The patient was intubated for
airway protection. Currently 100% on FiO2 40%.
.
Labs in the ED significant for EtOH level 495. Urine tox screen
otherwise negative.
.
ROS: Unable to obtain.
Past Medical History:
None
Social History:
Reports drinking on average 2 beers/day. Day prior to admission
had 12 beers. Denies illicit drug use. Works at the Cheesecake
Factory.
Family History:
NC
Pertinent Results:
ADMISSION LABS:
[**2142-5-1**] 06:20PM BLOOD WBC-9.6 RBC-5.46 Hgb-16.5 Hct-50.6 MCV-93
MCH-30.3 MCHC-32.7 RDW-12.7 Plt Ct-360
[**2142-5-1**] 06:20PM BLOOD PT-10.3 PTT-28.4 INR(PT)-0.9
[**2142-5-1**] 06:20PM BLOOD Fibrino-221
[**2142-5-1**] 06:20PM BLOOD UreaN-7 Creat-0.6
[**2142-5-1**] 06:20PM BLOOD Lipase-43
[**2142-5-1**] 06:20PM BLOOD ASA-NEG Ethanol-495* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-5-1**] 06:26PM BLOOD Glucose-105 Lactate-2.0 Na-149* K-3.8
Cl-108 calHCO3-23
[**2142-5-1**] 06:26PM BLOOD Hgb-17.0 calcHCT-51
IMAGING:
CXR: Endotracheal tube ends 2 cm above the carina. Nasogastric
tube
ends in the stomach. Clear lungs.
CT Head w/o contrast: No acute intracranial process
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
28 M with no past medical history who was found unresponsive at
work with alcohol intoxication.
ACUTE DIAGNOSES:
# Alcohol Intoxication: The patient was intubated in the field
for GCS 4 and inability to protect airway. He was admitted to
the ICU where he taken off sedation and subsequently extubated
several hours after admission. His alcohol level was 495 on
admission. Urine Tox screen was negative. The patient was
interviewed with a phone interpreter and denied co-ingestions.
He denied suicidality. Social work evaluated the patient and
offered out pt services.
# Hypernatremia: Sodium 149 on admission. Attributed to free
water deficit. The patient's free water deficit was treated
with D5W and his sodium trended down to normal.
# Transitional: The pt was instructed to follow up with his
primary care physician.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. [**Known lastname 47766**],
You were admitted to the [**First Name (Titles) **] [**Last Name (Titles) **]
care unit after you were found unresponsive at work. You were
drinking a large amount of alcohol, and this caused you to
become unresponsive and not able to protect your airway. In the
emergency department, you had a breathing tube placed to help
you breathe, until you were more alert and could start breathing
on your own again. It is very dangerous to continue drinking
this much alcohol, and if you continue to drink this much you
will endanger your life.
In the ICU, we were able to remove the breathing tube, and you
did well. We gave you IV fluids and vitamins.
While you were here we had our social work and addiction
specialist evaluate you for excessive alcohol use.
MEDICATION INSTRUCTIONS:
- Medications ADDED: None.
- Medications STOPPED: None.
- Medicatins CHANGED: None.
Followup Instructions:
Please follow-up with your primary care doctor.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"980.0",
"780.01",
"E860.0",
"305.01",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
2862, 2868
|
1918, 2778
|
312, 365
|
2933, 2933
|
1184, 1184
|
4018, 4194
|
1161, 1165
|
2833, 2839
|
2889, 2912
|
2804, 2810
|
3084, 3885
|
264, 274
|
393, 961
|
1201, 1895
|
3910, 3995
|
2948, 3060
|
983, 989
|
1005, 1145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,697
| 179,815
|
48259
|
Discharge summary
|
report
|
Admission Date: [**2160-10-21**] Discharge Date: [**2160-10-24**]
Date of Birth: [**2085-10-31**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] was a
74-year-old man with diabetes, known history of coronary
artery disease, status post LAD stent in [**2157**] who was
admitted to the CCU after cardiac catheterization, no PCI,
showing three vessel disease. The patient reported to [**Hospital3 6265**] on the day of admission with complaint of chest
discomfort and shortness of breath. The patient has a
baseline expressive dysphagia, but was able to communicate
the fact that he had chest pain, diaphoresis, dyspnea.
At [**Hospital3 3583**], the patient was noted to have ST
depressions in leads I, aVL, V3 through V6. Cardiac enzymes
revealed a troponin of 34.6, and a CK of 1,428. The patient
was put on a heparin drip, nitroglycerin drip, and
transferred to the [**Hospital1 18**] for cardiac catheterization. Prior
to transfer, it was noted that the patient had a recent rise
in his baseline creatinine from 1 to 2.0.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Diabetes mellitus.
3. Hypertension.
4. Small vessel cerebrovascular accident in [**2159-4-18**] with
residual expressive dysphagia.
5. Depression.
6. Head injury in [**2126**] with two seizures.
7. Gastroesophageal reflux disease.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Norvasc.
2. Glyburide.
3. Protonix.
4. Zoloft.
5. Lopressor.
6. Plavix.
7. MVI.
8. Folate.
9. Hydrochlorothiazide.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 109/56, heart rate 95, respiratory rate 21, 02
saturation 96% on 5 liters. Pulmonary artery pressures
56/28. General: The patient was alert, oriented, in no
apparent distress. He had some difficulties with verbal
expression. HEENT: Moist mucous membranes, EOMI, oropharynx
clear. Neck: No lymphadenopathy appreciated on examination.
Normal thyroid. JVD approximately 10 cm. Lungs: Coarse
throughout, rales at bases bilaterally. Cardiovascular:
Difficult to assess examination given the patient's loud lung
sounds. No murmurs, rubs, or gallops appreciated on
examination. Abdomen: Soft, nontender, nondistended.
Extremities: No clubbing, cyanosis or edema.
HOSPITAL COURSE: The patient was taken for cardiac
catheterization given his elevated troponins and history of
chest pain and dyspnea. The cardiac catheterization revealed
moderately elevated right and left-sided filling pressures
with a pulmonary capillary wedge pressure of 25. Three
vessel coronary artery disease. Moderate diastolic
dysfunction. After careful consideration, a consensus
decision was made not to stent any of the patient's coronary
artery lesions. In addition, he was given 40 mg of IV Lasix
for his elevated pulmonary capillary wedge pressure. He was
then transferred to the Cardiac Care Unit for further
management.
There, he was evaluated by the team and noted to be in
respiratory distress. A chest x-ray was obtained which
showed frank pulmonary edema. He was thus diuresed with IV
Lasix. The patient produced only moderate amounts of urine
to the diuretic. An ABG was obtained which showed a pH of
7.31, PC02 40, P02 of 86. The patient was felt to be
relatively stable with respect to his pulmonary function and
thus was not intubated.
That night, the patient had additional episodes of
respiratory distress. He was treated with IV nitroglycerin
drip, morphine, and Lasix. On this regimen, the patient's
dyspnea resolved; however, the following day, the patient
again had additional episodes of dyspnea. Chest x-ray was
again obtained which showed increased pulmonary edema. This
was thought to likely be secondary to ischemic cardiogenic
shock. The patient was thus started on dopamine and
dobutamine.
The following day, these medications were weaned off and the
patient was maintained on oxygen via nasal cannula and CPAP
during his episodes of respiratory distress. Again, the
patient was not intubated. The patient's creatinine
continued to rise during his admission. Thus, a Renal
consult was obtained. In the setting of worsening renal
function the patient also became slightly acidotic with a pH
of 7.27. It was felt that the patient was becoming volume
overloaded and would likely benefit from hemodialysis.
A discussion was had with the family about the possibility of
hemodialysis with regards to the patient's code status. The
patient's family stated that they would need an additional
hour to make a decision on these matters. During this time,
the patient had a large bowel movement and dropped his blood
pressure with a systolic blood pressure in the 60s. Shortly
thereafter the patient then coded. At that time, the
patient's family stated that they would like the patient to
be DNR/DNI. Thus, no further interventions were attempted.
The patient then passed away.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 9719**]
MEDQUIST36
D: [**2160-10-24**] 11:10
T: [**2160-10-25**] 10:17
JOB#: [**Job Number 101680**]
|
[
"276.2",
"414.01",
"785.51",
"V45.82",
"410.71",
"428.0",
"250.00",
"424.0",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"00.13",
"37.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
2331, 5212
|
1448, 1597
|
1612, 2313
|
1101, 1425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,413
| 160,275
|
39678
|
Discharge summary
|
report
|
Admission Date: [**2142-9-3**] Discharge Date: [**2142-9-6**]
Date of Birth: [**2077-8-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
cardiac tamponade s/p pericardiocentesis with drain placement
Major Surgical or Invasive Procedure:
pericardial tap and drain placement
History of Present Illness:
The patient is a 65 y/o female with PMHx lung cancer (unknown
type) stage IIIB, prior PE, bilateral DVT with IVC filter who
presents to the CCU s/p pericardiocentesis with pericardial
drain placement.
The patient was in her usual state of health until [**9-1**], when
she woke up feeling "lousy." She felt fatigued, had several
episodes of NB/NB vomiting with crampy abdominal pain with some
diarrhea. She also noted dyspnea on exertion. This progressed
to dyspnea even at rest. On the morning of [**9-3**], she went to her
PCP's office who then sent her to the ED. At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], she
had a CT A/P with contrast. The read there was suggestive of
saddle pulmonary embolus and she was sent to [**Hospital1 18**] for further
management.
.
On review of systems, she denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
.
In the ED, initial vitals were Temp:98.7 HR:124 BP:124/68
Resp:20 O(2)Sat:98. The patient's CT scan was reviewed by [**Hospital1 18**]
radiologists who did not agree with the diagnosis of PE as they
felt that the pulmonary arteries were very poorly opacified.
They also noted a large pericardial effusion. Interventional
Cardiology performed a bedside echo which seemed to raise the
possibility of tamponade. The patient then started to become
hypotensive, with pressures dropping to the 80s and 90s. IC
decided to take the patient to the cath lab for a percutaneous
pericardiocentesis. The patient received one unit of FFP in the
ED prior to procedure.
.
In the cath lab, the patient had ~600cc of fluid drained with a
pericardial drain placed. She was transferred to the CCU in
stable condition.
Currently, she complains of [**9-4**] pleuritic chest pain that
worsens with deep breaths and movement. It is improved with
leaning forward. She received morphine 2mg IV which lowered the
pain to a [**2142-4-30**].
Past Medical History:
Stage IIIB lung adenoca s/p chemo/radiation finished [**9-3**].
Supposedly stable disease per patient.
Bilateral DVTs (failed coumadin, lovenox)
Prior PE (DVTs progressed to PE, b/l subsegmental)
IVC filter
moderate COPD (FEV1 70%)
radiation pneumonitis
Social History:
-Tobacco history: [**1-27**] ppd for 35years, quit 14 years ago
-ETOH: occasional beer on weekends
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father with
HTN.
Physical Exam:
On Admission:
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 4 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTA bilaterally
ABDOMEN: Soft, obese. NTND. No HSM or tenderness. +bowel sounds
EXTREMITIES: trace edema bilateral lower extremities to feet. 2+
DP/PT pulses
Pertinent Results:
[**2142-9-3**] 08:00PM OTHER BODY FLUID TOT PROT-5.5 GLUCOSE-18
LD(LDH)-588 AMYLASE-47 ALBUMIN-3.6
[**2142-9-3**] 08:00PM OTHER BODY FLUID WBC-1100* RBC-[**Numeric Identifier 87449**]*
POLYS-1* LYMPHS-11* MONOS-10* OTHER-78*
[**2142-9-3**] 04:50PM GLUCOSE-118* UREA N-21* CREAT-0.7 SODIUM-133
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-22 ANION GAP-17
[**2142-9-3**] 04:50PM estGFR-Using this
[**2142-9-3**] 04:50PM ALT(SGPT)-37 AST(SGOT)-40 ALK PHOS-72 TOT
BILI-0.4
[**2142-9-3**] 04:50PM LIPASE-44
[**2142-9-3**] 04:50PM cTropnT-<0.01
[**2142-9-3**] 04:50PM TOT PROT-ERROR -ERROR
[**2142-9-3**] 04:50PM WBC-7.0 RBC-3.55* HGB-10.6* HCT-31.5* MCV-89
MCH-29.8 MCHC-33.6 RDW-14.9
[**2142-9-3**] 04:50PM NEUTS-82.7* LYMPHS-9.6* MONOS-5.5 EOS-1.7
BASOS-0.4
[**2142-9-3**] 04:50PM PLT COUNT-256
[**2142-9-3**] 04:50PM PT-42.8* PTT-35.4* INR(PT)-4.5*
Brief Hospital Course:
65 y/o female with PMHx lung cancer stage IIIB, bilateral DVTs
with PE while therapeutic on coumadin, IVC filter who presents
to the CCU s/p pericardiocentesis and placement of pericardial
drain. Currently hemodynamically stable.
# Tamponade - Patient underwent pericardiocentesis with
pericardial drain placement after which she was hemodynamically
stable, although complaining of some positional chest pain which
was treated with morphine and indomethacin. Drain was pulled on
[**9-5**]. Pericardial fluid showed metastatic adenocarcinoma; we
contact[**Name (NI) **] outpatient oncologist and they plan to f/u as an
outpatient and discuss treatment options at that time. Of note,
pericardial fluid cx from [**9-3**] [**1-27**] showed GPC in clusters, but
pt was afebrile with nl WBC; likely due to contamination. ECHO
on [**9-6**] demonstrated: "small amount of pericardial fluid
adjacent to the right atrium. There is still some residual
echogenic material near the apex of the right ventricle. The
inter-ventricular septum has a "bounce". This is often seen
immediately after pericardiocentesis and usually resolves."
Reaccumulation of fluid was not enough to justify window and the
decision was made to have a repeat echo 1 week after discharge.
Pt was started on metoprolol 12.5 mg [**Hospital1 **] prior to discharge.
She remained hemodynamically stable with minimal chest pain
controlled with indomethacin, with plan to follow up as
outpatient with PCP and oncology.
.
# Coagulopathy - Elevated INR on admission. Was on 5mg coumadin
5 days a week, 2.5 2 days a week. Likely this was too high and
cause her INR to increase. Received 1 unit FFP in ED. Per
records from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Date range (1) 87450**]: pt had progression of
thrombus on therapeutic coumadin and lovenox so ivc filter was
placed; CT [**2141-5-31**] showed numerous PE on therapeutic INR so their
new target was INR [**3-29**]. Coumadin was restarted on [**9-4**] with
goal INR 3.
Medications on Admission:
Coumadin 5mg MTWFSa
Coumadin 2.5mg Th, Sun
Paxil 10mg
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
2. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for chest pain.
Disp:*45 Capsule(s)* Refills:*0*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2
days.
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: take on [**9-8**] and [**9-9**], please check INR on [**9-10**]. .
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
Disp:*1 inhaler* Refills:*2*
7. Outpatient Lab Work
please check INR on Monday [**9-10**] and call results to Dr.
[**Last Name (un) **] at [**Telephone/Fax (1) 87451**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a collection of fluid around your heart that was causing
your shortness of breath and fatigue. WE drained 600 cc of fluid
and put a drain in temporarily. We tested the fluid and found
that it had cancer cells in it. Your oncologist knows this and
you will see him next thursday to discuss the next steps. You
had some fluid reaccumulation on your echocardiogram today but
not enough to justify placing a window to drain the fluid. We
would like you to have an echocardiogram in 1 week to see if the
fluid is increasing. If you have symptoms of increasing
shortness of breath, chest pressure or fatgue, please call Dr.
[**Name (NI) 87452**].
.
Medicaiton changes:
1. Please start Indomethicin to use for chest discomfort as
needed.
2. Start albuterol inhaler to treat your wheezes and help you
breathe better
3. Start Metoprolol Succinate to slow your heart rate down.
4. Continue coumadin but take 5 mg Thursday and Friday, change
to 2.5 mg on Saturday and Sunday, then check your INR on Monday
[**9-10**].
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 87453**], MD
Specialty: Hematology Oncology
When: Thursday, [**9-13**] at 11:45am
Location: [**Location (un) **] HEMATOLOGY ONCOLOGY
Address:1 [**First Name8 (NamePattern2) 9241**] [**Last Name (NamePattern1) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**2142**]
[**Location (un) 5028**],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 87451**]
faxed to: [**Telephone/Fax (1) 87454**]
.
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Primary Care
When: [**2143-9-11**]:40pm
Location: [**Hospital 46644**] MEDICAL CENTER
Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 32949**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"423.3",
"285.9",
"496",
"V10.11",
"423.9",
"V12.51",
"V58.61",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
7717, 7723
|
4680, 6704
|
375, 413
|
7826, 7826
|
3796, 4657
|
9016, 9936
|
3112, 3245
|
6808, 7694
|
7744, 7805
|
6730, 6785
|
7977, 8993
|
3260, 3260
|
273, 337
|
441, 2678
|
3274, 3777
|
7841, 7953
|
2700, 2955
|
2971, 3096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,304
| 120,540
|
32635
|
Discharge summary
|
report
|
Admission Date: [**2119-2-9**] Discharge Date: [**2119-2-11**]
Date of Birth: [**2055-11-29**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Zithromax / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Transfered from OSH s/p cholecystectomy with bile leak followed
by ex lap with drainage of bilious fluid, and pneumothorax s/p
CVL placement being transferred for [**First Name3 (LF) **] to correct continue
leak
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Intubation s/p extubation
History of Present Illness:
61 yo female with h/o DM2, COPD on home O2, h/o DVT/[**Hospital **]
transferred from [**Hospital3 4107**]. She underwent cholecystectomy
on [**2-1**] then represented to [**Hospital3 4107**] for abdominal pain.
She was found to have significant ileus and ascites, and
underwent exploratory laparotomy which showed a 2cm hole in the
base of the systic duct with 1 Liter bilious ascites. There was
ischemic bowel with massive ileus and distention due to bile
peritonitis. Her hospitalization was also complicated by a CVL
placement with subsequent pneumothorax. A left sided chest tube
was place, and also a right femoral line was placed. She is
being transferred here for [**Hospital3 **] in AM to fix the continued bile
leakage. Of note, she has been treated with vancomycin,
metronidazole, and levofloxacin at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] for
peritonitis.
.
Currently, she states she is having severe pain in her abdomen.
She denies CP. Her breathing is slightly labored, but she
thinks that's secondary to her large abdomen. She otherwise
denies fevers, chills, headache, or any other symptoms. She
request pain medications. She was on a dilaudid PCA at the OSH.
.
Also on chroinc steroids for COPD.
Past Medical History:
1. Diabetes
2. Chronoc obstructive pulmonary disease
3. T9-10 vertebral fractures.
4. h/o DVT/PE
5. Chronic back pain
6. Right knee osteonecrosis s/p right knee replacement [**Doctor First Name **]
7. Hyperthyroidism
8. Anxiety
9. Enterococcus bactermia
Social History:
Widowed. lives independently. Denies alcohol, smoking.
Family History:
NC
Physical Exam:
vitals - T 98.8 P 120 ST BP 154/74 RR 17 89% O2 sat on 4L NC
gen - Alert awake,
heent - MMM, No icterus, no signs of conjunctivitis
cv - S1S2 RRR
pulm - Coarse breath sounds anteriorly, Decreased BS b/l, few
scattered rhonci. left chest tube in place with no air leak
noted
abd - BS hypoactive; TTP diffusely but particulary in RLQ.
bandage in place with JP drain with bilious fluid. + tympany to
percussion
ext - warm, no edema. Multiple echymosis.
neuro - alert and awake. No focal abnormalities.
Pertinent Results:
[**2119-2-9**] 09:51PM GLUCOSE-162* UREA N-22* CREAT-0.9 SODIUM-145
POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-13
[**2119-2-9**] 09:51PM ALT(SGPT)-17 AST(SGOT)-16 LD(LDH)-253* ALK
PHOS-106 AMYLASE-25 TOT BILI-0.4
[**2119-2-9**] 09:51PM LIPASE-8
[**2119-2-9**] 09:51PM ALBUMIN-2.6* CALCIUM-7.1* PHOSPHATE-3.3
MAGNESIUM-2.2
[**2119-2-9**] 09:51PM WBC-8.0 RBC-3.40* HGB-10.0* HCT-31.0* MCV-91
MCH-29.3 MCHC-32.1 RDW-16.3*
[**2119-2-9**] 09:51PM NEUTS-96.0* LYMPHS-2.0* MONOS-1.8* EOS-0.2
BASOS-0.1
[**2119-2-9**] 09:51PM PLT COUNT-229
[**2119-2-9**] 09:51PM PT-16.3* PTT-29.8 INR(PT)-1.5*
.
EKG: sinus, no significant ST segment changes.
.
[**2119-2-10**]
[**Year (4 digits) **]:
Impression: Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
Autotome 44 using a free-hand technique. Contrast medium was
injected resulting in complete opacification. Slight
extravasation was noted at the cystic duct remnant. The calibre
and course of the intrahepatic ducts and the CBD was normal; no
filling defects were noted. A 10cm by 9mm Cotton [**Doctor Last Name **] biliary
stent was placed successfully. Otherwise normal [**Doctor Last Name **] to third
part of the duodenum
.
[**2119-2-9**]
Chest x-ray
Tubing projected over the left lower hemithorax could be a
pleural drain,
impinges on the mediastinum and then could be folded quite
sharply, to the
point of occlusion. Clinical examination recommended. Thickening
of the left apical pleural margin extends into the mediastinum
is new concerning for hematoma related to line insertion
attempt. No radiopaque central venous catheter is seen. Mild
left lower lobe atelectasis is new. Heart size is normal.
Stomach is moderately distended with air and a right upper
quadrant drainage catheter is at the lower margin of the liver
.
[**2119-2-10**]
Left basal pleural tube is sharply folded as it impinges on the
mediastinum, and may be effectively occluded. Pleural effusion,
if any, is small. No pneumothorax. Lobular thickening of the
left apical pleural margin could be either loculated effusion or
extrapleural hematoma from attempted line placement, as
discussed with the house officer caring for this patient earlier
in the day. Severe left lung atelectasis is unchanged.
.
Marked azygos distention in part reflects supine positioning
nevertheless
indicates elevated central venous pressure or volume. The heart
is probably not enlarged.
.
[**2119-2-10**] 5:13 am PERITONEAL FLUID
GRAM STAIN (Final [**2119-2-10**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 6:05A [**2119-2-9**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
REPORTED BY PHONE TO DR [**First Name (STitle) **],J [**2119-2-11**] 3PM.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
MICU COURSE:
63 y/o female with COPD,diabetes, and h/o DVT is transfered from
OSH after exploratory laparotomy for bile duct leak following
cholecystectomy, also s/p left CVL placement with subsequent PTX
s/p left chest tube placement, transferred here for [**Month/Day/Year **] to
address continued bile duct leak. [**Month/Day/Year **] done and stent placed
without difficulty. Patient electively intubated during
procedure and successfully extubated.
# Bile duct leak:
Patient underwent cholecystecomy on [**2-1**], followed by
exploratory laparotomy on [**2-7**] found to have 2 cm hole at cystic
duct with bilious drainiage, and 1L of bilious ascites, and
likely peritonitis given acute abdomen on vanco/levo/flagyl
Transferred to [**Hospital1 18**] for [**Hospital1 **]. She remained hemodynamically
stable throughout hospital stay. [**Hospital1 **] was performed on [**2119-2-10**]
and a stent successfully placed. Antibiotics changed to
vanco/zosyn for better GNR coverage, as peritoneal fluid grew
GNRs, yet to be speciated. She should have a repeat [**Date Range **] in 8
weeks to remove the stent and to reassess. Her diet should be
advanced slowly as tolerated.
# Left Pneumothorax:
In context of subclavian attempt at OSH s/p chest tube
placement. On arrival to [**Hospital1 18**], x-ray revealed malpositioning
of chest tube. Thoracics was consulted for removal. On serial
chest x-rays here, PTX resolved.
# COPD:
Was intubated at [**Hospital1 **] postoperatively, but self extubated.
Transferred on ventimask 50% FIO2. On chronic po steroids at
home, transitioned to IV regimen initially as she was NPO.
Should be transitioned back to her home regimen as tolerated.
# History of DVT/PE:
On coumadin as outpatient which was held in preparation for [**Hospital1 **]
and removal of chest tube. Heparin resumed following these
procedures.
Medications on Admission:
MEDICATIONS ON TRANSFER:
1. Fortical 1 spray each nostril every 48 hrs
2. Vitamin B12 1000 mcg every 30 days
3. Dilaudid PCA (dose unclear)
4. Narcan PRN
5. Zofran 4 mg IV q6H PRN
6. Dilaudid 1 mg q4H PRN
7. tylenol 650 mg Q6H PRN
8. Lopressor 5 mg IV q2H PRN HR>120
9. Fentanyl Citrate 25 mcg q30 mins PRN
10. HISS
11. Solumedrol 20 mg IV x 3 days
12. Spiriva inhaler 1 puff daily
13. Advair 500/50 puff [**Hospital1 **]
14. Xopenex 1.25 mg q4H PRN
15. Coumadin 2 mg daily (currently held)
16. Protonix 40 mg IV daily
17. Levofloxacin 500 mg IV daily
18. Metronidazole 500 q8H
19. Vancomycin 1 gm q12h
20. TPN daily
.
ADMISSION MEDICATIONS:
1. KCL 40 meq 3 x daily
2. Spiriva 18 mcg INH daily
3. Fortical 1 spray alternating nostrils daily
4. Vitamin D 400 units daily
5. Prednisone 30 mg daily
6. Mag oxide 400 mg [**Hospital1 **]
7. MVI daily
8. Trazadone 50 mg qhs
9. Advair 1 puff [**Hospital1 **]
10. Amoxicillin 500 mg [**Hospital1 **]
11. Neurontin 300 mg TID
12. Oxycodone 50 mg q6H PRN
13. Singulair 10 mg daily
14. Cymbalta 60 mg daily
15. Lasix 40 mg daily
16. Protonix 40 mg [**Hospital1 **]
17. Synthroid 112 mcg daily
18. B12 1000 mcg IM monthly
19. Iron 325 mg daily
20. Oxycontin 20 mg [**Hospital1 **]
21. Xopenex 1 puf q4H PRN
22. Dilaudid 2 mg PO q4H PRN
23. Coumadin 2 mg daily
24. Ativan 0.5 mg [**Hospital1 **]
25. Albuterol INH q4h prn
26. Atroven neb q4H PRN
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Bupivacaine (PF) 0.25 % (2.5 mg/mL) Solution Sig: One (1) ML
Injection INFUSION (continuous infusion).
4. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
5. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
6. Levothyroxine 200 mcg Recon Soln Sig: One (1) Recon Soln
Injection DAILY (Daily).
7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
8. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig: One
(1) Recon Soln Injection Q24H (every 24 hours).
9. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for anxiety.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
# Bile duct leak
# Left pneumothorax s/p chest tube placement at OSH
Secondary
# COPD
# DVT/PE
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for an [**Hospital1 **]. This procedure went
well and you had a stent placed to fix your biliary leak. You
were intubated during the procedure and successfully extubated
following the [**Hospital1 **]. You should have a repeat [**Hospital1 **] in 8 weeks to
have the stent removed. Your diet should be advanced as
tolerated. You also had your chest tube removed on this
admission.
Followup Instructions:
You have the following appointments for repeat [**Hospital1 **]
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2119-4-11**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2119-4-11**] 8:00
Completed by:[**2119-2-12**]
|
[
"496",
"250.00",
"V12.51",
"E878.8",
"997.4",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9985, 10000
|
5749, 7618
|
516, 568
|
10147, 10172
|
2753, 5530
|
10650, 10984
|
2212, 2216
|
9053, 9962
|
10021, 10126
|
7644, 7644
|
10196, 10627
|
8286, 9030
|
2231, 2734
|
265, 478
|
596, 1845
|
5726, 5726
|
7669, 8263
|
1867, 2123
|
2139, 2196
|
5565, 5691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,764
| 130,529
|
31219
|
Discharge summary
|
report
|
Admission Date: [**2117-10-5**] Discharge Date: [**2117-11-12**]
Date of Birth: [**2039-9-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
elevated LFTs
Major Surgical or Invasive Procedure:
paracentesis
liver biopsy
colonoscopy with biopsy
History of Present Illness:
77M with T3N2 papillary RCC s/p L.
nephrectomy who recently started on Pazopanib [**2117-8-16**], seen in
[**Hospital 478**] clinic on day of admission and found to have elevated
LFTs.
.
Father [**Name (NI) **] was doing well until roughly 2weeks prior to when
he
began to develop increased non-bloody loose stool and mild
increase in fatigue. He did not start Imodium and tried to
increase his fluid intake. He did well at home until yesterday
when he developed LLQ discomfort spontaneous onset. No fevers,
Rare chills. Pain was localized and [**4-12**] but persisted. No
N/V,
no increased abdominal girth. +dark urine. No melena, baseline
dark stools on iron. He went to OSH ED yesterday where Cr 3.0,
HCO3 12,
HCT 33, WBC 6.7 with 60% polys, but Tbili 4.8, alkphos 619, ALT
710, AST 281. CT done at OSH but report not available.
.
He was told he had ascites and discharged with no speicific
therapy. Today he notes that his abdominal discomfort has
nearly
resolved. He continue to have loose stool up to 6 times per day
without blood. He denies cough, fevers. No chest pain,
orthopnea or LE edema. No N/V. No RUQ pain. Urine remains
dark. He denies
rash.
.
VS in clinic: BP: 125/71. Heart Rate: 85. Weight: 147.8. Height:
69. BMI: 21.8. Temperature: 96.5. Resp. Rate: 16. Pain Score: 0.
O2 Saturation%: 100.
Past Medical History:
Past Oncologic History:
-- [**4-/2114**] developed hematuria and mild flank pain and was found
to have a large lobulated 6cm mass in his left kidney consistent
with renal cell carcinoma.
-- He underwent further preoperative evaluation and was found to
have a 1 cm lesion in the right kidney as well as a lesion in
the
L4 vertebrae which was positive by bone scan.
-- [**2114-5-7**] He underwent laparoscopic left nephrectomy at [**Hospital2 **]
[**Hospital3 6783**] Hospital by Dr. [**Last Name (STitle) 68051**]. He was felt to be at high risk
of recurrence, particularly given the lesion in the right renal
and L4 areas.
-- [**5-/2114**] until present he has been managed conservatively with
q3 month CT scans with most recent being in [**3-/2117**] where all
lesions were noted to be slightly increasing in size.
-- [**6-/2117**] noted to have 13lb unintentional weight loss,
increased
fatigue and worsening anemia with Hct of 26.
-- [**2117-6-28**] transfused 2U PRBC for worsening anemia
-- [**2117-8-10**] CT torso for worsening fatigue: Disease progression
with enlargment of known lesions and new ascites. Consented for
ancillary trials DF-HCC 08-078 and DF-HCC 06-105.
-- [**2117-8-24**] ASL MRI per DF-HCC 08-078 done, started on Pazopanib
800mg PO QD
.
Past Medical History:
Status post left shoulder surgery,
nephrolithiasis, history of lumbar radiculopathy, esophageal
stricture status post dilatation, macular degeneration,
hypertension, hypercholesterolemia, osteoarthritis status post
epigastric hernia repair
Social History:
He continues to smoke [**2-4**] cigarettes/day and drinks
2-4beer/week. He is a retired priest, and continues to work for
the [**Doctor Last Name 23432**]. He does still perform occasional weddings.
Family History:
No history of kidney cancer. Mother with breast cancer after
60. No siblings.
Physical Exam:
On admission
VS: T95.2 BP 130/60 HR 82 RR18 O2 sat 98% RA
GEN: NAD seated comfortably, no jaundice
HEENT: Pupils equal round and reactive, extraocular movements
intact, oropharynx clear w/o lesions or petechiae, sclera
anicteric
NECK: supple
CV: nl s1s2, regular rate and rhythm,
PULM: clear to auscultation bilaterally w/good air movement, no
crackles/wheezes
ABD: soft, ND, +BS. mild tenderness in LLQ
EXT: warm, well perfused, no cyanosis/clubbing/edema, no open
lesions
SKIN: no rashes
NEURO: AOx3, CN2-12 grossly intact, 5/5 strength in all
extremities,
grossly normal sensation, gait steady.
.
.
Discharge Exam:
temp 98.7 133/70 77 16 98% RA
GEN: NAD
HEENT: scleral and skin icterus, MMM, No JVD
CV: nl s1s2, regular rate and rhythm, no m/r/g
PULM: CTA anteriorly
ABD: NTND, BS +.
EXT: 1+ pulses, bil tibial edema trace
SKIN: icteric, no rashes
NEURO: grossly intact
Pertinent Results:
[**2117-10-6**] 12:00AM GLUCOSE-136* UREA N-70* CREAT-3.1* SODIUM-143
POTASSIUM-4.0 CHLORIDE-114* TOTAL CO2-14* ANION GAP-19
[**2117-10-6**] 12:00AM ALT(SGPT)-637* AST(SGOT)-250* CK(CPK)-23* ALK
PHOS-612* TOT BILI-5.3* DIR BILI-4.9* INDIR BIL-0.4
[**2117-10-6**] 12:00AM TOT PROT-5.6* ALBUMIN-3.3* GLOBULIN-2.3
CALCIUM-8.3* PHOSPHATE-4.8* MAGNESIUM-1.3*
[**2117-10-6**] 12:00AM TSH-LESS THAN
[**2117-10-6**] 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-10-6**] 12:00AM WBC-5.9 RBC-3.05* HGB-9.0* HCT-26.6* MCV-87
MCH-29.6 MCHC-34.0 RDW-16.7*
[**2117-10-6**] 12:00AM NEUTS-64.9 LYMPHS-22.3 MONOS-7.1 EOS-5.2*
BASOS-0.4
[**2117-10-6**] 12:00AM PLT COUNT-204
[**2117-10-6**] 12:00AM PT-12.9 PTT-27.3 INR(PT)-1.1
[**2117-10-5**] 09:06PM URINE HOURS-RANDOM
[**2117-10-5**] 09:06PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2117-10-5**] 09:06PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2117-10-5**] 09:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-10-5**] 03:24PM LACTATE-2.6*
[**2117-10-5**] 03:05PM UREA N-71* CREAT-3.5* SODIUM-142
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-17* ANION GAP-19
[**2117-10-5**] 03:05PM estGFR-Using this
[**2117-10-5**] 03:05PM LIPASE-58
[**2117-10-5**] 03:05PM TOT PROT-6.7 ALBUMIN-3.9 GLOBULIN-2.8
CALCIUM-9.5 PHOSPHATE-5.5* MAGNESIUM-1.4*
[**2117-10-5**] 03:05PM ACETMNPHN-NEG
[**2117-10-5**] 03:05PM WBC-6.5 RBC-3.84* HGB-11.0* HCT-33.7* MCV-88
MCH-28.7 MCHC-32.7 RDW-16.1*
[**2117-10-5**] 03:05PM PLT COUNT-228
[**2117-10-5**] 03:05PM PLT COUNT-228
[**2117-10-5**] 03:05PM GRAN CT-4020
.
.
[**2117-11-9**] 06:42AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE IgM
HBc-NEGATIVE
[**2117-10-6**] 12:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2117-10-27**] 01:44PM BLOOD antiTPO-LESS THAN
[**2117-11-9**] 06:42AM BLOOD tTG-IgA-18.
.
Discharge Labs:
.
[**2117-11-12**] 09:20AM BLOOD WBC-8.7 RBC-2.73* Hgb-8.1* Hct-25.0*
MCV-92 MCH-29.8 MCHC-32.5 RDW-16.9* Plt Ct-347
[**2117-11-9**] 06:42AM BLOOD PT-18.5* PTT-34.2 INR(PT)-1.7*
[**2117-10-27**] 01:43PM BLOOD Fibrino-744*
[**2117-11-12**] 09:20AM BLOOD Glucose-138* UreaN-16 Creat-2.9*# Na-138
K-3.0* Cl-105 HCO3-24 AnGap-12
[**2117-11-9**] 06:42AM BLOOD ALT-28 AST-42* AlkPhos-484* TotBili-13.0*
[**2117-11-12**] 09:20AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.7
[**2117-11-9**] 06:42AM BLOOD calTIBC-143 VitB12-1109* Folate-7.2
Ferritn-2427* TRF-110*
[**2117-11-7**] 08:45AM BLOOD T4-8.4 T3-85 calcTBG-1.07 TUptake-0.93
T4Index-7.8 Free T4-1.4
.
Brief Hospital Course:
This is a 77yo M with T3N2 papillary RCC s/p L.nephrectomy who
recently started on Pazopanib [**2117-8-16**], who was originally
admitted for elevated LFTs thought to be [**1-5**] Pazopanib
heptotoxicity, C diff colitis and acute on chronic renal
failure. .
.
# Acute on chronic renal failure: Pt s/p nephrectomy with
baseline Cr ~[**1-6**]. Developed acute on chronic RF in the setting
of sepsis which did not improve. Cr went up to 8.0. Tunnled
dialysis line was placed and recieved 4 dialysis treatments
[**Date range (1) 42768**]. Planned to start out patient 3 weekly dialysis
sessions On tuesday [**11-16**] . Continues calcium carbonate 500mg
TID for phos chelation, Nephrocaps 1 cap QD
Low potasium diet.
.
# Infection: Initiatially treated for sepsis + c.dif with IV
Vanc/flagyl + PO Cipro + Vanco from [**Date range (1) 73681**]. Now repeated
stools for c.dif neg, otherwise Bcx/Ucx negative. Was treated
with total 10 days of PO vanco after disconinuing other systemic
antibiotics.
.
# diarrhea: initially had c.dif for which recieved treatment now
repeated c.dif assays negative yet diarrhea continues.
Colonoscopy showed diffuse erythema, friability, exudates and
ulceration likely pseudomembranes in the rectum and sigmoid but
biopsies were normal. Continues to have diarrhea, stool studies
repeated [**11-3**] and [**11-4**] for C.dif tox, culture and ova/parasites
all negative. Celiac serology negative. Qualitative stool for
Fat is positive. D.d. for continuing diarrhea - 1.
malabsorption: supported by positive fat, possibly [**1-5**] to his
intra-hepatic cholestasis. 2. drug side effect [**1-5**] to Abx 3.
infection: less likely now with neg cultures and repeated ng
C.dif 4. inflammatory: unlikely in the setting of normal
colonic biopsies. Diarrhea is now improved on Loperamide.
Continues loperamide 2mg TID. [**Month (only) 116**] consult with GI in the out
patient seetting of no resolution.
.
# A fib: a number of Afib/flutter/RVR episodes during this
admission. On rate control with metoprolol. [**Country **] score = 2 per
age + HTN, but with liver failure, increased INR anticoagulation
differed d/t bleeeding risk. Now well controlled with Metoprolol
PO 50 TID today. Aspirin 81mg daily is given for stroke
prevention.
.
# Grave's disease: newly diagnosed per elevated TFTs ([**10-26**] Ft4
2.3 TSH < 0.02) and positive TSI Ab ( = 337 normal < 140).
Except for AF episodes remains non-thyrotoxic clinically.
Started low dose Methimazole 5mg q 48h. Will require repeated
TFT's in three weeks. Follow up with endocrinology has been
arranged.
.
# Cholestatic liver injury and Jaundice: secondary to Pazopanib
heptotoxicity. Imaging w/o structural abnormalities or ductal
dilatation. Pt mentating well, no asterixis. Continues
cholestyramine and topical camphor menthol for pruritus. Will
need continued follow-up of his liver functions including INR
and PTT. Follow-up with Liver service has also been arranged.
.
# Anemia: normocytic, high RDW. no B12/Folate/Iron deficiencies
per labs, but ferritin may be falsely elevated in the setting of
his other conditions. Has possible malabsorption and a few guiac
positive stools. Thus anemia is likely multifactorial and
secondary to chronic illness + CRF + possible malabsorption and
occult GI bleeding. Epo was not started in the setting of
malignancy. CBC's should continue to be trended. Iron labs
should be followed and repletion considered. GI may be consulted
for his intestinal issues.
.
# Renal Cell Carcinoma: per patient's oncologist no further
treatment is considered at this point due to patient's various
other complicating medical issues.
.
# HTN: Was on several agents at home which were D/C'ed in the
setting of sepsis and hypotension. During his admission was well
controlled on metoprolol alone.
.
# Tobacco abuse: Was on Bupropion at [**Last Name (un) **] which was held during
this admission. Continued abstinence was advised.
.
# PVD: was on home CILOSTAZOL, this was held during this
admission.
.
# Goals of care and Code Status: prognosis discussion, goals of
care and code status issues were broached and discussed during
this admission. At this point patient wishes to remain at full
code. Continued discussion of the above is advised.
.
# DVT PPx - treated with SQ heparin
.
# Discharge planning: screened and accepted to Holy Trinity Nsg
Home in
[**Hospital1 1559**]. Will continue dialysis with [**Location (un) **] Dialysis in
[**Hospital1 1559**] as well.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - one Tablet(s) by mouth daily
BUPROPION HCL - (Prescribed by Other Provider) - 100 mg Tablet
Sustained Release - 1 Tablet Sustained Release(s) by mouth DAILY
CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth every
day
CILOSTAZOL - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth DAILY
LISINOPRIL - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 40 mg Tablet
- 1 Tablet(s) by mouth once a day
LOVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth DAILY
METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule, Delayed Release(E.C.)(s) by
mouth DAILY
PAZOPANIB [VOTRIENT] - 200 mg Tablet - 4 Tablet(s) by mouth once
a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth once a day
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth twice a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - Dosage uncertain
SODIUM BICARBONATE (ANTACID) - (OTC) - Powder - [**12-5**] tsp twice
a day
VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
3. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
6. methimazole 5 mg Tablet Sig: One (1) Tablet PO Q48H (every 48
hours).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID WITH MEALS ().
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Holy Trinity Eastern Orthodox Nursing & Rehabilitation Center -
[**Hospital1 1559**]
Discharge Diagnosis:
Elevated LFTs secondary to pazopanib
C difficile infection
acute on chronic renal failure
renal cell carcinoma
Grave's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 **] due to
elevated liverfunction tests concerning for liver failure due to
the chemotherapy, Pazopanib. The hepatology team was consulted
and agreed that the elevation in liver function tests was due to
Pazopanib. You underwent a liver biopsy that was also
consistent with drug-induced liver injury.
You underwent a colonoscopy because of persistent diarrhea and
biopsies were taken which were normal. You were treated with
antibiotics for clostridium difficile infection.
You were also noted to have an irregular heart rate. We treated
you with medications for this and it improved.
You also were noted to have worsening kidney function for which
you were treated with dialysis, at the time of discharge your
renal functions seem to have stablized and the renal team's
recommendation was that you continue dialysis treatments as an
outpatient.
You were also noted to have an over-active thyroid during
admission. You were started on medication for this.
Please make the following changes to your medications:
- The following medications were stopped: Amlodipin, Bupropion,
Calcitriol, Cilostazol, Hydrochlorothiazide, Lisinopril,
Lovastatin, Metoprolol succinate, Pazopanib, Cholecalciferol
(vitamin D), Ferrous Sulfate, Omega-3 Fatty Acids(fish oil),
Sodium Bicarbonate (antacid), Preservision.
.
This is now your full medication list:
# omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
# camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
# cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
# aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
# metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
# methimazole 5 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
# calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID WITH MEALS
# loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for diarrhea.
# B complex-vitamin C-folic acid (nephrocaps) 1 mg Capsule
Sig: One (1) Cap PO DAILY (Daily).
Followup Instructions:
Please call your oncologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3877**] Phone:
[**Telephone/Fax (1) 13016**] to arrange for further follow-up.
.
Please also keep the following appointments:
.
Department: DIV OF GI AND ENDOCRINE
When: TUESDAY [**2117-11-23**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Department: LIVER CENTER
When: MONDAY [**2117-12-27**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2117-12-30**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2117-11-19**]
|
[
"458.29",
"276.51",
"789.51",
"E933.1",
"198.5",
"197.6",
"427.89",
"362.50",
"783.21",
"275.42",
"305.1",
"570",
"427.31",
"715.90",
"786.52",
"189.0",
"286.9",
"272.0",
"V45.73",
"511.9",
"788.5",
"273.8",
"576.8",
"403.90",
"585.4",
"584.5",
"242.00",
"276.2",
"008.45",
"V02.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"50.11",
"38.95",
"39.95",
"38.91",
"45.25",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
13953, 14064
|
7205, 11675
|
287, 339
|
14235, 14235
|
4478, 6522
|
16675, 17989
|
3483, 3564
|
13108, 13930
|
14085, 14214
|
11701, 13085
|
14386, 15445
|
6538, 7182
|
3579, 4186
|
4202, 4459
|
15475, 16652
|
234, 249
|
367, 1697
|
14250, 14362
|
3006, 3248
|
3264, 3467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,076
| 162,889
|
19416+57049
|
Discharge summary
|
report+addendum
|
Admission Date: [**2147-11-30**] Discharge Date: [**2147-12-6**]
Service: TRA
HISTORY OF PRESENT ILLNESS: This is an 85 year old male,
status post motor vehicle accident. He was the restrained
driver of a motor vehicle that crashed into a guard rail.
The etiology the guard rail is unclear. [**Name2 (NI) **] may have
fallen asleep at the wheel verus having a syncopal episode.
Patient states that he blacked out while driving and that the
next thing that he remembers is bring pulled out of the
driver by EMS. Wife was with him at the time and states that
he hit the guard rail while driving.
PAST MEDICAL HISTORY: Is significant for hypertension,
coronary artery disease, status post coronary artery bypass
graft and "kidney problems." [**Name2 (NI) **] has multiple allergies
to penicillin, Biaxin, Ceclor and Tequin and takes
medications Procrit, Colace, iron, lactulose, terazosin,
Lopressor, Diltiazem, Zocor, Plavix and calcium and Lasix and
atorvastatin.
PHYSICAL EXAMINATION: On admission temperature 99.6 degrees
Fahrenheit, heart rate 67, blood pressure 188/54, respiratory
rate 20 and breathing at 98 percent on 2 liters nasal
cannula. Was alert and oriented times three in no apparent
distress. Normocephalic, atraumatic. Heart was regular rate
and rhythm and he was clear to auscultation bilaterally. His
abdomen was soft, nontender and nondistended. He had no
edema in his extremities.
HOSPITAL COURSE: At this time the patient was admitted to
the [**Hospital1 69**] for further
management and evaluation. Patient was assesses at length in
the trauma bay and was admitted to the surgical Intensive
Care Unit. Laboratories were drawn. Toxicology screen was
negative. Electrolytes were within normal limits. His
hematocrit at this time was 37.4. Electrocardiogram revealed
some first degree AV block with normal sinus rhythm with
occasional ectopy but no ischemic changes. Chest x-ray
revealed no pneumothorax or fractures. Pelvis x-ray revealed
no fractures. CT scan of the cervical spine revealed no
fractures or malalignment with some degenerative joint
disease. CT scan of the head revealed blood in his right
frontal sulcus, left sylvian fissure and left quadrigeminal
plate cistern consistent with subarachnoid hemorrhage.
Convex collection of blood was found in the right frontal
region likely representing epidural hemorrhage. There was
small intraventricular blood. There were no fractures.
The patient was started on Dilantin at this time per
neurosurgery's request. He was given morphine as needed for
pain control. Goal blood pressure systolically was less than
140. Patient had an arterial line placed at this time.
Nicardipine was started as well for blood pressure lowering
purposes. The patient received a full syncopal work up and
ruled out for myocardial infarction via enzymes. The patient
received an echocardiogram that revealed trace aortic
stenosis and mild aortic regurgitation. Patient was
receiving intravenous fluids at this time. A Foley catheter
was placed. The patient was wearing pneumboots for
prophylaxis for deep venous thrombosis. The patient was
receiving Pepcid for gastrointestinal prophylaxis. The
patient receiving a regular insulin sliding scale. On
hospital day number two the patient was noted to be stable
and received a CT scan of this head that revealed no changes
in the size or severity of his bleeds.
On hospital day number three the patient was restarted on all
of his home medications and had an MRA of his head and neck
which was also negative. On hospital day number three the
patient was transferred to the floor from the Intensive Care
Unit without complaints. At this point neurosurgery had
signed off and suggested that he receive a repeat head CT
scan in two weeks and a follow up appointment in clinic. On
hospital day five the patient started to have somewhat
declining mental status and on urinalysis appeared to have
likely urinary tract infection. He was started on Bactrim at
this time. The case was also discussed with his primary care
physician and the results of his syncopal work up were
relayed and later in the day on [**2147-12-4**], hospital
day five patient had somewhat decreased oxygen saturations in
to the mid to high 80s requiring larger amounts of oxygen by
cannula. The patient was ruled out again for myocardial
infarction by enzymes. An arterial blood gas was drawn that
was within normal limits. Lasix 10 mg was given intravenous.
An electrocardiogram was performed that revealed no
significant changes and a CT scan of the head was performed
which revealed no new changes or no new increase in size of
bleed. Patient was also seen by physical therapy and
occupational therapy at this time. They suggested that this
patient would likely benefit from an intensive rehabilitation
stay and on hospital day number six the patient had been
switched to aztreonam as the patient had spiked a fever to
101.4 and didn't appear to be improving from his likely
urinary tract infection with white counts of 20,000. The
patient was to receive aztreonam fro one week and on hospital
day number seven patient was improving. His mental status
appeared to be clearing. The patient had been off one to one
sitters for greater than 24 hours at this time. The patient
was taking a regular diet, cardiac heart healthy. His sodium
was repleted with a recent level of 127. He was receiving
salt tablets at this time and there were no other active
issues. Thus the patient was able to be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Right epidural hematoma, bilateral subarachnoid
hemorrhages.
2. Hypertension.
3. Coronary artery disease.
4. Congestive heart failure.
5. Renal insufficiency.
6. A 4 cm abdominal aneurysm.
RECOMMENDED FOLLOW UP: The patient to follow up in
neurosurgery in two weeks to re-evaluate these hemorrhages
with follow up CT scan of his head, to call to schedule an
appointment, [**Telephone/Fax (1) 52776**].
DISCHARGE MEDICATIONS: Metoprolol 100 mg B.I.D
Simvastatin 40 mg daily
Lisinopril 5 mg daily.
Terazosin 2 mg h. s.
Acetaminophen 325 mg to 650 mg P.O. q 4 to 6 hours as needed
for pain.
Colace 100 mg B.I.D
Dulcolax 10 mg daily as needed.
Phenantoin 100 mg t.i.d.
Polysaccharide iron complex 150 mg daily.
Calcium acetate 667 mg t.i.d. with meals.
Furosemide 20 mg daily.
Lactulose 20 grams in 30 ml P.O. B.I.D
Diltiazem 180 mg daily
Heparin sodium 5,000 units subcutaneous injection t.i.d.
Famotidine 20 mg daily
Sodium chloride 1 gram tablets t.i.d.
Aztreonam 500 mg q 8 hours intravenous.
Epogen 20,000 q week.
Regular Humulin insulin sliding scale as directed. There
will be an accompanying print out of his most recent sliding
scale with the discharge paper work.
DISPOSITION: The patient is stable and to be discharged to
Rehabilitation.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2147-12-6**] 13:44:41
T: [**2147-12-6**] 14:54:37
Job#: [**Job Number 52777**]
Name: [**Known lastname 133**],[**Known lastname 133**] F Unit No: [**Numeric Identifier 9811**]
Admission Date: [**2147-11-30**] Discharge Date: [**2147-12-12**]
Date of Birth: [**2061-12-31**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Tequin / Biaxin / Amoxicillin / Ceclor / Trimox
Attending:[**First Name3 (LF) 5964**]
Addendum:
The pt was not discharged on [**12-6**] as anticipated, but stayed at
[**Hospital1 8**] on the floor until [**2147-12-12**]. During that time the pt
completed a 7 day course of Aztreonam for a UTI. There were no
adverse events or other medical issues. The pt was discharged
to a rehab facility on [**12-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**]
Completed by:[**2147-12-12**]
|
[
"414.00",
"599.0",
"593.9",
"E819.0",
"V45.81",
"852.06",
"428.0",
"401.9",
"852.46"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7858, 8091
|
5593, 5802
|
6029, 7835
|
1446, 5572
|
5814, 6005
|
1006, 1428
|
119, 611
|
634, 983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,053
| 179,392
|
42781
|
Discharge summary
|
report
|
Admission Date: [**2156-3-5**] Discharge Date: [**2156-3-8**]
Date of Birth: [**2081-5-9**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 y/o woman who writes with her right hand but does most other
things with her left presented today from [**Hospital3 **] s/p
tPA for right MCA syndrome. She was in her normal state of
health ( which according to her daughter is active, lives alone,
has no issues) until about 11:15 am when she was found on the
ground. The last time she was seen in her normal condition was
about 1 hour prior. She was alert, oriented, with an agnosia to
her florid left sided weakness. At OSH she was noted to have
virtually no movement of the left side with eye deviation to the
right. TPA was given after a CT scan showed hyperdense right MCA
(distal) and no bleed. After the tPA she was note dto be
obtunded, eyes closed and not responding. There are various
reports on this where someone noted that this happened
spontaneously and by EMS report here in the ED at [**Hospital1 **] they states
that she was given IV Ativan and then became
lethargic. These events however are not mentioned in the notes
that accompany her. Here in the ED she was very lethargic with
eyes closed, could not hold open her lids and was very
dysarthric. She had no acute complaints when I asked her.
Past Medical History:
HTN
HLD
AF discovered 2 weeks prior to admission and not anticoagulated
Had recent aspiration of a pancreatic cyst
TIA in [**2134**] (had left CEA in [**2134**])
R carotid reported to be 75% narrow.
Social History:
Denies tobacco, etoh, other drugs. Lives on her own. She is
active likes to go ball room dancing.
Family History:
Multiple family members in [**Name (NI) 4754**] with strokes. Daughter
mentioned grandmother, and various aunts and uncles of the
patient.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.6 P:70 R: 16 BP: 140/70 SaO2:96% 2L
General: lethargic, NAD.
HEENT: NC/AT, MMM.
Neck: Supple
Pulmonary: Lungs CTA bilaterally frontal fields
Cardiac: RRR
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: cherry angiomas.
Neurologic:
-Mental Status: Lethargic, cant keep her eyes open. Able to tell
me her name, her handedness, the date accurately. She is very
dysarthric, minimal speech output given lethargy. No paraphasic
errors noted. She has a right gaze deviation that I cant
overcome. She is not neglecting the left side.
-Cranial Nerves:
I: Olfaction not tested.
II: pupils pinpoint, reactive.
III, IV, VI: Left gaze dev.
V: not tested.
VII: left facial droop.
VIII: hearing decreased b/l.
IX, X: not tested.
[**Doctor First Name 81**]: not tested.
XII: not tested.
(not tested)* lethargic and will be tested later.
-Motor:
Left side: Arm antigravity with antigravity movement of the
biceps and triceps. Her IP is 2+ to 3-. She is able to flex and
extend at the knee with her heel on the bed. TA was 3. Right
side: Full at the upper and lower extremity. Lethargic and some
limitation to testing based on effort.
-DTRs: 2 at the biceps triceps. Right knee is 3+ and left knee
2. none at the ankles. Plantar response was extensor
bilaterally.
-Coordination:not tested.
-Gait: not tested .
.
.
Discharge Physical Exam:
AOx3 recalls [**3-13**] words, no visual or sensory inattention and
performs line bisection normally. Slight left NLF flattening and
no oethr cranial nerve deficits. Left pronator drift with left
arm>leg weakness and 4+/5 in shoulder abdiction and extensors
and [**5-15**] in flexors in arm and IP 4+/5 and otehrwise [**5-15**] in left
leg. Left extensor plantar with withdrawal on right. No sensory
deficits. No ataxia.
Pertinent Results:
Laboratory invetsigations:
[**2156-3-5**] 06:14PM BLOOD WBC-8.0 RBC-4.91 Hgb-14.8 Hct-43.4 MCV-88
MCH-30.2 MCHC-34.2 RDW-13.1 Plt Ct-206
[**2156-3-5**] 06:14PM BLOOD Neuts-80* Bands-0 Lymphs-18 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-3-5**] 06:14PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Ellipto-OCCASIONAL
[**2156-3-6**] 02:05AM BLOOD PT-11.3 PTT-22.9* INR(PT)-1.0
[**2156-3-5**] 06:14PM BLOOD Glucose-104* UreaN-9 Creat-1.0 Na-140
K-4.1 Cl-105 HCO3-20* AnGap-19
[**2156-3-6**] 02:05AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 Cholest-190
.
Other pertinent labs:
[**2156-3-7**] 06:05AM BLOOD ALT-23 AST-28 AlkPhos-124* TotBili-0.7
[**2156-3-5**] 07:55PM BLOOD cTropnT-<0.01
[**2156-3-6**] 02:05AM BLOOD %HbA1c-6.1* eAG-128*
[**2156-3-6**] 02:05AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 Cholest-190
[**2156-3-6**] 02:05AM BLOOD Triglyc-78 HDL-48 CHOL/HD-4.0 LDLcalc-126
[**2156-3-6**] 02:05AM BLOOD TSH-2.7
[**2156-3-7**] 06:05AM BLOOD Digoxin-1.9
[**2156-3-5**] 06:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge labs:
[**2156-3-8**] 05:35AM BLOOD WBC-11.1* RBC-5.21 Hgb-15.2 Hct-42.1
MCV-81* MCH-29.1 MCHC-36.1* RDW-13.3 Plt Ct-242
[**2156-3-8**] 10:55AM BLOOD PT-11.5 PTT-70.8* INR(PT)-1.1
[**2156-3-8**] 05:35AM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-133
K-4.1 Cl-97 HCO3-26 AnGap-14
[**2156-3-8**] 05:35AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
.
.
Urine:
[**2156-3-5**] 05:42PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.023
[**2156-3-5**] 05:42PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2156-3-5**] 05:42PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2156-3-5**] 05:42PM URINE Mucous-RARE
[**2156-3-8**] 09:43AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2156-3-8**] 09:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
[**2156-3-5**] 05:42PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Microbiology:
[**2156-3-8**] URINE URINE CULTURE-PENDING
.
.
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2156-3-5**] 4:39 PM
NON-CONTRAST HEAD CT: Evaluation for hemorrhage is somewhat
limited due to
recent contrast bolus four hours prior, though no definite
hemorrhage is
identified. There is no shift of the usually midline structures.
Suprasellar
and basal cisterns are widely patent. No mass or mass effect is
evident.
There is subtle loss of [**Doctor Last Name 352**]-white matter differentiation in the
right insular
ribbon, findings concerning for right MCA territory infarction.
MRI with
diffusion is recommended for increased sensitivity for
detection. The
ventricles and sulci are normal in size and configuration. There
is no scalp
hematoma or acute skull fracture. The visualized paranasal
sinuses and
mastoid air cells are well aerated.
IMPRESSION:
1. No definite hemorrhage, though limited due to recent contrast
bolus at
outside hospital.
2. Subtle loss of [**Doctor Last Name 352**]-white matter differentiation in the right
insular
ribbon concerning for evolving subacute infarction in the right
MCA territory.
.
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST [**2156-3-6**] 10:18 AM
FINDINGS:
MRI OF THE HEAD.
Restricted diffusion is identified in the vascular territory of
the right MCA,
with no evidence of hemorrhagic transformation. Additionally,
multiple foci
of restricted diffusion are also visualized on the left cerebral
hemisphere
and right temporo-occipital region. The ventricles and sulci are
unchanged
and appear slightly prominent, likely age related and
involutional in nature.
On FLAIR, few foci of high signal intensity are noted in the
subcortical white
matter, which are nonspecific and may reflect chronic
microvascular ischemic
disease. In the left frontal convexity, small focus of
restricted diffusion
is also identified (image #20, series #5).
The orbits, the paranasal sinuses and the mastoid air cells are
unremarkable.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid
arteries, there
are flow-stenotic lesions at M2/M3 segment on the right and also
decreased
flow on the distal branches of the left middle cerebral artery,
likely
consistent with atherosclerotic disease. The basilar artery
appears patent
with dominance of the left vertebral artery, the right vertebral
artery is not
visualized, probably is hypoplastic.
IMPRESSION: Subacute ischemic event is identified on the right
middle artery
vascular territory, involving the insula and also scattered foci
of restricted
diffusion in both cerebral hemispheres consistent with
thromboembolic ischemic
event as described above.
The MRA of the head demonstrates flow-stenotic lesions at the
middle cerebral
artery bifurcations involving the M2/M3 segments, no aneurysms
are identified.
Probably the right vertebral artery is hypoplastic.
.
CHEST (PORTABLE AP) Study Date of [**2156-3-6**] 10:39 AM
Compared with several minutes earlier on the same day, the
coiled tube has
been removed. An NG tube is now present, tip extending beneath
diaphragm,
overlying the stomach. Patchy opacity at both lung bases with
suspected small bilateral effusions are unchanged. No
pneumothorax detected.
.
CHEST (PA & LAT) Study Date of [**2156-3-8**] 9:41 AM
FRONTAL AND LATERAL CHEST RADIOGRAPHS: A nasogastric tube
terminates within the stomach. Since the [**2156-3-6**]
examination there has been improved aeration at the lung bases.
No new superimposed consolidation or opacity is seen. There is a
persistent small left pleural effusion. The heart size is
normal. The hilar and mediastinal contours are within normal
limits. There is no pneumothorax.
IMPRESSION: No new consolidation or opacity since [**2156-3-6**].
Improved bibasilar aeration.
.
.
Cardiology:
TTE (Complete) Done [**2156-3-8**] at 4:00:44 PM FINAL
Conclusions
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Brief Hospital Course:
74 year old woman with multiple vascular risk factors including
recently diagnosed atrial fibrillation (not anticoagulated),
right carotid stenosis and prior left CEA was transferred from
OSH post tPA (6-7 hours post event) for possible intervention
following acute onset of left-sided weakness and dysarthria.
Patient had received lorazepam at the OSH which accounted for
considerable drowsiness. Patient did not receive intervention
and was observed in the ICU for post tPA monitoring. Patient had
episodes of AF with RVR and was initially treated with digoxin
and PRN IV metoprolol and latterly with a reduced dose of po
metoprolol given borderline BPs. She was started on IV heparin
and warfarin. She passed S&S and placed on a regular diet. TTE
showed no atrial or ventricular clot with preserved global and
regional biventricular systolic function. She was assessed by PT
and OT and deemed to benefit from rehab and was therefore
transferred to rehab on [**2156-3-8**] on warfarin with an IV heparin
bridge. She has neurology follow-up.
.
.
# Neurology:
On admission, the patient was drowsy and lethargic but alert and
oriented felt likely secondary to lorazepam. She was dysarthric
without evidence of aphasia and had a right gaze deviation
without apparent neglect. She had a left facial droop and left
hemiparesis without sensory disturbance.
CT-head showed subtle loss of [**Doctor Last Name 352**]-white matter differentiation
in the right insular
ribbon concerning for evolving subacute infarction in the right
MCA territory without evidence of hemorrhage post tPA. MRI
showed subacute right MCA infarct involving the insula in
addition to multiple foci of restricted diffusion in the left
cerebral hemisphere and right temporo-occipital region
consistent with embolic infarcts. MRA revealed right M2/M3
segment stenosis on the right and decreased
flow in the distal branches of the left MCA felt likely
consistent with atherosclerotic disease.
Given the above, the decison was made not to intervene based on
her improved motor function, the location of the clot in the
distal MCA portion, and documented (75%) stenosis of the right
carotid, which would have made intervention both risky and
difficult. She was therefore admitted to the ICU for observation
post tPA on [**2156-3-5**].
The likely cause of her embolic infarcts is non-anticoagulated
AF.
Stroke risk factors were assessed and patient was monitored on
telemetry and this revealed persistent AF with episodes of RVR.
HbA1c was 6.1% and FLP revealed Cholesterol 190 TGCs 78 HDL 48
LDL 126. Serum and urine tox screens were normal. CEs were
negative and TSH was 2.7. Pravastatin was therefore increased to
80mg daily. Aspirin was stopped. Patient was maintained on a
HISS to maintain normoglycemia and fingersticks were
unremarkable.
Echo showed no left atrial mass or thrombus with normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function EF >60%.
Anti-hypertensives were held to allow autoregulation and she was
initially treated with IV digoxin for AF with RVR. She was then
treated with PRN IV metoprolol and transferred to the floor on
[**2156-3-6**]. Patient was started on IV heparin 24 hours after tPA
and was started on warfarin on [**2156-3-6**]. She was restarted on
low dose metoprolol 25mg tid on [**2156-3-8**] and her BP was closely
monitored.
There was initial concern regarding her swallowing and an NG
tube was initially placed in the ICU. On further assessment on
[**2156-3-8**] by S&S, she was passed for regular diet.
Patient continued to improve neurologically and had no evidence
of neglect and on discharge had mild left hemiparesis. Patient
was assessed by PT and OT and deemed to benefit from rehab and
was therefore transferred to rehab on [**2156-3-8**] on warfarin with
an IV heparin bridge. She has neurology follow-up.
.
# Cardiology:
Patient was monitored on telemetry and ECG showed SR with LBBB
with AF noted on telemetry. Patient had episodes of AF with RVR
in the setting of stopping her metoprolol, lisinopril and
amlodipine to allow autoregulation of BP and improve perfusion.
Given embolic strokes she was started on IV heparin as a bridge
to warfarin especially concerning her recent biopsy. Aspirin was
stopped. Digoxin was initially started in the ICU out of
concerns regarding BP compromise from other agents. Digoxin
level was 1.9 and digoxin was ultimately stopped on transfer to
the floor. Patient had continued AF episodes with asymptomatic
RVR into the 120s-140s although BP was borderline in 100s/110s
and was treated with PRN IV metoprolol and on the day of
discharge transitioned to low dose metoprolol 25mg tid whichshe
tolerated well with BPs maintained in 120s. Patient was
evaluated with a TTE which showed no left atrial mass or
thrombus with normal biventricular cavity sizes with preserved
global and regional biventricular systolic function EF >60%. She
was transferred to rehab on metoprolol 25mg tid and we have held
lisinopril and amlodipine. Pravstatin was increased as above to
80mg daily. She was discharged on an IV heparin infusion with a
goal PTT 50-70 given her recent stroke. PTT should be checked
every 6 hours, and heparin can be stopped once INR is
therapeutic (2.0-3.0) for 24 hours.
Medications on Admission:
Aspirin 81mg qd
metoprolol 100mg [**Hospital1 **]
Amlodipine 5mg qd
Lisinopril 40mg daily
Pravastatin 40mg daily
omeprazole
Iron
vit D
Discharge Medications:
1. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. iron 325 mg (65 mg iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
4. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six [**Age over 90 1230**]y (650) units Intravenous
Infusion: Continue until INR is therapeutic for 24 hours. Goal
PTT 50-70 given recent stroke.
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Outpatient Lab Work
Daily INR and PTTs every 6 hours while on heparin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary diagnosis:
1) Right middle cerebral artery infarct s/p tPA with aetiology
likely secondary to embolism from atrial fibrillation
2) Atrial fibrillation with episodes of rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic:
AOx3 recalls [**3-13**] words, no visual or sensory inattention and
performs line bisection normally. Slight left NLF flattening and
no oethr cranial nerve deficits. Left pronator drift with left
arm>leg weakness and 4+/5 in shoulder abdiction and extensors
and [**5-15**] in flexors in arm and IP 4+/5 and otherwise [**5-15**] in left
leg. Left extensor plantar with withdrawal on right. No sensory
deficits. No ataxia.
Discharge Instructions:
Dear Mrs. [**Known lastname 92430**],
You were admitted to the [**Hospital1 18**] inpatient neurology stroke
service as a transfer for a stroke in the right side of your
brain. While you were here we obtained an MRI which confirmed
your stroke and on blood vessel imaging showed a blockage of one
of the arteries on the right side of your brain, consistent with
the stroke you had been treated for at [**Hospital3 **].
You were very drowsy on arrival here felt likley due to the
lorazepam that you had received. We treated your stroke with a
clot-busting medication called tPA and for this you were
initially admitted to the ICU for observation. You were stable
and transferred to the floor.
You did well on the floor and due to low blood pressure we have
held your amlodipine (Norvasc) and lisinopril and reduced your
metoprolol for the time being. You did have episodes of high
heart rate as we had reduced your metoprolol. You had an
echocardiogram which showed no evidence ofa clot in your heart
and this showed that your heart was pumping well.
The likely cause of your stroke was your irregular heart rate
called atrial fibrillation which causes clots to form in the
heart and then can go to the brain and cause a stroke. For this,
we have started you on a medication called heparin which is
given intravenously in addition to warfarin. The heparin will be
stopped when the warfarin level (INR) is at the correct
therapeutic range. You will need frequent blood tests at rehab
to monitor your INR and you will need to continue warfarin as an
outpatient lifelong.
There were initial concerns regarding your swallowing and you
were assessed by the speech and swallow specialists and they
felt you could have a normal diet. You were assessd by PT and
you strength has improved since your initial presentation and at
this time you are ready to go to rehab to continue your recovery
on [**2156-3-8**].
.
The following changes were made to your medications:
We STARTED Warfarin 5mg daily to thin your blood and reduce your
risk of further stroke given your atrial fibrillation
We STARTED heparin IV which you shoudl continue until your
warfarin level (INR) is in the correct range
We INCREASED pravastatin to 80 mg daily
We DECREASED metoprolol to 25mg three times daily
We STOPPED aspirin
We HELD lisinopril and amlodipine given low blood pressure
.
Please continue your other medications as previously prescribed.
Followup Instructions:
Please see your PCP on discharge from rehab.
.
We have arranged the following neurology follow-up:
Department: NEUROLOGY
When: FRIDAY [**2156-5-7**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"427.31",
"V12.54",
"401.9",
"434.11",
"433.10",
"272.4",
"V45.88",
"437.0",
"342.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16850, 16897
|
10537, 15822
|
286, 293
|
17140, 17140
|
3832, 4460
|
20194, 20682
|
1846, 1988
|
16008, 16827
|
16918, 16918
|
15848, 15985
|
17749, 20171
|
4976, 6096
|
2607, 3366
|
2028, 2295
|
227, 248
|
321, 1491
|
6105, 7927
|
7945, 10514
|
16937, 17119
|
4482, 4960
|
17155, 17725
|
1513, 1714
|
1730, 1830
|
3391, 3813
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,723
| 199,450
|
6448
|
Discharge summary
|
report
|
Admission Date: [**2189-9-4**] Discharge Date: [**2189-9-14**]
Date of Birth: [**2141-4-2**] Sex: F
Service: GYN
This 48 year old nulligravida Cambodian female with menarche
age 14 and menses every 25 days lasting 4-5 days, LMP the end
of [**2189-5-20**], was admitted on [**2189-9-4**], for a right
salpingo-oophorectomy and total abdominal hysterectomy. She
had been diagnosed this spring with DCIS of the right breast.
This had been treated with radiation therapy. A second set of
breast biopsies had taken place in the past 2 weeks. The
biopsy on the right was benign. The biopsy on the left was
reported at the time of admission to be positive for DCIS
with the possibility of microinvasion. As an adolescent, she
underwent an emergency appendectomy in [**Location (un) 6847**]. Her
appendix was ruptured. The surgery was complicated by a
probable postoperative abscess which required a second
surgery and drainage a short time after the 1st one. For many
years thereafter, she had left sided back pain. This was
possibly attributable to degenerative disease involving the
vertebral column. Currently, she had some problem with right
sided back pain. In [**2182-8-20**], she underwent her 1st
pelvic exam in many years per her primary care physician. [**Name Initial (NameIs) **]
pelvic mass was found on the left. An ultrasound examination
that [**Month (only) **] demonstrated a cyst with multiple septa. The
cyst was approximately 7 cm in diameter. It was removed
surgically here at the [**Hospital3 **]. It proved to be a
serous cystadenoma. She had extensive abdominal and pelvic
adhesions at that time and had an intraoperative enterotomy
which was repaired. She had a long complicated postoperative
course. She had never tried to conceive. Her menses had been
regular up until the time of radiation therapy for her breast
cancer this spring. Because of the DCIS, it was deemed
advisable per her breast surgeon and oncologist that she
undergo a right oophorectomy and, in addition, because
tamoxifen was to be included in her regimen of therapy, a
removal of the uterus if possible. Her gynecologic history
was further complicated by the fact that in [**2185**], while
she was being followed during the years after her left
salpingo-oophorectomy, a pelvic ultrasound exam and then an
MRI had suggested that she had a complex mass involving the
right adnexa consistent with an ovarian carcinoma. Exploratory
surgery was suggested. She preferred not to have surgery at
that time. She used some form of Chinese herbal therapy
instead. Meanwhile, follow-up ultrasound and MRI exams
suggested that the earlier exams had been over-read and
that what she had was an ovary with a dilated right tube
surrounding it, creating the impression of a mass with
multiple septa and a solid component to it. This issue had
never been fully resolved except that time and lack of
further changes had suggested that whatever was going on in
the right adnexa was probably benign.
The remainder of her history was noteworthy for an allergy to
aspirin.
On physical examination, she was a well developed, well
nourished Oriental female in her late 40s, in no acute
distress. Her blood pressure was 112/65. Her pulse was 60,
her weight 142 pounds. There was an ample hypogastric midline
surgical incision scar on her abdomen and 2 recent incisional
scars in her breasts. On pelvic examination, the uterus was
normal in size and shape and anteflexed and felt as if it
were fixed in position. The left adnexa were absent. The
right adnexa contained a 4-5 cm soft cystic mass contiguous
with the uterus.
On the date of admission, she was taken to the operating
room. On opening the abdomen, she was found to have extensive
anterior wall abdominal adhesions. Once these had been
taken down, her sigmoid colon was seen to be draped across the
back of her right adnexa and uterus and to obscure the left
aspect of the uterus where her previous dissection had taken
place. It was possible to dissect the sigmoid colon
off the right adnexa. It was now seen that her fimbria were
normal. The right tube was dilated and was wrapped around an
ostensibly normal ovary. It was possible to isolate
both the ureter and the infundibulopelvic vessels on
that side and divide the latter, freeing the adnexa for
removal. Continued dissection of the sigmoid, however, led to
the conclusion that there were no dissectible planes between
the adhesions and the left aspect of the uterus.
GYN/oncological consultation was obtained. The
left side of the bowel was mobilized by the consulting
surgeon. During the course of this potion of her procedure,
the external iliac vessels were injured.
Cardiovascular surgery was then called to the operating room
and this injury was repaired. The surgery was completed by
the GYN/oncology team. In view of the fact that she would
have to be on large doses of anticoagulants and the severity
of the adhesions involving the left adnexa, it was decided to
leave the uterus in place. Prior to the arrival of the
GYN/oncology team, the sigmoid colon had been explored. It
appeared as if a single diverticulum involving the bowel had
been transected during the dissection of the sigmoid colon off
the posterior aspect of the fundus, leaving a small neat
defect in the sigmoid colon. Since the patient had had a bowel
prep, the colon was empty. This round defect was repaired by
the GYN/oncology team. In addition, another area of the
sigmoid colon serosa was oversewn for security sake. The
patient developed hematuria after the retroperitoneal
dissection had begun. An injury to the bladder muscularis,
but not the mucosa, was discovered. This was repaired as well.
Prophylactic anticoagulant therapy was begun almost
immediately after surgery was completed.
Postoperatively, the patient's course was complicated. She
had received ample amounts of fluid during the surgery and
during the first night, she experienced transient bigeminy. A
subsequent follow-up with cardiac enzymes indicated that she
had not sustained any kind of myocardial infarction. Her
electrolytes and fluid balance were corrected. Her left leg
became markedly edematous. An initial Doppler study was
negative. A follow-up Doppler study the next day confirmed
that she did have a deep vein thrombosis involving
the damaged common femoral vein. She had been
placed on anticoagulation prophylactically after surgery. The
dose of anticoagulation was increased. Over the course of
the ensuing week, the edema involving the lower extremity
resolved substantially. At the time of discharge, she had a
good femoral pulse and minimal edema involving her left thigh.
She had had good dorsalis pedis pulses throughout her
hospital course. Additional postoperative complications
included a transient ileus involving a portion of the small
bowel and the development of a subcutaneous hematoma which was
drained approximately a week postoperatively. After that had
been evacuated, normal bowel function returned rapidly. The
patient had been on antibiotics because of the extent of her
surgery and the bowel and bladder repairs. These were
discontinued part way through the hospitalization, but once
the hematoma was noticed, she was placed on Keflex and
ultimately on Levaquin. The latter was continued after her
discharge.
DISCHARGE DIAGNOSES: Extensive pelvic and abdominal
adhesions, right hydrosalpinx, bilateral ductal carcinoma in
situ of the breasts, intraoperative enterotomy and cystotomy
and iliac vessel damage with repair, deep venous thrombosis
treated with anticoagulation, superficial incisional
hematoma, evacuated.
OPERATIONS: EXPLORATORY lAPAROTOMY, LYSIS OF ADHESIONS, RIGHT
SALPINGO-OOPHORECTOMY, INCIDENTAL ENTEROTOMY AND REPAIR,
REPAIR OF BLADDER MUSCLE INJURY, INJURY AND REPAIR OF ILIAC
VESSELS
COMPLICATIONS: BOWEL, BLADDER AND VESSEL INJURY, CARDIAC
BIGEMINY, DEEP VEIN THROMBOSIS, ILEUS, SUPERFICIAL WOUND
HEMATOMA, EVACUATED
CONDITION: IMPROVED, DISPOSITION: VNA TO MONITOR INCISION AND
ANTICOAGULATION WITH LOCAL SURGEON, RETURN TO DR.[**Last Name (STitle) 24801**]
OFFICE IN 3 WEEKS [**First Name11 (Name Pattern1) 1158**]
[**Last Name (NamePattern1) 24802**], [**MD Number(1) 24803**]
Dictated By:[**Last Name (NamePattern1) 24804**]
MEDQUIST36
D: [**2189-9-14**] 14:15:22
T: [**2189-9-14**] 20:03:59
Job#: [**Job Number 24805**]
f1
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[
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icd9cm
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[
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"39.32",
"39.31",
"99.04",
"86.04",
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icd9pcs
|
[
[
[]
]
] |
7338, 8401
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,080
| 185,945
|
10213
|
Discharge summary
|
report
|
Admission Date: [**2167-2-12**] Discharge Date: [**2167-3-10**]
Date of Birth: [**2093-11-27**] Sex: F
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
Spanish-speaking only with a history of hypertension and
diabetes who was admitted for progressively worsening
shortness of breath. Over two months prior to admission the
patient experienced increased exertional shortness of breath
as well as two-pillow orthopnea, and peripheral edema. She
did not have any episodes of chest pain. She was admitted
initially to [**Hospital3 17310**] where she had a chest
x-ray demonstrating congestive heart failure. She was ruled
out for myocardial infarction. An echocardiogram there
demonstrated an ejection fraction of 30% with wall motion
abnormalities as well as severe mitral regurgitation. She
was transferred to the [**Hospital1 69**]
for catheterization.
PAST MEDICAL HISTORY: (Significant for)
1. Hypertension.
2. Type II diabetes.
3. Status post appendectomy.
4. Status post cholecystectomy.
ALLERGIES: She has no known drug allergies.
FAMILY HISTORY: Unremarkable.
MEDICATIONS ON TRANSFER: Aspirin 325 mg p.o. q.d.,
Isordil 10 mg p.o. t.i.d., IV heparin, IV Lasix 40 mg q.d.
PHYSICAL EXAMINATION ON ADMISSION: She was relaxed with no
evidence of acute distress. Temperature was afebrile and
hemodynamically stable, was satting 95% on 2 liters. Heart
had normal sounds, 3/6 systolic murmur over the left sternal
border radiating to the axilla. Lungs revealed good breath
sounds bilaterally but she did have bibasilar crackles.
Abdomen revealed normal bowel sounds, soft, and nontender.
Extremities revealed +1 edema, nontender. Neurologic
examination revealed alert and oriented times three and
grossly nonfocal.
LABORATORY ON ADMISSION: White count of 4.3, hematocrit
of 46.4, platelets 159. Sodium 140, potassium 4.2,
chloride 103, bicarbonate 31, BUN 21, creatinine 0.9, glucose
of 40. Hemoglobin A1c was 7.3. CKs were 35, 85, and 60.
Troponin was less than 0.1. She had a normal set of liver
function tests.
EKG on admission demonstrated sinus rhythm at 70 with
.................... pattern but no acute ST changes. No
evidence for old myocardial infarction.
HOSPITAL COURSE: The patient is a 73-year-old with history
of hypertension and diabetes, admitted initially to the
cardiac service after being ruled out for myocardial
infarction at [**Hospital3 17310**]. The patient had a
cardiac catheterization on [**2-13**] which showed clean
coronaries but very severe mitral regurgitation. The patient
was transferred to the cardiothoracic surgical service and
had a mitral valve replacement with a porcine valve on
[**2-16**]. The patient tolerated the procedure well.
Postoperative period was complicated with failure to wean.
In addition, she was taken to the operating room twice
postoperatively. Once for tamponade secondary to bleeding
and the second time for entangled Swan-Ganz catheter in the
atrial sutures. She was postoperative atrial fibrillation on
postoperative day 10, for which she was started on
amiodarone. She also had postoperative pneumonia which was
treated with .................... with levofloxacin. Sputum
cultures and blood cultures were entirely negative except for
1/4 bottles growing Staphylococcus epidermidis which was
thought to be a contaminant. Due to failure to wean she was
transferred to the intensive care unit on [**3-3**];
however, soon afterwards was extubated and since then
remained off the ventilator. She was diuresed aggressively
with Lasix, and in addition was treated with captopril for
afterload reduction. Postoperative echocardiogram showed
evidence for global hypokinesis, multiple cardiac effusion,
mild mitral regurgitation with decreased leaflet motion of
the valve with elevated gradient higher than what would be
expected with this prosthesis. Given this, the patient was
kept on good regimen with beta blockers and captopril. She
was called out from the intensive care unit to the medical
floor on [**3-7**]. Since then she has been hemodynamically
stable. No recurrent episodes of atrial fibrillation on
amiodarone. She was diuresed further with Lasix and was kept
on the same medications. Of note, she did have an episode of
vasovagal after being in the rest room; however, no recurrent
episodes, no arrhythmias documented.
The patient was seen by physical therapy and acute
rehabilitation was suggested. The patient was to be
discharged from [**Hospital1 69**] to
.....................
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Captopril 50 mg p.o. t.i.d.
3. Lasix 40 mg p.o. b.i.d.
4. Amiodarone 400 mg p.o. q.d. to be discontinued on
[**3-25**].
5. Combivent 2 puffs p.o. q.4h. p.r.n.
6. Insulin sliding-scale.
7. Zantac 150 mg p.o. q.d.
8. Multivitamin 1 tablet p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Haldol 0.5 mg IV q.6h. p.r.n.
DISCHARGE DIAGNOSES:
1. Cardiomyopathy secondary to mitral regurgitation.
2. Status post porcine mitral valve replacement.
3. Postoperative atrial fibrillation.
4. Diabetes.
5. Hypertension.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7021**] M.D. [**MD Number(1) 34067**]
Dictated By:[**Name8 (MD) 34068**]
MEDQUIST36
D: [**2167-3-10**] 14:40
T: [**2167-3-10**] 13:58
JOB#: [**Job Number 22529**]
|
[
"425.4",
"423.9",
"998.11",
"424.0",
"518.81",
"427.31",
"997.1",
"428.0",
"426.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"39.61",
"34.03",
"34.09",
"88.72",
"88.53",
"37.23",
"35.24",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
1113, 1128
|
4998, 5437
|
4612, 4977
|
2260, 4560
|
4575, 4585
|
168, 904
|
1809, 2242
|
1154, 1261
|
927, 1095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,569
| 198,298
|
48052
|
Discharge summary
|
report
|
Admission Date: [**2198-8-3**] Discharge Date: [**2198-8-6**]
Date of Birth: [**2135-4-27**] Sex: F
Service: MEDICINE
Allergies:
Cefepime / Zosyn / Bactrim / Optiray 350
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent to left anterior
descending artery
History of Present Illness:
History was obtain per pt records and confirmed with pt's family
b/c pt was groggy s/p catheretization.
.
Ms [**Known lastname 71796**] is a 63 yo F with a history of CLL diagnosed in
[**2187**], and asthma, who presented with chest pain which started
while on the toilet at 11pm the night before [**Date range (1) 41463**]. She
characterized her pain as sudden in conset, substernal heaviness
[**5-26**], persistently pressing and radiating to her back. She does
not that she occasionally has chest pain w/her asthma but that
this was different in that it did not resolve. At that time she
denied n/v or pain radiating to the jaw or arm but did notice
some SOB and diaphoresis. Given the persistent chest pain, the
pt presented to ED. Family had noted that pt had complained of
non-specific gastrointestinal complaints over the last week (no
fevers) as well as more frequent asthma symptoms this summer w/
some chest discomfort associated w/ these symptoms.
.
Chest pain was sudden onset, substernal heaviness [**5-26**] that came
on at 11pm while at home. She mentions that she does sometimes
get chest pain with her asthma, but this pain was unusual as it
didn't go away. She did have associated diaphoresis, and the
pain radiated to her back. No nausea.
.
In the ED, initial vitals were 97.4 89 153/82 18 97. Patient had
[**6-26**] chest heaviness. Trop was found to be 0.10. Patient
recieved SL nitro and 4mg IV morphine and nitro gtt was started.
She also recieved ativan, and was started on a heparin gtt. MRI
of the chest was perfomred, which was negative for dissection.
Pt was transferred to the floor for further management at which
time her BP was ~130/70.
.
However, over the remainder of the night and early morning, she
continued to have persistent chest pain and significant EKG
changes were noted including T-wave inversions V3-V5 and ST
elevations in I and aVR just under 1mm. Second troponin was
0.21. These changes were new at 7am as compared to her admission
EKG from 11pm the night prior. We gave her nitro SL, heparin and
plavix bolus of 300mg. Pain resolved, but patient was scheduled
for stat cardiac catheterization. On cath, pt was found to have
a 60% ulcerated lesion in LAD, 2 drug eluting stents placed. R
heart cath showed wedge pressure of 33. Pt had nitro drip
titrated up and received 160mg of lasix and began actively
diuresing at which point chest pain improved. Bedside echo
showed akinesis of nateriorlateral wasll on prelim read.
.
On arrival to the CCU s/p cath, pt was stable condition after
placement of a drug eluting stent in the proximal LAD and was
admitted for further monitoring and management.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. Cardiac review of
systems is notable for absence of paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
CLL -diagnosed in [**2187**]
-began FCR Chemotherapy on [**2195-12-9**]. Course complicated
with 3 separate hospitalizations. Hospitalized [**Date range (1) 101337**] for
febrile neutropenia. No fever source found. Readmitted [**12-26**] to
[**2196-1-7**] with fever to 103.7F. Defervesced with broad antibiotic
coverage; again source not found. Found to have bilateral
pleural
effusions, R>L. On [**2195-12-29**], underwent R thoracentesis with
removal of 1.4 liters fluid that was consistent with exudative
process. Effusion reaccumulated. On [**2196-1-4**], underwent a R
thoracoscopy with drainage of pleural effusion and biopsy of 3
pleural nodules. Fluid was transudative. Pleural fluid cultures
were negative. On [**2196-1-18**], readmitted after developing fever to
103.6F with shortness of breath. Again no source found. Large L
pleural effusion tapped on [**2196-1-19**] with improvement.
(5) Received cycle 2 Fludarabine/Cytoxan X 2 days on [**1-25**] and
[**2196-1-27**]. Rituximab held.
(6) On [**4-8**], [**2-24**], received full dose FCR with Rituxan
included, and Neulasta support.
(7) Received cycle 4 full dose FCR [**Date range (1) 101338**].
h/o asthma
h/o osteopenia
.
Social History:
Lives w/husband who is health care proxy. Pt has 2 daughters who
are very involved.
-Tobacco history: distant, quick smoking ~20yrs ago smoked
1/2ppd for ~20yrs
-ETOH: none
-Illicit drugs: none
Family History:
Mother died of CHF, had 2MI's and ashtma
Her husband was hospitalized with an MI last month. Her
granddaughter may have been diagnosed with rubella last month;
the patient has not been in contact with this granddaughter
since this diagnosis, although she was likely in contact with
her soon before the diagnosis.
Physical Exam:
PHYSICAL EXAMINATION:
GENERAL: groggy, pale but NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PER, EOMI. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP was difficult to appreciate b/c of body
habitus, ~8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. However respiratory exam limited to antior
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No LE edema. No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
LABs on Admission:
[**2198-8-3**] 01:22PM BLOOD WBC-9.1 RBC-4.41 Hgb-13.4 Hct-39.2 MCV-89
MCH-30.5 MCHC-34.3 RDW-13.3 Plt Ct-429
[**2198-8-3**] 01:45AM BLOOD WBC-10.9 RBC-4.48 Hgb-13.8 Hct-39.9
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.3 Plt Ct-399
[**2198-8-3**] 01:45AM BLOOD Neuts-82.3* Lymphs-10.6* Monos-4.0
Eos-2.5 Baso-0.6
[**2198-8-3**] 01:22PM BLOOD Plt Ct-429
[**2198-8-3**] 01:22PM BLOOD PT-12.1 PTT-28.2 INR(PT)-1.0
[**2198-8-3**] 01:45AM BLOOD Plt Ct-399
[**2198-8-3**] 01:45AM BLOOD PT-11.7 PTT-22.7 INR(PT)-1.0
[**2198-8-3**] 01:22PM BLOOD Glucose-136* UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-98 HCO3-27 AnGap-16
[**2198-8-3**] 01:45AM BLOOD Glucose-113* UreaN-17 Creat-0.7 Na-140
K-3.8 Cl-101 HCO3-26 AnGap-17
[**2198-8-3**] 01:22PM BLOOD ALT-28 AST-29 LD(LDH)-190 CK(CPK)-88
AlkPhos-64 TotBili-0.8
[**2198-8-3**] 01:45AM BLOOD CK(CPK)-61
[**2198-8-3**] 01:22PM BLOOD CK-MB-11* MB Indx-12.5* cTropnT-0.21*
[**2198-8-3**] 07:52AM BLOOD cTropnT-0.21*
[**2198-8-3**] 01:45AM BLOOD cTropnT-0.10*
[**2198-8-3**] 01:45AM BLOOD CK-MB-4 cTropnT-0.09*
[**2198-8-3**] 01:22PM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
.
Labs on Discharge:
[**2198-8-5**] 07:01AM BLOOD WBC-7.1 RBC-4.09* Hgb-12.7 Hct-36.6
MCV-90 MCH-31.1 MCHC-34.7 RDW-13.4 Plt Ct-366
[**2198-8-6**] 06:40AM BLOOD WBC-7.6 RBC-4.00* Hgb-12.5 Hct-35.9*
MCV-90 MCH-31.3 MCHC-34.9 RDW-13.2 Plt Ct-329
[**2198-8-5**] 07:01AM BLOOD PT-12.9 PTT-28.0 INR(PT)-1.1
[**2198-8-5**] 07:01AM BLOOD Plt Ct-366
[**2198-8-6**] 06:40AM BLOOD PT-16.5* PTT-31.1 INR(PT)-1.5*
[**2198-8-6**] 06:40AM BLOOD Plt Ct-329
[**2198-8-5**] 07:01AM BLOOD Glucose-89 UreaN-18 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-31 AnGap-11
[**2198-8-6**] 06:40AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-144
K-4.4 Cl-114* HCO3-29 AnGap-5*
[**2198-8-4**] 01:43PM BLOOD CK(CPK)-108
[**2198-8-4**] 06:05AM BLOOD CK-MB-13* MB Indx-11.9* cTropnT-0.25*
[**2198-8-4**] 01:43PM BLOOD CK-MB-11* MB Indx-10.2* cTropnT-0.22*
[**2198-8-5**] 07:01AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.3
[**2198-8-6**] 06:40AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0
.
Portable TTE (Focused views) Done [**2198-8-3**]
Conclusions
Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is severely depressed (LVEF= 20 %)
secondary to akinesis of the anterior septum, anterior free
wall, and apex; and hypokinesis of the inferior septum and basal
inferior free wall. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2196-1-18**], left ventricular contractile function is
severely reduced.
.
MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Study Date
of [**2198-8-3**] 4:23 AM
FINDINGS:
MRA OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The
thoracic and
upper abdominal aorta demonstrates a normal caliber and
configuration
throught. The aortic root is measuring 3.1 cm, the ascending
aorta 2.4 cm, the aortic arch is 2.1 cm, the descending aorta is
2.2 cm at the misportion and 2.1 cm at the level of diaphragm.
There is no evidence of abnormal signal within the aortic lumen
throughout. The wall of the aorta is thin and regular
throughout. Origins of the celiac artery, SMA, and renal
arteries are patent.
MRI OF THE CHEST: There is no evidence of mediastinal or hilar
lymphadenopathy. There is no evidence of pleural or pericardial
effusion. No abnormality was detected in the visualized lung
fields. Multiplanar 2D and 3D reconstructions and subtraction
images were utilized for evaluation of the above findings
(series 1204, 1205, and 1206).
IMPRESSION: No evidence of aortic dissection.
.
Portable TTE (Complete) Done [**2198-8-4**] at 10:48:11 AM
Conclusions
The left atrium is mildly dilated. There is moderate to severe
regional left ventricular systolic dysfunction with akinesis of
the mid- anterior and anteroseptal walls, as well as all distal
LV segments. The remaining segments contract normally (LVEF =
30%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Moderate to severe regional left ventricular
systolic dysfunction, c/w LAD disease.
Compared with the prior study (images reviewed) of [**2198-8-3**],
there has been minimal change.
.
Brief Hospital Course:
Ms [**Known lastname 71796**] is a 63 yo F with a history of CLL diagnosed in
[**2187**], and asthma, who presented with chest pain which started at
11pm the night before [**Date range (1) 41463**]; found to have T-wave inversions
V3-V5 and ST elevations in I and aVR just under 1mm this AM
w/second troponin was 0.21 so was takenn to cath where 2 drug
eluting stents were placed in LAD.
.
# STEMI: Pt had chest pain and found to have elevated tropinin
of 0.1 on admission. Pt initially had improvement of chest pain
on nitro, heparin drip and morphine on floor but this AM again
had worsening chest pain and new ekg changes were found compared
to admission EKG. Pt went urgently to cath where found to have
~60% stenosis of LAD, 2 drug eluting stents were successfully
placed. Pt was placed on integrelin drip, aspirin 325mg daily,
plavix 75mg, atorvostatin 80mg. She was started on captopril
3.125 mg TID as well as metoprolol 12.5 [**Hospital1 **] and was transitioned
to enoxaparin from heparin with a goal of bridging to warfarin
on discharge. She had echocardiograms on [**8-3**] and [**8-4**] that
showed severely reduced LV function with EF of 20% on [**8-3**] with
minimal improvement on [**8-4**] to EF of 30%. Pt's chest pain
resolved and clnicial status improved and she was transferred to
the floor. Pt did well with PT and felt much improved by day of
discharged. Outpt follow up w/Dr. [**Last Name (STitle) 171**] was planned. As outpt,
may consider adding spironolactone at later time. Repeat ECHO is
planned for ~6weeks time to assess if there has been any recover
of cardiac function and improved EF to determin if ICD placement
is necessary. Given risk of thrombus development pt was also
started on coumadin w/lovenox bridge.
.
Note: oncologist and PCP were emailed to touch base regrading
any anticoag concerns given CLL hx
.
# Asthma: some recent history of more frequent med use over the
summer. Home meds were continued Flovent 110mcg inh po bid and
Salmeterol 50mcg inh [**Hospital1 **] PRN wheezing as well as albuterol nebs
PRN. Asthma was stable. Asthma exacerbations over the last month
or so may actually have been related to cardiac issues and
ischemia.
.
# Hx of Avascular necrosis bilaterally in ankles: Was on
Diclofenac 75mg at home for pain management. However, given
stent placement and addition of plavix and aspirin, pt was
changed to Tramadol 50 mg [**11-18**] [**Hospital1 **] prn.
.
# CLL: CLL was diagnosed in [**2187**]. Touched base w/oncologist
regarding potential anticoagulation; no concerns at this time.
.
Pt was full code during this admission. Husband is health care
proxy; daughters are very involved.
Medications on Admission:
Diclofenac 75mg po daily prn
Flovent 110mcg inh po bid
Ativan 0.5mg po qhs
Omeprazole 20mg po daily
Salmeterol 50mcg inh [**Hospital1 **] PRN wheezing
Tylenol PRN fever, pain
Calcium carbonate + Vitamin D - 500 mg (1,250 mg)-200 unit po
bid
Vitamin B12 - 1,000 mcg po daily
Glucosamine
MVI
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): Take every day for one year, do not stop taking unless
Dr. [**Last Name (STitle) 171**] tells you to. .
Disp:*30 Tablet(s)* Refills:*11*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain.
7. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours) as needed for
wheezing.
8. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
9. Cyanocobalamin (Vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Take until Dr. [**Last Name (STitle) **]
tells you to stop. .
Disp:*6 syringe* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO QAM (once a day (in
the morning)).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
16. Outpatient Lab Work
Please check INR and Chem 7 on wednesday [**8-8**] and call
results to Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 9347**].
17. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute systolic Dysfunction
ST Elevation Myocardial Infarction
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for the opportunity to participate in your care.
You had chest pain and a heart attack and was brought to the
cathterization lab. A blockage was found in your left anterior
descending artery and 2 drug eluting stents were placed. It was
found that your heart was weak because of the heart attack and
you received a diuretic to remove extra fluid. Your heart
function has recovered somewhat during your hospital stay and we
have started you on 2 medicines to help your heart work better.
A physical therapist saw you and recommended an activity program
to follow for the next 4 weeks. Your right groin site where the
catheterization was done looks very good with only minimal
bruising. Until your heart is stronger, please weigh yourself
every morning before breakfast, call Dr. [**Last Name (STitle) 171**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days. Please also
watch for swelling in your legs, trouble breathing or trouble
lying flat at night.
We made the following changes in your medicines:
1. STOP taking Omeprazole. This interferes with the action of
the Plavix (Clopidogrel)
2. Start taking Ranitidine instead to prevent heartburn.
3. STOP taking diclofenac, this can cause bleeding along with
your other blood thinning medicines. Take Tramadol instead for
pain. Dr. [**Last Name (STitle) **] can increase the dose if you still have pain
at home.
4. Start taking aspirin and clopidogrel (Plavix) every day to
prevent the stent from clotting off. Do not skip any doses or
stop taking these medicines unless Dr. [**Last Name (STitle) 171**] tells you to.
This is very important to prevent another heart attack.
5. Start taking Metoprolol XL to lower your heart rate and help
your heart recover from the heart attack.
6. Start taking Lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
7. Start taking Warfarin (coumadin) to prevent blood clots now
that your heart function is weak. You will have another
echocardiogram in about 1 month and you may be able to stop the
coumadin if your heart function has improved.
8. Until your coumadin level is 2.0-3.0, you need to take
Lovenox injections to prevent blood clots as well. Dr. [**Last Name (STitle) **]
will tell you when to stop taking the Lovenox.
9. Start taking Atorvastatin, a medicine to lower your
cholesterol. You will need to have blood tests in 6 weeks and 6
months to check your liver function (rare side effect). Pleaes
tell Dr. [**Last Name (STitle) **] if you have any muscle cramps on this
medicine.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2198-8-22**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] and Dr. [**Last Name (STitle) 171**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2198-10-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], 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
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 1158**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 10535**]
Phone: [**Telephone/Fax (1) 9347**]
Appt: [**8-13**] at 9:30am
Completed by:[**2198-8-6**]
|
[
"428.0",
"300.00",
"V87.41",
"428.21",
"733.49",
"204.10",
"410.11",
"493.90",
"414.01",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.40",
"00.46",
"88.53",
"00.66",
"36.07",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
16070, 16076
|
11041, 13700
|
309, 394
|
16189, 16189
|
6314, 6319
|
18906, 19967
|
5139, 5454
|
14041, 16047
|
16097, 16168
|
13726, 14018
|
16340, 18883
|
5469, 5469
|
3611, 3684
|
5491, 6295
|
259, 271
|
7437, 11018
|
422, 3503
|
6333, 7418
|
16204, 16316
|
3715, 4911
|
3525, 3591
|
4927, 5123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,939
| 138,752
|
40744
|
Discharge summary
|
report
|
Admission Date: [**2108-7-8**] Discharge Date: [**2108-7-13**]
Date of Birth: [**2055-5-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Endoscopy
Banding of esophageal varices
Intubation
History of Present Illness:
53yoM with HepC but no known cirrhosis/varices, h/o EtOH who
presented initially to [**Hospital **] Hospital from [**Location (un) 89090**]correctional facility with abdominal pain and hematemesis
(bucket full). There, he was noted to have stable vitals signs
but guaic positive from below; Hct was 29.8, INR 2. He then had
a large bout of hematemesis and was given 2u PRBC's, 2u FFP,
intubated with Fent/Versed/Vecuronium, started on Octreotide gtt
and given 40 mg IV PPI (vs PPI gtt?) and 4mg IV Morphine x1.
In the ED, initial vitals: p105 142/77 15 100%. Never
hypotense in the ED.
Labs significant for: Hct 32.5, Plts 97, INR 1.9, fibrinogen
normal 231, free Ca 0.86, Lactate 2.6, Tbili 5.6, AST/ALT
140/51, and renal function 29/0.8. ABG 7.55 / 38 / 303 / 34 on
AC 100% PEEP 5, TV 500.
In the ED he was given 1L NS, 1g IV CTX, continued PPI
gtt/Octreotide gtt/Versed gtt/Fentanyl gtt. He had NGT placed
but was coiled in esophagus and so NGT was replaced and coffee
grounds were lavaged. No current bright red blood return. Stat
RUQ u/s was done which showed fatty cirrhotic liver, patent
portal and hepatic vasculature with appropriate flow directions,
extensive parahepatic varices, trace ascites, splenomegaly, and
2 right sided kidneys.
On exam here, he appeared to have sequelae of liver disease with
jaundice, distended abdomen, hepatomegaly; noted to have blood
in his NGT.
Past Medical History:
from [**Location (un) **] correctional facility infirmary
- Hepatitis C cirrhosis
- EtOH
- Anemia
- Asthma
- HTN
- Compressed Disc
Social History:
Currently incarcerated at [**Location (un) **] correctional facility. H/o ETOH
abuse, details unclear. Former smoker.
Family History:
NC
Physical Exam:
Exam on admission:
VS 96.9 104/48 p66 99% on 50% 500 x 14 PEEP 8
Thin, jaudniced appearing M, intubated and sedated with dried
blood around nares and mouth, +scleral icterus, pinpoint pupils
not very reactive. Carotid pulsations noted.
Inspiratory stridor noted diffusely on both sides, with
decreased breath sounds on the L and decreased at the bases
Hyperdynamic heart with S1/S2 noted, no m/g, very easily
palpable PMI at midclavicular line
Abd soft, not tender or grossly distended, liver edge palpable
5cm below R costal margin
No BLE edema noted, legs are very thin but warm, not mottled
Skin jaundiced, with spider angioma on thighs
Neuro exam deferred
On discharge, he was afebrile with stable vital signs. His
liver edge was palpable but smaller than noted on previous exam.
Mild diffuse tenderness to palpation, improved.
Pertinent Results:
Admission Labs:
[**2108-7-7**] 11:38PM PT-20.3* PTT-35.0 INR(PT)-1.9*
[**2108-7-7**] 11:38PM PLT COUNT-97*
[**2108-7-7**] 11:38PM WBC-5.7 RBC-3.16* HGB-11.2* HCT-32.5*
[**2108-7-7**] 11:38PM HGB-12.0* calcHCT-36 O2 SAT-93 CARBOXYHB-4
MET HGB-0
[**2108-7-7**] 11:38PM GLUCOSE-124* LACTATE-2.6* NA+-141 K+-4.0
CL--97* TCO2-30
.
Additional labs:
[**2108-7-13**] 06:50AM BLOOD WBC-4.8 RBC-3.34* Hgb-11.8* Hct-34.4*
MCV-103* MCH-35.3* MCHC-34.2 RDW-16.2* Plt Ct-112*
[**2108-7-13**] 06:50AM BLOOD Glucose-84 UreaN-9 Creat-0.6 Na-134 K-3.8
Cl-103 HCO3-24 AnGap-11
[**2108-7-13**] 06:50AM BLOOD ALT-37 AST-82* AlkPhos-102 TotBili-2.9*
[**2108-7-13**] 06:50AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.6
[**2108-7-13**] 06:50AM BLOOD PT-19.8* PTT-38.5* INR(PT)-1.8*
.
Microbiology:
[**2108-7-8**] 10:57 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2108-7-9**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2108-7-11**]): NO GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
Endoscopy [**2108-7-8**]:
Impression: Varices at the lower third of the esophagus and
gastroesophageal junction (ligation)
Erythema, congestion and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Otherwise normal EGD to second part of the duodenum
.
[**2108-7-7**] FRONTAL CHEST RADIOGRAPH: An endotracheal tube
terminates 4.5 cm above the carina. Orogastric tube is coiled
within the esophagus. The heart size is normal. The hilar and
mediastinal contours are within normal limits. A left basilar
density may reflect an early consolidation. There is no
pneumothorax or pleural effusion
.
[**7-7**] ABDOMEN U.S.
1. Coarsened, echogenic liver, compatible with cirrhosis. Trace
ascites.
Extensive parahepatic varices and splenomegaly signifying portal
hypertension. Patent portal and hepatic venous and hepatic
arterial flow, with appropriate flow directions.
2. Enlarged slightly heterogeneous pancreas. Correlate to
pancreatic enzymes to exclude pancreatitis.
3. Incidental finding of two right-sided kidneys.
Brief Hospital Course:
Primary reason for hospitalization:
53yoM with HepC and newly diagnosed cirrhosis on RUQ u/s
without known varices who presents with hematemesis, hepatitis,
coagulopathy.
Active Issues:
1.Hematemesis -- On admission pt was vomiting bright red blood,
c/f large volume blood loss. He was transfused 3 units RBCs and
received FFP. He was intubated to protect his airway and had an
endoscopy which revealed grade II-III varices. The varices were
banded and the bleeding subsided. He was treated with an
octreotide drip, IV PPI, and IV ceftriaxone for SBP prophylaxis.
His Hct improved over the course of his admission, and he had
no further episodes of hematemesis. He completed five days
treatment courses with octreotide and ceftriaxone. He continued
to have melena but this also resolved during his admission. He
will need repeat endoscopy in [**2-16**] weeks and follow up with GI
specialist as outpatient (see scheduled appointments). He was
also started on Pantoprazole [**Hospital1 **] on discharge, as well as
sulcrafate to be continued for a total of 10 days.
.
2. Left upper lobe collapse, LLL pneumonitis: Seen incidentally
on CXR, likely [**2-15**] aspiration of blood vs GI contents in the
setting of hematemesis vs intubation. His repeat CXR showed
interval re-inflation of the LUL but persistent small area of
opacification of the LLL. He remained afebrile, breathing
comfortably and oxygenating well on room air, so clinical
suspicion for pneumonia was low. Sputum cultures did not grow
organisms.
.
3. Cirrhosis -- likely [**2-15**] ETOH abuse given history and AST:ALT
ratio > 2. He has several signs of chronic liver disease on
exam, including spider angiomata, palmar erythema, and palpable
liver edge below costal margin. He was started on lactulose
TID, titrated to 3 BMs/day. He should continue to follow up
with his GI specialist as an outpatient.
.
4. H/o ETOH: Pt stated that he had not consumed ETOH since
incarceration, which was 4 days PTA. He was initially started
on CIWA scale to monitor for s/sx ETOH withdrawal, but after 2
days this was discontinued.
.
5. DVT prophylaxis: He was encouraged to wear pneumoboots to
prevent DVT as SC heparin was contraindicated in the setting of
acute bleed.
.
6. Diet -- His diet was gradually advanced as tolerated, and on
the day of discharge he was doing well with normal diet.
.
Chronic issues:
Asthma -- he remained stable on his home dose inhalers.
.
Hypertension -- no known home meds (although takes nadolol for
varices), BP remained well controlled throughout stay.
.
Transition:
He will need repeat endoscopy in [**2-16**] weeks for re-eval of
varices, as well as outpatient follow up with GI for his varices
and liver disease (see scheduled appointments). He should
refrain from ETOH consumption, and minimize use of tylenol due
to his liver disease (no more than 2g/24 hours). On discharge
he was afebrile and breathing comfortably, however if he
develops fever, SOB, or cough productive of green-yellow sputum
he should get repeat CXR due to his risk of pna from aspiration
and intubation. He should also follow up with his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] ([**Telephone/Fax (1) 26677**]) within 1 week of leaving the [**Location (un) **]
correctional facility.
Medications on Admission:
from [**Location (un) **] correctional facility infirmary
- Prilosec 20 mg daily
- Nadolol 20 mg daily
- Ibuprofen 600 mg tid PRN, ordered on the 25th
- Flovent
- Lidocaine patch
- Oxycodone 5 mg
- Flonase
Discharge Medications:
1. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 bowel movements per day.
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever: Total dose should not exceed
2g/24 hours.
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. sucralfate 1 gram Tablet Sig: One (1) gram PO QID (4 times a
day): Please dispense liquid suspension to be taken until
[**2108-7-20**].
7. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) patch Topical once a day: Apply to affected area for 12
hours, remove for 12 hours before applying new patch.
8. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain.
9. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays each nostril Nasal once a day.
10. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Esophageal varices
Anemia
Cirrhosis
.
Secondary:
HCV
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you had an episode of
vomiting a large amount of blood. When you arrived, your blood
pressure was very low due to your blood loss and you received a
blood transfusion. You were intubated to protect your airway
and help you breathe, and then had an endoscopy which showed
bleeding vessels in your esophagus called varices, which are due
to your liver disease. The varices were banded to stop the
bleeding. You were treated in the Intensive Care Unit for two
days and your blood pressure improved. The breathing tube was
removed and you were transferred to the medicine floor.
.
On the medicine floor, you were treated with medications to
prevent bleeding of the varices and for your liver disease. You
did not experience any re-bleeding. Your blood counts continued
to improve, and you resumed eating a normal diet.
.
Please note the following changes to your medications:
-ADDED Lactulose 30mL PO TID (titrated to 3 BMs/day)
-ADDED Simethicone 40-80 mg PO/NG QID:PRN gas
-ADDED Sucralfate 1 gm PO/NG QID (Continue for 10 days, until
[**2108-7-20**]. Please dispense liquid suspension.)
-ADDED Pantoprazole 40 mg [**Hospital1 **]
.
Please continue to take the rest of your home medications as
prescribed by your provider.
Followup Instructions:
Please have your facility make you an appointment with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], by calling [**Telephone/Fax (1) 89091**]
Department: ENDO SUITES
When: FRIDAY [**2108-7-20**] at 3:00 PM (please arrive at 2 PM)
Department: GI-WEST PROCEDURAL CENTER
When: FRIDAY [**2108-7-20**] at 3:00 PM (please arrive at 2 PM)
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: LIVER CENTER
When: FRIDAY [**2108-7-27**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"456.20",
"518.0",
"572.3",
"276.8",
"518.81",
"070.70",
"571.2",
"275.2",
"507.0",
"275.41",
"285.1",
"303.91",
"286.9",
"401.9",
"V15.82",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.91",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9852, 9867
|
5136, 5309
|
315, 368
|
9986, 9986
|
2978, 2978
|
11436, 12530
|
2100, 2104
|
8684, 9829
|
9888, 9965
|
8452, 8661
|
10137, 11034
|
2119, 2124
|
11063, 11413
|
264, 277
|
5324, 7499
|
396, 1791
|
2994, 5113
|
2138, 2959
|
10001, 10113
|
7515, 8426
|
1813, 1947
|
1963, 2084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,057
| 138,666
|
4103
|
Discharge summary
|
report
|
Admission Date: [**2157-8-23**] Discharge Date: [**2157-9-5**]
Service: CARDIOTHORACIC
Allergies:
Reserpine / Phenobarbital / Niacin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
dyspnea on exertion, known aortic stenosis
Major Surgical or Invasive Procedure:
s/p AVR/CABG
History of Present Illness:
81yo woman w/known AS, worsening dyspnea over last several
months referred for AVR. Scheduled for preop cardiac
catheterization prior to surgery
Past Medical History:
1. Aortic Stenosis
2. Mechanical fall c/b Subdural hematoma [**8-20**] and right orbital
and nasal fracture, s/p ORIF and closed reduction
3. Anemia with baseline HCT around 30
4. Hypertension
5. DM II
6. CHF
[**12-20**] Echo: EF 55-60%. Moderately severe AS with [**Location (un) 109**] 0.7cm2,
peak aortic gradient 43mmHG, mean gradient 23mmHG. Mild AI. 2+MR
(may be underestimated), [**1-17**]+TR. Moderate LAE, mild [**Last Name (un) **].
Moderate to severe pulmonary artery systolic hypertension. EF
55-60%.
7. Breast cancer s/p Left Mastectomy [**2148**]
8. Total abdominal Hysterectomy [**2152**]
9. Carpal tunnel surgery
[**61**]. Urge/Stress incontinence: pt straight caths self 3x/day
11. Multiple urinary tract infections
12. Left femoral neck fracture [**2154**] s/p left hip
hemiarthroplasty
Social History:
retired. Lives alone in [**Location (un) 620**]. Lost 2 husbands, the last in
[**2147**]. has 3 daughters. Remote h/o smoking [**1-17**] gigarettes/day.
No alcohol or illicit drug use.
Family History:
Mom had diabetes and HTN. No h/o heart disease. Breast cancer
in mom and daughter.
Physical Exam:
Preop:
Gen- NAD
Skin- Unremarkable
HEENT- PERRL-EOMI, MMM- oropharynx benign, neck supple- no
lymphadenopathy
Pulm- CTA
C/V- RRR
Abdm- Soft, NT/ND/NABS
Ext- warm well perfused
Neuro- grossly intact
Postop:
Gen-NAD
Neuro- A+Ox3, lft sided weakness LUE>LLE with slight facial
droop
Pulm- CTA bilat
C/V- RRR, sternum stable
Abdm- soft, NT/ND/NABS
Incision- CDI
Ext- Warm, no edema, Lft EVH site CDI
Pertinent Results:
[**2157-8-23**] 08:30PM UREA N-30* CREAT-1.2*
[**2157-8-23**] 08:30PM WBC-26.5* RBC-4.36 HGB-13.2 HCT-39.9 MCV-92
MCH-30.3 MCHC-33.1 RDW-19.1*
[**2157-8-23**] 08:30PM PLT COUNT-228
[**2157-8-23**] 03:01PM UREA N-27* CREAT-1.0 CHLORIDE-113* TOTAL
CO2-22
[**2157-8-23**] 03:01PM PT-15.4* PTT-36.3* INR(PT)-1.4*
[**2157-9-5**] 03:20AM BLOOD WBC-12.8* RBC-2.53* Hgb-7.9* Hct-24.2*
MCV-96 MCH-31.1 MCHC-32.5 RDW-17.1* Plt Ct-114*
[**2157-9-5**] 03:20AM BLOOD Plt Ct-114*
[**2157-9-5**] 03:20AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2*
[**2157-9-5**] 03:20AM BLOOD Glucose-153* UreaN-46* Creat-1.3* Na-142
K-5.0 Cl-104 HCO3-29 AnGap-14
[**2157-9-1**] 01:59AM BLOOD ALT-119* AST-66* AlkPhos-106 Amylase-40
TotBili-0.5
[**2157-9-1**] 01:59AM BLOOD Lipase-41
[**2157-8-30**] 02:51AM BLOOD Albumin-2.8* Phos-3.7 Mg-2.7*
[**2157-8-25**] 10:32AM BLOOD HEPARIN DEPENDENT ANTIBODIES- neg
Brief Hospital Course:
Pt was a direct admission to operating room (please see OR
report for full details), she had an AVR(#21 pericardial
valve)CABGx3(LIMA-LAD, SVG-Diag, SVG-RCA)and repair Coronary
sinus. Pt tolerated the operation however in the immediate
post-op period she was noted to have a distended abdomen,
metabolic acidosis, poor urine output with bladder pressures of
32 and an elevated WBC. The general surgery service was
consulted and pt was tapped for 1.5 liters of acitic fluid. The
hepatobiliary service was also consulted as was ID and renal.
Over the next several days the pt had elevated BUN/Cr, LFT's and
WBC all resolved without clear explaination. The patient was
slow to wake and had diffuse muscle weakness post-op and
therefore was not extubated until POD 4, she was noted to have
left sided weakness and difficulty swallowing after extubation,
she failed a swallow evaluation and a head CT at that time
showed a subacute infarct in the same area as a previous
subdural hematoma.
The patient stayed in the ICU after extubation because her
pulmonary status was tenuous requiring vigorous pulmonary
toilet.
The patient continued to make progress over the next several
days but it was felt by the ICU team that she would require a
stay in rehabilitaion before returning home. On POD 13 it was
felt that the patient was stable and ready for discharge to
rehabilitation.
Medications on Admission:
1. Quinapril 20 QD
2. Atenolol 100 QAM/50 QPM
3. Lasix 40 QD
4. Lovastatin 20 QD
5. Protonix 40 QD
6. Ativan 1 QHS/prn
7. Glucophage 500 TID
8. Folate
9. Vit B&E
10. Darvocet N-100 prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous twice a day.
7. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) cc PO BID
(2 times a day).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
s/p AVR(#21 pericardial)CABGx3(LIMA-LAD,SVG-Diag, SVG-RCA)Repair
of coronary sinus ([**8-23**])
s/p AVR(#21 pericardial)CABGx3(LIMA-LAD, SVG-Diag,
SVG-RCA)Repair of Coronary sinus([**8-23**])
CVA w/ residual left sided weakness
PMH:HTN, CAD, DM2, CRI, Urinary incontinance(straight cath
3x/day)frequent UTI's, SDH/orbital floor fx s/p ORIF, L hip
replacement, s/p TAH, s/p Rt mastectomy, s/p carpal tunnel
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 [**First Name (STitle) **] [**Doctor Last Name **] 2-3 weeks after d/c from rehab
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2157-9-5**]
|
[
"414.01",
"570",
"285.9",
"276.2",
"571.5",
"E870.0",
"995.92",
"998.2",
"403.91",
"997.02",
"584.5",
"789.5",
"287.5",
"428.0",
"729.89",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"54.91",
"96.6",
"35.21",
"39.61",
"99.07",
"96.04",
"96.71",
"99.04",
"38.93",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5530, 5573
|
2953, 4325
|
290, 305
|
6023, 6032
|
2049, 2930
|
6233, 6388
|
1530, 1616
|
4561, 5507
|
5594, 6002
|
4351, 4538
|
6056, 6210
|
1631, 2030
|
208, 252
|
333, 479
|
501, 1308
|
1324, 1514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,899
| 188,726
|
12358
|
Discharge summary
|
report
|
Admission Date: [**2163-3-14**] Discharge Date: [**2163-3-20**]
Date of Birth: [**2107-6-30**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
male with no previous cardiac history, referred for
outpatient cardiac catheterization to evaluate positive
stress test following exertional angina symptoms.
PAST MEDICAL HISTORY: Etoh use, [**1-23**] drinks per day, no past
surgical history, no known allergies.
HOSPITAL COURSE: On [**2163-3-14**] the patient was taken to the
cardiac catheterization lab following elective admission
where he was found to have a proximal right coronary artery
stenosis approximately 90% and a mid RCA stenosis of about
95%. The patient had a discrete left main stenotic lesion
approximately 80% and a proximal LAD lesion approximately
80%. A diag 2 lesion identified 70% discrete stenosis, a
proximal circ and mid circumflex lesions both 60-70%
stenosis. The patient had an ejection fraction of 60%.
Based on these findings, cardiothoracic surgery consult was
obtained and patient was deemed appropriate candidate for
coronary artery bypass grafting. So on [**2163-3-15**] the patient
was taken to the operating room where he underwent a coronary
artery bypass graft times four. His grafts showed LIMA to
diag, saphenous vein to distal LAD, saphenous vein to OM,
saphenous vein to the acute marginal branch. Postoperatively
he was transferred to the cardiac surgery recovery unit,
maintained on pressors briefly. The patient was awakened and
extubated. Pressors were slowly weaned off. He was
transferred to the floor where he began tolerating a regular
diet, ambulating with PT, chest tubes and cardiac pacing
wires were removed. However, the patient developed onset of
atrial fibrillation with controlled rate and was started on
Amiodarone. The patient was seen by physical therapy, deemed
independent for discharge directly home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS: Acetylsalicylic acid 325 mg po q day,
Metoprolol 25 mg po bid, Lasix 20 mg po bid times 7 days, KCL
20 mEq po bid for 7 days, Colace 100 mg po bid, Zantac 150 mg
po bid, Amiodarone 400 mg po q d and Percocet 5/325 [**12-22**] po q
4-6 hours prn pain. Patient is to follow-up with Dr. [**Last Name (STitle) **]
in [**1-24**] weeks and his primary care physician [**Last Name (NamePattern4) **] [**1-24**] weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2163-3-19**] 12:59
T: [**2163-3-19**] 14:14
JOB#: [**Job Number 38496**]
|
[
"998.11",
"V11.3",
"413.9",
"997.1",
"305.1",
"427.31",
"427.32",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.15",
"37.22",
"88.56",
"34.03",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2034, 2727
|
497, 1947
|
184, 372
|
395, 479
|
1972, 2010
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,274
| 179,148
|
42974
|
Discharge summary
|
report
|
Admission Date: [**2131-4-14**] Discharge Date: [**2131-5-14**]
Date of Birth: [**2083-1-21**] Sex: F
Service: Kidney Transplant Surgery Service
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
female status post kidney and pancreas transplant, history of
chronic diarrhea, history of C. diff colitis, toxic
megacolon, status post subtotal colectomy in [**2129-10-24**],
status post ileostomy reversal in [**2129-12-24**], status
post ventral hernia repair in [**2130-3-24**], peritoneal dialysis
catheter in [**2130-3-24**], status post placement of multiple IJ
catheters, history of bowel obstruction here now with acute
onset of abdominal pain, nausea, and vomiting, and no fever.
PAST MEDICAL HISTORY: Diabetes type 1, CAD, blind,
hypertension, osteopenia, depression, gastroparesis, anemia,
colitis, EF of 40%, MR, history of VRE, angina, zoster.
PAST SURGICAL HISTORY: CABG, pancreas transplant,
appendicitis, subtotal colectomy, ileostomy takedown,
bilateral vitrectomies, PD cath placement, a gastric
resection in [**2130-7-24**] with repair of 2 hernias, and a
bowel resection in [**2130-7-24**].
MEDICATIONS AT HOME: Prednisone 5 p.o. daily, Bactrim on
Monday/Wednesday/Friday, Lomotil p.r.n., sodium bicarbonate
1300 b.i.d., aspirin 81 daily, enalapril, loperamide,
Lopressor, MVI, Protonix 40 daily, Epogen, midodrine, Lasix
160 daily, Rapamune 4 mg daily.
LABORATORIES ON ADMISSION: White count 5.7, hematocrit 50.2,
platelet count 168. Sodium 140, potassium 4.2, chloride 95,
CO2 of 27, BUN 32, K 4.3, glucose 84. AST 40, ALT 19,
alkaline phosphatase 176.
RADIOLOGIC STUDIES: A chest x-ray was within normal limits.
A KUB on admission revealed multiple loops of dilated small
bowel indicating small bowel obstruction.
A CT of the pelvis with contrast revealed high-grade small-
bowel obstruction with transition point identified at the
site of surgical anastomosis within the left lower quadrant;
a moderate amount of ascites; a distended gallbladder, which
contained tiny gallstones but no evidence of gallbladder wall
thickening to suggest acute cholecystitis; unremarkable
appearance of the pancreas and renal transplant.
A chest x-ray on admission demonstrated low lung volumes; no
acute cardiopulmonary process; prominent and dilated small-
bowel gases in the upper abdomen representing partial image.
HOSPITAL COURSE: She was taken to the OR on [**4-14**] by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] for a small-bowel obstruction at the level
of the ileorectal anastomosis. She underwent resection of the
ileorectal anastomosis, a Hartmann procedure, and ileostomy
under general anesthesia. She returned to the SICU
postoperatively in stable condition. Please see operative
report for full details.
The pathology report of the ileorectal anastomosis
demonstrated congestion and autolysis of the mucosa with
fibrous peritoneal adhesions.
A neurology consult was obtained on [**4-16**] due to right eye
deviation. The patient was examined, and assessment and
recommendations included on physical exam her eyes looking to
the right. Recommendations included continuation of holding
sedation. Recommendations included obtaining a head CT to
make sure that she did not have ophthalmic bleed causing eye
findings as well as an EEG.
A head CT on [**4-16**] demonstrated probable small left
frontal subdural hematoma, left facial swelling; and no
evidence of herniation. Of note, she continued to third space
secondary to the small-bowel obstruction. IV Zosyn and
linezolid were continued. A urine culture on admission
demonstrated greater than 100,000 colonies of Klebsiella,
resistant to Bactrim; otherwise, pansensitive. Blood cultures
were negative. Peritoneal fluid intraop was cultured, and
results were negative for growth on the aerobic and anaerobic
bottles. A MRSA screen was done that was negative as well as
a VRE screen that was negative. A repeat urine culture on [**4-25**] demonstrated 10:100,000 colonies of yeast; and she required
IV levofloxacin.
A cardiology consult was obtained for tachycardia into the
130s as well as for postop hypotension with systolic's in the
60s. Cardiology's recommendations included volume
resuscitation with gradual wean of pressors as well as
holding beta blockers and starting aspirin when surgically
appropriate. Troponins were checked with peaking at 1.92 on
[**4-15**]. Recommendations from cardiology included keeping
hematocrit greater than 30 and with improvement of the blood
pressure restarting Lopressor 25 mg b.i.d.. Nitrates and
calcium channel blockers were recommended to be held. There
was noted that she had diffuse 3-vessel disease.
Her colostomy was putting out anywhere from 2 liters to 1-1/2
liter per day. Stoma was pink. The enterostomal nurse
specialist followed the patient throughout this hospital
course. The patient was followed by nutrition, and TPN was
started as the patient was n.p.o. postoperatively. Nephrology
followed the patient throughout this hospital course. She
required hemodialysis. Her pancreas transplant continued to
function; and amylase and lipase remained in the range of 39
and 30 with a slight increase to 71 and 39, respectively,
throughout this hospital course. Blood sugars remained
controlled in the 80s to low 130s. Her blood pressure
improved and pressors were weaned off. She was restarted on
aspirin and beta blocker. Her hematocrit remained in the
range between 28 and 25. This trended downwards toward the
end of her hospital stay to 22, for which she was restarted
on Epogen. She required labetalol as well as hydralazine for
blood pressures in the 169/72 range. The patient was
extubated on [**4-24**]. An NG tube remained in place. A
postpyloric feeding tube was placed, and the patient was
started on Nepro at 30 cc per hour goal. TPN was
discontinued. She underwent a bedside swallow eval for which
she showed signs of aspiration with thin liquids only after
taking a small amount of food. Given her altered mental
status, suggestions included a trial of nectar-thick liquids
and ground-solid consistency with one-to-one supervision
only. She continued on postpyloric feedings. Physical
therapy was instituted, and the patient was assisted out of
bed her. Her blood pressures continued to be labile and
hypertensive. She continued to receive intermittent dialysis.
Repeat blood cultures were done for a temperature spike on
[**5-6**] - on postop day #23 - up to 101.1. These cultures
demonstrated staph coag negative isolated from 1 set only. A
urine culture was also done which showed contamination with
mixed flora as well as staph coag negative 10:100,000
organisms. Repeat blood cultures were done that were
negative.
On [**4-27**], the patient again experiencing difficulty with her
mental status post extubation with some aphasia as well as
confusion. Neurology was consulted. Recommendations included
holding the narcotics and sedating medications as well as
repeating a head CT. Repeat head CT with contrast
demonstrated possible left frontal convexity. Extra-axial
high-density collection seen on [**4-16**] was no longer
identified. No new intracranial hemorrhage was noted. There
was interval improvement in the ethmoid sinus opacification
and scalp swelling. Physical therapy worked with her to
increase strength. Electrolytes were corrected. She remained
on dialysis with gradual improvement and improvement of her
mental status. Vital signs remained stable. Her Foley
catheter was removed. The patient intermittently complained
of pain in her abdomen. She received IV Dilaudid with
improvement. On [**5-3**], she underwent an abdominal CT with
contrast that demonstrated no evidence of bowel obstruction.
No CT findings to explain the patient's abdominal pain;
although the study was limited without IV contrast. There was
unchanged appearance of the pancreatic and renal transplant,
a small 2- x 1.1-cm fluid collection was noted in the abdomen
midline to the subcutaneous tissues. A repeat swallow eval on
[**4-30**] was done. The patient passed this study without signs
of aspiration. Diet was advanced slowly to regular food with
thin liquids.
A psychiatry consult was obtained on [**2131-5-2**]. It was
felt that the patient was experiencing some delirium and
night where she would be calling out and was very agitated.
Recommendations included Seroquel 12.5 mg to 25 mg at bedtime
and consideration for Haldol if Seroquel was ineffective. To
continue search for delirium, the patient had blood cultures
repeated. These were subsequently found to be negative. A
repeat urine culture was sent off. This was negative. Stool
was sent for C. diff as the patient continued to have stool
outputs of approximately 2 liters. Stool cultures for C. diff
were negative. The ET nurse followed the patient for frequent
pouch changes. It was felt the patient's pouch was
overfilling with stool and gas. A convex wafer was used with
an econ seal with a drainable pouch to gravity drainage. The
patient experienced quite a bit of peristomal excoriation
with evidence of a yeast infection. Nystatin powder was
applied. The patient underwent a repeat abdominal CT that
demonstrated no evidence of bowel obstruction.
On [**5-4**], these patient's blood pressure decreased to 71/40.
She was bolused with IV fluids without improvement.
Cardiology was consulted. Of note, EKG changes were noted,
but were not different than the prior EKGs on [**4-15**]. It
was felt that systolic blood pressure was possibly related to
sepsis or medications. Repeat blood cultures were done and
subsequently found to be negative. Of note, the patient's
beta blocker had been increased the previous day, and other
anti-hypertensives had been reinstituted. Her pre
hospitalization medications were reinstituted. Seroquel was
also suspected. She was transferred to the SICU for pressor
support on [**2131-5-5**] Seroquel was stopped. Haldol was
stopped. The patient was ultrafiltrated while in the SICU.
Her blood pressure improved
On [**2131-5-5**], psychiatry was consulted again for evaluation
for delirium versus depression. The patient requested her [**Hospital **]
hospital desipramine and was upset that she had been removed
from desipramine. Psychiatry's recommendations included
holding desipramine given anticholinergics effects and
history of multiple bowel obstructions. Low-dose Haldol was
recommended. No evidence of delirium was noted at that time.
White blood cell count was normal at 4.9, hematocrit 25.
Haldol was given, and the patient appeared to be calmer.
Social work followed the patient. She was transferred back to
the medical surgical unit where she gradually improved and
was able to ambulate independently. Her tube feeds continued.
She continued to pass large amounts of brown, loose stool.
The patient was continued on Haldol and was alert and
oriented, and she was still requesting desipramine. After
much discussion with the patient's outpatient psychiatrist,
desipramine 25 mg p.o. was restarted. She remained in the
hospital pending rehab placement. Upon further review,
physical therapy cleared the patient for home. The patient
and her husband were instructed in ostomy pouch changes. She
continued to have large volume stool output, requiring low-
dose Imodium b.i.d.. Remeron 7.5 mg was started.
A podiatry consult was obtained on [**2131-5-12**] for left 2nd
toe eschar. This was debrided, and normal saline wet-to-dry
dressings were initiated b.i.d.. There was no evidence for
surgical intervention on the right foot. Eschar was debrided
to the soft tissue. There was no erythema or edema noted. The
underlying tissue was viable.
On [**2131-5-14**] the patient was discharged home. Haldol was
stopped. The patient was instructed in how to change her
colostomy pouch as well as perform postpyloric feedings at
home. Both she and her husband received education.
Desipramine was increased to 50 mg after discussion with
outpatient psychiatrist. Antibiotics were stopped.
Immunosuppression continued throughout this hospital course.
She remained on Imuran 25 mg every other day, prednisone 5 mg
daily; and Rapamune was titrated to 4 mg p.o. daily for a
level of 10 while on 6 mg.
DISCHARGE DIAGNOSES: Small-bowel obstruction; status post
pancreas transplant; status post renal transplant,
nonfunctioning; end-stage renal disease; depression; anxiety;
Klebsiella urinary tract infection.
DISCHARGE FOLLOWUP: The patient was scheduled to follow up
in the outpatient transplant clinic.
DISCHARGE MEDICATIONS: Included Bactrim single strength
every Monday/Wednesday/Friday, prednisone 5 mg p.o. daily,
Imuran 25 mg p.o. every other day, Atrovent MDI b.i.d.,
Flovent 2 puffs b.i.d., [**Doctor First Name **] 60 mg p.o. b.i.d., loperamide
20 mg p.o. daily, Protonix 40 mg p.o. daily, atorvastatin 10
mg p.o. daily, mirtazapine 7.5 mg p.o. at bedtime, Rapamune 6
mg p.o. daily, aspirin 325 mg p.o. daily, metoprolol 25 mg
p.o. b.i.d., simethicone 80-mg tablets p.o. p.r.n. q.4h.,
Reglan 5 mg p.o. q.i.d. a.c. and h.s. for nausea, midodrine
10 mg p.o. q. Monday/Wednesday/Friday prior to hemodialysis,
and desipramine 50 mg p.o. daily. Tube feedings at home were
to continue with Nepro full strength with 25 grams benne
protein at 40 cc per hour for a 12-hour cycle per day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2131-5-18**] 17:04:26
T: [**2131-5-19**] 12:20:02
Job#: [**Job Number 92760**]
|
[
"995.92",
"553.21",
"782.8",
"432.1",
"362.01",
"250.51",
"276.51",
"369.4",
"250.61",
"560.9",
"458.29",
"300.00",
"569.69",
"410.71",
"997.4",
"787.91",
"038.9",
"579.3",
"V58.65",
"285.9",
"V42.83",
"997.1",
"V45.81",
"996.81",
"293.0",
"403.91",
"536.3",
"518.5",
"585.6",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.21",
"96.6",
"45.62",
"39.95",
"38.93",
"45.79",
"00.17",
"00.14",
"86.28",
"99.15",
"53.51",
"96.72",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12299, 12486
|
12608, 13631
|
2418, 12277
|
1198, 1454
|
944, 1176
|
184, 201
|
12507, 12584
|
230, 750
|
1469, 2400
|
773, 920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 110,745
|
48695
|
Discharge summary
|
report
|
Admission Date: [**2134-6-15**] Discharge Date: [**2134-7-5**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
CC:[**Last Name (STitle) 102394**]
Major Surgical or Invasive Procedure:
Temp R HD cath
History of Present Illness:
48 YO M with sarcoidosis with ESRD s/p failed transplant, h/o
hep B/C/?D, h/o paf on coumadin, h/o pulmonary aspergillosis,
presented from NH to OSH with neck stiffness, was found to be
hypotensive to the 80s, was started on vancomycin and
transferred to the [**Hospital1 18**]
.
In the field T101.8 108 111/66, in ED BP 79/53. was given
ceftazidine, gentamicin, transplant was consulted for possible
line removal, and renal were consulted. In addition his INR was
5 and was given FFP. He was given 250cc NS and transferred to
the ICU.
.
In the ICU, he states he's had an aching neck pain [**11-10**] and
stiffness for the past day, he denies trauma, or headache, light
sensitivity or rash, this pain is new onset. He otherwise
denied f/c, cough/sob, cp, diarrhea, n/v, no urine output on
baseline. no recent travel.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-4**] now on HD- L
groin line
IVC stent
Sarcoidosis
Pulmonary aspergillosis
DM
Chronic HCV
Hypertension
Sinusitis,
Paroxysmal atrial fibrillation, C. difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity DVT ([**2132**])
Pancreatitis
Bilateral BKA
Right index finger amputation
Social History:
Patient currently living at rehab facility. Smoked 1 ppd X 30
years but quit one year ago. No alcohol. Previous drug use
(IVDU). Girlfriend is involved in his care.
Family History:
Mother, brother with diabetes.
Physical Exam:
PE: VS 96.3 93/59 106 20 94% 2L
Gen: lethargic, AAOx3, speaking in full sentences
HEENT: EOMI, PERRLA, neck unable to touch chin to chest,
OP dry,
Chest: crackles at the bases bilaterally
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, ND +BS no guarding or rebound
Ext: R BKA, L BK (dark skin around sutures, otherwise clean,
dry)
R index finger amputation, wound CDI, no erythema fluctuance
Neuro: moves all 4, AAOx3
Pertinent Results:
[**2134-6-15**] 12:40PM BLOOD WBC-20.6*# RBC-4.05* Hgb-11.9* Hct-38.7*
MCV-96 MCH-29.5 MCHC-30.9* RDW-16.8* Plt Ct-385
[**2134-6-15**] 12:40PM BLOOD Neuts-71* Bands-0 Lymphs-13* Monos-16*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2134-6-15**] 12:40PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2134-6-15**] 12:40PM BLOOD PT-61.9* PTT-68.8* INR(PT)-7.7*
[**2134-6-15**] 12:40PM BLOOD Glucose-64* UreaN-84* Creat-11.3*#
Na-130* K-5.2* Cl-93* HCO3-13* AnGap-29*
[**2134-6-16**] 02:14AM BLOOD Calcium-8.4 Phos-5.0*# Mg-2.2
[**2134-6-16**] 02:14AM BLOOD Vanco-14.8
.
EKG SR 106bpm NA, peak P waves. no ST-T changed, no change from
previous.
.
CXR:
Suspicion of diffuse process in lungs possibly reoccurrence of
aspergillosis. As translation of findings on plain chest
examination into findings observed on previous CT may be
difficult, consider the possibility to ascertain these new
findings by renewed CT examination of this patient known to have
rather advanced sarcoidosis. Stat report delivered to emergency
room board.
Brief Hospital Course:
Assessment/Plan: 48M with sarocoidosis, amyloidosis-->ESRD on HD
with hx mult line infections, who p/w MRSA bacteremia,
endocarditis, pre-vertebral cervical abscess.
.
# MRSA bacteremia/Pre-vertebral abscess/Endocarditis: Pt
presented with neck pain/stiffness. Found to have prevertebral
(c3-4) abscess with associated discitis/osteomyelitis on CT &
MRI. Source likely MRSA bacteremia from infected HD catheter
(in L groin). Blood cx's from [**6-15**] grew MRSA in [**8-8**] bottles;
cx's from [**6-17**] grew MRSA in [**2-2**] bottles. Surveillance cultures,
following initiation of antibiotics, from [**6-18**] thru [**6-22**] were no
growth. TTE showed moderate-sized
mobile vegetation on mitral valve, which will be treated with
antibiotics only. Pt was treated with both vancomycin and
gentamicin. Gentamicin was discontinued on [**2134-6-25**], and the
patient was continued on vancomycin. He went for a washout of
cervical abscess w/ neurosurgery on [**2134-6-24**]. Abscess grew MRSA
as well. He is to continue on vancomycin 8wks from [**6-24**], which
was the date of his prevertebral abscess washout. Pt
defervesced following initiation of antibiotics. A tunnelled
catheter was replaced in the groin on [**2134-7-5**].
Neurosurgery does not feel that there is a need for follow up
imaging and he will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2134-7-26**].
.
# ESRD: Thought to be due to amyloidosis. He is status post
failed renal transplant. He is maintained on chronic HD on a
Tues-Thurs-Sat schedule.
.
# Right index finger pain: likely due to progressive dry
gangrene. He is status post amputation of distal portion on
[**2134-6-7**] by plastic surgery and given progression of gangrene, the
rest of the digit to the MCP was removed with flap revision on
[**2134-6-30**].
.
# Anemia: likely multi-factorial--related to CKD/anemia of
chronic disease & operative loses. He receives Epo at HD, was
stable during this admission.
.
# H/o asperg infxn: Itraconazole was continued for prophylaxis.
.
# H/o adrenal insufficiency: related to chronic steroid use (for
possible renal transplant or amyloid). He received stress dose
steroids for surgery and by the time of discharge had been
tapered down to his outpatient regimen of prednisone 5mg
alternating with 2.5mg daily.
.
# Delirium: CT head w/ contrast unremarkable. Altered mental
status attributed to infection exacerbated by pain medication.
By the time of discharge, patient was back to baseline.
.
# DM: well controlled on insulin sliding scale.
.
# Afib: The patient was in NSR throughout the admission. His
metoprolol was continued, but given his multiple procedures and
also given that his INR was supratherapeutic on admission, his
coumadin was held. It was restarted on the day of discharge,
with a goal of [**3-6**] which will have to be monitored upon
discharge.
.
# Psych: celexa was continued.
.
# FEN: Please maintain patient on a renal, diabetic, fluid
restricted (to 1.5L/day) diet.
.
# PPx: subcut heparin, ppi
.
# Comm: HCP [**Name (NI) 102395**] [**Name (NI) 10664**] (girlfriend) [**Telephone/Fax (1) 102392**]
.
# Code: Full (discussed with pt & HCP).
Medications on Admission:
Prednisone 5MG QD, 2.5mg QD
Provigil 100mg QD
Nephrocaps QD
Sensipar 60mg QD
Itraconazole 200mg [**Hospital1 **]
Fosrenol 50mg TID
Renagel 2400mg TID
Citalopram 30mg QD
Folic Acid 1mg QD
Metoprolol 12.5mg QD
Vicodin ES TID
MOM 30ml [**Hospital1 **] PRN
Tramadol 50mg [**Hospital1 **] PRN
Tylenol PRN
Dulcolax 10mg PRN
Coumadin 1mg QHS
Discharge Medications:
1. Outpatient Lab Work
Please check CBC/diff, ESR, CRP every week and fax to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of Infectious Diseases ([**Telephone/Fax (1) 16411**].
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
15. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
18. Vancomycin 1000 mg IV HD PROTOCOL
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please check INR, goal [**3-6**].
21. Outpatient Lab Work
Please check INR daily, patient just being restarted on coumadin
on [**2134-7-5**] after tunnelled line placement. Goal INR is [**3-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary:
MRSA bacteremia
Endocarditis
Pre-vertebral cervical abscess
Gangrene of right index finger
.
Secondary:
ESRD on HD likely secondary to amyloidosis
Anemia
History of aspergillus infection
Diabetes Mellitus
Atrial Fibrillation on coumadin
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted for infection of the heart valves and the
space around your spinal cord. You have been on intravenous
antibiotics during this admission and will continue on these
antibiotics for a total of 8 weeks. You also had further
amputation of the right index finger secondary to progressive
gangrene.
.
If you experience fevers or chills, nausea/vomiting, chest pain
or shortness of breath, please seek medical attention.
Followup Instructions:
With Dr [**First Name (STitle) **] in Infectious Diseases (ID) Clinic on [**7-26**] at
9:30am.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
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"997.62",
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"038.11",
"285.21",
"135",
"277.39",
"996.62",
"730.04",
"995.92",
"117.3",
"255.4",
"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"86.73",
"39.95",
"38.95",
"84.01",
"99.07",
"03.09",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
8875, 8918
|
3364, 6559
|
312, 328
|
9208, 9227
|
2267, 3341
|
9706, 9934
|
1773, 1806
|
6945, 8852
|
8939, 9187
|
6585, 6922
|
9251, 9683
|
1821, 2248
|
239, 274
|
356, 1181
|
1203, 1574
|
1590, 1757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,301
| 179,785
|
37992
|
Discharge summary
|
report
|
Admission Date: [**2193-4-10**] Discharge Date: [**2193-4-14**]
Date of Birth: [**2124-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Peanut
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left lower lobe squamous cell carcinoma of lung
Major Surgical or Invasive Procedure:
[**2193-4-10**]:
1. Left thoracotomy and lower lobectomy.
2. Partial bronchoplasty
3. Buttressing of bronchial suture line with intercostal
muscle.
4. Thoracic lymphadenectomy.
5. Flexible bronchoscopy.
History of Present Illness:
Mr. [**Known firstname 2491**] [**Known lastname 84879**] is a 69 year old male with history of heavy
smoking and asbestos exposure history with ESKD on HD undergoing
transplant evaluation, who presented repeated episodes of mild
hemoptysis, which prompted a CT chest that
showed a LLL endobronchial lesion. Mr. [**Known lastname 84879**] [**Last Name (Titles) 1834**]
bronchoscopy with Dr. [**Last Name (STitle) **] on [**2193-2-6**] with bronchial brushing
and TBNA LLL revealed NSCLC consistent with squamous cell
carcinoma. Further workup with PET CT revealed sub-cm
intra-luminal lesion in the left lower lobe superior segment
bronchus is FDG avid (Suv max =13). No definite FDG-avid
metastatic disease. Mild FDG uptake also in lateral left 7th rib
with no corresponding osseous abnormality on CT whcih is
nonspecific. Head MRI did not demonstrate evidence of metastatic
disease. Cervical mediastinoscopy 4L/4R biopsies failed to
detect malignant spread to these lymph nodes. He presents now
for surgical resection.
Past Medical History:
PMH: HTN, hx CVA, COPD, ESRD on HD T/TH/SA, anemia of chronic
disease, hx L nephrolithiasis, hx colonic polyps
PSH: L radiocephalic AV fistula ([**10/2191**]), L upper arm AV
fistula ([**3-/2192**]), cervical mediastinoscopy ([**2193-3-5**])
[**Last Name (un) 1724**]: ASA 81', Plavix 75', Metoprolol XR 100', Simvastatin 40',
Albuterol nebs 2.5mg/3ml Q6H prn, Spiriva 18mcg', EPO w HD,
Folate 1', Paricalcitol w HD, Sevelamer 2400 QAC, 1600
Qsnack([**Hospital1 **]), Tamsulosin XR 0.4', Dilaudid [**12-28**] prn, Tylenol
650''', B complex-VitC-Folate 400', Senna 1'' prn
Social History:
Pt moved to US [**3-/2192**] from former Soviet Republic to [**State 3908**] to
live with daughter and son-in-law for increased social support
due to ongoing fatigue. Pt only speaks Russian. Married with
two supportive children. 135 pack year history of smoking, quit
[**2190**] because secondary to dizziness. Retired mechanic with heavy
asbestos exposure. Rare ETOH. no known drugs
Family History:
Grandmother with lung cancer died age 74, father died in war.
Physical Exam:
P/E at discharge:
VS: T: 97.6 P: 87 BP: 140/70 RR: 20 O2sat: 96RA
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L, no respiratory distress; L thoracotomy incision
C/D/I with dermabond; L chest tube site C/D/I with
tegaderm/gauze
ABD: soft, NT, ND
PELVIS: deferred
EXT: WWP, no CCE
NEURO: strength intact/symmetric, sensation intact/symmetric
Pertinent Results:
LABORATORIES:
[**2193-4-11**] 02:41AM BLOOD WBC-8.6 RBC-2.99* Hgb-10.1* Hct-28.9*
MCV-96 MCH-33.8* MCHC-35.1* RDW-17.4* Plt Ct-217
[**2193-4-14**] 07:15AM BLOOD WBC-6.0 RBC-2.83* Hgb-9.4* Hct-28.3*
MCV-100* MCH-33.1* MCHC-33.2 RDW-17.0* Plt Ct-225
[**2193-4-11**] 02:41AM BLOOD Glucose-97 UreaN-39* Creat-9.1*# Na-135
K-5.0 Cl-95* HCO3-27 AnGap-18
[**2193-4-14**] 07:15AM BLOOD Glucose-128* UreaN-34* Creat-6.5*# Na-139
K-3.8 Cl-92* HCO3-33* AnGap-18
[**2193-4-11**] 02:41AM BLOOD ALT-12 AST-25 LD(LDH)-218 CK(CPK)-866*
AlkPhos-79 TotBili-0.3
[**2193-4-14**] 07:15AM BLOOD Calcium-8.3* Phos-4.2# Mg-2.1
MICROBIOLOGY: MRSA screen NEGATIVE
RELEVANT IMAGING:
CXR [**2193-4-13**]: There is no appreciable evidence of pneumothorax.
Subcutaneous air appears to be slightly decreased in the left
chest wall. Mediastinal contours are unremarkable. Right basal
atelectasis is unchanged.
PATHOLOGY: PENDING
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2193-4-10**] and had an open left lower lobectomy, partial
bronchoplasty. The patient tolerated the procedure well and was
admitted to the SICU postoperatively secondary to patient's
multiple medical comorbidities. He was admitted to the SICU
with an epidural, L chest tube to suction and a foley catheter.
Neuro: Preoperatively, the patient had an epidural catheter
placed. Post-operatively, the epidural functioned well with
adequate pain control. On POD2, patient had episode of
agitation/combativeness during which he self-d/c'd his epidural.
This episode required restraints and IM haldol following which
patient was coherent and cooperative throughout remainder of
admission. When tolerating oral intake, the patient was
transitioned to oral pain medications. Patient refused po
narcotics and reported adequate pain control with tylenol.
CV: Preoperatively, plavix was held but ASA continued. On POD1
patient had new onset afib refractory to IV lopressor 5mg x 4
doses. Amiodarone bolus and gtt were initiated after which
patient converted to NSR. Amiodarone was transitioned to po and
metoprolol dose was changed to 100 [**Hospital1 **]. Patient instructed to
discontinue metoprolol succinate at home in favor of metoprolol
tartrate 100mg [**Hospital1 **]. At time of discharge patient is in NSR.
Plavix restarted POD2. Vital signs were routinely monitored.
Pulmonary: Patient had left chest tube placed at time of
surgery. Tube was placed to suction postop. Changed to water
seal 4am on POD1 and subsequently removed later that day. Post
pull CXR demonstrated no PTX. Pulmonary toilet including
incentive spirometry and early ambulation were encouraged. On
day of discharge, patient with SaO2 96%RA at rest and 90-92 with
deep breathing on ambulation. Vital signs were routinely
monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced from clears to
renal regular diet on POD0. He was also started on a bowel
regimen to encourage bowel movement. Patient on hemodialysis and
oliguric at baseline. Renal followed throughout admission.
Foley was removed on POD#1. Patient was taken for hemodialysis
on POD1 and POD3 which he tolerated well. Intake and output
were closely monitored.
ID: Patient was given preoperative antibiotic prophylaxis with
ancef. The patient's temperature was closely watched for signs
of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a renal regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 81', Plavix 75', Metoprolol XR 100', Simvastatin 40',
Albuterol nebs 2.5mg/3ml Q6H prn, Spiriva 18mcg', EPO w HD,
Folate 1', Paricalcitol w HD, Sevelamer 2400 QAC, 1600
Qsnack([**Hospital1 **]), Tamsulosin XR 0.4', Dilaudid [**12-28**] prn, Tylenol
650''', B complex-VitC-Folate 400', Senna 1'' prn
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-25**] nebs Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4000mg acetaminophen
per day. .
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO
ONCE MR2 (Once and may repeat 2 times) as needed for snack.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower lobe endobronchial lesion
ESRD on HD T/TH/Sat
Hypertension
CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Chest pain
-Incision develops drainage or redness
-Chest tube site remove dressing and cover site with a bandaid
Pain
-Acetaminophen 650 mg every 6 hours as needed for pain
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than 10 pounds
MEDICATIONS
-Please take all medications listed here as prescribed and take
no other previous medications.
-Discuss medications with your primary care physician at your
next visit.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in two to three weeks. Please
call [**0-0-**] to make an appointment and request that
patient be scheduled for a chest x-ray 30 minutes prior to his
appointment. Dr.[**Name (NI) 5067**] office is located on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Radiology (for your chest
x-ray) is on the fourth floor of the [**Hospital Ward Name **] [**Hospital Ward Name **]
clinical center.
Follow-up with Dr. [**Last Name (STitle) **] nephrologist. Hemodialysis
Tues/Thurs/Sat
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and/or Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 3315**]
within ten days of discharge. Call ([**Telephone/Fax (1) 1300**] to make an
appointment.
Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2193-5-2**] 8:00
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2193-5-10**]
9:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2193-6-10**] 2:20
Completed by:[**2193-4-14**]
|
[
"403.91",
"162.5",
"285.21",
"585.6",
"307.9",
"V45.11",
"V12.54",
"496",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.49",
"33.23",
"03.90",
"39.95",
"40.11",
"33.48"
] |
icd9pcs
|
[
[
[]
]
] |
8694, 8700
|
4027, 6849
|
334, 542
|
8818, 8818
|
3100, 3741
|
9682, 10979
|
2614, 2678
|
7230, 8671
|
8721, 8797
|
6875, 7207
|
8969, 9659
|
2693, 2697
|
2711, 3081
|
247, 296
|
3760, 4004
|
570, 1595
|
8833, 8945
|
1617, 2193
|
2209, 2598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,861
| 184,242
|
50848
|
Discharge summary
|
report
|
Admission Date: [**2148-12-4**] Discharge Date: [**2148-12-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chief Complaint: Left back pain/hematoma.
.
Reason for transfer: Hematocrit drop.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: This 88 year old gentleman with CAD
s/p PCI to LAD and RCA, atrial fibrilation on coumadin, and
prior CVA presented to ED with left flank ecchymosis and pain.
Small ecchymosis were first noticed 4-5 days ago. Yesterday the
wife noted the entire right back, sacral area, and left side had
turned deep red, purple. No trauma or precipitating event. The
pt initially noted some pain but this resolved by the time he
came to the ED. There was no lightheadedness, dizziness, chest
pain or dyspnea. Of note the last INR check 3 weeks ago was
reportedly normal.
.
In the ED, VS: T 97.2 Hr 83 BP 112/69 RR 18 Sat 100% RA. His hct
was found to be six points lower than baseline at 34.7 (10:30
am). INR was 4.8. A CT torso revealed a right flank hematoma but
no RP bleed; he was admitted for observation. The patient
remained hemodynamically stable and he continued to deny back
pain, lightheadedness or dizziness. On the floor the hematocrit
was noted to be 28.1 at 4:50 pm. Orthostatics were check and
were notable for a drop of blood pressure from 148 to 130 from
lying down to standing. Given the drop in hematocrit and the
orthostasis, it was decided to transfer the patient to the MICU
for further monitoring. FFP was started on transfer.
.
The patient continues to have no complaints of back pain, LH, or
dizziness. He says he feels well.
.
ROS: He notes good appetite and stable weight but wife notes he
often does not eat lunch when working. He denies SOB, CP,
palpitations, , melena, BRBPR, hematuria. He notes expressive
aphasia since his CVA.
Past Medical History:
1) CAD s/p DES to RCA and LAD [**10-15**], had nl echo at that time.
2) Atrial fibrillation on coumadin
3) CVA in [**2144**] with resultant expressive aphasia
4) S/p right hemicolectomy in [**2139**], has history of GI bleed w/
clots per rectum, followed by Dr. [**First Name (STitle) 2643**] (GI)
5) CKD (recent baseline crt 1.4, GFR 48)
6) Borderline diabetes melitus, diet controlled (hgb A1C 6.4)
7) Hypertension
8) Prostate cancer status-post radiation with radiation
proctitis s/p argon laser therapy in [**2144**]
9) Elevated cholesterol
10) GERD: manifested as chronic cough, seen by ENT for scope
11) Cystic mass excision on his shoulder in [**2141**]
12) Gout
13) History of sinusitis
14) Elevated PTH
15) Trigger finger
Social History:
Social History: Married, lives w/ wife. Active in contruction
contracting business, which he manages, since [**2086**]. No heavy
lifting or labor involved.
Prior cigar smoker (for many years), until stroke in '[**44**]. Rare
ETOH. No ilicit drugs.
Family History:
Family History: Father with a history of diabetes mellitus.
Mother with history of brain tumor.
Physical Exam:
Physical Exam:
VS: T: 97.5 HR: 65 BP: 109/63 RR: 14 O2 Sat: 96% RA
Gen: WD/WN Caucasian gentleman. NAD, pleasant
Head: NC/AT,
Eyes: PERRL, EOMi, some difficulty with tracking
Mouth: MMM, OP clear
Neck: No LAD, JVP nl
Chest: Lungs CTA b/l exc. scattered rales at R base
Cor: RR, S1 S2 nl with no murmur, rub, or gallop.
Abdomen: Flat, NT, ND, ecchymosis across right abdomen
Back: large right back, flank, and sacral ecchymosis, non-tender
to palpation
Ext: , 1+ DP pulses
Neuro: A&Ox3, CN 2,3,4,5,6,7,12 grossly intact.
Some difficulty verbalizing some words/starting sentences,
Strength 5/5 in LE, patellar reflexes 1+ bilaterally
Sensation intact to light touch,
Skin: Large ecchymosis as above, no other rashes
Pertinent Results:
Data:
.
WBC 6.6 N:82.9 L:10.5 M:5.3 E:0.6 Bas:0.6
Hgb 11.3/Hct 34.7 MCV 90
Plts 253
.
Hct: 10:30 an 34.7 => 4:50 pm 28.1 => 8:30 pm 26.5
.
Na 139 Cl 103 BUN 32 Glu 117 AG=6
K 4.5 HCO3 30 Cr 1.6
estGFR: 41/50
.
PT: 43.3 PTT: 36.7 INR: 4.8, repeat INR 2.3 at 8:30 pm
.
Imaging:
CT Torso [**2148-12-4**] preliminary read: "1. Large right back and
flank hematoma. 2. No retroperitoneal hematoma. 3. Multiple
subcentimeter pulmonary nodules. Short-interval three-month
followup imaging is recommended to document stability"
.
CT Head [**2148-12-4**] preliminary read: "old left mca territory
infarct." Otherwise no intracranial bleed or mass.
.
ECG [**12-4**]: A. fib (65), left axis, TWF III, aVF, no acute SST-T
changes.
Brief Hospital Course:
.
Assessment/Plan: 88 year old gentleman with atrial fibrillation
on coumadin, CAD s/p DES [**10-15**] on aspirin and plavix, and prior
CVA who presents with back pain and R flank bruising and is
found by CT Torso to have large R back and flank hematoma in
setting of supratherapeutic INR. Transferred to MICU after
hematocrit noted to have 6 point drop from presentation, 12
point total from baseline. He remains hemodynamically stable
with no back discomfort.
.
#) Back/R flank hematoma: Thought to be secondary to elevated
INR, 4.8 for which asa/plavix/coumadin were stopped and FFP was
given. There was concern for acute bleeding with a 6 point HCT
drop; however, HCT bumped appropriately after 2 units of PRBC's.
No evidence of trauma. Pt had 2 peripheral IV's and an active
T+S. HCT was monitored and goal was >28 given history of CAD.
Pt's HCT remained stable and he was transferred to the medical
floor from the ICU, where again HCT remained stable. INR was
allowed to trend down and lower dose coumadin (2.5mg) was
restarted when HCT was stable. Pt will go home on 2.5mg coumadin
and have INR checked Monday. Pt was monitored on tele; there
were no events of significance.
.
#) Elevated INR: INR initially 4.8, in therapeutic range after 2
units of FFP. Poor nutrition may be contributing (wife called in
this AM to remind pt to eat). No other clear precipitant. LFTs
WNL. Coumadin was initially held and resumed upon stabilization
of HCT. Pt resumed coumadin at 2.5mg and will have INR checked
on monday.
#) Atrial fibrillation: CHADSS is 4. Coumadin initially held and
resumed at lower dose of 2.5mg (home 4mg/2.5mg alternating) upon
stabilization of bleed.
.
#) CAD: S/p DES [**10-15**], no active symptoms, ECG without new
ischemia. Pt's PCP and cardiologist, Dr. [**Last Name (STitle) **] [**Name (NI) 653**] re:
bleed, asa/plavix/coumadin. After discussion, with patient's PCP
it was decided to stop plavix (as it has been >1yr since stent
placement), resume ASA at lower dose (81mg) and resume coumadin
with INR checks and management per pt's cardiologist. Pt unsure
of doses of metoprolol and whether he is on ACE/[**Last Name (un) **]/?dose. Pt
instructed to clarify doses of these medications.
Hyperlipidemia: Pt continued on outpatient zetia.
.
#) H/o CVA:
-Low dose ASA restarted upon discharge. Plavix discontinued.
.
#) Pulmonary nodules on CT chest: Pt has h/o cigar smoking. Pt
should follow up the nodules in the outpatient setting.
.
#) Thrombocytopenia: Thought to be consumptive. Resolved without
intervention and remained within normal limits.
.
#) Acute renal failure on CKD: Pt's baseline 1.2, etiology
thought to be prerenal. Cr returned to baseline.
.
#) Borderline DM: Pt placed on FS QID, diabetic diet.
.
#) GERD:
- Continue pantoprazole.
.
Medications on Admission:
.
Medications at home:
Colchicine as needed (last week has taken daily)
Coumadin 5mg 4 days/2.5mg 3 days
diovan-per wife but discussed with Dr. [**Last Name (STitle) 105728**]>lisinopril 10mg
daily?
plavix 75 daily
Zetia 10mg daily
Protonix 40 daily
aspirin 325mg daily
Metoprolol 25 mg tid
.
Medications on transfer:
Aspirin, plavix, zetia, protonix (all doses the same)
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient [**Name (NI) **] Work
PT/INR/PTT
please have labs drawn Monday [**2148-12-9**] and fax results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 105729**] at [**Telephone/Fax (1) 80070**]
6. Colchicine 0.6 mg Tablet Sig: as directed Tablet PO as
directed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: please confirm dose of this medication with your
PCP.
8. Diovan 40 mg Tablet Sig: as directed Tablet PO once a day:
please confirm dose of this medication with your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Major: intramuscular hematoma R.latissimus dorsi
elevated INR
atrial fibrillation
CAD
Discharge Condition:
good, stable HCT, INR therapeutic
Discharge Instructions:
You were admitted for a bleed into one of your muscles. You were
given blood products to increase your blood count and reverse
the effects of your coumadin. Your blood counts were monitored
and remained stable. Your plavix was stopped this admission. You
will resume aspirin at 81mg instead of 325mg. You will resume
coumadin at 2.5mg until further discussion with your
cardiologist.
.
If you develop fevers/chills, dizziness, increasing
discoloration of the back/abdomen/flank, abdominal pain, nausea,
vomiting, please contact your doctor or go to the emergency
room.
.
Please take your medications as prescribed and follow up with
the appointments below.
Followup Instructions:
Please contact your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] at [**Telephone/Fax (1) 14148**] to
schedule a follow up appointment in the next week.
.
Please contact your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 5768**] to
arrange for a follow up appointment.
|
[
"584.9",
"414.01",
"728.89",
"585.9",
"427.31",
"V45.82",
"790.92",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8818, 8824
|
4581, 7365
|
344, 351
|
8954, 8990
|
3838, 4558
|
9696, 10090
|
3007, 3088
|
7787, 8795
|
8845, 8933
|
7391, 7393
|
9014, 9673
|
7414, 7684
|
3118, 3819
|
239, 306
|
407, 1954
|
7709, 7764
|
1976, 2709
|
2741, 2975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,768
| 151,227
|
53642
|
Discharge summary
|
report
|
Admission Date: [**2200-7-22**] Discharge Date: [**2200-7-31**]
Date of Birth: [**2123-10-10**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Fatigue, melena
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 56835**] is a 76 year old man with a history of hypertension,
type II diabetes mellitus, ESRD on HD, rectal cancer s/p
resection and partial colectmy who presented to the [**Hospital1 18**] ED
with fatigue and a hematacrit drop noted at hemodialysis today.
He last saw his PCP [**Last Name (NamePattern4) **] [**7-11**] and complained of fatigue. A CBC was
checked and he had a hct of 31 when his previous hct in [**Month (only) 958**]
was 40 (although he's bounced between the mid-20's and 40
before). This morning, a hct was checked and it was noted to be
19.6 and was 23.6 p dialysis after 3 kg was removed today. The
stool in his colostomy was also noted to be guiac positive.
The patient reports increasing DOE over the prior 3-4 weeks PTA,
worse in the evening; "darkening" stool for 1-2 weeks PTA,
increased amounts of gas. The patient has also complained of
intermittent nausea and vomiting approximately for 1 hour after
meals for about 2 weeks but only would vomit up food; denies
hematemesis or coffee ground emesis. He has noted some
lightheadedness and dizziness but no syncopal episodes. He
reports non-radiating substernal chest pressure when nauseous
that was often relieved by vomiting; denies associated
diaphoresis or dyspnea; chest pressure not worse with exertion.
.
Denies prior episode of melanotic stools.
.
ROS: denies fevers, chills, weight loss, cough, orthopnea, PND,
visual changes, abdominal pain, weakness, numbness/paresthesias.
Past Medical History:
rectal cancer s/p resction in [**2183**] (with XRT and chemo) and
[**2189**]; has colostomy
hypertension
diabetes mellitis (resolved since lost weight w/ CA)
end stage renal disease on hemodialysis x 12 years
mitral regurg
tonic-clonic seizure after HD in [**2190**]; none since
Left retinal hemorrhage
left temporal meningioma
s/p cholecystectomy
gallstone pancreatitis
h/o AV graft clot [**12/2199**]
cataracts
Social History:
Retired cryogenic engineer. Lives in [**Location (un) 55**] with wife.
Quit smoking at age 40. No EtOH.
Family History:
sister with CVA. Strong family history of DM
Physical Exam:
On Admission:
VS: T 96.6 HR 106 BP 176/66 RR 23 Sat 100% RA
Gen: Pleasant man in bed in no apparent distress.
HEENT: NG tube in place with pink liquid. +upper/lower dentures,
MMM. PERRL.
Neck: Supple, NT. No cervical or supraclavicalar lymphadenopathy
CV: III/VI HSM loudest at apex, II/VI crescendo-decrescendo
murmur radiating to carotids.
Pul: scant crackles at right base, otherwise clear
Abd: Soft, NT, ND +BS
Ext: no edema, DP 2+ bilaterally
Neuro: A&O x3, no gross defecits
On Transfer from MICU HD #3
VS: T 98.6 HR 104, regular BP 110/48 RR 20 Sat 100% RA Wt:
140 lbs
Gen: Pleasant man in bed in no apparent distress.
HEENT: NCAT. PERRL 3-->1. EOMI intact. Muddy sclera. MMM. OP
non-erythematous and without lesions. Neck supple without LAD.
CV: RRR. III/VI HSM loudest at apex. SEM at RUSB III/VI
radiating to carotids.
Pul: CTAB.
Abd: Soft, NT, ND +BS. Dark brown stool in ostomy.
Ext: no edema, DP 2+ bilaterally. No rashes. Joints: no
swelling, no erythema, no warmth.
Neuro: A&O x3. CN II-XII intact. Sensation grossly intact to
LT. Good distal UE and LE strength.
Pertinent Results:
Admission Laboratory Results:
[**2200-7-22**] 08:40AM BLOOD WBC-7.1 RBC-2.29*# Hgb-6.9*# Hct-19.6*#
MCV-86 MCH-30.3 MCHC-35.3* RDW-16.8* Plt Ct-307
[**2200-7-22**] 11:50AM BLOOD Neuts-79.0* Lymphs-14.1* Monos-5.3
Eos-1.2 Baso-0.4
[**2200-7-22**] 08:40AM BLOOD Glucose-195* UreaN-70* Creat-7.1* Na-135
K-3.8 Cl-93* HCO3-27 AnGap-19
[**2200-7-22**] 08:40AM BLOOD Calcium-8.7 Phos-2.8#
.
Cardiac Enyzmes:
[**2200-7-22**] 11:50AM BLOOD CK(CPK)-76
[**2200-7-23**] 05:15PM BLOOD CK(CPK)-75
[**2200-7-24**] 02:04AM BLOOD CK(CPK)-67
[**2200-7-24**] 05:31PM BLOOD CK(CPK)-45
[**2200-7-25**] 02:02AM BLOOD CK(CPK)-60
[**2200-7-22**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2200-7-23**] 05:15PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2200-7-24**] 02:04AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2200-7-24**] 09:59AM BLOOD CK-MB-3 cTropnT-0.06*
[**2200-7-25**] 02:02AM BLOOD CK-MB-NotDone cTropnT-0.06*
.
Laboratory W/U for ?Liver Disease:
[**2200-7-26**] 06:20AM BLOOD ALT-6 AST-11 AlkPhos-58 TotBili-0.2
DirBili-0.2 IndBili-0.0
[**2200-7-26**] 06:20AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2200-7-26**] 06:20AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40
[**2200-7-26**] 06:20AM BLOOD AFP-1.6
[**2200-7-22**] 11:50AM BLOOD CEA-2.9
[**2200-7-26**] 06:20AM BLOOD IgG-1126 IgA-452* IgM-38*
[**2200-7-26**] 06:20AM BLOOD HCV Ab-NEGATIVE
Work up for anemia:
[**2200-7-27**] 06:05AM BLOOD calTIBC-135* Ferritn-1415* TRF-104*
.
ECG [**2200-7-22**] 11:29:20 AM
Sinus rhythm with borderline 1st degree A-V block; Anterolateral
ST-T changes are nonspecific. Since previous tracing of
[**2199-6-27**], no significant change
.
DUPLEX DOP ABD/PEL LIMITED [**2200-7-24**] 4:53 PM
1. Normal grayscale and Doppler examination of the liver. Air in
the common duct could be related to the endoscopy of earlier
today.
2. Normal appearance of the spleen and a patent splenic vein at
the hilum. The peripancreatic portions of the splenic vein could
be assessed with CT or MRI, since the pancreatic bed was
obscured by bowel gas.
.
CHEST (PORTABLE AP) [**2200-7-25**] 11:59 PM
IMPRESSION: Left costophrenic angle blunting which likely
represents a small left pleural effusion. No other acute process
is demonstrated.
.
[**2200-7-22**] EGD:
Nodule in the middle third of the esophagus
Enlarged gastric folds
Blood in the stomach
Polyps in the duodenal bulb
No blood was seen in the duodenum.
Otherwise normal EGD to second part of the duodenum
.
[**2200-7-24**] EGD:
Enlarged gastric folds vs gastric varices were seen in the
fundus. A blood clot and some fresh blood was seen.
Polyp in the duodenum
A very small nodule vs vein was seen in the mid esophagus. There
was no bleeding.
Blood in the stomach
Otherwise normal EGD to second part of the duodenum
.
MRI ABDOMEN W/O & W/CONTRAST [**2200-7-26**] 11:13 AM
1) Soft tissue mass within the duodenum causing dilatation of
the distal common bile duct. It is unclear, on this examination,
if this mass arises from the ampulla or duodenal wall. Further
evaluation of the distal CBD and pancreatic ducts should be
performed with ERCP. However, if the sphincter cannot be
assessed via ERCP, MR imaging of this region could be performed
following duodenal distention with oral contrast (water).
2) Pneumobilia; this may be related to a prior procedure, such
as sphincterotomy.
3) Cholecystectomy.
4) Findings consistent with chronic pancreatitis.
5) Hemosiderosis.
6) Incompletely characterized left lower pole renal mass. It is
felt that calcifications are causing the decreased signal on
both T1 and T2-weighted images. Noncontrast CT would be helpful
to confirm the presence of calcification.
.
ECHO Study Date of [**2200-7-29**]
No echocardiographic evidence of endocarditis. Symmetric LVH
with preserved global and regional biventricular systolic
function. Moderate aortic stenosis with mild aortic
regurgitation. Compared with the prior study (images reviewed)
of [**2199-6-24**], aortic stenosis may have slightly progressed.
Pulmonary hypertension is no longer appreciated. The other
findings are similar.
Brief Hospital Course:
In summary, this is a 76 year old man with Type II DM, ESRD on
HD, who present with 3-4 week history of fatigue, 1-2 weeks of
"dark stool" found to be severely anemic, with melanotic stools.
ED Course: NG lavage in the ED was notable for pink return with
some small clots. The pink color lightened but did not clear.
His HR was stable in the 80's and his blood pressure was stable
in the 130's systolic. He was given IV protonix and 1 u prbc and
transferred to the MICU for further care.
.
ICU Course: In the ICU his hematocrits were closely followed and
he was maintained on telemetry. He received a total of 3 units
of PRBCs. Antihypertensives were initially discontinued, but
metoprolol was restarted after an episode of aflutter vs afib
with rates in 150s; associated with sensation of chest pain and
dyspnea. Returned to NSR after (Per patient he had a prior
episode of afib during AV graft 1 year ago and was cardioverted
immediately to NSR).
.
#GI Bleed:
Based on the postive NG lavage and melanotic stools Mr. [**Known lastname 56835**] [**Last Name (Titles) 8783**]t two EGDs to assess for an upper GI bleed. They
revealed fresh blood and clots in the stomach, but no active
source of bleeding; large gastric folds vs. varices; and a
polypoid mass in duodenum. Given the potential for gastric
varices, an US was performed that demonstrated normal portal
vein flow, no evidence of thrombosis; splenic vasculature was
not well visualized. An MRI/MRA of abdomen was subsequently
performed which demonstrated normal splenic vasculature, no
evidence of gastric varices; a duodenal mass that might be
arising from the ampulla of the pancreas; hemosiderosis. Iron
studies were not consistent with hemachromatosis. Liver
function tests were normal. Hepatitis tests were normal.
.
He received a total of 4 [**Location **]; he was dicharged home on
HD#9 with non-melanotic stools and Hct stable x 2 days.
.
# Anemia: likely a combination of anemia of chronic renal
failure and blood loss from UGIB. Received a total of 4 U
PRBCs. Epo increased to 12,000 Units at dialysis.
.
#CARDIOVASCULAR
Mr. [**Known lastname 56835**] had two episodes of an arrhythmia. The first
occurred in the ICU, appeared to be atrial flutter and resolved
with resumption of metoprolol (which was d/c'd on admission).
The second episode occured on HD#3 and appeared to be atrial
flutter with irregular ventricular response and atrial ectopy;
it lasted for ~3 hours; metoprolol was increased to 37.5 mg TID.
At the time of discharge he was in NSR for 36 hours on tele.
.
Mr. [**Known lastname 56835**] was also initially tachycardic on standing and with
exertion, though this improved with PT and increasing his BB.
.
HTN: blood pressure was well controlled on anti-hypertensive
medication doses lower than his home doses. He will be
discharged on nifedipine 30 mg [**Hospital1 **] and metoprolol 37.5 mg TID
and will follow up with Dr. [**First Name (STitle) **] for BP monitoring.
.
#Chest Pain/Pressure: Mr. [**Known lastname 56835**] presented complaining of
substernal chest pain worse after meals and resolving with
vomiting with suggested a GI/GERD etiology, however did not
improvement after his PPI was increased to [**Hospital1 **] dosing as an
outpatient. Cardiac etiology was ruled out by negative cardiac
enzymes x3. Admission EKG had no new ischemic changes. He also
has a normal stress MIBI from [**8-5**].
.
#ID: Strep virodans was isolated in 1 set of blood cultures
obtained on admission. He spiked a temperature to 101.8 and was
recultured; fever trended downwarded and was afebrile for >24
hours at time of discharge. TTE was negative for endocarditis.
Four subsequently blood culture sets had no growth at the time
of discharge; Mr. [**Known lastname 56835**] will follow-up with PCP for final
results of the blood cultures.
.
# ESRD ON HD: Mr. [**Known lastname 56835**] was continued on his T, Th, Sat
dialysis schedule. The MRI/MRA of the abdomen showed a
incompletely characterized left lower pole renal mass; Mr.
[**Known lastname 56835**] will have a dedicated MRI of the kidney as an outpatient
to further characterize this mass.
Medications on Admission:
ASA 325mg daily
Folic Acid 1mg daily
Fosrenol 750 TID w/ meals
Metoprolol 50mg TID
Minoxidil 2.5mg daily
Nephrocaps 1 tab taily
Nifedical xl 60mg twice daily
Protonix 40mg twice daily (recently increased)
Sevelamer 800mg TID
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Lanthanum 250 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day): with meals.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): with meals.
Disp:*180 Tablet(s)* Refills:*1*
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
7. Folic Acid Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Upper GI Bleed
Anemia
atrial flutter controlled with metoprolol
deconditioning
.
Secondary Diagnoses:
Chronic Kidney Disease on hemodialysis
H/O Diabetes Mellitus
history of rectal cancer s/p partial colectomy x 2 with
colostomy
Hypertension
Mitral Regurgitation
Atrial Stenosis
h/o gallstone pancreatitis s/p CCY
Discharge Condition:
Stable; non-melanotic stools; hematocrit stable; in normal sinus
rhythm
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for anemia (low red blood cells)
and blood in your stool. To treat your anemia, you received
blood transfusions. Your blood counts stabilized and the amount
of blood in your stool decreased substantially.
You underwent several studies to try to identify the source of
the blood in your stool, but a clear source was not found. You
need to undergo one more study to try and determine the cause of
the bleeding. This study (an EGD) will be performed with
ultrasound to look at blood flow in the stomach; biopsies may
also be taken at this time.
You also had a fever when you were in the hospital. One set of
blood cultures had a bacteria that sometimes can infect the
valves of your heart. An ultrasound of your heart (TTE) was
performed and did not show any evidence of such an infection.
Follow-up blood cultures did not grow this bacteria; though the
final result needs to be followed up on.
Your heart went into an irregular rhythm twice during the
hospital stay, but seems to be controlled when you are on your
metoprolol.
You should take all medications as prescribed. You are taking
lower amounts of blood pressure medications now then when you
were admitted; you need to follow-up with your primary care
physician to have your blood pressure checked and your
medications adjusted as needed. Because of the bleed, we
temporarily stopped your aspirin. You should follow-up with
your primary care care physician to discuss restarting the
aspirin.
You should follow-up as indicated below.
You should contact your physician or return to the Emergency
Department for:
-lightheadedness/feeling like you might pass out
-worsening shortness of breath or fatigue, particularly with
exercise
-if you notice blood in your stools or really dark stools
-persistent vomiting or if you vomit up blood or your vomit
looks like coffee grounds
-fevers, particularly >102
-shaking chills
-chest pain or chest pressure, or feeling like your heart is
racing.
-if you seem confused or less alert than normal or lose
consciousness
-other symptoms that are concerning to you
Followup Instructions:
Please schedule a follow-up EGD with ultrasound performed by Dr.
[**Last Name (STitle) **] to evaluate the folds in your stomach and take biopsies
as needed. Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1983**] to
schedule this appointment. This appointment should occur in the
next 1-2 weeks.
.
You should follow-up with your primary care physician [**Last Name (NamePattern4) **].
[**First Name (STitle) **] at [**Telephone/Fax (1) 250**] within two week of discharge. Dr.
[**First Name (STitle) **] will follow the results of the blood cultures and will
monitor your blood pressure.
.
You should continue your normal dialysis schedule.
.
You should call MRI to schedule a dedicated MRI of the kidney.
You can call them at ([**Telephone/Fax (1) 6713**] to schedule this
appointment. Your primary care physcian can provide a referral
for this.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-10-17**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
Completed by:[**2200-7-31**]
|
[
"285.21",
"428.0",
"424.0",
"V44.3",
"280.0",
"403.91",
"578.9",
"427.32",
"790.7",
"V10.06",
"041.09",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12827, 12885
|
7668, 11814
|
317, 325
|
13262, 13336
|
3587, 7645
|
15500, 16743
|
2414, 2460
|
12089, 12804
|
12906, 13006
|
11840, 12066
|
13360, 15477
|
2475, 2475
|
13027, 13241
|
262, 279
|
353, 1839
|
2489, 3568
|
1861, 2276
|
2292, 2398
|
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