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62,646
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12676
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Discharge summary
|
report
|
Admission Date: [**2168-5-16**] Discharge Date: [**2168-6-22**]
Date of Birth: [**2099-6-25**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Enterocutaneous fistula
Major Surgical or Invasive Procedure:
[**2168-5-17**]: ex-lap, LOA, repair gastrotomy, take-down ECF;
ileo-colonic anastomosis, repair sigmoid perforation
[**2168-5-30**]: repair gastric perforation and gastric bleed
History of Present Illness:
The patient is a 68F who underwent coronary artery bypass graft
in [**2167-5-21**]. Her hospital course was long and complicated by
multiple chest re-explorations and washouts for bleeding. The
patient developed small bowel obstruction related to ischemic
stricture that required ex-lap and bowel resection. Her hospital
course was further complicated by an open abdomen and
enterocutaneous fistula. The patient is now approximately 9
months out for undergoing exploratory laparotomy and distal
small bowel resection for an ischemic stricture leading to a
complete small bowel obstruction. Her postoperative course was
complicated by development of enterocutaneous fistula which has
been managed conservatively over the last 9 months as she
recovered from her acute event. Unfortunately, we were unable
to get satisfactory control of the enterocutaneous fistula and
she was having significant skin breakdown. Additionally, she was
unable to take oral intake due to increase in the fistula output
and was maintained on parenteral nutrition. She satisfactorily
healed from the initial surgery, and is now taken to the
operating room for take down of the fistula.
Past Medical History:
Dyslipidemia
hypertension
migraines
h/o amaurosis fugax
osteoarthritis
Past Surgical History:
s/p hysterectomy
s/p cervical disc surgery [**76**] yrs ago
[**2167-5-28**]: Emergency RVAD placement for RV failure and
cardiogenic
shock.
[**2167-5-28**]: Emergency mediastinal exploration for bleeding.
[**2167-5-29**]: Mediastinal exploration for excessive bleeding.
[**2167-6-2**]: Mediastinal exploration and washout and unsuccessful
attempt at weaning of RVAD.
[**2167-6-3**]: Mediastinal exploration for bleeding and washout.
[**2167-6-8**]: Mediastinal washout, weaning and explantation of
RVAD and sternotomy closure.
[**2167-6-22**]: exlap, small bowel resection
[**2167-7-30**] ex lap with removal of necrotic bowel
[**2167-8-2**] enterotomy repair
[**2167-8-3**] bedside washout, enterotomy repair
[**2167-8-6**] bedside washout, ileal drain, vac placement
[**2167-8-8**] bedside washout, repair of enterotomy
[**2167-8-10**] bedside washout, LUQ drain placement
[**2167-8-10**] Trache and vac change
[**2167-9-2**] STSG to abdomen from left thigh
[**2167-9-16**] FTSG to left face from left chest
[**2167-10-27**] sternal pustule I&D
Social History:
-Married with several children. Family supportive.
-Tobacco history: 45 pack year history (current)
-ETOH: occ
-Illicit drugs: denies
Family History:
Sister died of pancreatic cancer a few months ago. No family
history of stroke, CAD.
Physical Exam:
Physical Exam on admission:
Vitals:Afebrile P 107 BP 112/68 RR 20 O2 97RA
GEN: AAx2
CV: RRR
Lungs: clear
ABD: Soft, diffuse tenderness to palpation throughout, no
guarding/rebound, no distension. EC fistula in place with
excoriation around the fistula site.
Ext: warm well perfused, no peripheral edema.
Pertinent Results:
At admission:
3.6 >32.4< 232
N:46.1 L:45.3 M:6.3 E:0.8 Bas:1.6
136 103 37
--------------< 77 AGap=11
4.4 26 0.8
Ca: 9.3 Mg: 2.0 P: 4.0
ALT: 58 AP: 335 Tbili: 0.9 Alb: 3.1 AST: 56
Iron: 38 calTIBC: 303 Ferritn: 575 TRF: 233
PT: 14.6 PTT: 33.4 INR: 1.3
Brief Hospital Course:
Ms. [**Known lastname **] was taken to the operating room on [**2168-5-17**], at which
time an exploratory laparotomy, take down of enterocutaneous
fistula, resection of small bowel and colon,
repair of sigmoid colotomy and repair of gastrotomy, and ventral
hernia repair with Marlex mesh were performed. In the operating
room, she required 3 u pRBC and pressors, and was taken to the
surgical ICU post-operatively intubated.
While in the ICU, she had improved uop; TPN; echo improved;
fever 101 w/thick sputum, she was pan cultured. She was weaned
off her dobutamine and started on dapto. She was extubated on
[**2168-5-20**] and off pressors. She diuresed 1L negative, continued on
TPN, and started on zosyn. her PICC and a-line was discontinued
on [**5-22**]. Her sputum cultures grew staph and pseudomonas. She was
up and out of bed that day as well.
She was transferred to floor on POD 6. Abdominal wound opened
while in the SICU [**12-23**] erythema, with negative Wound Cx. VAC
placed POD6 to abdominal wound. The left JP was removed on POD9
for low output. Right JP removed POD10 for low output. A
flexiseal rectal tube was placed on POD7 given increased BMs,
and CDiff x 3 were sent and were all negative. The patient was
began on TF through her G-tube on [**2168-5-25**], and slowly advanced.
Nutrition service was consulted, and she worked with physical
therapy.
On [**5-28**], tube feeds were seen coming out of the upper part of the
surgical wound and on [**5-29**] a large amount of blood was found to
be coming through the ostomy site and she was transferred to the
TSICU. Was taken back to the operating room on [**5-30**] for repair
of gastric perforation. A drain was placed near the perforation.
She was transferred back to TICU post op. Tracheostomy was
performed. Her hct remained stable but her VAC had high
abdominal output on [**2168-6-1**]. Her ASA and plavix were
discontinued due to oozing from her wounds. On [**6-3**], her VAC was
changed for leakage and it was replaced. She was febrile to 102
that day and cultures were sent. She was restarted on her ASA
and plavix and a CT abd/pelvis was obtained due to her fevers.
ID was consulted and her linezolid was changed to vancomycin.
She had multiple cultures showing pseudomonas in her sputum and
she had MRSA. She was switched from zosyn to ceftaz. She was
transferred from the TSICU to SICU on [**6-8**] and continued to
spike fevers and remained tachycardic. On [**6-10**] chronic pain
service was consulted and she was started on a dilaudid drip.
She was started on inhaled tobramycin on [**6-12**] but that was soon
discontinued due to minimal response. A family discussion took
place on [**6-15**] and a decision was made to place Ms. [**Known lastname **] on CMO
status. She was transferred out of the ICU to the floor on [**6-17**]
and remained on morphine with valium and ativan prn, this was
then changed to dilaudid drip. She was transferred to
THE [**Hospital **] CARE CENTER
[**Street Address(2) 39154**]
[**Location (un) **], [**Numeric Identifier 39155**]
Phone: [**Telephone/Fax (1) 39156**] ♦ Toll Free: [**Telephone/Fax (1) 39157**] ♦ Fax:
[**Telephone/Fax (2) 39158**]hospice house on [**2168-6-22**]
Medications on Admission:
artificial tears once a day, acetaminophen 325 q6, buspar 15mg
TID, plavix 75mg OD, lorazepam 0.5mg BIDprn, lopressor 25mg [**Hospital1 **],
omeprazole 20mg OD
Discharge Medications:
1. hydromorphone 10 mg/mL Solution Sig: Three (3) mg/hour
Injection INFUSION (continuous infusion).
Disp:*5 bags* Refills:*2*
2. hydromorphone 2 mg/mL Solution Sig: 2-4 mg Injection per hour
as needed for pain / dyspnea.
Disp:*5 bags* Refills:*5*
3. lorazepam 2 mg/mL Syringe Sig: 1-4 mg Injection Q2H (every 2
hours) as needed for agitation.
Disp:*qs syringes/week* Refills:*2*
4. diazepam 5 mg/mL Syringe Sig: Ten (10) mg Injection Q2 PRN ()
as needed for anxiety.
Disp:*qs syringes/week* Refills:*5*
5. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. glycopyrrolate 0.2 mg/mL Solution Sig: 0.1 mg Injection Q6H
(every 6 hours) as needed for secretions.
7. acetaminophen 1,000 mg/100 mL (10 mg/mL) Solution Sig: 1000
(1000) mg Intravenous Q6H (every 6 hours) as needed for pain.
8. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospice House
Discharge Diagnosis:
CABG c/b SBO, s/p BR and chronic Enterocutaneous fistula(ECF)
now s/p ex-lap, LOA, take-down ECF w/SBR, and ileo-colonic
anastomosis; c/b large GI bleed [**5-30**] and gastrocutaneous fistulA
S/P EX LAP [**2168-5-30**] for Exploratory laparotomy, take down
enterocutaneous fistula, resection of small bowel and colon,
repair of sigmoid colotomy and repair of gastrotomy, and ventral
hernia repair with Marlex mesh.
*Klebsiella/Pseudomonas in wound
*Pseudomonas pneumonia
Discharge Condition:
Mental Status: Confused/sedated
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Patient to be transferred to Hospice services at
THE [**Hospital **] CARE CENTER
[**Street Address(2) 39154**]
[**Location (un) **], [**Numeric Identifier 39155**]
Phone: [**Telephone/Fax (1) 39156**] ♦ Toll Free: [**Telephone/Fax (1) 39157**] ♦ Fax:
[**Telephone/Fax (1) 39158**]
Followup Instructions:
No appointments
Please notify Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of patient status at [**Telephone/Fax (1) 673**]
Completed by:[**2168-6-22**]
|
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45,157
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46511
|
Discharge summary
|
report
|
Admission Date: [**2120-8-17**] Discharge Date: [**2120-9-11**]
Date of Birth: [**2062-7-28**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
generalized weakness
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement
Aspiration and drainage of perinephric fluid collection
History of Present Illness:
58F with history of nephrolithiasis and multiple episodes of
postobstructive renal failure, history of urosepsis; presenting
to ED with weakness, N/V/D x 3 days. Per patient, she has been
generally well except for 3 days ago, when had vomiting shortly
followed by diarrhea. States she has been okay in the last
couple days, but today had a visitor who told her she looked
unwell with weight loss, poor appetite, and abnormal looking
skin. She thus presented to the ED. Denies abdominal pain, back
pain, dysuria, cramping pain or feelings of passing kidney
stone. Does note ?hematuria. No fevers, chills, or shortness of
breath.
.
In the ED, initial vs were: T98.7, P116, BP 68/40, R18, O2 sat
99% on RA. UA with WBCs and RBCs. ARF with creatinine 4. Lactate
2.7, AG 21. WBCs 23K with immature forms. Patient was given 3L
IVFs, levofloxacin and metronidazole. BP improved to 90s
systolic. RR in 30s.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. No back pain.
Past Medical History:
Multiple episodes of postobstructive renal failure related to
nephrolithiasis; creatinine as high as 7. Most recent creatinine
1.7 in 4/[**2118**].
- Nephrolithiasis [**1-1**] hyperPTH with residual calcium stones.
History of L laser lithotripsy, R perc nephrolithotripsy and L
ESWL, intermittent ureteral stents. No current stents in place.
- Primary hyperparathyroidism with resultant hypercalcemia;
surgically corrected.
- History of septic shock [**1-1**] urosepsis in [**1-/2118**] Medical Center
Social History:
Lives with 23 year old daughter. Does not work. Nonsmoker, no
drug use, etoh few times per year only.
Family History:
No DM, coronary disease or cancers per the patient.
Physical Exam:
General: Alert, oriented, no acute distress. Flat affect.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, diffuse
abdominal TTP max in LUQ> LLQ and epigastrium; no rebound
tenderness or guarding, no organomegaly
Back: +nephrostomy drain and pigtail catheter from L flank.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema or rash.
Pertinent Results:
Labs on admission:
[**2120-8-17**] 11:46PM GLUCOSE-78 UREA N-101* CREAT-2.7* SODIUM-147*
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-16* ANION GAP-21*
[**2120-8-17**] 11:46PM CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-2.0
[**2120-8-17**] 11:46PM WBC-22.3* RBC-3.78* HGB-9.8* HCT-28.9*
MCV-76* MCH-26.0* MCHC-34.1 RDW-16.0*
[**2120-8-17**] 11:46PM NEUTS-77* BANDS-6* LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ATYPS-2* METAS-2* MYELOS-0
[**2120-8-17**] 11:46PM PLT COUNT-243
[**2120-8-17**] 04:05AM ALT(SGPT)-39 AST(SGOT)-42* LD(LDH)-370* ALK
PHOS-132* AMYLASE-92 TOT BILI-5.6* DIR BILI-4.5* INDIR BIL-1.1
[**2120-8-17**] 12:29AM LACTATE-2.7*
[**2120-8-16**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-9.0*
LEUK-MOD
[**2120-8-16**] 07:00PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
Micro:
[**2120-8-30**] 3:40 pm ABSCESS LEFT KIDNEY
GRAM STAIN (Final [**2120-8-30**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
[**2120-8-30**] SWAB (nephrostomy tube) GRAM STAIN-FINAL; WOUND
CULTURE-FINAL {VIRIDANS STREPTOCOCCI}; ANAEROBIC CULTURE-FINAL
[**2120-8-29**] URINE FUNGAL CULTURE-FINAL {[**Female First Name (un) **] ALBICANS}; ACID
FAST CULTURE-PRELIMINARY
[**2120-8-20**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2120-8-17**] URINE URINE-GRAM STAIN - UNSPUN-FINAL; URINE
CULTURE-FINAL {VIRIDANS STREPTOCOCCI} INPATIENT
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC
GRAM POSITIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC
GRAM POSITIVE ROD(S), ANAEROBIC GRAM POSITIVE ROD(S)}; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
Labs on discharge:
[**2120-9-11**] 05:00AM BLOOD WBC-7.8 RBC-2.66* Hgb-6.4* Hct-21.4*
MCV-80* MCH-24.2* MCHC-30.1* RDW-21.4* Plt Ct-579*
[**2120-9-5**] 06:17AM BLOOD Neuts-63.6 Lymphs-28.3 Monos-5.7 Eos-1.7
Baso-0.7
[**2120-9-11**] 05:00AM BLOOD Plt Ct-579*
[**2120-9-3**] 06:14AM BLOOD Ret Man-2.8*
[**2120-9-11**] 05:00AM BLOOD Creat-1.1
[**2120-9-4**] 06:31AM BLOOD ALT-9 AST-16 AlkPhos-57 TotBili-0.5
[**2120-8-20**] 05:30AM BLOOD Lipase-39
[**2120-9-4**] 06:31AM BLOOD Albumin-2.2*
Pertinent Imaging:
[**2120-8-16**] CT ABDOMEN AND PELVIS
1. Obstructing stone at distal left ureter, measuring 7 mm and
increase of the left hydronephrosis, with significant amount of
perinephric stranding, and multiple calculi, which suggests
calyceal rupture though additional pyelonephritis not excluded.
Stable hydronephrosis on the right with a small amount of
perinephric stranding. Many renal stones seen in the left lower
calyx and the atrophic right kidney.
2. Peripancreatic stranding, with limited evaluation of pancreas
due to lack of IV contrast. In the appropriate clinical setting,
this finding could indicate acute pancreatitis.
3. Scattered diverticula in the descending colon with paracolic
fat stranding; however, stranding could be from the adjacent
left kidney.
4. Probably normal appendix.
.
[**2120-8-17**] Liver/Gallbladder U/S:
IMPRESSION:
Cholelithiasis without evidence of cholecystitis or
choledocholithiasis.
.
[**2120-8-16**] CXR:
IMPRESSION: Evidence of retrocardiac density - pneumonia versus
progressive atelectasis.
.
[**2120-8-23**] CT ABDOMEN AND PELVIS
IMPRESSIONS:
1. No change in size of low-density perinephric fluid collection
following left percutaneous nephrostomy. Again this likely
reflects a combination of hematoma mixed with urine.
2. Unchanged collection of contrast material posterior to the
left kidney
following procedure.
3. No intraperitoneal or retroperitoneal hematoma to explain
hematocrit drop.
4. 6-mm left ureteral calculus unchanged in location, with
decrease in
hydroureter.
5. Cholelithiasis without cholecystitis.
6. Bilateral renal calculi, unchanged.
.
[**2120-8-26**] UE DOPPLER
IMPRESSION: No left upper extremity DVT
.
[**2120-8-29**] CT ABDOMEN AND PELVIS
IMPRESSION:
1. Increase in size of low-density, perinephric fluid
collection, with
interval increase in number of air foci within the fluid
collection following left percutaneous nephrostomy, while this
may represent a urinoma, seroma or hematoma, superinfection
cannot be excluded.
2. Stable hydronephrosis of the left kidney with mild decrease
in size of
superior subcapsular fluid collection, concerning for calyceal
rupture, as described before.
3. Bilateral renal stones.
4. Atrophic right kidney.
5. Left 7 mm distal ureteral obstructing stone.
6. Stable bilateral small pleural effusion with bilateral
dependent
atelectasis; cannot rule out superinfection.
7. Cholelithiasis.
8. Fibroid uterus.
.
[**2120-9-5**] CT ABDOMEN AND PELVIS
IMPRESSION:
1. Interval improvement in multiloculated bilateral perinephric
collection, with near complete collapse of the left
posterolateral cavity containing a previously placed pigtail
catheter in situ.
2. Bilateral coarse renal calculi and ureteral calculi,
unchanged.
3. No other significant changes with persistent bilateral small
pleural
effusion and basilar atelectasis right hepatic lobe
hypoattenuating lesion, cholelithiasis and fibroid uterus.
Brief Hospital Course:
Ms [**Known lastname 28893**] is 58F with history of nephrolithiasis and
postobstructive renal failure, history of urosepsis, who
presented to the ER with N/V and weakness and found to have
UTI/pyelonephritis, ARF, and severe sepsis. She was admitted to
the medicine service and a brief summary of her hospital course
organized by problem is described below.
## Sepsis/pyelonephritis/peri-nephric abscess: When patient was
admitted she had fever, leukocytosis, tachycardia with evidence
of end organ dysfunction. Her sepsis was likely due to a urinary
source given her history, UA with bacteria, and appearance of
left kidney. She had previously had stents, but none currently.
On HD2 she had a percutaneous nephrostomy placed to decompress
left ureter d/t obstruction with stone. She was started on a
cipro/cefepime antibiotic regimen. Infectious disease was
consulted on HD 8 and followed her through the course of her
stay. She improved clinically over the next 11 days.
Despite the nephrostomy placement and antibiotics, her
leukocytosis and intermittent fever resumed on HD11. She had a
repeat CT scan on HD14 which revealed perinephric abscess. This
was accessed and drained by interventional radiology the
following day. Antibiotics were changed to meropenem and
vancomycin. Patient defervesced and leukocytosis resolved.
Urology was made aware of her condition, but did not want to
intervene further until her abscess improved.
A repeat CT scan was done on HD21. It revealed the abscess with
the pigtail catheter was resolving, but that 2 other abscesses
were present. These were deemed too small to drain by IR and
will likely resolve with antibiotics. Although the imaging
revealed a resolved abscess, her drain was still putting out
20-40ml of fluid/day. The decision was made to keep it in.
At the time of discharge she had a normal WBC, was afebrile for
>10days. Her vancomycin was stopped because she did not grow
out MRSA and her meropenem was changed to ertapenem for ease of
dosing. According to ID, she will stay on this for 1-2 weeks
after the pigtail catheter drain is taken out. Exact course
will be determined in her follow-up [**Known lastname 648**] with ID. She was
discharged with instructions for weekly labs (Weekly labs: LFT,
CBC w/ diff and BMP) to monitor for toxicity of the antibiotic.
She was set up with home nursing care to help with the pigtail
catheter drain to her perinephric abscess and the nephrostomy
tube at home.
She will return to discharge clinic this next week and her PCP
the week following. When her drain stops putting out, she is to
have it clamped for a day. After that day she will have a
repeat scan of her kidney to make sure the fluid did not
re-accumulate. This will be coordinated by discharge clinic or
by her PCP. [**Name10 (NameIs) **] note, she has an aversion to all of the CT scans
and IR Fellow [**First Name8 (NamePattern2) **] [**Doctor Last Name **] pgr[**Pager number 98787**] will protocol her scan to
just the kidney rather than a full abdomen and pelvis. Please
page her to protocol this scan.
Patient will continue to follow-up with Infectious Diseases as
an outpatient as well. An [**Pager number 648**] has been made for her.
They will dose and make further changes to her antibiotics.
## Anemia. Pt experienced a significant hct drop in setting of
her illness and IVF: 35->16.2 over course of 10 days (HD1 to HD
11). Pt refused blood products d/t her religious beliefs
(orthodox Rastafari). There was no evidence of active bleeding
with exception of small amount from nephrostomy drainage. CT
scan showed no retroperitoneal bleed on HD15. She had an INR of
1.8 on HD4 that was reversed with vitamin K. Her anemia was
microcytic, but iron studies did not reveal iron deficiency.
Her cipro was stopped d/t concern for medication causing
hemolysis. Hematology was consulted and did not feel this was
the case. They started erythropoietin on HD21 ([**8-31**]). Iron was
started as well. Her Hct was followed daily and was stable and
slowly increasing on the last 9 hospital days (Hct 17--> 21).
She will follow-up with hematology in clinic and discuss Epo and
iron treatment as an outpatient. She may be evaluated for G6PD
d/t the Cipro with hematology as well.
## Acute Renal Failure in the setting of CKD. Ms. [**Known lastname 28893**] has CKD
from previous episodes of postrenal failure. Her ARF was likely
due to both her stone obstructing her ureter and her sepsis
limiting flow to the kidney. Her ARF resolved after the
nephrostomy tube was placed antibiotic therapy started. Her Cr
went from 4.0 on HD1 to 1.1 at discharge.
## Elevated LFTs. Her bilirubin, transaminases, and LDH were
high at the time of admission. This was thought to be due to
ischemic insult from hypotensive episode. These lab
abnormalities resolved with treatment of urosepsis and IV
hydration. They were rechecked every 4 days and after being
within normal limits on HD11, HD15, and HD 20 they were no
longer checked.
## Nephrolithiasis. Patient has residual stone burden as was
seen previously. In the past she has not wanted to undergo
procedures to resolve this. Urology put in her left
percutaneous nephrostomy tube, ordered a urine gram stain and
culture which grew out Strep Viridians. Patient is to follow-up
with Dr. [**Last Name (STitle) 770**] as outpatient to discuss surgical management of
her stones after her infection resolves. His number is:
[**Telephone/Fax (1) 5727**]. Patient was told that Dr. [**Last Name (STitle) **] could help her
initiate treatment with him again.
##Yeast in urine found on culture X2. She had fluconazole
treatment PO for this.
##Depression: Patient started to feel depressed about the
severity and course ofher treatment. She did not want to see a
psychiatrist since she "knows the cause of her depression".
Social work was consulted to help her deal with some of her home
issues
## Diarrhea during hospital stay patient had diarrhea for 4
days. Cdiff negative x 3. Stool sent for guaiac, cx, OP and
nothing was found. She had normal BM for 10days prior to
discharge
## Positive blood cultures. The only positive blood cultures
revealed organisms suggestive of skin contamination
(propionibacterium and corynebacterium). Repeat cultures with
no growth for the remainder of stay.
## Hypernatremia. Patient was found to have hypernatremia (Na:
149) on HD [**1-3**]. With aggressive NS fluid resuscitation it
resolved for the remainder of her hospital course.
## FEN: At the time of discharge patient no longer required IV
fluids, was tolerating a normal diet, and oral medications
## Prophylaxis: Patient had heparin injection for the majority
of her stay. When she was able ambulate without problem, she
requested pneumo boots/ambulation rather than heparin. She had
no indication for GI ppx.
## Code: DNR/DNI
## Disposition: Patient discharged home with IV therapy, VNA for
drain care and weekly lab draws, appointments with hematology,
ID, discharge clinic, and her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Medications on Admission:
Vit D
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday) for 1 months.
Disp:*12 ml* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
DAILY (Daily).
Disp:*30 Recon Soln(s)* Refills:*2*
6. Outpatient Lab Work
Patient needs weekly BMP, CBC, and LFT's drawn while on
ertapenem. These labs can be entered into the [**Hospital1 **] system to be
followed by all of her physcians
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Severe sepsis
Pyelonephritis
Nephrolithiasis
perinephric abscess
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because of a severe infection
that began in your kidney. This infection likely started
because of a stone obstructing the urine flow from your kidney
to the bladder. You required drainage of your kidney and a
nearby abscess and an extended course of antibiotics.
.
Please return to the hospital or call your doctor if you have
fever greater than 101, abdominal or back pain, bleeding or pain
with urination, difficulties with your nephrostomy tube, or any
new symptoms that you are concerned about.
.
Since you were admitted, the following changes were made to your
medication regimen:
* ertapenem: this is an antibiotic that will be administered IV
by your home care nurse. This will be followed by the
infectious disease doctors. [**First Name (Titles) 2172**] [**Last Name (Titles) 648**] with them is listed
below
* Epoetin Alfa : this medicine is for your anemia, it will be
administerd by home health as well. The hematologists will
follow your course on this medicine. You have an [**Last Name (Titles) 648**]
with them in 2 days. The information is below.
* Iron: these pills will help your anemia and this course will
be followed by the hematologists as well. These medications can
cause constipation, so make sure to eat fiber and take medicines
like colace and senna to help with bowel movements.
Please continue to see the infectious disease doctors, here is
your next [**Last Name (Titles) 648**] information:
[**2120-9-25**] 09:30a ID,[**First Name8 (NamePattern2) **] [**Doctor Last Name 1037**]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
Please continue to see the hematologists for your anemia. Your
next [**Hospital Unit Name 648**] information below:
[**2120-9-13**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) **] J.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
You have an [**Location (un) 648**] with discharge clinic at [**Hospital **] on the 20th to assess the drainage of your drain and
to help schedule a repeat CT scan when the drainage stops.
Please get your blood drawn before clinic so they can follow up
your labs. Your [**Hospital 648**] info is below:
[**2120-9-17**] 01:50p [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
Please see Dr. [**Last Name (STitle) **] for continuity of your care. Your
[**Last Name (STitle) 648**] info is below:
[**2120-9-26**] 01:45p [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
After your infection resolves, Dr [**Last Name (STitle) 770**] (your urologist) will
have to be contact[**Name (NI) **]. At that point you can decide how to
approach the management of your stones and your nephrostomy
(tube draining urine from your kidney). His number is
[**Telephone/Fax (1) 5727**]. Dr. [**Last Name (STitle) **] can help you reestablish care with him.
Followup Instructions:
Please continue to see the infectious disease doctors, here is
your next [**Last Name (STitle) 648**] information:
[**2120-9-25**] 09:30a ID,[**First Name8 (NamePattern2) **] [**Doctor Last Name 1037**]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
Please continue to see the hematologists for your anemia. Your
next [**Hospital Unit Name 648**] information below:
[**2120-9-13**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) **] J.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
You have an [**Location (un) 648**] with discharge clinic at [**Hospital **] on the 20th to assess the drainage of your drain and
to help schedule a repeat CT scan when the drainage stops.
Please get your blood drawn before clinic so they can follow up
your labs. Your [**Hospital 648**] info is below:
[**2120-9-17**] 01:50p [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
Please see Dr. [**Last Name (STitle) **] for continuity of your care. Your
[**Last Name (STitle) 648**] info is below:
[**2120-9-26**] 01:45p [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
After your infection resolves, Dr [**Last Name (STitle) 770**] (your urologist) will
have to be contact[**Name (NI) **]. At that point you can decide how to
approach the management of your stones and your nephrostomy
(tube draining urine from your kidney). His number is
[**Telephone/Fax (1) 5727**]. Dr. [**Last Name (STitle) **] can help you reestablish care with him.
|
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20,688
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Discharge summary
|
report
|
Admission Date: [**2161-1-31**] Discharge Date: [**2161-2-10**]
Date of Birth: [**2102-2-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mysoline / Levofloxacin
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 year old female with history of stage IIA breast cancer and
pancreatic cancer (liver mets) on chemo with 5-FU, leucovorin
and irinotecan presents acutely short of breath found to have
bilateral pulmonary emboli. Patient was on lovenox (?since [**Month (only) 205**])
for biliary stent clot until 4 days ago when she stopped prior
to paracentesis. She had a paracentesis the day prior to
admission, 2L fluid removed. She felt well post-procedure. At 4
a.m. on day of admission, she went to get a drink of water. She
noticed sudden onset SOB, felt like she was going to pass out,
right sided chest pain, pleuritic in nature associated with some
nausea. No diaphoresis, no cough. She called her husband and he
drove her to the emergency room. CT chest showed large,
bilateral pulmonary emboli involving both right and left main
pulmonary arteries.
ROS: (+) nausea and fatigue at baseline. No fevers.
.
ED: Tachycardic to 140, sbp 90-100, 82% RA. 3L NS. Given dose of
Levoflox, Flagyl, Vanco. Started on Heparin. Possible allergic
reaction (rash on arm) to Levoflox so stopped.
Past Medical History:
Stage IIA, T1, N1, M0 right breast adenoca s/p
Adriamycin/Cytoxan and Taxol completed [**2-/2159**]
s/p right mastectomy w/ reconstruction [**3-14**]
pancreatic ca w/ liver mets dx [**4-15**], omental mets
s/p biliary stent (?malignant stricture)
Hypothyroidism
HTN
PCOS
s/p BSO for benign left ovarian cystadenoma, [**3-15**]
Depression/anxiety
[**Doctor Last Name **] mal seziures as a child
s/p appy
s/p ovarian cyst removal
GERD
Anemia on Aranesp
Social History:
lives in [**Location 7658**], married, child is 2nd year med student. No
EtOH, no tobacco.
Family History:
no history of malignancies
Physical Exam:
98.3F HR 120 BP 125/71 RR 19 98% face tent (50%, 10 lpm)
Gen: cachetic appearing, tachypneic, speaking in full sentences
HEENT: Mucous membranes moist, on face tent
CV: S1, S2, regular, tachycardic, no murmurs appreciated
Pulm: good air movement, no wheezes, crackles, rhonchi
Abd: (+) bowel sounds, well-healed surgical scars, distended,
(+) fluid wave, mild, diffuse discomfort. No rebound or
guarding. small
3mm subcutaneous rounded nodule at umbilical scar site
Ext: warm, well-perfused, no edema. (+) distal pulses
Pertinent Results:
EKG: sinus tachycardia with wavy baseline. Right axis. S1, qIII
T wave inversions in III. difficult to assess ST-T changes. Poor
R wave progression.
.
Studies:
[**1-30**] peritoneal fluid: 4+ polys, no microorgs seen, culture
pending. 465 RBCs 300 WBCs (3%polys, 27%lymphs, 34 % monos, 14%
macros 22% others)
[**1-31**] UA negative
[**1-31**] CK 66 MB (not done) Trop 0.23
.
[**1-31**] CT Chest Right and left main pulmonary emboli. New R
pleural effusion, increased intra-abd ascites c/w peritoneal
carcinomatosis.
Increase in size/number of innumerable hepatic metastasis and
large pancreatic mass consistent with significant interval
progression of disease. Evid of splenic infarcts.
[**1-31**] Head CT: negative for hemorrhage, no evidence of mets.
.
[**2-4**] Noncontrast Head CT: No sign of hemorrhage, shift. No overt
interval change from [**2161-1-31**]. No overt extracranial
abnormalities
Brief Hospital Course:
58 year old female with breast ca and progressive metastatic
pancreatic ca who presented with acute shortness of breath and
was found to have bilateraly pulmonary emboli. She was started
on IV heparin but developed a persistent GI bleed. Her mental
status remained poor despite holding sedating medications and
negative head CT. Given her poor prognosis due to her
progressive cancer, bilateral pulmonary emboli and inability to
anticoagulate due to persistent GI bleeding, her family made the
decision to make the patient DNR/DNI and eventually CMO. She
was started on a morphine drip and continued on oxygen mask for
comfort. She died on [**2161-2-10**] at 2:50pm.
Medications on Admission:
Vicodin 1-2 tabs q5-6h prn
Fentanyl 250 mcg q72h
Lovenox 100 mg sc qday (held for past 4 days)
dulcolax 2 tabs [**Hospital1 **]
1 sennokot qday
Lactulose qday
Prilosec 20mg qd
Neurontin 300mg tid
Pancrease 2-6 tabs before each meal
Imodium prn
Compazine prn
zofran prn
lorazepam prn
Flonase prn
MSContin 15mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
breast cancer
metastatic pancreatic cancer
bilateral pulmonary emboli
Discharge Condition:
expired
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
4587, 4596
|
3538, 4211
|
318, 324
|
4709, 4719
|
2614, 3313
|
2029, 2057
|
4617, 4688
|
4237, 4564
|
2072, 2595
|
259, 280
|
352, 1430
|
3401, 3515
|
1452, 1905
|
1921, 2013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,446
| 173,780
|
9038
|
Discharge summary
|
report
|
Admission Date: [**2191-9-20**] Discharge Date: [**2191-9-24**]
Date of Birth: [**2108-6-1**] Sex: F
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
malaise, SOB x3-4 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old female with IPF on 2-3L NC home O2, DM2, depression,
h/o CVA 5 years prior presenting with progressive malaise x [**3-17**]
days, increased DOE, and shortness of breath referred from PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] for increased oxygen requirement and ? PNA. Patient
reports increased malaise over weekend with mild cough
productive of white sputum. Daughter had also noticed increased
DOE after approx. 1 min of walking as opposed to 3 minutes. She
also repors chest congestion but denies chest pain,
palpitations, fever, chills, decreased PO intake, N/V/D, leg
pain or swelling. O2 sats have been stable around 95% on 3L NC.
She made appointment with PCP and was seen in clinic where she
was noted to be 85% on 5L NC with rhonchi heard on right.
.
In the ED, initial vs were: T98.6 BP127/73 HR110 RR22 94% 3L.
CXR was difficult to interpret but revealed possible lingular
infiltrate so she was given CTX and Azithro. Blood cx x 2 drawn
prior to abx. Labs remarkable for lactate 2.2, WBC 7. She
desaturated to 78% on 3L so placed on NRB. She was weaned down
to 6L so initially was going to floor but had repeat episode of
desaturation so placed on NRB and bed request changed to ICU
given O2 requirement. VS prior to transfer: HR 100-120 BP 130/80
94% 6L NC.
.
On the floor, breathing mildly improved with O2 and pt anxious
but not coughing.
Past Medical History:
# Diabetes Mellitus
# Pontine Stroke in [**2186**] - reportedly had carotid duplex exams
at that time and no intervention recommended. She recoverd
nearly completely, though has residual mild left hemiparesis.
# Depression - she developed profound depression following her
stroke, now treated
# Hypercholesterolemia
# Hypertension
# Pulmonary Fibrosis - Followed by Dr. [**Last Name (STitle) 575**], established
care in [**2191-7-14**]. Presumed IPF although no biopsy performed.
[**Last Name (un) **] n any medicatiosn other than O2. Largely asymptomatic with
routine daily activities, but dyspnea develops with increased
exertion. Pulmonary function tests [**7-/2191**] show FEV1 and vital
capacity 0.88 and 1.0 (44 and 35% predicted respectively).
Vital capacity may be underestimated due to abrupt termination
of exhalation. Pulmonary function tests done at [**Hospital3 **] on [**2191-7-21**] show that she was not able to perform
lung volumes or diffusing capacity. Her spirometry showed FEV1
of 0.96 and vital capacity 1.1. There was no improvement after
albuterol.
Social History:
She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a
widow since [**2159**]. She worked as an appraiser for the IRS until
age 78, a job she really enjoyed. She retired at the time of her
stroke. She has two daughters, one, [**Name (NI) **], who accompanies her
lives in [**State 350**], and another who lives in [**State 5887**].
She has a son who lives in [**Name (NI) 12000**]. She smoked only for 10
years and quit many years ago. She has one alcoholic beverage
per night ([**Location (un) 21601**], scotch, or glass of wine). Denies TB
exposure. She has a dog but no other pets.
.
Family History:
No known pulmonary disease.
Physical Exam:
General: Alert, oriented, no acute distress, speaking in partial
sentences, not using accessory muscles, appears fatigued and
dyspenic with minimal movement
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Dry velcro crackles at bases bilateral to mid lung fields
with coarse crackles left and right mid to upper lung. No
wheezes
CV: Regular rate and rhythm, normal S1 + S2 with prominent P2,
2/6 systolic murmur LUSB
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
On admission:
[**2191-9-20**] 03:20PM BLOOD WBC-7.9 RBC-3.69* Hgb-10.4* Hct-31.7*
MCV-86# MCH-28.1# MCHC-32.8 RDW-17.5* Plt Ct-244
[**2191-9-20**] 03:20PM BLOOD Neuts-85.0* Lymphs-8.8* Monos-3.3 Eos-2.3
Baso-0.5
[**2191-9-20**] 03:20PM BLOOD Glucose-140* UreaN-13 Creat-0.8 Na-136
K-4.2 Cl-98 HCO3-29 AnGap-13
[**2191-9-20**] 03:20PM BLOOD Calcium-9.3 Phos-2.5* Mg-1.8
[**2191-9-20**] 03:54PM BLOOD Lactate-2.3*
On discharge:
[**2191-9-23**] 06:45AM BLOOD WBC-7.0 RBC-3.41* Hgb-9.3* Hct-30.2*
MCV-89 MCH-27.4 MCHC-30.8* RDW-17.7* Plt Ct-274
[**2191-9-23**] 06:45AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-140
K-4.4 Cl-102 HCO3-30 AnGap-12
EKG [**2191-9-20**]
Sinus rhythm. Leftward axis. Delayed R wave progression with
late precordial QRS transition. Modest low amplitude right
precordial T wave changes. Findings are non-specific. Since the
previous tracing of [**2190-8-27**] sinus tachycardia is absent and axis
is less leftward.
Chest Xray [**2191-9-20**]
Severe pulmonary fibrosis, without new airspace opacity
definitively seen
CTA Chest [**2191-9-21**]
IMPRESSION:
1. No evidence of pulmonary embolus. Moderate-to-severe
pulmonary arterial
hypertension with evidence of right heart strain.
2. Similar appearance of extensive fibrotic disease with UIP/IPF
features.
Diffusely increased lung density cannot be adequately evaluated
with this
non-high-resolution CT technique, although could represent
pulmonary edema,
infection or acute exacerbation of fibrotic process.
3. Stable left upper lobe 6-mm nodule.
4. Large hiatal hernia.
5. Thyroid nodule, stable.
6. Compression fracture, stable.
7. Subcentimeter liver hypodensity, which is too small to
characterize,
stable.
Brief Hospital Course:
83 year old woman with pulmonary fibrosis admitted with
progresive malaise and DOE with increased O2 requirement last
3-4 days.
# Hypoxic respiratory distress: The patient was admitted to the
MICU due to her high oxygen requirement. The differential for
the patient's respiratory distress included either bacterial or
viral PNA, PE, CHF, or IPF exacerbation. She was started on a
5-day course of ceftriaxone and azithromycin to cover for CAP.
She underwent a CTA which showed no evidence of a PE. She was
initially placed on a 100% NRB, but was able to be weaned to
nasal cannula oxygen soon after reaching the MICU. She remained
stable on 5-6L NC O2, with O2 sats in the mid 90s. She did
desaturate to the mid 70s-80s with exertion, however, both her
and the family say that is her normal baseline. She would
recover to the mid 90s quickly with rest. Steroids were not
given as the patient seemed to be improving on the antibiotics
with a rapid wean off the NRB. Ms. [**Known lastname 10113**] was transferred to
the General Medicine Floor when she was stable on 6L nasal
cannula. Pulmonary evaluated her and recommended supplemental
O2 to maintain O2sats > 90%. Initiation of steroids was deferred
for now based on patient's preference and concern re: glycemic
control but could consider a steroid trial if she does not
progress as expected while at inpatient pulm rehab. Vasodilator
therapy should be considered as an outpatient once disease more
stabilized but not currently. Patient should schedule
appointment with pulmonologist Dr. [**Last Name (STitle) 575**] within 1-2 weeks of
discharge for repeat echocardiogram, spiromemtry/DLCO, +/-
imaging.
.
# DM2: The patient's metformin was held as she got a contrast
load for her CTA. She was covered with an ISS while in-house.
Metformin restarted on discharge.
.
# Hypertension: Home amlodipine was initially held in MICU, then
restarted once pressures began to increase.
.
# Hyperlipidemia: Continue home atorvastatin 10mg.
.
# History of CVA: Continued on daily aspirin.
.
# Depression and Anxiety: Continued on Lexapro, Mirtazapine and
ativan as needed.
.
# Normocytic Anemia: Nl MCV with widened RDW. [**Month (only) 116**] have element
of iron deficiency anemia given ferritin 31. Should have
further workup as an outpatient.
.
# Lung nodule: Stable 6mm left upper lobe nodule seen on CTA
chest compared to 6/[**2191**].
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Amlodipine 2.5 mg PO/NG DAILY
Aspirin 325 mg PO/NG DAILY
Azithromycin 250 mg PO/NG Q24H
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
CeftriaXONE 1 gm IV Q24H
Escitalopram Oxalate 20 mg PO DAILY
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC (per Insulin Flowsheet)Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
Mirtazapine 15 mg PO/NG HS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Other
Continuous oxygen by nasal cannula as needed to maintain O2sat
>90%
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Pneumonia versus Upper Respiratory Infection
2. Interstitial Pulmonary Fibrosis
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 for shortness of breath and increasing oxygen
requirements. You were treated for pneumonia with antibiotics.
For several days you were in the in the intensive care unit so
that specialized pulmonologists could watch your breathing
status closely. You were transferred to the general medicine
floors when your oxygen requirements were more stable.
You will be discharged to pulmonary rehab. Please continue to
take your home medications as directed.
Followup Instructions:
Please schedule an appointment with Dr. [**Last Name (STitle) 575**] ([**Telephone/Fax (1) 612**])
in the Pulmonary Clinic within [**1-15**] week of discharge from
pulmonary rehab.
Previously scheduled appointments:
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2192-1-31**] at 11:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2192-1-31**] at 11:00 AM
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2192-1-31**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"480.9",
"438.89",
"728.87",
"518.84",
"250.00",
"300.4",
"V46.2",
"515",
"280.9",
"401.9",
"416.8",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9379, 9451
|
5901, 8301
|
292, 298
|
9578, 9578
|
4192, 4192
|
10249, 11138
|
3464, 3493
|
8798, 9356
|
9472, 9557
|
8327, 8775
|
9754, 10226
|
3508, 4173
|
4619, 5878
|
230, 254
|
326, 1715
|
4206, 4605
|
9593, 9730
|
1737, 2813
|
2829, 3448
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,474
| 135,385
|
34540
|
Discharge summary
|
report
|
Admission Date: [**2102-6-12**] Discharge Date: [**2102-6-13**]
Date of Birth: [**2031-8-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Right internal carotid artery stenosis - symptomatic- with
uncomplicated stent placement
Major Surgical or Invasive Procedure:
Right internal carotid stenting
History of Present Illness:
70 yo F with ihistory of hypertension, hyperlipidemia, and
supraventricular tachycardia who is s/p right ICA stenting for
symptomatic high grade right carotid stenosis. She notes that
starting 3-4 months ago, she has had intermittent blurry vision,
felt like a veil was over her right eye and seeing "purple
spots" especially in bright light. She denies facial numbness
or droop or other neurological symptoms including muscle
weakness.
.
Here, she underwent catheterization revealing 90% right ICA
stenosis which was successfully stented. Nitroprusside was
started due to hypertension in 200's in the lab to maintain BP
in 100-150 range. Upon arrival to the CCU, her BP was within
range off of nitroprusside.
.
On review of symptoms, she 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.
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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Symptomatic right carotid stenosis - with amaurosis fugax and
purple spots seen
Supraventricular Tachycardia - has received Adenosine 3 times
over the past year, followed by Dr. [**Last Name (STitle) **] at [**Hospital1 112**]
Cholecystectomy
Anxiety
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse, drinks 3-4 glasses
wine/night.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father had a CABG in his 70s.
Physical Exam:
VSS, afebrile
Gen: NAD, Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP as is lying flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Neuro: 5/5 strength UE/LE, sensation intact, CN 2-12 intact
Pertinent Results:
[**2102-6-12**] 09:11PM WBC-6.3 RBC-3.83* HGB-11.8* HCT-35.4* MCV-92
MCH-30.8 MCHC-33.4 RDW-13.6
[**2102-6-12**] 09:11PM GLUCOSE-120* UREA N-14 CREAT-0.8 SODIUM-134
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
Brief Hospital Course:
Patient admitted following R internal carotid artery stent
placment for symptomatic carotid stenosis - 90% [**Country **] lesion on
cathetarization. The artery was stented with good flow, no
bruits on exam. Patient was stable through-out hospitalization,
neuro exam revaled no focal deficits. Patient was discharged in
stable condition on Plavix and home blood pressure medications.
Medications on Admission:
Plavix 75mg daily
Prozac 40mg daily in the pm
Atenolol 50mg [**Hospital1 **]
Diovan 160mg daily in the pm
Lipitor 40mg daily in the pm
Aspirin 325mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Right Carotid Artery Stenosis
Secondary:
SVT - has received Adenosine 3 times over the past year,
followed by Dr. [**Last Name (STitle) **] at [**Hospital1 112**]
s/p cholecystectomy
Anxiety
Discharge Condition:
stable, neurologic exam intact
Discharge Instructions:
You were admitted for a carotid stenting which was successful.
If you develop fevers, chills, headache, confusion, numbness,
tingling, weakness in your extremities, or difficulty with
speech, or any other concerning symptoms please contact your
doctor or go to the emergency room.
.
Please take all your medications as prescribed and follow up
with the appointments below. You have to take aspirin and Plavix
(Clopidogrel). You should continue with Valsartan and You should
be able to resume your Atenolol in 1 to 2 days if your systolic
blood pressure is >110. Please have your blood pressure checked
by your primary care doctor in 1 to 2 days.
Followup Instructions:
Please follow up with your PCP within the next couple days.
.
To follow up with Dr. [**First Name (STitle) **] in one month. Appointment will be
arranged.
|
[
"362.34",
"V45.89",
"300.00",
"433.10",
"272.4",
"414.01",
"427.89",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"88.42",
"00.45",
"88.41",
"00.61",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
4401, 4407
|
3375, 3762
|
404, 438
|
4651, 4684
|
3128, 3352
|
5378, 5536
|
2159, 2271
|
3968, 4378
|
4428, 4630
|
3788, 3945
|
4708, 5355
|
2286, 3109
|
276, 366
|
466, 1713
|
1735, 1987
|
2003, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,364
| 174,697
|
43950
|
Discharge summary
|
report
|
Admission Date: [**2106-6-24**] Discharge Date: [**2106-7-7**]
Date of Birth: [**2031-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Zenker's diverticulum
Major Surgical or Invasive Procedure:
* Transcervical diverticulectomy with cricopharyngeal myotomy
* Exploration of neck and wide drainage, EGD and possible
thoracic exploration [**2106-6-26**]
History of Present Illness:
75 yo M with large Zenker's diverticulum causing dysphagia and
emesis who was admitted for transcervical resection.
Past Medical History:
obstructive sleep apnea, type II diabetes mellitus,
hyperlipidemia, nephrolithiasis, s/p cholecystectomy, s/p
tonsillectomy, s/p suspension micro carbon dioxide laser
cricopharyngeal myotomy of Zenker diverticulum [**2090-11-8**],
Endoscopic CO2 laser Zenker diverticulotomy [**2092-1-31**]
Social History:
Works in design. Lives with wife. [**Name (NI) 1139**]: Quit 40 years ago.
EtOH: 1-2 drinks 2 times per month. Drugs: none
Family History:
Mother with hypertension
Physical Exam:
On admission to Medical ICU:
Vitals: T: 97.1 BP: 155/51 P:75 R:23 O2: 98% RA
General: Alert, oriented, no acute distress, conversant, and
cooperative with exam
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, II/VI systolic ejection murmur,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On day of discharge:
VS: T: 98.6 HR: 53 SB BP: 134/68 RR 16 Sats: 98% RA
General: alert oriented no distress
HEENT; normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Incision: neck incision clean dry intact, no erythema, JP site
clean
Pertinent Results:
[**2106-6-24**] CK(CPK)-182 CK-MB-4 cTropnT-<0.01
[**2106-6-24**] GLUCOSE-220* UREA N-23* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-29 ANION GAP-12
[**2106-6-24**] CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2106-6-24**] WBC-8.6# RBC-4.20* HGB-12.9* HCT-36.8* MCV-88 MCH-30.7
MCHC-35.0 RDW-12.4 PLT COUNT-165
[**2106-7-7**] WBC-8.0 RBC-3.60* Hgb-10.8* Hct-31.7* MCV-88 MCH-29.9
MCHC-33.9 RDW-13.4 Plt Ct-416
[**2106-7-7**] Glucose-75 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-102
HCO3-29
.
[**2106-6-24**] CXR
Nasogastric tube ends well seated in the upper stomach. Skin
staples and
surgical drains project over the left supraclavicular region of
the neck. No pneumothorax or mediastinal widening. Heart size
normal. Lungs clear.
.
[**2106-6-25**] CXR
No evidence of pneumomediastinum or abnormal mediastinal
widening.
However, if there is concern for esophageal leak, CT would be
more sensitive in its detection. Findings were discussed with
the house officer by phone at 10 a.m. on [**2106-6-25**].
.
[**2106-6-26**] CXR
There is some minimal increased opacity of the upper mediastinum
bilaterally. This could be post-operative change or
inflammation; however, if there is concern for an esophageal
leak CT would be more sensitive. There continues to be
subsegmental atelectasis at the left lower lung with partial
obscuration of the left hemidiaphragm and a small left pleural
effusion. Otherwise the lungs are clear.
.
[**2106-6-26**] CT chest with contrast
1. Upper mediastinal extraluminal air and fluid collection with
extensive
adjacent edema, greater than expected postoperatively. This
collection at
points appears contiguous with the esophageal lumen, concerning
for breakdown of the esophageal closure.
2. Small bilateral pleural effusions, with associated
atelectasis. No
evidence of pneumonia.
3. Secretions within the right main stem bronchus, with possible
evidence of minimal aspiration in the right upper lobe.
Esophagus
[**2106-7-6**]: There is no evidence of leak from the cervical
esophagus or residual posterior esophageal pouch. Contrast
passes freely through the esophagus.
[**2106-7-3**]: Contrast pools in the residual pouch in the proximal
esophagus. A tiny linear streak of contrast extends from the
residual posterior esophageal pouch without significant pooling,
which may represent a tiny leak. Contrast passes freely through
the esophagus into the stomach.
IMPRESSION: Possible tiny esophageal leak.
[**2106-7-7**] WBC-8.0 RBC-3.60* Hgb-10.8* Hct-31.7* MCV-88 MCH-29.9
MCHC-33.9 RDW-13.4 Plt Ct-416
[**2106-7-7**] Glucose-75 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-102
HCO3-29
Micros
[**2106-6-30**] pleural 4+ PMN, no orgs
[**2106-6-26**] fluid 4+ PMN, 3+ GPC, 2+GPR, 1+GNR; prevotella and C.
albicans
[**2106-6-26**] Tissue cx 2+ PMN, 1+ GPC, 1+GNR: prevotella and C.
albicans alloderm
[**2106-6-26**] Blood cx P
[**2106-6-26**] Tissue cx Prevotella also found, susc pending
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a transcervical diverticulectomy with
cricopharyngeal myotomy on [**2106-6-24**]. Briefly, the surgery was
complicated by extremely friable mucosa which necessitated
suture closure of the defect with placement of an alloderm patch
for increased support. Please see the operative report for
further details. He was transported to the PACU in good
condition with a left neck JP drain and NGT in place.
Post-operatively he became hypertensive with systolics in the
190's to 200's that were unresponsive to hydralazine,
nitroglycerine, and nitro paste. He was transferred to the the
ICU for increased blood pressure monitoring and Medicine was
consulted. His blood pressure normalized with a labetalol drip
that was weaned off several hours later. A cardiac work-up
failed to show any evidence of myocardial infarction. A CXR on
POD #1 showed a mildly widened mediastinum without clear signs
of mediastinitis. On POD #2 the patient spiked a fever 101.4 and
was pan-cultured (including fluid from JP drain). His
antibiotics coverage was broadened from clindamycin to
Vancomycin/Ciprofloxacin/Flagyl. Given the concerning widening
of the mediastinum on repeat CXR, CT chest was ordered which
showed extraluminal air and edema. In conjunction with purulent
JP drainage, Thoracic Surgery was consulted for open exploration
of neck and possibly chest. The patient was taken to the OR
overnight on [**2106-6-26**] for neck washout. The tissue and fluid
cultures from this surgery showed mixed bacteria and [**Female First Name (un) **]
albicans. As a result fluticasone was added to the antibiotic
regimen. Immediately post-operatively his blood sugars were high
(200s) and since he was given a goal rate of 65ml/hr through NG
tube. He was started on an insulin drip and then Lantus and
Regular Q6 [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations on [**2106-6-29**]. He also
reached goal NGT feeds on [**2106-6-29**] and his sugars became well
controlled. He continued to have a left sided pleural effusion
and interventional pulmonology did a therapuetic and diagnostic
thoracentesis, getting 600cc out. The fluid analysis showed a
transudative effusion with 4+POLYMORPHONUCLEAR LEUKOCYTES but no
microorganisms. He was kept nothing by mouth and tube feeds were
slowly advanced to a goal of 75cc/hr through his nasogastric
tube. On [**2106-7-3**] he had a barium swallow to evaluate for
esophageal leak. The study could not rule out a leak and so he
was not allowed to eat, and tube feeds were continued, until
[**2106-7-6**] when he had a repeat barium swallow that showed no leak.
He will complete a 21 day course of clindamycin, cipro,
fluticasone. On [**2106-7-7**] he was discharged home on insulin
(lantus). He will follow-up with Dr. [**First Name (STitle) **], [**Last Name (un) **] and his PCP
and Infectious Disease.
Medications on Admission:
Lipitor QHS
glipizide [**Hospital1 **]
metformin TID
Januvia daily
omeprazole daily
Omnaris nasal spray daily
aspirin 325 mg daily
Tylenol PRN
Motrin PRN
Tylenol
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 20 days.
Disp:*40 Tablet(s)* Refills:*0*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 20 days.
Disp:*40 Tablet(s)* Refills:*0*
3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 20 days.
Disp:*80 Capsule(s)* Refills:*0*
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous once a day: take as directed.
Disp:*1 bottle* Refills:*2*
7. One Touch Ultra Test Strip Sig: One (1) strip
Miscellaneous four times a day.
Disp:*120 strips* Refills:*2*
8. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day.
Disp:*120 lancets* Refills:*2*
9. Insulin Syringe Ultrafine [**1-3**] mL 29 x [**1-3**] Syringe Sig: One
(1) syringe Miscellaneous once a day.
Disp:*90 syringes* Refills:*2*
10. One Touch Ultra System Kit Kit Sig: One (1) meter
Miscellaneous as directed.
Disp:*1 meter* Refills:*2*
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM.
13. metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM.
14. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever or pain.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diabetes mellitus
hyperlipidemia
Nephrolithiasis
Obstructive sleep apnea
zenkers diverticulitis
mediastinitis
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
-Incision develops drainage
Neck JP: empty daily and keep a log of output. Should drain fall
cover site with a clean dressinag and call the office
[**Telephone/Fax (1) 2348**]
Pain
-Acetaminophen 650 mg every 6-8 hours as needed for pain
-Ibuprofen 400-600 mg every 8 hours as needed for pain take with
food and water
-Oxycodone 5 mg as needed for pain
Acitivity
-Shower daily. Wash incision with mild soap & water, rinse pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No driving while taking narcotics
-Take stool softner with narcotics
Medications
-Continue to monitor fingerstick blood sugars. Keep alog. Lantus
insulin daily
-Antibitics: Clindamycin, Cipro and Fluconazole through [**2106-7-26**]
-Metoprolol 50 mg daily. Your blood pressure was elevated
during your hospital course 130-160. Please follow-up with your
PCP for further management.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2106-7-20**] 11:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-20**] 8:45
[**Location (un) 861**] Radiology NOTHING TO EAT OR DRINK AFTER MIDNIGHT
Esophagus Study [**Location (un) 861**] Radiology XDI UPPER GI (TCC) RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-20**] 10:30
Nothing to Eat or DRINK after Midnight [**2106-7-20**]
Provider: [**Name10 (NameIs) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2106-7-26**] 9:00 infectious disease in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **] Basement level.
Follow-up with [**Hospital **] Clinic Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] [**Telephone/Fax (1) 9979**] [**7-21**] 1:30 pm. Please call sooner if your blood sugars are not
well controlled.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3845**] [**Telephone/Fax (1) 16335**]
Completed by:[**2106-7-7**]
|
[
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"272.4",
"998.59",
"998.31",
"519.2",
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"E870.0",
"E878.8",
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"518.81",
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"250.00",
"530.6",
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icd9cm
|
[
[
[]
]
] |
[
"42.82",
"34.91",
"38.93",
"96.6",
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icd9pcs
|
[
[
[]
]
] |
10144, 10202
|
4976, 7877
|
298, 457
|
10356, 10356
|
2030, 4953
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11572, 12775
|
1074, 1100
|
8090, 10121
|
10223, 10335
|
7903, 8067
|
10507, 11549
|
1115, 2011
|
237, 260
|
485, 602
|
10371, 10483
|
624, 917
|
933, 1058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,468
| 182,009
|
13644
|
Discharge summary
|
report
|
Admission Date: [**2198-4-22**] Discharge Date: [**2198-4-24**]
Date of Birth: [**2150-4-20**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Cardiac arrest.
Major Surgical or Invasive Procedure:
CVL placement.
Endotracheal intubation.
History of Present Illness:
Ms. [**Known lastname 41168**] is a 48F with DM, ESRD on HD, who is transferred to
[**Hospital1 18**] s/p cardiac arrest. Found in her car by EMS in asysole,
unknown how long down, revived with CPR, epi and atropine x3,
bicarbonate, calcium. Per ER, initially back in sinus tach, then
PEA arrest, then back into sinus tach. Intubated in field,
difficult, c/b aspiration.
She initially was evaluated at [**Hospital 4199**] hospital. There, labs
notable for K to 6.3, glucose 503, with gap of 30. Given
epinephrine 3mg, calcium chloride x3, atropine 1mg, bicarbonate
2amp, insulin 15units, narcan 2mg, albuterol, vancomycin 1g,
zosyn 3.75g. Started on levophed and dopamine drips. Given 500cc
saline. Head CT there with question of SAH. Fem line placed
emergently, nonsterile. Sent to [**Hospital1 18**] for consideration of
neurosurgical eval.
In the [**Hospital1 18**] ER, vitals were 33.5 90 153/79 22 98. Neuro exam,
not w/d to pain, no gag, pupils fixed at 8mm bilat. No family
with her. CT head was reviewed here and felt more consistent
with edema rather than SAH. Glu 207. EKG with prominent peaked T
waves, given 1 amp bibarb, 1g Ca gluc, kayexalate, started on
fentanyl drip. On arctic sun. VS: HR 100 BP 159/74 100% on Fi)2
15 PEEP 5 on CMV rate 14 T 33.7. Access is femoral line.
In the MICU, patient intubated and unable to provide any
additional history.
Past Medical History:
ESRD on HD
DM
s/p L AKA and toe amputations
Social History:
Unknown.
Family History:
Unknown.
Physical Exam:
On MICU admission
Vitals 33.7 97 163/74 18 98% on AC 550,18,5,0.5
General Chronically ill appearing
HEENT Pupils fixed and dilated ~8mm, vomitus in nares
Neck Supple
Pulm Lungs with coarse sounds bilaterally
CV Regular S1 S2 no m/r/g
Abd Soft nontender +bowel sounds
Extrem s/p L BKA, multiple toe and finger amputations with dry
gangrene of fingers, R foot wound
Neuro No corneals, +dolls eyes, no gag, no withdrawal to pain
Lines/tubes/drains R femoral line in place, L HD catheter
Pertinent Results:
CBC 12.8>35.6<258, MCV 102
Chem 135/5.8/92/18/79/8.3<276
Ca [**97**].7, Mag 2.4, Phos 8.1
CK 238, MB 11, MBI 4.5, Tropn 0.4
INR 1.5, PTT 25.8, fibrinogen 621
lactate 4.1
ABG 7.34/37/431
[**Last Name (un) 4199**] labs
CBC 8.8>35.4<204
Chem 132/6.4/87/15/77/9<503 gap=30
ALT 46, AST 50, Tbil 2.6, ALKP 485
CK 102, Tropn 0.59
INR 1.4
ABG 7.01/76/59
lactate 7.8
acetone negative
ser tox negative (ASA, tylenol, EtoH, barbituates, benzos, TCA)
Micro:
[**4-22**] blood cultures PENDING
Images:
[**4-22**] CT head worsening edema worrisome for herniation per
initial d/w radiology, final read pending
[**4-22**] CXR
AP supine portable view of the chest is obtained. A Perm-A-Cath
in
the left IJ extends into the cavoatrial junction. ET tube tip
terminates at approximately 5.6 cm above the carina. An NG tube
courses into the left upper abdomen, tip excluded from view.
There is cardiomegaly which appears stable. Increased central
peribronchovascular opacities may represent pulmonary edema. No
large pleural effusion or pneumothorax is seen.
IMPRESSION: Pulmonary congestion. Cardiomegaly. Tubes and lines
positioned adequately.
EKG: SR @97, nl axis, QRS 126 with LBBB type pattern. prominent
T's in V1-V2 which are less sharply peaked from prior. RsR'
morphology in V4-V6, I with TWI in those leads. low voltage in
limb leads. Poor baseline.
OSH EKG: SR @73, rightward axis, QRS 146 LBBB like morphology,
with peaked T's, STD with TWI in V4-V6, TWI III and vF
Brief Hospital Course:
A 48 y/o woman with DM and ESRD on HD presents after found s/p
cardiac arrest, resuscitated in the field.
* Cerebral edema with impending herniation. Likely post-hypoxic
etiology. Worsening on progressive CT head. Neuro exam very
concerning - is overbreathing vent still. She was
hyperventilated to goal pCO2 of 26-30 per cooling protocol.
Neurosurgery was consulted and did not feel bolt was indicated.
After 24 hours on the cooling protocol, patient was rewarmed
with no recovery of neurologic function. There was no activity
on EEG. There were no brainstem reflexes and patient de-satted
during apnea test (see below).
* Out-of-hospital cardiac arrest. Suspect arrest secondary to
ESRD related metabolic disturbance, most likely hyperkalemia.
However with DM and ESRD obviously also at significant risk for
ACS. She was started on CVVHD on the first hospital day for
hyperkalemia. While on apnea test SpO2 dropped slightly and
patient coded, depsite immediately stopping test. Pt underwent
PEA and did not respond to atropine, epinephrine and CPR. She
became very difficult to ventilate (stiff and low compliance)
and was pronounced dead after ~20 min.
* Hyperkalemia. Pt initially admitted with hyperkalemia and
improved on CVVH and with kayexelate. Initially peaked TW, but
no QRS changes.
* Anion gap. Likely related to ESRD and elevated lactate in
setting of out-of-hospital arrest. As above, she was started on
CVVHD and continued up until the code blue (see below).
* DM. She initially presented to OSH with elevated gap and
hyperglycemia. Upon admission to [**Hospital1 18**] she was continued on
insulin sliding scale.
* Goals of care and in-hospital code blue. Given the prolonged
cardiac arrest in the field and lack of neurologic recovery
after rewarming, goals of care were addressed with family. At
the time of the in-hospital code blue, her code status remained
full code although there was a family meeting planned for the
afternoon. Initially she was extubated as there was concern that
the ET tube was occluded. Chest compressions were continued for
several cycles. Patient was given atropine and epinephrine and
reintubated. Bag ventilations were attempted but there was very
high resistence. Given the poor prognosis and very
low-probability for any neurologic recovery (after her
out-of-hospital cardiac arrest), the code blue was stopped.
Medications on Admission:
home meds unknown
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2198-4-25**]
|
[
"585.6",
"250.43",
"V49.76",
"288.60",
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"403.91",
"427.5",
"250.13",
"507.0",
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"443.9",
"348.4",
"V45.11",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
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] |
icd9pcs
|
[
[
[]
]
] |
6351, 6360
|
3881, 6251
|
312, 353
|
6411, 6420
|
2392, 3858
|
6476, 6514
|
1863, 1873
|
6319, 6328
|
6381, 6390
|
6277, 6296
|
6444, 6453
|
1888, 2373
|
257, 274
|
381, 1754
|
1776, 1821
|
1837, 1847
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,279
| 144,278
|
27755
|
Discharge summary
|
report
|
Admission Date: [**2186-8-8**] Discharge Date: [**2186-8-12**]
Date of Birth: [**2171-5-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Traumatic injury of right upper extremity and transection of
brachial artery.
Major Surgical or Invasive Procedure:
Debridement and closure right arm, and repair of right brachial
artery disruption with interposition graft of right non-reversed
saphenous vein.
History of Present Illness:
15F in [**Doctor Last Name **] (back seat) rollover MVA, questionable LOC, RUE
injury with arterial bleeding and significant blood loss at
scene, tourniquet placed on scene; pt reports placing R hand
against window as rollover occurred
Past Medical History:
pyelonephritis (discharged from [**Hospital **] Hospital [**8-7**])
Social History:
Grandmother is legal guardian, has h/o behavioral disorder. Has
been in group homes in past
Family History:
non contributary
Physical Exam:
MS/NEURO: [ _ ]A/O [ _ ]FC [ _ ][**First Name8 (NamePattern2) 2995**] [**Last Name (un) 45802**]:
HEENT: [ _x ]PERRLA, EOMI
CVS: [ _x ]RRR no murmur. no gallop
Resp: [ x_ ]CTA-B
Abd: [ x_ ]S/NT/ND/+BS
Ext: [ _x ]No. P. Edema [ _ ]+1 Edema [ _ ]+2 Edema [ _ ]+3
Edema
Inc: [ x ] C/D/I
right hand brisk cap refill. sensation and motor intact
Pertinent Results:
RADIOLOGY
TRAUMA #2 (AP CXR & PELVIS PORT):No evidence of acute injury
CT HEAD W/O CONTRAST: No acute intracranial abnormality or
fracture.
CT C-SPINE W/O CONTRAST: No evidence of fracture or malalignment
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRASTN; CT PELVIS
W/CONTRAST: no evidence of traumatic injury to the chest,
abdomen or pelvis
FOREARM (AP & LAT) RIGHT:Status post trauma. Brachial artery
repair. Evaluate for fracture: No evidence of fracture or
dislocation. Gas in the soft tissues is likely postoperative
[**2186-8-8**] 05:23PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2186-8-8**] 05:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2186-8-8**] 05:23PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2186-8-8**] 03:06PM HCT-21.4*#
[**2186-8-8**] 11:50AM TYPE-ART PO2-220* PCO2-38 PH-7.44 TOTAL
CO2-27 BASE XS-2
[**2186-8-8**] 11:50AM GLUCOSE-116* LACTATE-1.0 NA+-134* K+-4.7
CL--107
[**2186-8-8**] 11:50AM HGB-7.5* calcHCT-23
[**2186-8-8**] 11:50AM freeCa-1.11*
[**2186-8-8**] 10:40AM TYPE-[**Last Name (un) **] PH-7.34*
[**2186-8-8**] 10:40AM GLUCOSE-127* LACTATE-3.3* NA+-138 K+-4.5
CL--105 TCO2-29
[**2186-8-8**] 10:40AM HGB-9.5* calcHCT-29 O2 SAT-61 CARBOXYHB-2 MET
HGB-1
[**2186-8-8**] 10:40AM freeCa-1.22
[**2186-8-8**] 10:20AM UREA N-12 CREAT-0.8
[**2186-8-8**] 10:20AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-50
AMYLASE-42 TOT BILI-0.3
[**2186-8-8**] 10:20AM LIPASE-25
[**2186-8-8**] 10:20AM ALBUMIN-3.2*
[**2186-8-8**] 10:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-8-8**] 10:20AM URINE HOURS-RANDOM
[**2186-8-8**] 10:20AM URINE HOURS-RANDOM
[**2186-8-8**] 10:20AM URINE GR HOLD-HOLD
[**2186-8-8**] 10:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2186-8-8**] 10:20AM WBC-11.5* RBC-3.55* HGB-9.5* HCT-29.0* MCV-82
MCH-26.8* MCHC-32.7 RDW-14.6
[**2186-8-8**] 10:20AM PLT COUNT-585*
[**2186-8-8**] 10:20AM PT-15.2* PTT-28.1 INR(PT)-1.4*
[**2186-8-8**] 10:20AM FIBRINOGE-544*
[**2186-8-8**] 10:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2186-8-8**] 10:20AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2186-8-8**] 10:20AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2186-8-8**] 10:20AM URINE AMORPH-RARE
[**2186-8-8**] 10:20AM URINE MUCOUS-RARE
Brief Hospital Course:
The patient is a 15-year-old female involved in a motor vehicle
crash. She was unrestrained back seat passenger in a [**Doctor Last Name **] that
sustained an MVC rollover. She sustained a significant degloving
and laceration injury to her right upper extremity with serious
vascular compromise. She presented to the trauma bay in
relatively stable condition. After assessing for any
intracerebral or abdominal injury, she was taken to the
operating room for right upper arm exploration.
She was found to have laceration of her Right brachial artery.
The saphenous vein was harvested from the right groin and her
brachial artery was repaired.
Post operatively patient remained stable. She was continually
followed by trauma, vascular, and hand services.
On [**2186-8-11**], patient showed signs of orthostatic hypotension and
she was transfused with 2 units of PRBCs. She responded
appropriately to the two units of blood and patient is being
discharged to home with visiting nurse care.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
laceration right brachial artery
Discharge Condition:
Good
Discharge Instructions:
You have injured your right brachial artery, and as a result had
surgery to repair the injury using saphenous vein graft from
your leg. You should not have any IVs or blood draws from your
right arm at the site of your injury. You should return to the
severe pain in your right arm, drainage from the site of your
injury, changes in sensation or temperature of your right
arm/hand, or nay other symptoms that are concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 1111**],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3121**] Follow-up
appointment should be in 2 weeks- Vascular
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6439**] Follow-up appointment
should be in 2 weeks- trauma
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Follow-up appointment should be in 1 week
([**Telephone/Fax (1) 2007**] for hand
Completed by:[**2186-8-12**]
|
[
"458.29",
"E819.1",
"903.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"39.58",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
5785, 5837
|
3941, 4935
|
392, 539
|
5914, 5921
|
1416, 3918
|
6403, 6933
|
1021, 1039
|
4990, 5762
|
5858, 5893
|
4961, 4967
|
5945, 6380
|
1054, 1397
|
274, 354
|
567, 804
|
827, 896
|
912, 1005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,980
| 188,199
|
37359
|
Discharge summary
|
report
|
Admission Date: [**2188-1-31**] Discharge Date: [**2188-2-9**]
Date of Birth: [**2126-12-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Incidentally found AAA that is increasing in size
Major Surgical or Invasive Procedure:
AAA repair
History of Present Illness:
This was a large infrarenal abdominal aortic aneurysm. This was
successfully treated with a Dacron bifurcated graft which
extended to the iliac bifurcation on the left given the presence
of a left common iliac artery aneurysm. There was excellent
hemostasis at the end of the case. Implant was an InterGard 19
x 9 vascular graft.
Past Medical History:
AAA (infrarenal 6cm)
CAD (s/p CABGx2)
HTN
dyslipidemia
Lung nodule right lung base
Embolic CVA right MCA, right posterior cerebral artery
CRI (Cr 1.6)
GERD
PSH: CAD s/p CABGx3 [**10/2187**] and CABGx4 [**2181**]
Social History:
Lives w/ wife, denies smoking, and elicit drug use. Occasional
ETOH.
Family History:
N/C
Physical Exam:
VS: 98.4 85 150/97 20 95% sat RA
Gen: alert and oriented x 3, NAD.
Heart: RRR, normal S1S2
Lungs: Has scaterred rhonchi, w/ productive cough
Abd: soft, non-tender, non-distended.
Extremities: both lower extremities are warm and well perfused
except for the left distal part of foot, the toes are cool and
red.
Pulses: Fem [**Doctor Last Name **] DP PT
[**Name (NI) 167**] palp palp palp dop
Left palp palp palp dop
Pertinent Results:
[**2188-2-8**] 03:58AM BLOOD WBC-11.0 RBC-3.71* Hgb-11.5*# Hct-33.3*
MCV-90 MCH-31.0 MCHC-34.6 RDW-15.6* Plt Ct-291
[**2188-2-8**] 12:34PM BLOOD K-4.3
[**2188-2-8**] 03:58AM BLOOD Glucose-88 UreaN-26* Creat-1.7* Na-139
K-3.2* Cl-102 HCO3-24 AnGap-16
[**2188-2-8**] 03:58AM BLOOD cTropnT-0.54*
[**2188-2-7**] 10:03AM BLOOD CK-MB-3 cTropnT-0.55*
Radiology Reports:
Cardiology Reports:
[**2188-1-31**] at 1:15:28 PM Portable TEE (Complete)
Conclusions
The left atrium is normal in size. No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
Overall left ventricular systolic function is moderately
depressed (LVEF= 40 %). The estimated cardiac index is normal
(>=2.5L/min/m2). No masses or thrombi are seen in the left
ventricle. Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). with normal free wall contractility.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are mildly thickened . No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
[**2188-2-1**] 4:51:18 PM ECG Study
Sinus tachycardia with right bundle-branch block and left
anterior fascicular block. Non-specific ST-T wave abnormalities.
Compared to the previous tracing of [**2188-1-23**] the rate is
increased. Otherwise, no diagnostic change.
[**2188-2-4**] 3:20:04 PM ECG Study
Sinus rhythm. Short P-R interval. Marked left axis deviation.
Right
bundle-branch block. R wave reversal in leads V2-V3 with
persistent Q waves through V6. Consider lateral myocardial
infarction. Other ST-T wave
abnormalities are also noted in leads I and aVL. Since the
previous tracing of [**2188-2-1**] the rate is slower and the right
bundle-branch block is more apparent.
[**2188-2-5**] 1:00:50 PM ECG Study
Baseline artifact. Probable sinus rhythm. Since the previous
tracing
ventricular premature beat is no longer seen. Otherwise,
findings are
unchanged.
[**2188-2-6**] 11:40:01 AM Portable TTE (Complete)FINAL
Conclusions
The left ventricular cavity size is normal. LV systolic function
appears depressed with apical akinesis/dyskinesis; regional wall
motion is not well visualized. Overall left ventricular ejection
fraction (??35-40%).Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trace mitral
regurgitation is seen is focused. There is no pericardial
effusion.
Brief Hospital Course:
[**2188-1-31**] Patient was a direct admit for an elective AAA repair.
Admitted via the holding room where patient was pre-oped,
consented and lined. Patient was then taken to the OR and
underwent open AAA repair. Patient tolerated procedure w/
expected bleeding intra-op, transfused PRBC and fluid
resuscitated. Thoracic epidural was placed, started Fentanyl
during case for pain management. Patient transferred to CVICU
intubated and sedated, patient also became hypotensive in the OR
Neosynephrine drip was started then weaned off. In the ICU
sedation was held and extubated. Patient awake and denied pain.
Post-op Hct of 22.6 was transfused 2U pRBCs.
[**2188-2-1**] POD1: BP stable, tachycardic started Lopressor IV.
Started clear liquids. Creatinine elevated despite good urine
output. Consulted renal for non-oliguric renal
failure-recommended renal US. WBC also elevated, blood cultures
were done. HCT still low, transfused with another unit PRBCs.
Continued w/ epidural Bupivicaine/Dilaudid for pain control with
good results. Transferred to [**Hospital Ward Name 121**] 5 VICU.
[**2188-2-2**] POD2: Vital signs stable. HCT remain low 24.4
transfused with PRBCs. Continued w/ epidural
Bupivicaine/Dilaudid w/ excellent pain control. Tolerating diet.
Creatinine is still elevated, renal US done per renal recs-No
evidence of hydronephrosis, perinephric collections or other
grayscale abnormalities. Technically limited Doppler evaluation
due to patient's inability to hold
breath. Diastolic flow was not reliably identified particularly
on the right.
Left main renal artery however demonstrated normal systolic and
diastolic
flow. Creatinine continue to rise and troponin rising, continued
to cycle.
[**2188-2-3**] POD3: Continued w/ excellent pain control on epidural
Bupivicaine/Dilaudid.
Creatinine continued to rise and so a troponin. Renal
following-nephrotoxic meds kept at minimum. Continued to cycle.
Tolerating diet. Noted to have significant bloody ooz from the
abdominal incision, bulky dressing applied, resolved evntually.
[**2188-2-4**] POD4: Vitals stable. HCT remain low at 24, transfused
PRBCs again. Troponin still rising now 0.56 despite creatinine
coming down and w/ good urinary output. Patient had an episode
of projectile vomiting an abdominal CT was done that showed
likely elius, though an early obstruction cannot be excluded.
Patient Made NPO. Eppidura catheter capped then d/c'd.
[**2188-2-5**] POD5: HCT is stable. Continued to have distended/tympanic
abdomen with several episodes of N/V, kept NPO. Creatinine
improving peaked at 2.8 now 2.5, Troponin continued to rise now
0.63 from 0.56. Patient also has an episode mottled of L lower
extremity despite palpable pulses. Cardiology consulted- recs
ECG, cardiac ECHO. ECG had no changes. Patient hypertensive-
recs beta blockers and Nitrates for BP control. Started Nitro
drip to keep SBP<150. Lower extremity resolved after Nitro was
started.
[**2188-2-6**] POD6: BP stable but remained on Nitro drip and on
Metoprolol IV. Echo was done- showed new apecal akinesis.
Cardiology following- continue Nitro drip then transition to
long acting PO Nitrates when able to take PO's. Remains
nauseaous w/ some vomiting. an NG tube was placed to decompress
stomach, able to drain large amounts of bileous liquid, was
discontinued inadvertently-kept NPO. Creatinine continue to
improve while troponin is still rising now 0.66.
[**2188-2-7**] POD7: Remained on Nitro drip to keep SBP <150, and
Metoprolol IV for HR control, weaned to off, after starting
Imdur and Metoprolol. Abdomen less distended, passing small
amouts of liquid stool. Started sips and tolerating. Troponin
now coming down 0.55 peaked at 0.66. Cardiology following
recommending P-MIBI outpatient, continue to hold Lisinopril.
Creatinine continued to improve as well Renal service signed
off. HCT is down to 26, transfused w/ 1 units PRBSc.
[**2187-2-8**] POD8: Overnight still had bouts of hypertensive, was
given PRN IV Hydralazine. Increased Imdur dose and Metoprolol
dose. Tolerating regular diet. Independently ambulating. D/c'd
telemetry, central line and foley-voided. Creatinine almost at
baseline and Troponin continue to go down. Plan to discharge to
home in AM.
01/9/010 POD9: Discharged to home in good condition, with
foley/leg bag as he was unable to void after removal. Pain free,
tolerating diet, voiding and moving his bowels, endependently
ambulating. Will FU w/ Dr. [**Last Name (STitle) 1391**] in [**4-3**] weeks, w/ his PCP
next week, need to FU w/ a cardiologist as well. Patient
recieved instructions regarding all of these. Will f/u with his
PCP on [**Name9 (PRE) 766**] to ahve urinary catheter removed.
Medications on Admission:
ASA 325 mg QD
Simvastatin 40 mg qd
Zetia 10 mg qd
Lisinopril 5 mg qd
Metoprolol 25 mg qd
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. 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*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
AAA now s/p open repair
Anemia- acute, related to blodd loss, required multiple blood
transfusions, now w/ HCT stable @>30.0
Acute renal failure- non-oliguric renal failure post
operatively, resolving
Acute myocardial infaction- post-operative new apecal akinesis
by echo and elevated troponins. Cardiology consulted, patient
stable, started on Nitrates and increased betablockers-need to
FU w/ PCP or cardiologist after discharge. Troponin trending
down. In house Cardiologist recommended p-MIBI in the future.
Hypertension- started on nitrates and increased beta blocker,
will FU w/ PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 28745**] next week.
History of:
-HTN
-Dyslipidemia
-AAA (infrarenal 6cm)
-CAD s/p CABGx3 [**10/2187**] and CABGx4 [**2181**]
-RBBB
-Lung nodule right lung base
-Embolic CVA right MCA, right posterior cerebral artery
-CRI (Cr 1.6)
-GERD
PSH: s/p Redo CABGx3 [**10/2187**] and CABGx4 [**2181**]
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm Repair Discharge Instructions
ACTIVITIES:
- [**Month (only) 116**] shower pat dry your incision, no tub baths
- No driving till seen in FU by Dr. [**Last Name (STitle) 1391**]
- No heavy lifting for 4-6 weeks
- Resume activities as tolerated, slowly increase activiy as
tolerated
- Expect your activity level to return to normal slowly
- Ambulate as tolerated
DIET:
- Diet as tolerated eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
WOUND:
- Keep wound dry and clean, call if noted to have redness,
draining, or swelling, or if temp is greater than 101.5
- Your staples will be removed on your FU with Dr. [**Last Name (STitle) 1391**]
MEDICATIONS:
- Continue all medications as instructed
FU APPOINTMENT:
- Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone:
[**Telephone/Fax (1) 1393**]
Followup Instructions:
Provider: [**Name10 (NameIs) 1391**], [**Name11 (NameIs) **] Phone: [**Telephone/Fax (1) 1393**] call to make a FU
appointment in [**4-3**] weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 55991**] [**2188-2-13**] 3:00
PM
Monitor your blood pressure and adjust your medication, as well
as monitor your renal function.
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] Phone: [**Telephone/Fax (1) 84020**] call to make a FU
appointment in 2 weeks, discuss: you were seen by a cardiologist
in house who recommends that you get P-MIBI testing in the
future.
|
[
"560.1",
"997.1",
"403.90",
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"441.4",
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"272.4",
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"285.1",
"518.89",
"410.91",
"E878.2",
"V45.81",
"585.9",
"V12.54",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
10186, 10269
|
4287, 8974
|
364, 376
|
11249, 11249
|
1540, 4264
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|
991, 1061
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,366
| 118,578
|
16551
|
Discharge summary
|
report
|
Admission Date: [**2169-2-2**] Discharge Date: [**2169-2-17**]
Date of Birth: [**2097-9-21**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 71-year-old male who
had transferred from [**Hospital3 3834**] with prolonged
pneumonia. The patient was originally admitted to [**Hospital3 28116**] on [**2169-1-8**] for community acquired pneumonia after
patient developed new onset pleuritic chest pain and
shortness of breath while shoveling snow on [**Holiday 1451**]. He
was found to have [**5-12**] blood cultures identified as staph
hominis. A TE was performed and preliminarily identified a
vegetation on the RV outflow tract.
He was transferred to [**Hospital1 69**] on
[**2169-1-12**]. Events from his previous admission here including
CTA which showed right lower lobe pneumonia and emphysema,
but no evidence of PE. The TE was reread by Cardiology here
who felt that the vegetation was actually an artifact. A
repeat TTE here confirmed no vegetations and an ejection
fraction of greater than 55%. He was found to have one out
of six blood cultures positive for coag negative staph. He
was also found to have urinary retention and has been with a
Foley catheter since.
He was discharged to [**Hospital6 46972**] on [**2169-1-18**] on a 21
day course of Vancomycin and Levaquin. The patient's
pulmonary functions subjectively improved until [**2169-1-26**] when
he became short of breath and had spiking fevers to 103.0 F.
He was readmitted to [**Hospital3 3834**] on [**2169-1-28**]. His
hospital course there was significant for new right middle
and left lower lobe pneumonia in addition to previous right
lower lobe. His Levaquin was stopped and he was started on
Tobramycin and Vancomycin. He was given Solu-Medrol times
one dose for wheezing. He was transferred to [**Hospital1 346**] for further evaluation.
On admission, the patient denies any cough or sputum
production. He states that he has shortness of breath only
when off oxygen and it is exacerbated when walking. He
denies, but has had night sweats and shaking chills. Over
the last month, he has never had blood sputum and has gained
weight. No calf pain. No diarrhea, nausea or vomiting. No
new rash, focal numbness or weakness. No recent sick
contacts or recent travel. No history of blood transfusions.
No history of TB.
PAST MEDICAL HISTORY:
1. Osteoporosis, hereditary diagnosis by bone scan in [**2156**].
2. Inguinal hernia repair on the right in [**2158**].
3. History of Rubella in [**2117**].
SOCIAL HISTORY: Retired accountant. Formally worked in the
Navy. Married and lives with wife. [**Name (NI) **] a 60 pack year
smoking history. Quit one year ago. Rare alcohol use. No
asbestoses exposure.
FAMILY HISTORY:
1. Brother with emphysema.
2. Mother died of heart disease.
3. Father died suddenly of unknown causes.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Albuterol Atrovent nebs q. six hours.
2. Flovent 220 mcg b.i.d.
3. Humibid 1200 p.o. b.i.d.
4. Heparin subcutaneous 5000 units b.i.d.
5. Tobramycin 400 q.d.
6. Protonix 40 q.d.
7. Fosamax 70 mg q. Friday.
8. Vancomycin 1.5 grams q. 18 hours.
9. Ceptaz 2 grams q. eight hours.
10. Tylenol p.r.n.
11. Percocet p.r.n.
PHYSICAL EXAMINATION: On admission temperature 96.0 F, blood
pressure 148/65, heart rate 113, respiratory rate 30, O2 sat
93% on four liters plus 40% facemask. In general the patient
had no labored breathing, although appears to be breathing
comfortably. Head, eyes, ears, nose and throat: Oropharynx
with thrush. Mucous membranes dry. Jugular venous pressure
not elevated. Neck supple. Anicteric sclerae. Pupils
equal, round and reactive to light. Chest: Decreased breath
sounds bilaterally at the bases, right more than left.
Egophony on the right lower lobe. Decreased tactile fremitus
on the right. Bronchial breath sounds in right. Dullness to
percussion right more than left. Occasional expiratory
wheezes. Heart: Regular rate and rhythm, normal S1, S2, no
murmur, gallop or rub appreciated. Abdomen: Soft,
nontender, nondistended with normoactive bowel sounds, no
hepatosplenomegaly. Extremities: Left PICC in place, clean,
dry and intact. No cyanosis, clubbing or edema. There is 2+
DP and PTs bilaterally. Neuro: Alert and oriented times
three, no gross motor or sensory defects.
LABORATORY DATA: Most recent include white count of 8.7,
hemoglobin 11.2, hematocrit 32.6. The patient did have a
white count of 17.7, however had subsequently decreased.
Platelets 438. [**2-4**] urinalysis negative. Bum 15,
creatinine 0.6, sodium 136, potassium 4.6, chloride 97,
bicarbonate 30, ALT 46, AST 33, alkaline phosphatase 109, t
bilirubin 0.3. Patient also ruled out with CKs of 23, 23 and
21. Troponin less than 0.3, less than 0.3 and less than 0.3.
The patient's peak liver enzymes were ALT of 110, AST 81, LD
287, alkaline phosphatase 202 that was on admission. The
enzymes have subsequently decreased.
The patient's hepatitis B antigen and antibody negative,
hepatitis C negative, ANCA negative, [**Doctor First Name **] negative, RS
negative, HIV negative.
VAT biopsy, the tissue had no microorganisms on gram stain
and was no growth for aerobic, anaerobic, acid-fast or fungal
cultures. Legionella also negative.
Sputum contaminated. Urine culture with no growth. Blood
cultures on [**2-3**] with no growth. Fungal cultures on [**2-2**]
with no growth. Pleural fluid gram stain no microorganisms.
Fluid culture no growth. Anaerobic culture no growth.
Acid-fast, none seen.
Last chest x-ray on [**2-14**] shows slight increase in right
lower lobe lung opacity. This may be due to a pneumonia or
atelectasis and small right pleural effusion.
A pathology of the VAT biopsy on [**2-9**] revealed pleural
biopsy adhesions, chronic inflammation and mesothelial
hyperplasia, no evidence of malignancy.
Right lower lobe wedge biopsy with patchy organizing
pneumonitis with focal prominent scarring, focal interstitial
fibrosis and focal interstitial chronic inflammation.
Pleural fluid taken on [**2169-2-7**], cytology negative for
malignant cells.
HOSPITAL COURSE:
1. PULMONARY: The patient was initially admitted to the
MICU for observation. The patient was never intubated in the
MICU. The patient, however had thoracentesis which revealed
the transudate and negative cytology for malignancy. A high
resolution CT Scan showed emphysema and evidence of
congestive heart failure and right lower lobe consolidation.
Rheumatological work up was negative.
The patient had been diuresed with Lasix p.r.n. The patient
in the MICU was started on only Ceftazidime. Other
antibiotics were discontinued. The patient did not complain
of dyspnea, cough or chest pain. On [**2169-2-9**], the patient
was taken for a VAT per CT Surgery with results as stated
above. Pulmonary consulted continued to follow and felt that
the patient had no need for steroids.
A right chest tube was placed on the day of the VAT. There
was never a pneumothorax and the chest tube was pulled per CT
Surgery on [**2169-2-13**]. The patient did develop some chest pain
a day or two following the surgery and described it as a band
around his chest. For thoroughness, the patient was ruled
out for a MI. The chest pain resolved on its on.
From a pulmonary standpoint, the patient continued to improve
throughout the hospitalization. He was given nebulizer
treatments, Flovent MDI, chest PT, incentive spirometry and
eventually began ambulating. The patient's O2 requirement on
discharge was four liters nasal cannula. The patient
Ceftazidime was discontinued on [**2169-2-16**]. The patient will
need follow up with Pulmonology as an outpatient.
2. URINARY RETENTION: The patient had a Foley for the
entire MICU stay and once transferred to the floor, the
patient was given a trial without the Foley. The patient did
not urinate without the Foley and had to be straight cathed.
The Foley was replaced. A second trial was given on
[**2169-2-15**]. The patient, again, failed the trial without the
Foley and the Foley was replaced.
Urology was consulted. Urology stated that the patient
should remain with the Foley in him for the next two weeks
and then follow up in [**Hospital 159**] Clinic as an outpatient. The
patient was also started on empiric Flomax for benign
prostatic hypertrophy.
3. ELEVATED LIVER FUNCTION TESTS: The patient was noted to
have elevated LFTs on admission, however they subsequently
decreased to normal. Unclear etiology as to why the LFTs
were elevated.
4. INFECTIOUS DISEASE: The patient's blood, sputum, pleural
fluid and tissue biopsy were all no growth. The patient had
a 12 day course of IV Ceftazidime while here in the hospital.
CONDITION ON DISCHARGE: The patient was discharged in good
condition on [**2169-2-17**] to [**Hospital6 46972**]. The patient is
to follow up with his PCP.
DISCHARGE MEDICATIONS:
1. Flomax 0.4 mg q.h.s.
2. Protonix 40 mg q. AM.
3. Albuterol nebs q. six hours p.r.n.
4. Atrovent nebs q. six hours p.r.n.
5. TUMs 500 mg t.i.d.
6. Vitamin D 400 IU q.d.
7. Miconazole powder 2% one application topically t.i.d.
p.r.n.
8. Colace 100 mg b.i.d.
9. Flovent MDI 110 mcg two puffs b.i.d.
FOLLOW UP: The patient was instructed to follow up in the
[**Hospital 159**] Clinic at [**Telephone/Fax (1) 164**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 44317**]
MEDQUIST36
D: [**2169-2-16**] 15:47
T: [**2169-2-16**] 16:32
JOB#: [**Job Number **]
|
[
"515",
"428.0",
"733.00",
"492.8",
"486",
"263.9",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"34.04",
"04.81",
"32.29",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2766, 2911
|
8961, 9269
|
6178, 8779
|
9281, 9657
|
3287, 6161
|
169, 2355
|
2936, 3264
|
2377, 2538
|
2555, 2750
|
8804, 8938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,199
| 162,255
|
28805
|
Discharge summary
|
report
|
Admission Date: [**2157-4-13**] Discharge Date: [**2157-4-17**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Left VATS pleural biopsy [**4-14**]
History of Present Illness:
This is an 88 yo M with a history of Afib, atrial thrombus, Head
and Neck cancer s/p excision and RXT in [**2150**], COPD, HTN, with a
recent history of chronic hemoptysis secondary to an eroding
broncholith, transferred to [**Hospital1 18**] from [**Hospital3 **] Hospital today
after massive hemoptysis for flex bronch. Of note, he underwent
flexible bronchoscopy with argon plasma coagulation on [**2156-4-2**] for the above and has been transferred for repeat
treatment. He underwent the flex bronch today with no
complications and was awaiting bronchial artery embolization in
IR when he suddenly developed respiratory distress, desatting on
room air from 95% to 80's and was started on a nonrebreather. He
was never hypotensive. A stat portable chest film was suggestive
of pulmonary edema and lasix 20 IV was pushed and a foley
catheter placed. He had received about 400cc of NS while
awaiting his second procedure. He is transferred to the MICU for
further treatment.
.
On arrival to the MICU, the patient had already put out about
300 cc in the foley bag, and was considerably less distressed,
satting 100% on the NRB. He was asking for food. He was changed
over to NC at 6L, satting 93% and was breathing at 25-29
breaths/min. He admits to cough, hemoptysis, diarrhea, no
difficulty chewing or swallowing.
Past Medical History:
Afib/Aflutter s/p ablation [**9-30**] (no anticoagulation)
tachy/brady (requiring BB at times)
head/neck CA s/p excision (R) & RXT [**2150**]
hypothyroidism
dysphagia
HTN
HLD
MI [**2133**] s/p CABG [**2134**]
Glaucoma
COPD
Depression/aniety
h/o atrial thrombus
Social History:
Retired from insurance industry, quit tobacco [**2128**] smoked 2
packs for many years. Drinks 2 beers/week
Family History:
non-contributory
Physical Exam:
VS: T: HR 116 BP: 109/74 RR 25 Sats; 96% 6L
General: sitting up in very mild respiratory distress
HEENT: EOMI, PERRL, mucus membranes moist
Neck: supple, no lymphadenopathy, JVP @ 11cm
Card: tachycardic normal S1,S2 1/6 SEM at base
Resp: decreased breath sounds 1/3 up on right, with bibasilar
rales and diffuse rhonchi, expiratory wheezing.
GI: NT/ND +BS
Extr: warm, no edema
Skin: well healed surgical scar extending from inferior lip to
base of throat on right, otherwise wwp.
Neuro: non-focal
Pertinent Results:
CXR [**4-11**] at OSH: RML opacity, CCT: moderate sized spiculated
soft tissue mass in the RML.
.
CXR [**4-14**] portable: FINDINGS: AP single view of the chest
obtained with patient in sitting semi-upright position is
analyzed in direct comparison with a preceding similar study
obtained approximately 11 hours earlier during the same date.
Typical central pulmonary edema has developed during the
interval. The previously described right lower lung field
density, apparently the site of a large mass, appears unchanged.
Brief Hospital Course:
88 yo M with large RML mass with hemoptysis, HTN, COPD, afib
admitted with respiratory distress.
.
#. Respiratory Distress: chest film and ivf raise suspicion for
acute pulmonary edema. Without hypotension, hypoxia from ?PE
seems unlikely. Could be bleeding into other lung from the
right, but would expect hemoptysis as well. Cardiac ischemia is
also possible given history. Is doing much better clinically
after moderate diuresis from single dose of IV lasix, now on
nasal cannula. Patient is DNR/DNI.
- continue supplemental O2
- repeat lasix as needed with goal of weaning off O2
- TTE
- cycle enzymes
- check BNP
- monitor on tele
.
#. Hemoptysis/RML mass: Patient had two episodes of hemoptysis
at outside hospital and was awaiting bronchial artery
embolization s/p flex bronch today when this event occurred.
Plan is to continue with embolization in AM. If patient bleeds
acutely overnight, will contact IR stat for embolization.
- maintain 2 large g PIV's
- active T&S
- will hold ctx and azithro
.
#. Diarrhea - patient has been complaining of diarrhea, can send
out c diff, but low suspicion.
.
#. COPD- stable. Continue nebs.
.
#. Afib/Tachy-Brady Syndrome: patient has been tachycardic all
day, but regular, ekg shows an ectopic atrial tachycardia.
Monitor on tele, continue home beta blockade.
.
#. CAD: history of MI in [**2128**]'s s/p cabg and has atrial thrombus
and afib. Unable to give anticoagulation, given hemoptysis.
Continue beta blocker and statin.
.
#. HTN: well controlled currently, continue beta blocker.
.
#. Hypothyroidism: not on supplementation, will check TSH
.
#. FEN: heart healthy low sodium diet, NPO at midnight.
.
#. PPx: pneumoboots
.
#. Access: 2 PIV's 18g/20g
.
#. Code- DNR/DNI
.
Briefly, Mr. [**Known lastname 69574**] was transferred to the floor from the MICU
on [**4-16**] in good condition after having his bronchial artery
embolization on [**4-15**] performed by IR. On the floor, on HD 4, the
patient had some episodes of tachyarrhythmia. The patient was
discharged to home on [**4-17**] after his foley catheter was removed
and he was able to void. He was weaned off of supplemental
oxygen with ambulating saturations in the low 90s. He was also
ambulating well, without much assistance. The patient did
continue to have some tachycardia, however his lisinopril was
started on HD 4 at 2.5mg and his pindolol was increased to 15mg
qdaily.
.
The patient was sent home after he voided, tolerated a regular
meal and with a normal heart rate.
Medications on Admission:
Pindolol 5 mg daily
robitussin DM
ceftriaxone 1gm (day 2) q24h
azithromax 500mg qd (day 2)
zocor 40mg qd
folate 1mg qd
trazadone 100mg hs
MVI
omega 3
Humabid 600mg [**Hospital1 **]
albuterol/atrovent
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
6. Pindolol 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Afib/Aflutter s/p ablation [**9-30**] (no anticoagulation),
tachy/brady (requiring BB at times), head/neck CA s/p excision &
RXT [**2150**], hypothyroidism, dysphagia, HTN, HLD, MI [**2133**] s/p CABG
[**2134**], Glaucoma, COPD, Depression/aniety, h/o atrial thrombus
Discharge Condition:
Good
Discharge Instructions:
Please call Dr.[**Name (NI) 5070**] office at ([**Telephone/Fax (1) 17398**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-No bathing or swimming for 2-4 weeks
Followup Instructions:
Please see your Primary care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], this week to
discuss your heart rate and your medication alterations during
your stay in the hospital.
Please call Dr.[**Name (NI) 5070**] office at ([**Telephone/Fax (1) 17398**] to schedule a
follow up appointment in two weeks. You will see him in his
clinic on the [**Location (un) 453**] of the [**Hospital Ward Name 121**] building in the Chest
Disease Clinic.
You will need to get a chest xray 45 minutes before your
appointment with Dr. [**Last Name (STitle) **]. You will go to the [**Location (un) **] of the
Clinical Center on the [**Hospital Ward Name 517**] for this xray.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"276.6",
"V45.81",
"V12.59",
"414.00",
"518.4",
"401.9",
"V15.82",
"786.6",
"428.0",
"787.91",
"365.9",
"786.3",
"V10.89",
"496",
"162.4",
"427.81",
"412",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.29",
"88.42",
"33.27",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6482, 6488
|
3187, 5678
|
278, 316
|
6800, 6807
|
2639, 3164
|
7080, 7882
|
2088, 2106
|
5929, 6459
|
6509, 6779
|
5704, 5906
|
6831, 7057
|
2121, 2620
|
228, 240
|
344, 1662
|
1684, 1947
|
1963, 2072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,567
| 188,565
|
26654
|
Discharge summary
|
report
|
Admission Date: [**2149-1-18**] Discharge Date: [**2149-1-21**]
Date of Birth: [**2069-6-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrochlorothiazide
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
s/p fall, altered mental status
admitted to ICU for hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 79yo woman with h/o AFib on coumadin, HTN, and
borderline DM who presented with confusion after a fall and was
found to have hyponatremia to 112.
She is amnestic to the events, so history is per review of her
chart. Apparently, her husband heard a bang and found his wife
on the floor. She thinks she was unconscious, but this has not
been confirmed. She had bumped the back of her head. When she
came to, she was somewhat confused. Upon arrival of EMS, she
was hypertensive and had a glucose was 121 at the scene. She
was also noted to have an episode of urinary incontinence en
route to [**Hospital3 **]. All she can remember is feeling
unsteady on her way to the bathroom last night around 2:30 and
then waking up at [**Hospital3 **].
Upon presentation to [**Location (un) **], she was hypertensive to 175/35 and
bradycardic with HR 56. EKG was felt to be at baseline. Labs
revealed a Na of 112 and she had a cavitary lesion in her RML on
CXR. CT of head and C-spine were normal. She was started on
hypertonic saline, and a PPD was placed on the left forearm.
She was given ceftriaxone and levofloxacin and sent to [**Hospital1 18**] for
further care.
In the emergency department, initial VS were 97.6 121/95 56
16 97% on 2L. Na was 115. She received a dose of vancomycin
and was admitted to the MICU for hypertonic saline and further
work-up of her cavitary lesion on CXR.
Upon arrival to the ICU, she is comfortable and asking for
water.
REVIEW OF SYSTEMS:
(+)ve: Unsteady gait for the last week. +Hoarse voice last
week associated with fatigue and loss of appetite. She has a
dry cough and PND that started today. She has had decreased PO
intake over the last week and feels dry now. Feels a little
cloudy.
(-)ve: fever, chills, night sweats, chest pain, rhinorrhea,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
Paroxysmal AFib on coumadin
HTN
Hyperlipidemia
Borderline DM
Hypothyroidism
h/o TIA
Borderline positive exercise stress in [**2147**] (done for rhythm
eval)
Mitral valve prolapse with moderate MR
s/p spinal fusion in [**2098**]
s/p TAH at age 41 for fibroids
s/p BSO, unclear indication, prior to TAH
Social History:
She lives with her 87yo husband, who has health problems. She
provides [**4-10**] of his care and also helps bring her sister to
doctor's appointments. She ambulates independentely. She has
two sons, one of whom lives in [**State 4260**] and the other in [**Location (un) **].
She tried smoking as a teen but never smoked regularly. Rare
wine. No illicits.
She has no known TB contacts. She has never been in contact
with homeless people or prisoners. Only travel outside U.S. was
to [**Country 12649**] and [**Country 65722**] 7 years ago.
Family History:
Father died at 92 of heart failure
Mother died at 83 after a series of strokes
Physical Exam:
99.5 143/82 66 19 95% 2L 85.2kg
GENERAL: Pleasant, well appearing woman in NAD
HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI.
Mucous membranes mildly dry. OP clear. Neck Supple.
CARDIAC: Borderline bradycardia, regular rate. Normal S1, S2. No
murmurs, rubs or [**Last Name (un) 549**].
LUNGS: Good air movement b/l with coarse inspiratory crackles
at both lung bases, about [**2-10**] of the way up R>L.
ABDOMEN: Round abdomen. +BS, soft and not tender. No
distention. +Hepatomegaly, with palpable smooth, nontender
liver.
EXTREMITIES: No edema or calf pain, difficult to appreciate DPs,
feet are warm, pneumoboots in place
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3 but sometimes wanders and loses train of thought
during history. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. Normal coordination. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
STUDIES:
CXR [**1-18**]: Parenchymal opacity abutting the horizontal fissure
indicating
consolidation or atelectasis in the right upper lobe. Right
perihilar
lucency, which could represent a cavitary lesion.
.
CT Chest [**1-18**]: There is patchy consolidation in the right upper
lobe and superior segment of the right lower lobe. There is no
evidence of cavitary lesion. Bilateral pleural effusions are
small on the right and trace on the left. Mild linear
atelectasis is also noted in the left lung base. Small
mediastinal lymph nodes are noted, but none meeting CT criteria
for pathologic enlargement. There is no pneumothorax. There is
atherosclerotic soft plaque in the thoracic aorta. The heart and
great vessels are otherwise unremarkable without pericardial
effusion. There is no axillary lymphadenopathy. This exam is
not optimized for subdiaphragmatic diagnosis. Within this
limitation, atherosclerotic calcification is noted at the celiac
origin. There are nonspecific periportal lymph nodes not
meeting the CT criteria for pathologic enlargement. Peripelvic
cysts are noted in the left kidney.
Degenerative changes of the thoracolumbar spine are noted. There
is no
suspicious lytic or sclerotic osseous lesion. The apparent
abrupt cutoff of an upper lumbar vertebral body on the sagittal
images is due to
misregistration of two concatenated sequences of acquired
images.
IMPRESSION:
1. Patchy consolidation in the right upper lobe and superior
segment of the right lower lobe consistent with pneumonia. No
cavitary lesion identified.
2. Small right and trace left pleural effusion.
3. Atherosclerotic disease as above.
.
OSH Head CT [**1-18**]: No evidence of hemorrhage. +Mucosal
thickening in maxillary, ethmoid, and sphenoid sinuses. No mass
or midline shift.
.
OSH CT C-spine [**1-18**]: No fracture or subluxation. Soft tissues
within normal limits.
[**2149-1-18**] 05:50AM BLOOD WBC-10.7 RBC-3.95* Hgb-11.9* Hct-33.8*
MCV-86 MCH-30.2 MCHC-35.3* RDW-13.3 Plt Ct-381
[**2149-1-18**] 05:50AM BLOOD Neuts-70 Bands-9* Lymphs-4* Monos-15*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2149-1-18**] 05:50AM BLOOD PT-25.8* PTT-37.0* INR(PT)-2.5*
[**2149-1-18**] 05:50AM BLOOD Glucose-110* UreaN-8 Creat-0.6 Na-113*
K-3.6 Cl-78* HCO3-24 AnGap-15
[**2149-1-18**] 09:23AM BLOOD Cortsol-18.9
[**2149-1-18**] 06:00AM BLOOD Lactate-1.1 Na-115* K-3.4*
Brief Hospital Course:
79yo woman with h/o AFib on coumadin admitted after a fall in
the context of hyponatremia.
# Hyponatremia: Patient was admitted to the ICU with a sodium of
112. DDx includes SIADH in setting dehydration, or medication
side effect (on HCTZ). Patient appearred hypovolemic on initial
exam. Per renal consult, the finding of dilute urine made HCTZ
side effect more likely than SIADH, but it is most likely that
she had a mixed picture. Initial sodium deficit of 15mEq, so
hypertonic saline was started at 28cc/hr. Her sodium persisted
to be 115 despite being at 46cc/hr, so that rate was continued
with plan for correction of 8-12mEq over 24 hours. Soidum was
checked frequently. Renal was consulted and agreed with plan.
Na increased to 119 and hypertonic saline was stopped at 6pm on
[**1-18**]. Sodium was 126 on time morning of transfer out of ICU on
[**1-19**]. On the floor, the patient did well. She was initially
still orthostatic and received gentle IV fluids. Her orthostasis
resolved and renal recommended fluid restriction. This, in
combination with salt tablets, resulted in Na of 130 at the time
of discharge. She will need a repeat sodium as an outpt, this is
scheduled for later this week, with follow-up with pcp.
# Pneumonia: While initial x-ray suggested a cavitary lung
lesion, this was not apparent on CT chest. Felt that this was
most c/w infection though did not have fever, leukocytosis, or
productive cough at presentation. She has no known risk factors
for TB and denies systemic signs of TB. A PPD had been placed
on [**1-18**] and a sputum ctx was ordered, although the patient was
unable to produce a sample for analysis. Tamiflu was d/c'd
after a negative flu swab. She was started on Levofloxacin
[**1-18**] and flagyl was d/c'd on [**1-19**]. She will need repeat CXR
at 6 weeks post-abx in order to ensure resolution of
consolidation. She will complete a 7 day course of levofloxacin
on [**1-24**]
# s/p fall: Likely due to unsteady gait, which may have been
from developing hyponatremia over the last several days.
Seizure is also a possibility, especially since she had urinary
incontinence and confusion afterwards, which may have been
post-ictal. Although she has a h/o AFib and positive stress
test, there is no evidence at present for arrhythmia or ischemic
event. CT head and neck negative for acute process. CEs
negative and no events on tele. PT consulted. She was somewhat
unsteady with ambulation, requiring a walker to assist her. PT
felt that she would benefit from home PT and continued use of
walker for now.
# Confusion: Likely from hyponatremia, but may have been
post-ictal. Would also consider the effect of sleep
deprivation, multiple hospital transfers on this 79yo woman.
She has a h/o amnestic episode a couple of years ago, raising
question that she may have underlying abnormal brain. Pt. was
alert and oriented am of [**1-19**] and continued to be so during
rest of hospital stay.
# Hepatomegaly on exam: LFTs normal.
# Radiographic evidence of sinusitis:
No fevers or symptoms to suggest need for treatment, but
consider as source for infection if she develops fevers.
# Paroxysmal AFib: Restarted coumadin on [**1-19**]. Continued
Atenolol. Need to follow inr closely on levofloxacin given drug
interaction. coumadin was held x 1 day as an inpatient for this
reason.
# HTN: continued atenolol, held HCTZ, which should be added to
her d/c summary as an allergy. Also started amlodipine given
persistent HTN. Was on 10 mg daily at time of discharge
# Hyperlipidemia: continued statin
# Borderline DM: fingersticks and gentle SSI
# Hypothyroidism: continued levothyroxine. TSH checked and
within normal range at 1.6.
CODE STATUS: Confirmed full, but she is thinking about this
EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 65723**] or [**Telephone/Fax (1) 65724**]
Medications on Admission:
MEDICATIONS (Confirmed with Pharmacy [**Telephone/Fax (1) 65725**])
Coumadin 2.5mg QD unknown dose
Atenolol 50mg QHS
HCTZ 25mg daily (recently changed to 1/2 tablet)
Simvastatin 20mg QHS
Levothyroxine 50mcg daily
Xalatan eye drops
ALLERGIES: PCN -- rash
Discharge Medications:
1. Outpatient Lab Work
Needs chem-7 (Na, K, Cl, Hco3, BUN, creat, glucose) and INR on
Friday [**1-24**]; Results should be faxed to the patients PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**], at [**Telephone/Fax (1) 65726**] (tel # is [**Telephone/Fax (1) 22629**])
2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: last day [**2149-1-24**].
Disp:*9 Tablet(s)* Refills:*0*
3. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other
day: alternating with 2 tablets every other day.
4. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
INR on Wednesday [**1-22**]; Results should be faxed to the patients
PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**], at [**Telephone/Fax (1) 65726**] (tel # is [**Telephone/Fax (1) 22629**])
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
[**Last Name (un) 65727**] hyponatremia with secondary complication: mental status
change
Pneumonia
Hypertension
Atrial fibrillation
Hypercholesterinemia
Hypothyroidism
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent with walker
Discharge Instructions:
Your hydrochlorathiazide was stopped and is now considered an
allergy since it caused your sodium to be very low.
We have started you on 3 new medications:
sodium tablets: Please discuss with your primary care doctor
how long you have to be on this medication.
Amlodipine: for blood pressure
Levofloxacin: for pneumonia.
We have made an primary care doctor appointment for you.
At this time, we did not schedule follow-up with the
nephrologist (kidney doctor) as your sodium has continued to
improve. If this continues to be an issue as an outpatient, your
PCP may consider [**Name Initial (PRE) **] referral.
Followup Instructions:
Appointment #1
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65728**]
Specialty: Primary Care--works with Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**]
Date/ Time: Wednesday, [**1-29**] at 10:30am
Location: [**Street Address(2) 65729**] , [**Location (un) 11269**], MA
Phone number: [**Telephone/Fax (1) 33146**]
Special instructions for patient: Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**] is going to
be away for the next few weeks and its important you follow up
with a doctor after your inpatient stay here. Your follow up
appt was booked with Dr [**Last Name (STitle) 65728**] instead just to go over your
issues regarding your stay. Please call your doctors office if
[**Name5 (PTitle) **] have any questions.
|
[
"293.0",
"789.1",
"V58.61",
"401.9",
"427.31",
"486",
"V15.88",
"244.9",
"272.4",
"424.0",
"276.1",
"790.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12435, 12503
|
6872, 10759
|
358, 364
|
12717, 12717
|
4464, 4464
|
13512, 14318
|
3380, 3461
|
11065, 12412
|
12524, 12695
|
10785, 11042
|
12874, 13489
|
3476, 4445
|
1910, 2472
|
254, 320
|
392, 1891
|
4481, 6849
|
12731, 12850
|
2494, 2797
|
2813, 3364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
663
| 177,445
|
45898+58865+58866
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-6**]
Date of Birth: [**2086-5-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS:
The patient is a 57-year-old female with a history of
high-grade dysplasia within her esophagus consistent with
Barrett's esophagus. She has a long history of esophageal
problems, history of vigorous achalasia, and esophageal
spasms status post long myotomy which she did well for a
period of time. She then developed achalasia and Dr.
[**Last Name (STitle) **] performed a laparoscopic myotomy after which she
has done well.
At this time she has had some biopsies which showed
adenomatous mucosa without any evidence of dysplasia. Since
her myotomy, she has actually done quite well and has been
quite happy, and eating, and had no regurgitation, or other
problems. She had a recent biopsy of her distal esophagus
which showed high-grade dysplasia. Hence, the decision was
made to do a Ivor-[**Doctor Last Name **] esophagogastrectomy.
PAST MEDICAL HISTORY:
Good general health. She denies heart disease, lung disease,
or diabetes. She has had an open cholecystectomy, a
bilateral TAH/BSO, as well as a laparoscopic [**Doctor Last Name **] myotomy.
She is status post knee replacement one year ago and walks
with a cane.
MEDICATIONS:
1. Amitriptyline 300 mg po q day.
2. Prilosec 20 mg po q day.
3. Trazodone 100 mg po q day.
PHYSICAL EXAMINATION:
On physical exam by Dr. [**Last Name (STitle) **], she was a well-developed
overweight woman who walks with a cane. She had a normal
head and neck examination. Neck was supple without mass,
nodes, or thyromegaly. Chest was clear to auscultation and
percussion. She has well-healed scar on the left. Her
abdomen is soft without hernias or masses. Extremities were
well perfused.
HOSPITAL COURSE:
She is admitted on [**2143-12-27**] as mentioned previously, an
Ivor-[**Doctor Last Name **] esophagogastrectomy. Postoperatively, she went to
the Surgical Intensive Care Unit. She had some issues with
low blood pressure which was in the 80s/40s and requiring
very small amount of Levophed.
She was extubated on postoperative day one, and her vital
signs remained stable. She did well and her pain was
controlled with her epidural. She remained in the unit on
postoperative day two, however, was transferred to the floor
on postoperative day two in stable condition. However, over
the course of the evening of postoperative day two, she
developed some confusion and pulled out her chest tube and
her Foley. Decision was made to remove Dilaudid from her
epidural, and the patient did better. The chest tube was
completely removed given that the chest x-ray confirmed it
was improperly positioned and out of the pleural cavity.
Given that there was drainage into her pleural cavity and
noted that the chest tube was no longer in place to drain the
fluid, the patient did have some difficulty with her oxygen
saturation. However, she maintained her O2 sats in the mid
90s on 50% facemask.
On the evening of postoperative day three, the patient had
been doing well all day. On the evening of postoperative day
three, the patient became confused again despite the Dilaudid
no longer being in her epidural, and she pulled out her
nasogastric tube as well as her Foley once again. Decision
was made to put her in soft restraints, and to replace the
nasogastric tube under fluoroscopic guidance on the following
day, which was done on postoperative day number four.
On the evening of postoperative day number four, the patient
had shortness of breath and her O2 saturation decreased to
the low 90s and she is having labored breathing, and was
slightly tachycardic. A chest x-ray was done which showed a
right pleural effusion which is consistent with fluid left
from her surgery. Decision was made to try to
fluoroscopically place a chest tube as well as
fluoroscopically replace her nasogastric tube.
On the following day, postoperative day number five, her
vital signs continued to remain stable. It was felt that
there was no enough fluid in her lungs to warrant putting a
chest tube in, however, a nasogastric tube was placed
fluoroscopically and the patient did well. At this point the
patient continued to improve clinically. Her tube feeds were
increased. She was tolerating them well with aggressive
pulmonary toilet. Patient's O2 sats continued to improve.
Her nasogastric tube was kept in place and continued to drain
fluid. Assumptions was made that the patient had a partial
delay of gastric emptying.
On postoperative day number eight, the patient's nasogastric
tubes were clamped and residuals were minimal. Hence, on
postoperative day number nine, the decision was made to start
the patient on sips. Patient remained afebrile. Vital signs
remained stable, and the patient was discharged home on tube
feeds in stable condition.
DISCHARGE DIAGNOSIS:
Status post Ivor-[**Doctor Last Name **] esophagogastrectomy.
DISCHARGE MEDICATIONS:
1. Amitriptyline 300 mg po q day.
2. Trazodone 100 mg po q day.
3. Nexium 40 mg tid.
4. Levaquin 100 mg po q day x2 days.
5. Albuterol inhaler two puffs qid prn.
6. Tylenol elixir 650 mg po q six prn.
7. Isocal tube feeds 70 cc/hour through the J tube.
DISCHARGE INSTRUCTIONS:
The patient will follow up with Dr. [**Last Name (STitle) **]. The patient
will get VNA services for help with her J tube and wound
care.
CONDITION ON DISCHARGE:
Is discharged home in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 2649**]
MEDQUIST36
D: [**2144-1-6**] 13:31
T: [**2144-1-8**] 08:03
JOB#: [**Job Number 14042**]
y
Name: [**Known lastname **], [**Known firstname 153**] M Unit No: [**Numeric Identifier 15598**]
Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-8**]
Date of Birth: [**2086-5-12**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: The patient actually discharged
on [**2144-1-8**] in stable condition with VNA services, to be
getting tube feeds, promote with fiber at 105 cc an hour to
be cycled in the evenings.
Please delete Isocal from the record.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**], M.D. [**MD Number(1) 207**]
Dictated By:[**Last Name (NamePattern1) 5543**]
MEDQUIST36
D: [**2144-1-8**] 09:08
T: [**2144-1-8**] 09:11
JOB#: [**Job Number 15599**]
Name: [**Known lastname **], [**Known firstname 153**] M Unit No: [**Numeric Identifier 15598**]
Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-8**]
Date of Birth: [**2086-5-12**] Sex: F
Service:
The patient was not discharged home on Levaquin. She
finished her Levaquin in-hospital. Hence, was sent home on
no antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**], M.D. [**MD Number(1) 207**]
Dictated By:[**Last Name (NamePattern1) 5543**]
MEDQUIST36
D: [**2144-1-8**] 10:47
T: [**2144-1-8**] 11:03
JOB#: [**Job Number 15600**]
|
[
"511.9",
"458.2",
"E878.2",
"614.6",
"535.10",
"537.89",
"530.89",
"530.19",
"530.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.5",
"54.59",
"42.41",
"42.52",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
4986, 5240
|
4900, 4963
|
1817, 4879
|
5264, 5404
|
1415, 1800
|
155, 999
|
1021, 1393
|
5428, 7168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,751
| 148,613
|
8786
|
Discharge summary
|
report
|
Admission Date: [**2109-11-14**] Discharge Date: [**2109-11-16**]
Date of Birth: [**2082-8-18**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
pt eloped
History of Present Illness:
27 yo woman with h/o IBS and type I and type II diabetes
mellitus c/b previous episodes DKA and recurrent sinusitis. The
patient was admitted [**10-31**] for DKA in the setting of
sinusitis and was discharged home on amoxicillin and
ceftriaxone. She presents now with one week elevated blood
glucose while on iv antibiotics for sinusitis. She noted that
for the past 2 to 3 days her blood glucose was greater than 600.
She spoke to a doctor who told her to increase her home dose of
insulin (50 humalog and 50 humulin [**Hospital1 **]) by 20 units. She did
this without response and the scheduled an appointment with Dr.
[**Last Name (STitle) 30693**] in clinic who sent her to the ED today.She noted
vomitting once yesterday, shortness of breath x2-3 days but she
has cold induced asthma, and an intermittent fever on Mon at
101.9. She also noted chills, diarrhea x 2d, + polyuria.
In the ED, she was tachycardic with blood glucose 953, metabolic
acidosis with anion gap 20, and ketone positive urine.
Additioally, she was found to have a lactic acidosis with
lactate 5.0. She was started on insulin gtt and iv fluid
hydration, and after 3-4 hours glucose 519, anion gap 17. She
notes increased urinary frequency with nocturia.
Past Medical History:
Type I and II diabetes mellitus, c/b previous episodes of DKA
chronic sinusitis
Irritable bowel syndrome
Gerd
Depression
asthma
Social History:
works as preschool teacher, lives with her husband, no children
at this time,
occasional EtOH, denies tob, illicits
Family History:
type II DM in materanal grandmother, paternal grandmother, and
one uncle, also
CAD
Physical Exam:
T 99.2 HR 128 BP 153/79 RR 18 98%RA
Gen: well-appearing, no acute distress, morbidly obese
HEENT: PERRL, EOMI, anicteric, MMM, OP clear, + sinus
tenderness
Neck: supple, no LAD
CV: RRR, no mrg, nml s1s2, hs distant [**1-14**] body habitus
Resp: CTAB, no w/r/r
Abd: +BS, obese, soft, NT, ND
Ext: no edema, 2+ DP pulses B
Neuro: A&Ox3, CN II-XII intact, sensation intact to light touch
Skin: warm/dry/intact, no rashes
Pertinent Results:
[**2109-11-14**] 10:20PM GLUCOSE-435* LACTATE-1.9 NA+-135 K+-4.5
CL--97* TCO2-32*
[**2109-11-14**] 08:24PM TYPE-[**Last Name (un) **] PH-7.40
[**2109-11-14**] 08:24PM GLUCOSE-519* LACTATE-5.5* NA+-131* K+-4.1
CL--92* TCO2-28
[**2109-11-14**] 08:24PM freeCa-1.13
[**2109-11-14**] 06:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
[**2109-11-14**] 06:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
[**2109-11-14**] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2109-11-14**] 06:00PM URINE RBC->50 WBC-<1 BACTERIA-RARE YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2109-11-14**] 05:00PM PHOSPHATE-5.5*#
[**2109-11-14**] 05:00PM WBC-9.1 RBC-4.79 HGB-13.1 HCT-40.7 MCV-85
MCH-27.3 MCHC-32.2 RDW-13.4
[**2109-11-14**] 05:00PM NEUTS-77.1* LYMPHS-19.2 MONOS-3.2 EOS-0
BASOS-0.5
[**2109-11-14**] 05:00PM HYPOCHROM-2+
[**2109-11-14**] 05:00PM PLT COUNT-342
Brief Hospital Course:
27yo woman with history of Type I and II diabetes mellitus,
presented in DKA. The patient was stabilized and ready for
transfer to the floor for further care, but prior to transfer
she eloped. During her brief hospitalization, the following
problems were addressed:
1. DKA: The patient has a history of repeated episodes of DKA,
most recently [**2109-10-31**], when she was also diagnosed with an
acute sinusitis. The sinus infection persisted and was likely
the cause of this second episode of DKA. She was started on an
insulin gtt and treated with aggressive IVF hydration with
supplemental potassium. Once her glucose was in the normal
range and anion gap closed, she was switched to subcutaneous
insulin administration. [**Last Name (un) **] consulted and made
recommendations on insulin dosing. The patient was tolerating a
po diet and SQ insulin regimen prior to transfer.
2. Sinusitis: The patient had been treated with 2 weeks
amoxicillin and 4 days ceftriaxone at the time of presentation
without improvement. She continued to spike fevers and have
sinus tenderness. Head CT showed mucosal thickening of the
right maxillary sinus. ENT was consulted. She was to be
continued on antibiotics but regimen was not finalized prior to
her elopement.
3. Dispo: The patient eloped without further care, diabetes
education, medications, and follow-up arranged.
Medications on Admission:
Rocephin
Humalog
Humalin
Prevacid
Nortryptiline
Zofran
Sudafed
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
sinusitis
Discharge Condition:
pt eloped
Discharge Instructions:
pt eloped
Followup Instructions:
pt eloped
|
[
"276.3",
"530.81",
"787.01",
"250.11",
"461.0",
"478.1",
"564.1",
"276.2",
"276.5",
"311",
"473.9",
"250.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4887, 4893
|
3397, 4774
|
274, 286
|
4951, 4962
|
2399, 3374
|
5020, 5033
|
1850, 1934
|
4914, 4930
|
4800, 4864
|
4986, 4997
|
1949, 2380
|
231, 236
|
314, 1550
|
1572, 1701
|
1717, 1834
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,683
| 135,221
|
8366
|
Discharge summary
|
report
|
Admission Date: [**2114-12-14**] Discharge Date: [**2114-12-22**]
Date of Birth: [**2051-9-28**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Diovan / Zetia / Dicloxacillin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB, Le edema
Major Surgical or Invasive Procedure:
Attempted VT ablation, right heart cath
History of Present Illness:
Pt is a 63 yoM w/ CAD(s/p CABG), CHF(EF 10-15%), PAF, MR who
presented to OSH([**Hospital3 **] Hosp) on [**12-11**] with SOB. He has
been hospitalized multiple times over the last few months. Most
recently [**11-29**] when he presented to OSH with SOB, found to be in
CHF. Has had persistent pleural effusions, the right was tapped
at that time. He was then discharged home on CHF regimen. He
then returned on [**12-11**] qwith worsening SOB and increased LE
edema. Does not weigh himself at home daily so unclear of weight
gain. States he has been taking his meds as instructed. States
that he normally gets SOB in the morning after taking his
metoprolol. Denies any chest pain, palpitations. No orthopnea,
PND. Has also recently had mild cough and sputum prodution but
denies fevers, chills.
.
At [**Hospital3 **] he was found to be in heart failure as well as
having a RLL PNA. He was given lasix, vanco, zosyn. Also had
runs of VT into the 150's, so was temporarily started on
lidocaine gtt. His ICD did not fire during this episode. Was
also on heparin gtt but that was stopped as well. He was then
transferred to [**Hospital1 18**] for possible cath on monday and further
diuresis.
.
ROS: No HA, visual changes, hearnig problems. [**Name (NI) **] nausea,
vomiting, diarrhea, abd pain, melena, BRBPR. No hematuria,
dysuria. No numbness, weakness. Otherwise negative on detailed
review.
Past Medical History:
- Ischemic Dilated Cardiomyopathy EF 10-15%(s/p ICD)
- CAD s/p CABG '[**00**], last cath [**12-16**] w/ patent LIMA-LAD but
diffusely diseased SVG to PDA, s/p stenting of SVG.
- Valvular Disease- MR, TR
- PAF
- PVD- s/p bypass
- Pulm HTN
- HTN
- Hyperlipidemia
- ThoracicAA/AAA- 4-5cm
- Peripheral Neuropathy
- H/o TIA
- COPD
- GERD
- Anxiety and Schizoaffective d/o
- CKD- creatinine 1.5
Social History:
Prior 3 ppd smoker, still smokes occasionally. History of ETOH
abuse,now sober for >5yrs. He is divorced and lives with his
girlfriend.
Family History:
Father had premature CAD. Mother died of stroke at yound age. No
sudden cardiac death.
Physical Exam:
T 97.3 BP 123/65 HR 84 RR 18 O2sats 98% RA Wt 81.7kg
Gen: Frail, cachectic gentleman, speaking in complete sentences,
comfortable, NAD
HEENT: PERRL, EOMI, mmm, anicteric, conjuctiva pale
Neck: + JVD to the ears, no LAD
Lungs: Decreased breath sounds throughout, no obvious crackles
Heart: Distant heart sounds, +S3, 2/6 SEM at apex
Abd: Soft, mildly distended, + sacral edema, + BS, unable to
palpate liver
Ext: 3+ pitting edema in LE feet->thigh, 2+ femoral, no bruits.
Unable to palpate DP/PT due to edema
Neuro: A&O times 3, grossly intact
Pertinent Results:
Admit Labs
[**2114-12-14**] 09:39PM BLOOD WBC-5.7 RBC-3.63* Hgb-9.5* Hct-30.1*
MCV-83 MCH-26.2*# MCHC-31.6 RDW-17.7* Plt Ct-192
PT-18.5* PTT-29.8 INR(PT)-1.7*
Glucose-137* UreaN-19 Creat-1.5* Na-139 K-4.2 Cl-100 HCO3-29
AnGap-14
Calcium-9.1 Phos-3.5 Mg-2.1
TSH-3.1 Free T4-1.7
.
CXR- Bilateral pleural effusions, right greater than left. No
signs for overt pulmonary edema or definite consolidation.
Brief Hospital Course:
63 yo M w/ ischemic cardiomyopathy EF 10-15%, 3+ MR, CAD who
presents with CHF and RLL PNA.
.
# CHF- He responded well to IV lasix at 40 [**Hospital1 **]. He was
ultimately changed to lasix 80 PO BID. We also continued beta
blocker and spironolactone. He should restrict his fluid and
check his weight daily at home
# CAD- Known CAD s/p CABG w/ patent LIMA to LAD and SVG to PDA
from previous cath. No chest pain. He ruled out at outside
hospital. No ECG changes. We continued ASA, plavix, statin
.
# Rhythm/PAF- He had episodes of VT on interrogation. He had an
attempted VT ablation complicated by cardiac arrest, requiring
intubatetion and brief CCU stay. He recvered well from that and
was extubated 30 hours later. We ultimately decided on just
continuing amiodarone at higher dose. He has an ICD.
.
# Vavular Disease(MR/TR)- 3+ MR. Treated as heart failure as
above.
Medications on Admission:
Oxycontin 20mg tid, plavix 75mg qday, aspirin 81mg qday,
amiodarone 100mg qday, metoprolol 12.5mg qday, lasix 40mg qday,
advair, spiriva, coumadin 5mg qday, hydralazine 10mg tid,
albuterol, simvastatin 80mg qday
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*1 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*1 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Ischemic Dilated Cardiomyopathy EF 10-15%(s/p ICD)
- CAD s/p CABG '[**00**], last cath [**12-16**] w/ patent LIMA-LAD but
diffusely diseased SVG to PDA, s/p stenting of SVG.
- Valvular Disease- MR, TR
- PAF
- PVD- s/p bypass
- Pulm HTN
- HTN
- Hyperlipidemia
- ThoracicAA/AAA- 4-5cm
- Peripheral Neuropathy
- H/o TIA
- COPD
- GERD
- Anxiety and Schizoaffective d/o
- CKD- creatinine 1.5
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500
Have your blood drawn to check your INR on Monday as usual. You
will be contact[**Name (NI) **] by your regular provider if any change in your
coumadin dose is necessary.
Take all medications as prescribed. Do not take hydralazine
anymore.
Followup Instructions:
Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up
appointment within 1-2 weeks.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2115-1-21**] 9:20
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-3-11**]
12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2115-3-11**] 1:00
|
[
"295.70",
"414.8",
"496",
"416.8",
"425.4",
"V45.81",
"V45.02",
"428.43",
"427.5",
"486",
"428.0",
"403.90",
"397.0",
"424.0",
"530.81",
"427.31",
"443.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"89.64",
"99.60",
"99.62",
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
5476, 5527
|
3469, 4350
|
332, 374
|
5959, 5966
|
3044, 3446
|
6380, 6907
|
2377, 2465
|
4612, 5453
|
5549, 5938
|
4376, 4589
|
5990, 6357
|
2480, 3025
|
279, 294
|
402, 1795
|
1817, 2208
|
2224, 2361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,174
| 126,170
|
17567
|
Discharge summary
|
report
|
Admission Date: [**2139-7-17**] Discharge Date: [**2139-7-19**]
Date of Birth: [**2074-9-4**] Sex: M
Service: MEDICINE
Allergies:
Atenolol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Atrioventricular dissociation and dyspnea on exertion
Major Surgical or Invasive Procedure:
Right internal jugular line placement ([**2139-7-17**])
History of Present Illness:
Mr. [**Known lastname 17684**] is a 64 year-old man with CKD, HTN, DM, HLD and CAD
who presents with two weeks of dyspnea on exertion that acutely
worsened today. He describes that he felt unable to catch his
breath in studio apartment and did not improve on opening the
windows. He also reported new lightheadedness on standing and
then called EMS and took one nitroglycerin with no improvement
in his symptoms. EMS arrived and was concerned for ST elevation
inferiorly, and gave 4 baby aspirin. His systolic blood pressure
was noted to be in the 80s by EMS and he was brought to [**Hospital1 18**]
for further evaluation.
In the [**Hospital1 18**] ED, he continued to be bradycardic to the 50s and
hypotensive with SBP in 70s and received 3L of NS via a right IJ
central venous access with modest improvement in blood pressure
to SBP in 90s. No ischemic changes were noted on initial ED EKG.
D-dimer was negative. Cardiac enzymes were not elevated. He
received emperic vancomycin and zosyn, although there was no
findings suggestive of sepsis (fever, elevated WBC, cough, rash,
wounds, urinary symptoms, chills or diaphoresis.) Cardiology was
consulted in the ED and it was determined that the patient was
in AV dissociation. He subsequently converted to sinus rhythm
and his blood pressure further improved with SBP in the 110s.
The patient was then transfered to the CCU for further care. On
transfer the vital signs were 97.3 57 102/65 16 98% 1L NC
On initial evaluation in the CCU, his vital signs were 60
112/68 SpO2 100% on RA. He was comfortable and without complaint
at rest. He denied chest pain, pleuritic pain, fevers, cough,
abdominal pain, nausea, vomiting, diaphoresis, dysuria,
diarrhea, melena, hematochezia, leg pain, leg swelling, trauma,
rash and pruritis.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
CKD
2. CARDIAC HISTORY:
- CABG: CAD s/p CABG x 5 in [**11-18**]
LIMA-LAD, SVG-Diag, SVG-OM1, SVG-OM2, SVG-RCA
3. OTHER PAST MEDICAL HISTORY:
Hypkalemia
Depression (suicide attempt [**2123**])
S/p Penile implant [**2133**] (MRI compatible)
GERD
Sciatica
Social History:
No tobacco. EtOH described as occasional wine, used to drink
more but not currently, denies h/o alcohol abuse. History of
cocaine and marijuana use, last in [**2132**], denies IVDU. Sexually
active with same male partner for past 12 years.
Family History:
No family history of premature coronary artery disease or sudden
death. Father has history of DM, died at age 89. Mother has
history of skin ca.
Physical Exam:
GENERAL: NAD. Oriented x3. [**Year (4 digits) **], affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with right IJ in place.
CARDIAC: Regular rhythm, No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. 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.
Pertinent Results:
Admission Labs
[**2139-7-17**] 07:24PM WBC-5.8 RBC-4.02* HGB-12.4* HCT-33.8* MCV-84
MCH-30.9 MCHC-36.7* RDW-13.8
[**2139-7-17**] 07:24PM PLT COUNT-157
[**2139-7-17**] 07:24PM GLUCOSE-255* UREA N-48* CREAT-4.5* SODIUM-136
POTASSIUM-5.4* CHLORIDE-109* TOTAL CO2-18* ANION GAP-14
[**2139-7-17**] 07:24PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-2.1
[**2139-7-17**] 07:24PM CK-MB-3
[**2139-7-17**] 07:24PM cTropnT-<0.01
[**2139-7-17**] 07:24PM FIBRINOGE-310
[**2139-7-17**] 08:04PM D-DIMER-<150
[**2139-7-17**] 07:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-7-17**] 07:24PM LIPASE-20
[**2139-7-17**] 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-7-17**] 08:55PM URINE BLOOD-TR NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2139-7-17**] 10:19PM LACTATE-0.8
Discharge Labs
[**2139-7-19**] 01:30AM BLOOD WBC-4.8 RBC-3.76* Hgb-12.0* Hct-32.6*
MCV-87 MCH-31.8 MCHC-36.6* RDW-13.6 Plt Ct-139*
[**2139-7-19**] 01:30AM BLOOD Glucose-139* UreaN-38* Creat-3.6* Na-139
K-5.2* Cl-112* HCO3-18* AnGap-14
[**2139-7-19**] 01:30AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
Studies
CXR AP [**2139-7-17**]:
FINDINGS: There is no focal consolidation concerning for
pneumonia. There are no pleural effusions or pneumothorax. The
cardiomediastinal and hilar
contours are stable demonstrating changes from median sternotomy
and CABG. A fractured uppermost sternal wire is unchanged. The
heart is normal in size.
IMPRESSION: No evidence of pneumonia.
CXR AP [**2139-7-17**] (S/p line placement:
FINDINGS: There is a new right IJ line with the tip in the lower
SVC. There is no evidence of pneumothorax. Allowing for
suboptimal inspiration, lungs are clear and mediastinal contour
is stable.
TTE [**2139-7-18**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Foal distal
septal/apical septal hypokinesis is suggested with overall left
ventricular ejection fraction preserved (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 aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-11-20**], no
change. If indicated, a repeat study with echo contrast may
better [**Year (4 digits) 11197**] distal LV/apical function.
Brief Hospital Course:
Primary Reason for Hospitalization:
64M with numerous cardiac risk factors and known CAD presents
with complaint of dyspnea with bradycardia and hypotension and
is found to be in complete AV dissociation.
Active Issues:
# RHYTHM: Patient has no known prior cardiac arrhythmias.
Evaluation of EKG in ED revealed AV dissociation. Cardiac
enzymes were reassuring for no acute ischemia. Lyme titers were
pending at time of discharge. It was felt that block most
likely occured [**1-14**] addition of verapamil to current regimen
(although there was not evidence of CCB toxicity on admission.)
All AV nodal blocking agents were held, including verapamil and
metoprolol. He was evaluated by EP felt AV dissociation did not
represent true complete heart block. They attributed the
dissociation to his recently added verapamil and recommended
this medication be discontinued. On discharge EKG showed a
normal sinus rhythm with AV conduction delay.
# CAD: Patient has known CAD with CABG x5 in [**11-18**]. EKG and
cardiac enzymes showed no e/o active ischemia. He was continued
on ASA 81mg daily.
# Hypotension: Patient was hypotensive on presentation with
minimal response to IVF resuscitation. Blood pressure improved
significantly after conversion to NSR.
# HTN: Patient's anti-hypertensive regimen consisted of
metoprolol and lisinopril. Lisinopril was recently discontinued
for verapamil by patient PCP per patient. All anti-hypertensive
meds were intially held due to hypotension and AV block. On
discharge, he was advised to continue to hold lisinopril due to
elevated K+ (5.2) and to follow up with his PCP regarding BP
control and monitoring of electolytes.
Chronic Issues:
# HLD: He was continued on home simvastatin 40mg.
.
# DM: He was continued on home insulin regimen (lantus, ISS).
# GERD: He was continued on home omeprazole.
Transitional Issues:
-Patient maintained full code status throughout hospitalization
-Avoid AV nodal blocking agents
-Pt advised to hold lisinopril given elevated K+ (5.2) and f/u
with PCP re BP control
Medications on Admission:
1. Aspirin 81 mg daily
2. Simvastatin 40 mg daily
3. Multivitamin daily
4. Folic Acid 1 mg daily
5. Metoprolol Succinate 25 mg daily
6. Omeprazole 20 mg Capsule daily
7. Metoclopramide 5 mg Tablet QIDACHS
8. Insulin Glargine 30 units QHS
9. Humalog sliding scale
10.Lisinopril 10 mg daily (recently discontinued for verapmil)
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
(40) Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. AV dissociation and junctional tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for shortness of breath which
was thought to be abnormal heart rhythm caused by a medication
called VERAPAMIL that you started recently. Your abnormal heart
rhythm resolved over the course of your hospital stay.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICATION
REGIMEN
STOP VERAPAMIL
STOP METOPROLOL SUCCINATE 25 mg by mouth daily to prevent
reoccurence of abnormal heart rhythm
CONTINUE TO HOLD LISINOPRIL until you see your primary care
physician as you have high potassium level which is likely a
consequence of your chronic kidney disease and would benefit
also from bicarbonate repletion
Followup Instructions:
Please schedule an appointment with your primary care physician
[**Name Initial (PRE) 176**] 7 days
.
Please schedule an appointment with cardiac electrophysiology
([**Telephone/Fax (1) 62**]) within 7 days
|
[
"530.81",
"250.00",
"426.89",
"272.4",
"V45.81",
"585.9",
"E942.4",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
10129, 10135
|
7085, 7291
|
321, 379
|
10243, 10243
|
4091, 7062
|
11056, 11266
|
3311, 3458
|
9513, 10106
|
10156, 10222
|
9163, 9490
|
10394, 11033
|
3473, 4072
|
2807, 2894
|
8954, 9137
|
228, 283
|
7306, 8756
|
407, 2698
|
10258, 10370
|
2925, 3038
|
8772, 8933
|
2720, 2787
|
3054, 3295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,606
| 134,057
|
2567
|
Discharge summary
|
report
|
Admission Date: [**2132-4-7**] Discharge Date: [**2132-4-12**]
Date of Birth: [**2062-10-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Codeine / Iodine / Niaspan / Avapro / Prednisone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 5(LIMA-LAD,SVG-OM1,Y toSVG
-DG,SVG-OM2,SVG-PLV) [**2132-4-7**]
History of Present Illness:
This 69 year old white male developed exertional left arm pain
and susternal pressure in [**Month (only) 956**] walking in an airport. This
recurred over several days and he eventually sought medical
care. A cardiac catheterization was performed in mid [**Month (only) **]
which revealed diffuse triple vessel disease. He was referred
for surgical revascularization.
Past Medical History:
hypertension
Hyperlipidemia
Chronic Kidney disease
gastroesophageal reflux
Gouty arthritis
Glaucoma
s/p shoulder surgery
noninsulin dependent diabetes mellitus
Social History:
Lives with his wife.
[**Name (NI) 1403**] as a lawyer.
Smoked [**2-2**] ppd for 10-15 years, quit in [**2091**].
Drinks 1-2 drinks weekly.
He does not use illicit drugs.
Family History:
Father died at 89, h/o CAD, CVAs, HTN. Mother died at 91 due to
CHF also had h/o CAD, Rectal CA, Melanoma and DMT2. Sister died
of breast CA at 59. Maternal Uncle died of MI in 50s
Physical Exam:
Admission:
Pulse: 56 Resp: 18 O2 sat: 97%
B/P Right: 132/79 Left: 137/64
Height: 69 inch Weight: 216 #
General: NAD
Skin: Dry [x] intact [x] healing surgical scar left shoulder
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: cath site Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**4-11**] INR 1.2- 5mg couamdin
[**4-12**] INR 1.5- 5mg couamdin
[**2132-4-11**] 05:30AM BLOOD WBC-12.8* RBC-3.13* Hgb-9.2* Hct-26.4*
MCV-84 MCH-29.6 MCHC-35.1* RDW-14.5 Plt Ct-200
[**2132-4-9**] 03:19PM BLOOD WBC-19.0* RBC-3.39* Hgb-10.3* Hct-29.6*
MCV-87 MCH-30.3 MCHC-34.7 RDW-14.3 Plt Ct-190
[**2132-4-9**] 03:19PM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1
[**2132-4-11**] 05:30AM BLOOD PT-12.3 PTT-25.2 INR(PT)-1.0
[**2132-4-11**] 05:30AM BLOOD UreaN-36* Creat-1.9* Na-135 K-3.8 Cl-99
HCO3-25
[**2132-4-10**] 05:30AM BLOOD UreaN-33* Creat-1.9* Na-139 K-4.0 Cl-102
HCO3-27 AnGap-14
Echo- intra-op
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2132-4-7**] at 1205pm.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. 2+ mitral
regurgitation persists. Aorta is intact post decannulation.
Brief Hospital Course:
He was admitted for same day surgery. Revascularization was
undertaken on [**4-7**] (see operative note for details). He weaned
from bypass on Propofol and Neo Synephrine infusions. He
transferred to the ICU in stable condition where he awoke
intact, weaned from the ventilator and pressors easily. He was
transferred to the floor.
He developed rapid atrial fibrillation to 190 which was well
tolerated on POD 2 and required a Diltiazem infusion to control
the ventricular response. He coverted to sinus rhythm after
several hours and after beta blockade was added. The Diltiazem
infusion was discontinued. Chest tubes were also removed with a
great improvement in his level of discomfort. He continued to
be diuresed towards his preoperative weight.
The patient was evaluated by the physical therapy service for
assistance with 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. Mr.
[**Known lastname 12982**] was claered for discharge to home by Dr. [**Last Name (STitle) **] on
POD#5 in good condition with appropriate follow up instructions.
Medications on Admission:
Atenolol 25 mg daily
Amlodipine 10 mg daily
Omeprazole 20 mg daily
Hydralazine 25 mg [**Hospital1 **]
Simvastatin 40 mg daily
Folic Acid 1 mg daily
Vitamin D 50 MU cap once every other week
Actonel 35 mg q Wednesday
Caltrate 600 D [**Hospital1 **]
Ecotrin 81 mg daily
Centrum Silver daily
Fish Oil 1200 mg caps TID
Timolol 5 mL eye drops daily
Lumagan 7.5 mL eye drops daily
ASterpro nasal spray prn
Epi pen (never used)
Benedryl prn
Zyrtec 30 mg daily
Discharge Medications:
1. Risedronate 35 mg Tablet Sig: One (1) Tablet PO wednesdays
().
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every [**5-6**]
hours as needed for pain.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 4 weeks.
Disp:*30 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
QID (4 times a day) as needed for stuffiness.
10. Outpatient Lab Work
serial PT/INR- first INR check on [**2132-4-14**]
dx: atrial fibrillation
goal INR [**3-5**]
fax results to -[**Telephone/Fax (1) 445**] Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: take
5mg [**2132-4-13**] then dose will change daily for goal INR [**3-5**], Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] to manage.
Disp:*30 Tablet(s)* Refills:*2*
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
s/p coronary artery bypass grafts
coronary artery disease
chronic kidney disease
hypertension
hyperlipidemia
gouty arthritis
glaucoma
geastroesophageal reflux
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid prn
Discharge Instructions:
Discharge Instructions: Please shower daily including washing
incisions gently with mild soap, no baths or swimming, and look
at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon: Dr [**Last Name (STitle) **] on [**5-15**] at 1:15pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8682**] ([**Telephone/Fax (1) 133**]in [**2-2**] weeks
Please fax INR results to Dr. [**Last Name (STitle) 8682**] for coumadin dosing-
[**Telephone/Fax (1) 445**] (conf. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12983**] [**4-11**])
Cardiologist: Dr. [**Last Name (STitle) **] in [**2-2**] weeks
Completed by:[**2132-4-12**]
|
[
"414.01",
"427.31",
"250.00",
"585.9",
"413.9",
"403.90",
"274.00",
"365.9",
"530.81",
"V45.89",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7529, 7600
|
3837, 5002
|
351, 448
|
7803, 7900
|
2164, 3814
|
8465, 9019
|
1234, 1416
|
5506, 7506
|
7621, 7782
|
5028, 5483
|
7948, 8442
|
1431, 2145
|
288, 313
|
476, 847
|
869, 1030
|
1046, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,484
| 162,377
|
48503
|
Discharge summary
|
report
|
Admission Date: [**2132-7-14**] Discharge Date: [**2132-7-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
admitted from OSH s/p fall with subdural hematoma for management
and evaluation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 y/o M with PMH of afib, DMII, hypercholesterolemia
transferered to [**Hospital1 18**] on [**7-14**] for evaluation of subdural
hematoma. The patient initially presented to [**Hospital3 **] ED after
having a syncopal episode on the morning of [**2132-7-14**]. Pt states
that he went to his bathroom at 8 am to take a bath and was
standing, turning on the fawcet and the next thing he remembers
is finding himself lying on his back in the tub. [**Hospital3 **]
notes state that patient felt lightheaded prior to fall but
patient later denied this. He denied any HA, CP or palpitations,
shortness of breath, diaphoresis, dizziness/LH prior to fall.
His daughter then called him at 9 am to help take him to an
opthalmology appt, but pt did not answer phone. Ten minutes
later daughter called him again and his father sounded "breathy,
winded" and that he did not need to go to the doctor's office
today and then his voice trailed off. The daughter then arrived
at his apartment and found his father asleep in bed but with
lacerations on both of his feet, specifically left toes. In
bathroom, shower curtain rod was down on floor. Patient did not
appear confused but seemed "out of it", no dysarthria, answered
questions appropriately, no numbness/weakness in extremities,
unclear if stool incontinence (soiled underwear in bathroom but
often happens at baseline). Per daughters, patient has not taken
his meds in 3 days, unclear if change in PO intake.
ROS on admission: +HA frontal and temporal "behind eyes", no
dizziness/LH, +neck pain secondary to collar, no melena, no
BRBPR, no vision changes, no dysarthria, no n/v/abd pain, no
sob. Daughters state he has had falls in past after feeling
dizziness/LH prior.
At [**Hospital3 **] ED, found to have small L subdural hematoma with
no midline shift or mass effect. Was transferred to [**Hospital1 18**] for
further neurosurgical evaluation. Here in our ED, neuro exam
unremarkable. CT head without contrast confirmed right frontal
subdural hematoma as well as low attenuation regions in L
frontal and L anterior temporal lobes c/w infarctions and age
indeterminant. CT C-spine with no fracture. No urgent
neurosurgical intervention deemed necessary but admitted to ICU
for q1hr neuro checks. Also given 10 mg Vitamin K and 2 units
FFP for INR 2.0.
Past Medical History:
PMH (full records not available):
1) Atrial fibrillation on coumadin dxed [**2119**]
2) DMII
3) hypercholesterolemia
4) CAD
5) CHF with EF 30% by echo [**2128**]
6) Chronic renal insufficiency with baseline creat 2.0
7) h/o Zoster
8) Thrombocytopenia with plt count as low as 125 in [**2128**]
Social History:
Lives home alone. Wife passed away from cancer. Denies tob and
EtOH. Independent with all ADLs and IADLs. Children in town.
Family History:
NC
Physical Exam:
T 96.6 BP 140/44 P 67 R 14 Sat 93-95% RA
Gen: A+O x 3, lying comfortably, NAD, speech clear, answering
?'s appropriately
HEENT: R surgical pupil and left pupil 1mm minimally reactive,
EOMI, OP clear with MM slightly dry, OP clear
CV: irreglarly irregular, no m/r/g
Pulm: CTA anteriorly
Abd: + BS, soft, NT, ND
Ext: no LE edema to knees, +2 DP pulses bilaterally; R LE with
purple discoloration over lateral aspect
Neuro: CN 2-12 intact, strength 4+/5 equal and symmetric
bilaterally, DTRs 2+ throughout flexors and extensors, neg
Babinski, no pronator drift
Skin: Abrasions on LEs. Left foot with dressing c/d/i.
Pertinent Results:
Labs on admission:
[**2132-7-14**] 05:45PM BLOOD WBC-7.7 RBC-3.03* Hgb-10.4* Hct-30.0*
MCV-99* MCH-34.1* MCHC-34.6 RDW-14.1 Plt Ct-91*
[**2132-7-14**] 05:45PM BLOOD PT-17.3* PTT-27.5 INR(PT)-2.0
[**2132-7-14**] 05:45PM BLOOD Glucose-132* UreaN-43* Creat-2.2* Na-140
K-4.4 Cl-106 HCO3-22 AnGap-16
[**2132-7-16**] 05:02AM BLOOD ALT-10 AST-19 AlkPhos-65 TotBili-2.6*
[**2132-7-14**] 05:45PM BLOOD Calcium-10.1 Phos-1.6* Mg-2.3
Other pertinent labs:
[**2132-7-14**] 05:45PM BLOOD Digoxin-0.5*
[**2132-7-17**] 05:11AM BLOOD PEP-NO SPECIFI
[**2132-7-18**] 09:30AM BLOOD Cortsol-16.9
[**2132-7-18**] 10:05AM BLOOD Cortsol-29.9*
[**2132-7-18**] 10:25AM BLOOD Cortsol-31.5*
[**2132-7-17**] 05:11AM BLOOD Free T4-1.2
[**2132-7-19**] 06:00AM BLOOD PTH-74*
[**2132-7-17**] 05:11AM BLOOD TSH-2.6
[**2132-7-14**] 05:45PM BLOOD calTIBC-302 VitB12-335 Folate-12.2
Ferritn-664* TRF-232
[**2132-7-17**] 05:11AM BLOOD Hapto-235*
[**2132-7-14**] 05:45PM BLOOD Iron-55
[**2132-7-14**] 05:45PM BLOOD cTropnT-0.02*
[**2132-7-15**] 04:38AM BLOOD CK-MB-3 cTropnT-0.02*
[**2132-7-17**] 05:11AM BLOOD GGT-8
[**2132-7-17**] 05:11AM BLOOD Ret Aut-2.1
Labs on discharge:
[**2132-7-21**] 04:55AM BLOOD WBC-7.6 RBC-3.03* Hgb-10.1* Hct-30.8*
MCV-101* MCH-33.2* MCHC-32.7 RDW-15.4 Plt Ct-99*
[**2132-7-21**] 04:55AM BLOOD Glucose-121* UreaN-36* Creat-1.7* Na-137
K-4.4 Cl-107 HCO3-22 AnGap-12
[**2132-7-21**] 04:55AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
[**2132-7-14**] 10:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2132-7-14**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2132-7-14**] 10:30PM URINE Hours-RANDOM UreaN-621 Creat-70 Na-50
TotProt-11 Prot/Cr-0.2
[**2132-7-14**] 10:30PM URINE U-PEP-ONLY ALBUM Osmolal-415
CXR [**2132-7-14**]:
1. Cardiomegaly. No overt CHF or pulmonary consolidations.
2. Coarse bilateral interstitial markings, which may be chronic
in nature.
Comparison with prior outside radiographs is recommended, if
available.
CT C-spine [**2132-7-14**]: Degenerative disease with no evidence of
acute fracture. Straightening of the normal cervical lordosis.
Emphysematous disease of the lung apices.
CT head without contrast [**7-14**]: isodense, extraaxial material c/w
right frontal subdural hematoma; low attenuation regions in L
frontal and L ant temporal lobes c/w infarctions, age
indeterminate
CT head without contrast [**7-15**]: No significant interval change
from previous day's study.
Echo [**2132-7-15**]: The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function appears
preserved (ejection fraction ?55%) but views are suboptimal. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild to moderate ([**2-3**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
EKG: slow afib, rate 50 bpm, TWI III, V1 and V2; flat AVF, V4
and V6, no baseline for comparison
Brief Hospital Course:
1. Subdural hematoma. 89 y/o M with h/o afib, CAD,
hypercholesterolemia who presented s/p syncopal fall with new
subdural hematoma. SDH was felt to be likely a consequence of
the syncopal fall. Patient was initially admitted to ICU for
close neurological monitoring and remained neurologically
stable. C-spine was cleared. Head CT was repeated in 24 hours to
assess for interval changes and SDH appearance was stable.
Neurosurgery recommended to hold anticoagulation for 4 weeks and
to keep platelets >100 for 7 days after the event. The patient
may continue Aspirin. The follow up appointment with
neurosurgery was arranged for the patient. He will follow up
with neurosurgery in 3 months and will have CT head repeated
prior to the appointment.
2. Syncope. Etiology of syncopal fall was not entirely clear. As
part of work up for syncope, the patient was ruled out for MI
with two sets of enzymes. Carotid US was done and showed <40%
bilateral carotid artery stenosis. Echo was unrevealing. CT head
was negative for acute pathology that would explain syncopal
event. The etiology of his syncope was felt possibly to be due
to orthostasis. The patient was orthostatic initially on the
floor. Cosyntropin stim test was done to r/o adrenal
insufficiency was normal. Tamsulosin was discontinued to
eliminate this as a cause of the patient's syncopal fall. The
patient was transfused one units of pRBCs and platelets and his
orthostasis has resolved. The possibility that he was dehydrated
from Lasix and/or poor po intake prior to admission was
entertained to explain his orthostasis. Electrophysiology were
consulted with the question of whether patient's slow a fib
could have caused his syncope (patient with a fib with rate down
to high 30's on telemetry at night) and whether he would be a
candidate for a pacemaker. They felt that this was unlikely and
that no further EP investigation was warranted.
3. Renal failure. Patient had mild elevation of creatinine on
admission from his baseline Cr of around 2.0. Lasix was held and
his Cr remained stable and was 1.7 at the time of discharge.
4. Atrial fibrillation. The patient has been in slow afib with
HR down to high 30's when asleep. He was asymptomatic. Coumadin
was held given new SDH. Digoxin level was checked on admission
and was 0.5. Digoxin was held given his slow rate. EP did not
think that his syncope was from cardiac cause and felt that a
pacemaker was not necessary. They recommended Holter as an
outpatient. Given patient's slow heart rate, his digoxin should
not be restarted. If the patient starts having rapid atrial
fibrillation, EP recommended metoprolol for rate control.
5. Thrombocytopenia. From [**Hospital3 **] and [**Hospital1 **] records appears
to have baseline in low 100s. No obvious offensive medications.
No splenomegaly on exam. Consider BM bx as outpatient given
anemia and thrombocytopenia.
6. Hypercholesterolemia. The patient was continued on Statin.
7. HTN. The patient was not on any antihypertensive [**Doctor Last Name 360**]. His
SBP were mostly within the normal range. If he needs to be
started on a medication for BP control, would favor starting a
beta-blocker as heart rate tolerates.
8. H/o CVA, remote. This was an incidental finding on CT head.
The patient was continued on aspirin 81 mg.
9. CHF. The patient has a h/o systolic dysfunction and EF around
30%. Echocardiogram was repeated here as part of work up for
syncope and showed EF 55% but mild LVH. Diuretics have been held
during this hospital admission as the patent appeared euvolemic
and because of slight increase in creatinine from baseline. The
patient will need to be closely monitored for signs of
decompensated CHF with daily weight. He needs to be on low Na
diet. Lasix can be given on as needed basis.
10. Indirect bilirubinemia, mild. Work up showed no signs of
intravascular hemolysis. This felt likely to be secondary to
hematomas after the fall.
11. Anemia, macrocytic. Baseline HCT 36-38 from [**Hospital1 **] records.
Patient had slow decreased in HCT of about 3 points from
admission and remained hemodynamically stable. There was no
evidence of hemolysis. Stool guaiacs were negative. Fe studies
were not consistent with iron deficiency anemia. B12 level was
low normal and the patient was started on B12 supplements.
Reticulocyte index was low 2.1% (not adjusted). The patient is
discharged on Epogen given his renal insufficiency. The patient
received a total of 2 units of pRBCs today for orthostatic
hypotension. UPEP and SPEP were checked and were normal.
12. BPH. Flomax was stopped to eliminate this as a cause of
orthostatis.
13. DM. Glycemic control was initially maintained with Insulin
sliding scale. The patient was then restarted on Avandia. His
finger sticks were mostly in low 100's.
14. Secondary Hyperparathyroidism. Serum calcium was nornal but
the patient did have an elevated Alk Phos and high PTH. His
secondary hyperparathyroidism is possibly due to chronic renal
insufficiency. The patient was started on Vitamin D supplements.
Medications on Admission:
1. Lasix 80 mg daily
2. Coumadin 4.5 mg daily
3. Digitek 0.125 mg daily
4. Namenda 10 mg daily
5. Avandia 4 mg daily
6. Mobic 15 mg daily
7. Aricept 10 mg daily
8. Lipitor 20 mg daily
9. Aldactone 25 mg daily
10. Flomax SA 0.4 mg daily
Discharge Medications:
1. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qd ().
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
10. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection
once a week.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Primary diagnoses:
1. Subdural hematoma
2. Syncopal fall
Seondary diagnoses:
1. Anemia, macrocytic
2. Atrial fibrillation
3. Chronic renal insufficincy
4. Benign prostatic hypertrophy
5. Thrombocytopenia
6. Hypercholesterolemia
7. Cerebrovascular accidents, seen on CT head
Discharge Condition:
Vital signs and neuro exam stable.
Discharge Instructions:
Please take all medications as prescribed. The patient should
not be on Coumadin for 4 weeks until [**2132-8-13**]. Then risk and
benefits of continuing anticoagulation will need to be discussed
with the patient's primary care physician.
Please follow up as listed below.
Please return to hospital if the patient having any new
neurological symptoms or any other concerning symtpoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 60585**] [**Telephone/Fax (1) 60586**] within 2 weeks
after leaving the hospital. Discuss risks and beneftis of
restarting Coumadin with your doctor. DIscuss if you need Holter
monitor with your primary care doctor.
You will need to have a repeat CT head and a follow up with
neurosurgery on the same date. Your CT scheduled for [**10-17**] at 10 am on the [**Hospital Ward Name 517**], [**Location (un) 470**]. Appointment with
Dr. [**Last Name (STitle) 9904**] [**2132-10-17**] at 11 am. Please call ([**Telephone/Fax (1) 102098**] with questions or if you need to reschedule.
Completed by:[**2132-7-22**]
|
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icd9cm
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[
[
[]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,581
| 123,458
|
3007
|
Discharge summary
|
report
|
Admission Date: [**2182-7-11**] Discharge Date: [**2182-8-12**]
Date of Birth: [**2109-6-2**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Hypoglycemia, seizure
Major Surgical or Invasive Procedure:
Colonoscopy, EGD
History of Present Illness:
73M w/ insulin-dependent type II DM presents with seizures and
hypoglycemia. He has been complaining recently of increasing
left leg pain and swelling. On [**7-10**] he went to the ED with these
symptoms, had a negative LENI, and was discharged home. He was
not eating well because of the pain, but continued to take his
usual insulin dose. Last night he fell at home, and was
complaining of left hip pain afterwards. Yesterday afternoon, he
was last seen sleeping in a chair by his son in the early
afternoon.
.
At 6pm his wife found him shaking. He had urinary incontinence.
She called EMS, and he was found to have a blood sugar of 17.
D50 was given and he had a slow recovery. In the ED, his initial
vitals were T 97.8 HR 68 BP 160/80 RR 18 RR 100%. He was at his
baseline MS [**First Name (Titles) **] [**Last Name (Titles) **]. CT head was negative. UA, CXR and left hip
and hand films were all negative. He was repeatedly
hypoglycemic, getting 3 doses of D50, and was eventually started
on a D10 drip.
.
On the floor, he was found to be seizing by the overnight
resident. He had left eye deviation, rhythmic arm movements, but
was still verbal and responsive. FS 129. Neurology was paged,
and the patient got 3x1mg IV ativan, followed by a loading dose
of 1gram of IV fosphenytoin. The patient was minimally
responsive on transfer to the ICU.
Past Medical History:
1. Diabetes, insulin dependent
2. Hypertension.
3. Hyperlipidemia.
4. History of mild peripheral vascular disease.
5. History of coronary artery disease status post rotational
atherectomy and PTCA of the LAD/D2 bifurcation in [**Month (only) **]
[**2175**].
6. Morbid obesity.
7. History of diastolic dysfunction
Social History:
Lives with his wife and daughter
- [**Name (NI) 1139**]: remote history
- Alcohol: denies
- Illicits: denies
Family History:
not known
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.2 P:67 R: 16 SBP: 140's SaO2:97%
General: patient somnolent and minimally responsive
HEENT: Sclera anicteric, pupils equal and pinpoint, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing. L>R 1+ edema.
Neurologic:
-Was in bed with head turned to left, eyes turned to left. When
asked what his name was he was able to give it to me, when asked
where he was at he was un-unintelligible, when I gave him
options
of school, home or hospital he said hospital. All throughout
this
time he was having tonic flexion of the RUE at the biceps and
wrist with his left hand extended tonically and associated with
this had flexion contraction off all four extremities at a 2 hz
frequency. He would occasionally life his right arm above his
head and occasionally bring his left hand to his face. His
pupils
were equal and reactive with conjugate gaze. They were deviated
to the left upper field and there was noted to be nystagmoid
movements of the eyes with no clear fast/slow phase. His
extremities were rigid right more then left. His reflexes were
brisk at the lower extremeties at the patella's. A family member
was in the room and he was unable to identify her during this
event.
DISCHARGE PHYSICAL EXAM:
(per attending note)
On exam, afebrile, up to 130-160 systolic, fsg 150-190
Awake, alert appropriate. He awakens, tells me he is fine,
without pain or complaints. Tells me it is [**2191-5-20**], does not
know he is in the hospital, knows his name, knows the name of
his
daughters. follows simple commands. no left/right confusion.
speech mildly dysarthric but otherwise fluent. PEERL, EOMI,
symmetric, audition intact, mild dysarthria, tongue protrudes to
midline. lifts arms and legs. sensation intact to light touch.
Pertinent Results:
Admission:
[**2182-7-11**] 07:45PM GLUCOSE-30* UREA N-17 CREAT-0.9 SODIUM-143
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2182-7-11**] 07:45PM ALT(SGPT)-32 AST(SGOT)-75* LD(LDH)-433* ALK
PHOS-73 TOT BILI-1.2
[**2182-7-11**] 07:45PM WBC-9.9 RBC-4.52* HGB-9.8* HCT-29.9* MCV-66*
MCH-21.7* MCHC-32.8 RDW-17.0*
[**2182-7-11**] 07:45PM NEUTS-85.1* LYMPHS-8.9* MONOS-4.6 EOS-0.9
BASOS-0.5
[**2182-7-11**] 07:45PM PT-12.6 PTT-28.1 INR(PT)-1.1
[**2182-7-11**] 08:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2182-7-11**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2182-7-12**] 12:00AM GLUCOSE-106* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
Micro:
Urine Cx on [**2182-7-13**]: No growth.
Blood Cx on [**2182-7-11**] pending.
CT Head w/o contrast [**2182-7-11**]:
IMPRESSION:
1. No evidence of acute intracranial process.
2. Small vessel ischemic disease.
3. Prominent sulci and ventricles, likely age-related
involutional changes.
Hand X-ray [**2182-7-11**]:
IMPRESSION: No radiographic evidence of acute traumatic injury
to the hand. Grossly, the wrist is intact as well.
MRI Head [**2182-7-13**]:
IMPRESSION: No acute infarct. Brain atrophy, small vessel
disease and
chronic right posterior frontal infarct.
MRA Head/neck [**2182-7-27**]:
Diffuse narrowing of the distal branches of the middle cerebral
arteries and posterior cerebral arteries, likely indicating
atherosclerotic disease, there is bilateral narrowing of the
carotid siphons, more significant on the right, also consistent
with atherosclerotic disease. Atherosclerotic disease identified
at the origin of the internal carotid arteries as described
above, correlation with carotid Doppler ultrasound is
recommended if clinically warranted.
Carotid U/S [**2182-7-30**]:
Significant plaque in the distal common and internal carotid
arteries with minimal plaque in the external carotid arteries.
Findings raise the possibility of an approximate 40-59% stenosis
in the distal common carotid arteries. There is probable
moderately severe stenosis in the left external carotid artery.
Flow in the vertebral arteries is prograde
EGD/Colonoscopy on [**2182-8-8**]
EGD reveals moderate-severe gastritis/esophagitis without
bleeding ulcers. On colonoscopy, we observed a single sessile
10mm polyp of benign appearance was found in sigmoid colon, and
this was not removed [**2-20**] patient being on plavix. Additionally,
a few diverticula with small openings were seen in the ascending
colon of mild severity. These were treated locally.
Brief Hospital Course:
73yo male with insulin dependent diabetes here with hypoglycemia
and repeated seizures. His seizure clearly related to
hypoglycemia. Patient has distant history of seizures 30yrs ago.
3mg Ativan and Dilantin 100mg PO TID caused his movements to
cease. Second seizure less clear what the inciting event was.
Head CT and MRI were both negative for acute intracranial
process. Patient began having frequent and prolonged seizures on
[**7-16**]. He became sedated with Ativan. He was transferred to the
neuro ICU for closer monitoring and possible need for more
sedating medications. He was loaded with Depakote, and continued
on Keppra and Dilantin. He initially had frequent electrographic
seizures without any clinical manifestation. This improved over
the night of [**7-17**] to [**7-18**], and he had only frontal slowing on
his EEG. He was transferred back to the neurology floor. While
on the floor, over the course of roughly a month the patient's
AEDs were titrated to their current regimen. Initially, he did
display some shaking movements that had no electrographic
correlates. These were thought to be rigors in the setting of a
urinary tract infection, for which he received adequate
treatment with IV antibiotics. He remained seizure free
throughout this duration. Note that he was briefly started on
valproic acid, which led to a transaminitis without obvious
lesions on RUQ ultrasound. His valproic acid was ultimately
discontinued.
Aside from the initial hypoglycemia episode, his blood sugars
remained on the higher side throughout his hospitalization and
finally attained control after initiating scheduled mixed dose
insulin on top of the insulin sliding scale. He had no further
complications related to his DMII, and his A1c was measured in
the 6-7 range. He had no major abnormalities on his lipid panel.
His metformin can be restarted on discharge at 500mg [**Hospital1 **].
His blood pressure was also difficult to manage, and ultimately,
he was well controlled on a regimen of PO labetalol, lisinopril
and HCTZ. If his blood pressures continue to remain elevated,
please consider increasing his labetalol to 300/400mg TID, or
adding imdur 30mg TID. He continues to be on aspirin and plavix
for his history of CVA and current cerebrovascular disease
(refer to MRA head/neck, carotid U/S).
On [**8-8**], the patient developed some hypotension down to 75mm
SBP and had some guaiac positive stool. He was volume
resuscitated and his blood pressures stabilized. He was seen by
GI who performed an EGD/colonoscopy, which revealed some
scattered diverticula and esophagitis/gastritis. He was placed
on a [**Hospital1 **] proton pump inhibitor, and following his procedure, his
blood pressures stabilized. He needs to return for a polypectomy
in the future while off of plavix x 5 days. The exact date of
this appointment will be conveyed to him in the future.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider: [**Name10 (NameIs) **]
[**Last Name (STitle) 14362**]) - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 30 mg Tablet - 1
Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet
Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - (Prescribed by
Other Provider) - 100 unit/mL (70-30) Suspension - subcutaneous
48 units in the am and 20 units at night
POTASSIUM GLUCONATE - (Prescribed by Other Provider) - 2 mEq
Tablet - 1 Tablet(s) by mouth once a day
VITAMIN E - (Prescribed by Other Provider) - 1,000 unit Capsule
- 1 Capsule(s) by mouth once a day
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day).
8. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO NOON (At Noon).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
HS (at bedtime).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for Constipation.
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
15. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: As instructed Subcutaneous AM and PM (insulin): Please
inject SQ 25 units before breakfast and 10 units before dinner.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Seizure disorder
Diabetes Mellitus
Hypertension
Cerebrovascular Disease
Discharge Condition:
Discharge Condition: Stable
Mental Status: Spanish-speaking only, alert, awake and oriented
Ambulatory status: Cannot ambulate independently, requires two
person assistance to ambulate. Requires aggressive physical
therapy and rehabilitation.
Discharge Instructions:
You were treated at [**Hospital1 18**] for seizures, poorly controlled
diabetes, cerebrovascular disease and hypertension. We made
numerous changes to your medications. You will require a few
weeks of extensive rehabilitation to regain your strength.
Please take your medications as noted below, and keep all of
your follow up appointments.
Followup Instructions:
Provider [**Name Initial (PRE) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 10314**] Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2182-9-25**] 4:30
Completed by:[**2182-8-12**]
|
[
"V58.67",
"280.9",
"401.9",
"211.3",
"282.49",
"707.23",
"414.01",
"272.4",
"250.80",
"562.10",
"530.10",
"707.03",
"345.90",
"348.30",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12572, 12642
|
7028, 9909
|
327, 345
|
12779, 12786
|
4337, 7005
|
13392, 13582
|
2204, 2216
|
11202, 12549
|
12663, 12737
|
9935, 11179
|
13027, 13369
|
2257, 3772
|
265, 289
|
373, 1725
|
12801, 13003
|
1747, 2061
|
2077, 2188
|
3797, 4318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,117
| 167,501
|
11584
|
Discharge summary
|
report
|
Admission Date: [**2178-3-25**] Discharge Date: [**2178-4-2**]
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
L sided weakness, problem with speech
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
Intubation
Mechanical ventilation
History of Present Illness:
Ms. [**Known lastname 36818**] [**Last Name (Titles) **] an 87 year old woman hx atrial fibrillation on
coumadin, right thalamic infarct, who was last known to be well
at 8pm on [**2178-3-24**], who was found by a nursing aide at 8am on
[**3-25**] to be dysarthria and severely phasic. The patient was able
to say that she was "cold". She had left-sided weakness. EMS was
called at 8:15am and patient was taken to [**Hospital1 18**]. En route, her
fs was 221 and she vomited two times.
In the ED, her exam was pupils reactive, with eye deviation to
the right, not following commands, and non verbal. Her arms were
drifting down bilaterally. At 9:49am, the patient developed
ventricular tachycardia. Vitals were BP 175/118 and HR 124. She
was given amiodarone 150mg iv once, followed by amiodarone
0.5mg/min drip. Patient was intubated and sedated with Propofol.
Her rhythm became atrial fib with rate in the 120's to 140's.
Her BP decreased to 119/74.
CT brain did not show early signs of infarct or bleed. CTA did
not show cutoff of an intracranial vessel. CT perfusion shows
increased mean transit time of the right MCA and left ACA
region. Patient was outside the window for TPA or mechanical
clot retrieval. She was admitted to the SICU.
Past Medical History:
Atrial Fibrillation
CVA
HTN
Hypercholesterolemia
Depression
Anxiety
Social History:
Lives alone in independent living facility since her husband
died. She has an aide for 12 hours per day, then for 1 hour in
the evening. At baseline, 1 assist transfer to wheelchair. 3
sons who live in the area, 1 son is a physician. [**Name10 (NameIs) 4273**] EtOH,
tobacco or IDU.
Family History:
Mother had CVA.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: Tc 103.7 BP 175/118 then 119/74 P 185 Vtach
then 124 R 16-21 02 99%
Gen: intubated
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: opens eyes to verbal, follows commands to wiggle
fingers
CN: decreased blink to threat on the left, tracks horizontally,
pupils 4 to 3mm bilaterally, no obvious facial droop
Motor: normal tone and bulk of all four extremities, no tremor
3/5 Strength of biceps and triceps bilaterally
2/5 Strength of legs bilaterally
Sensory: withdraws with all four extremities to noxious stimuli
Reflex: T BR B K A toes
Left 2 2 2 2 2 mute
Right 2 2 2 2 2 mute
Coord: unable to assess
UPON TRANSFER TO MICU:
======================
97.0 99 121/73 97%RA
GEN: ill appearing, aphasic
HEENT: poor dentition, dry mucus membranes
CV: irregualr, s1, s2, noi m/g/r
RESP: CTA anteriorly, allthough some rhochi laterally
ABD: soft, NT, ND
EXT: minimal edema
NEURO: aphasic, moves all extermities.
Pertinent Results:
ADMISSION LABS:
================
[**2178-3-25**] 10:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2178-3-25**] 10:24PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2178-3-25**] 10:24PM URINE RBC-[**4-8**]* WBC-[**4-8**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2178-3-25**] 10:05PM PT-29.0* PTT-150 IS HIG INR(PT)-2.9*
[**2178-3-25**] 10:03PM CK(CPK)-49
[**2178-3-25**] 10:03PM CK-MB-NotDone cTropnT-0.67*
[**2178-3-25**] 10:24AM GLUCOSE-187* LACTATE-3.5* NA+-131* K+-5.0
CL--96* TCO2-24
[**2178-3-25**] 10:10AM GLUCOSE-210* UREA N-14 CREAT-0.8 SODIUM-132*
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-18
[**2178-3-25**] 10:10AM ALT(SGPT)-15 AST(SGOT)-23 CK(CPK)-53 ALK
PHOS-90 TOT BILI-0.7
[**2178-3-25**] 10:10AM cTropnT-0.11*
[**2178-3-25**] 10:10AM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.8
[**2178-3-25**] 10:10AM TSH-0.19*
[**2178-3-25**] 10:10AM WBC-10.6 RBC-4.14* HGB-13.3 HCT-40.3 MCV-97
MCH-32.3* MCHC-33.1 RDW-14.0
[**2178-3-25**] 10:10AM NEUTS-63.5 LYMPHS-32.8 MONOS-2.1 EOS-1.0
BASOS-0.6
[**2178-3-25**] 10:10AM PT-17.6* PTT-23.8 INR(PT)-1.6*
MICROBIOLOGY:
=============
[**2178-3-25**] 8:23 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2178-3-26**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2178-3-28**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2178-3-25**] 10:24 pm URINE
URINE CULTURE (Final [**2178-3-28**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2178-4-1**] 10:52 am SPUTUM Site: EXPECTORATED
Source: Endotracheal.
GRAM STAIN (Final [**2178-4-1**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2178-4-4**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
YEAST. RARE GROWTH. 2ND TYPE.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE #
246-1943Y([**2178-3-25**]).
[**3-25**] BCx x 2: negative
[**3-29**] BCx x 2: negative
[**3-29**] UCx: negative
[**3-31**] BCx x 1: negative
[**3-31**] C. diff: negative
[**3-31**] UCx: negative
[**4-1**] BCx x 2: negative
[**4-1**] UCx: negative
[**4-2**] BCx: negative
[**3-31**] DFA negative for Influenzae A & B
STUDIES:
========
[**3-25**] CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
IMPRESSION:
1. CT perfusion findings are consistent with acute ischemia in
the right MCA and right MCA/ACA watershed distribution as well
as the left ACA distribution. Possible acute ischemia in the
left PCA territory. No evidence for intravascular thrombus or
intracranial hemorrhage.
2. 3-mm left PCA P2 segment aneurysm without evidence for
hemorrhage.
CHEST (PORTABLE AP) [**2178-3-25**]
IMPRESSION:
1. Endotracheal tube extending into the left main stem bronchus.
Repositioning is required. This was discussed with the nurse
caring for the patient, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at cell number [**Serial Number 36819**], at
approximately 10:45 a.m.
2. Increased opacity of the left lung base, possibly
representing aspiration. Followup radiographs are recommended.
3. Stable cardiomegaly with no evidence of acute congestive
heart failure.
EKG [**3-25**]
Atrial fibrillation, average ventricular rate 120. Left anterior
hemiblock. Intraventricular conduction delay. Non-specific
lateral repolarization changes. Cannot exclude anterior
myocardial infarction of indeterminate age though unlikely.
Compared to the previous tracing of [**2177-3-13**] ventricular response
rate to atrial fibrillation is faster, ventricular ectopy is
absent, and the late precordial R wave progression (suggesting
interval anterior myocardial infarction)is new.
CHEST (PORTABLE AP) [**2178-3-26**]
IMPRESSION:
1) Endotracheal tube abutting the right lateral tracheal wall.
The tube should be slightly advanced for more optimal placement.
2) Proximal gastric tube, with the side port just below the
gastroesophageal junction, might be edvanced 15-20 cm.
3) Improving left upper lobe aeration with persistent bibasilar
opacities, likely atelectasis.
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST [**2178-3-26**]
IMPRESSION:
No evidence for acute ischemia.
Extensive small vessel ischemic sequela.
Aneurysm of the left PCA and left Posterior Communicating
Artery.
Portable TTE (Complete) Done [**2178-3-26**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %) secondary to akinesis of the
interventricular septum, anterior free wall, and apex. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The ascending aorta is mildly dilated. The
aortic valve is not well seen. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2177-7-18**], the left ventricular ejection fraction is now
severely reduced, most likely secondary to coronary artery
disease and intercurrent myocardial infarction.
[**2178-3-27**] EEG
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized background, bursts of generalized slowing, and
occasional additional slowing on the right side. The first two
abnormalities signify a widespread encephalopathic condition
affecting both cortical and subcortical structures.
Medications, metabolic disturbances, and infection are among the
most common causes. There was additional focal slowing on the
right, indicating subcortical dysfunction and likely related to
the abnormality described on the requisition. Nevertheless,
there were no epileptiform features. An abnormal cardiac rhythm
was
noted.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2178-3-29**]
LIVER/GALLBLADDER ULTRASOUND: This evaluation is limited due to
lack of patient mobility. The liver is of normal echotexture
with no gross focal lesions identified. There is no intra- or
extra-hepatic ductal dilatation. The common duct measures 5 mm.
The gallbladder is not visualized and likely absent. There is
appropriate forward portal venous flow. The pancreas is not
demonstrated due to overlying bowel gas. The spleen is
incompletely visualized, however, appears to measure 7 cm. There
is a small amount of perihepatic fluid.
IMPRESSION:
Limited examination. Small perihepatic fluid. Otherwise
unremarkable liver gallbladder ultrasound.
CHEST (PORTABLE AP) [**2178-4-2**]
The ET tube tip is 3 cm above the carina but note is made that
the tip impinges the right tracheal wall, thus it should be
repositioned to prevent stricture or malacia. The right internal
jugular line tip terminates in distal SVC. The NG tube tip
passes below the diaphragm with its tip most likely below the
inferior margin of the film. The heart size is mildly enlarged
but stable. The mediastinal silhouette is unremarkable.
Bilateral pleural effusions are moderate-to-large, slightly
progressed since yesterday although it might be contributed by
slightly different position of the patient. No evidence of
failure is present. No focal consolidations worrisome for
pneumonia are identified although they may be obscured by
overlying effusion.
Portable TTE (Complete) Done [**2178-4-2**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
regional left ventricular systolic dysfunction with akinesis of
the septum, mid- and distal anterior wall and distal LV
segments/apex, with relative preservation of
inferolateral/lateral wall contraction (LVEF = 25-30%). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction. Mild right ventricular systolic dysfunction. Mild
aortic regurgiation.
Compared with the prior study (images reviewed) of [**2178-3-26**],
biventricular function has slightly improved, although the
regional distribution of wall motion abnormalities is similar.
Severity of mitral regurgitation and pulmonary hypertension has
lessened. The other findings are similar.
Brief Hospital Course:
The patient is an 87M w/ h/o right thalamic bleed and residual
left leg weakness, CVA in [**2169**], HTN, afib on coumadin who
presented [**3-25**] from independent living after being found to be
nonverbal and have left-sided weakness by her nurse aide. Her
blood sugar was 221 and she vomited twice on the way to the
hospital. Soon after arriving to the ED, she went into ?vtach
for about 5 minutes and was started on an amio drip after an
amio load of 150mgx1. She was intubated and converted back to
her native rhythm, afib in the 120s, and put on labetalol for
rate control. Her last INR before this was 1.5 on [**3-19**]. Head
CT/CTA showed evidence of acute right MCA/watershed stroke and
the patient was admitted to the neuro ICU service. She was
outside the window for TPA or mechanical clot retrieval. She was
febrile to 104 and started on Vanc/Zosyn. She required pressors
(neosynephrine) until [**3-26**] at 5pm and was also extubated on
[**3-26**]. Her urine was found to be growing E. coli and sputum to be
growing coag+ staph.
Cardiology was consulted for her vtach and recommended stopping
amio and starting diltiazem drip as well as titrating up BB
(switching labetalol to metoprolol) and starting ACEI as
tolerated by BP. Troponins rose from 0.11 in the ED to a peak of
0.87 [**3-27**]. CK peaked at 10 and MBI at 4.0 (last values). TTE
found EF of 20% 2/2 akinesis of the interventricular septum,
anterior free wall, and apex; this is down from 55% in [**2177**]
which had normal wall motion. Troponin elevation thought to be
secondary to increased cardiac demand.
MRI head done on [**3-26**] showed no evidence of acute ischemia. The
findings on CT were thought to be possibly artifact per the
neuro team. She failed a speech and swallow eval and NGT was
recommended, although this was attempted twice unsuccessfully
due to patient not cooperating. She was given one dose of
coumadin and her INR increased to 6.9.
On [**2178-3-27**], she was transferred to the MICU service for medical
management of her altered mental status and multiple medical
problems, including dysarthria, aphasia, elevated troponin,
newly depressed EF, coag + staph in sputum and klebsiella in her
urine.
During her course in the MICU, the patient continued to be
altered. Given newly depressed EF, elevated troponin, VT on
arrival to ED, and new wall motion abnormalities, the priamry
event for her altered mental status may in fact have been an MI,
with hypotension/ischemia exacerbating underlying neurologic
deficits. Infection with staph in sputum and klebsiella in urine
also may have contributed. EEG was negative for seizure. For a
presumed NSTEMI, diltiazem drip was changed to esmolol drip for
beta blockade. Nitro gtt was later instituted for afterload
reduction. She was also started on digoxin daily.
For her coag + staph in sputum she was continued on vancomycin
for MRSA pneumonia. Zosyn was switched to ceftriaxone after UCx
sensitivities returned. However, the patient continued to spike
fevers despite treatment with vancomycin and ceftriaxone. In
the setting of rising WBC, she was switched to cefepime for
added pseudomonal coverage. She was pan cultured, which did not
show any new source of infection.
During her course, she became increasingly tachypneic with cough
and was re-intubated for airway protection and increased work
of breathing. She remained coagulopathic and received vitamin K
and FFP to reverse. DIC panel was negative. Her INR may have
been elevated in the setting of warfarin with amiodarone,
antibiotics and malnutrition. Her renal function returned to
baseline during her course. She also was found to have
transaminitis, which was thought to be due to hypoperfusion. In
this setting, amiodarone and statin were held. Hep serologies
negative, and RUQ U/S was negative.
Vascular surgery was consulted for concern for ischemic digits
(R fingers > L fingers > toes). She was started on argatroban
gtt.
Towards the end of her hospitalization, the patient required
pressor support. After extensive discussion with her HCP and
family, the patient was made CMO. She expired shortly after
extubation and withdrawal of intensive medical management.
Medications on Admission:
Lisinopril 5mg daily
Lasix 20mg daily
Synthroid 0.15 mg daily
Diltiazem SR 120mg qam
Vitamin D 400 units daily
Oxybutynin 10mg qam
Labetalol 100mg [**Hospital1 **]
Remeron 30mg qhs
Lipitor 20mg qhs
Coumadin 3mg on Sunday, Monday, Tuesday, Wednesday and 2mg on
Thursday, Friday, and Saturday
Tylenol #3 prn pain
Pericolace two tabs [**Hospital1 **]
Lactulose 30cc daily
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Respiratory failure
2. Altered mental status
3. Non ST elevation MI
4. Cardiac Arrhythmias (atrial fibrillation, ventricular
tachycardia)
5. Pneumonia
6. Urinary tract infection
7. Acute Renal Failure
8. Coagulopathy
9. Digit Ischemia
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
Completed by:[**2178-4-25**]
|
[
"507.0",
"348.30",
"427.31",
"038.9",
"401.9",
"482.41",
"428.23",
"427.1",
"430",
"410.71",
"785.52",
"570",
"428.0",
"041.4",
"V58.61",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.04",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18298, 18307
|
13639, 17844
|
300, 382
|
18588, 18598
|
3431, 3431
|
18652, 18688
|
2066, 2084
|
18265, 18275
|
18328, 18567
|
17870, 18242
|
18622, 18629
|
2099, 3412
|
223, 262
|
410, 1657
|
3447, 13616
|
1679, 1749
|
1765, 2050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,260
| 137,350
|
15670
|
Discharge summary
|
report
|
Admission Date: [**2162-9-27**] Discharge Date: [**2162-10-12**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Transfer from OSH for GI bleed
Major Surgical or Invasive Procedure:
Capsule endoscopy
History of Present Illness:
42 y/o F with etoh cirrhosis and [**Hospital 45206**] transferred from OSH
where she originally presented on [**9-16**] with two episodes of
dark, tarry stools. OSH ED notes state patient is very well
known to their ED, and had recently been admitted prior to ED
presentation with large GI bleed requiring multiple transfusions
and FFP. She had felt unwell the day prior to ED presentation,
with some abdominal discomfort and decreased appetite.
.
While at [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital, the patient had working
diagnosis of LGIB. Had upper and lower endoscopies revealing
ulcers in distal esophageus at site of previous banding, mild
gastritis in body/antrum of stomach, but no evidence of active
bleeding. Per [**Hospital1 18**] GI fellow, colonoscopy earlier today
reportedly revealed non-bleeding internal hemorrhoids--there is
no record of this in transfer paperwork. Per d/c summary, the
patient did not have a hematocrit drop and was hemodynamically
stable, was tolerating PO diet and had a benign abdominal exam.
The patient was transferred to [**Hospital1 18**] for further workup to
possibly include capsule endoscopy. VS as reported on d/c
summary prior to transfer were 98.2, 99/16, 64, 20, 95% RA. Labs
were INR 1.59, with normal Chem7 and Hct 29.6. Of note, AMA form
signed by patient on [**9-16**], but lab technician confirmed that
patient has been admitted since that day.
.
Per OSH med sheets and paper orders, Protonix and octreotide gtt
were started on [**9-24**]. She was given vitamin K 10 mg daily on
[**9-26**] and earlier today. Regular diet was started this afternoon,
and her telemetry was discontinued. It appeared that the patient
was ordered for a CT angiogram in the early morning of [**9-26**] to
evaluate for rectal bleeding, but this was later held.
.
Review of sytems: Patient states "everything," when asked if
anything is bothering her. When requested to specify, she denies
everything except anxiety and displeasure at being in hospital
overnight. Specifically denied chest pain, dyspnea, abdominal
pain, nausea, vomiting, diarrhea, tingling, or numbness.
.
On floor, patient was tearful and anxious, stating her desire to
go home and return for her capsule study tomorrow.
Past Medical History:
Alcoholic cirrhosis
s/p cholecystectomy [**2153**]
Gastroesophageal reflux disease
Bipolar disorder
Htn
Depression/anxiety
Social History:
Not participating in interview. Per OSH ED notes, SocHx notable
for "recently stopped drinking alcohol." Per prior d/c summary
in [**5-29**]: "Smokes 1 pack of cigarrettes per 1-2 weeks. Drinks
heavily, unable to quantify how much. Drink rum when husband is
home (2 days per week). Describes herself as a binge drinker -
unable to say how much. Denies current or prior IVDU. Lives
with husband and 2 children, ages 14 and 15."
Family History:
Non-contributory.
Physical Exam:
Physical exam on discharge:
VS - Temp 98.1, BP 94/58 , HR 73 , RR 18 , O2-sat 98% RA
GENERAL - disheveled, anxious caucasian woman
HEENT - NC/AT, EOMI, sclerae anicteric
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
NEURO - awake, alert, oriented, muscle strength 5/5 throughout,
sensation grossly intact throughout. gait steady
Pertinent Results:
1. Labs on admission:
[**2162-9-27**] 11:30PM BLOOD WBC-3.5*# RBC-3.12* Hgb-9.5* Hct-28.1*
MCV-90# MCH-30.4# MCHC-33.8 RDW-19.0* Plt Ct-131*#
[**2162-9-27**] 11:30PM BLOOD Neuts-59.2 Lymphs-25.1 Monos-9.9 Eos-4.2*
Baso-1.6
[**2162-9-27**] 11:30PM BLOOD PT-20.0* PTT-37.0* INR(PT)-1.8*
[**2162-9-27**] 11:30PM BLOOD Fibrino-148*
[**2162-9-27**] 11:30PM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-138
K-3.9 Cl-110* HCO3-23 AnGap-9
[**2162-9-27**] 11:30PM BLOOD ALT-24 AST-51* LD(LDH)-127 AlkPhos-69
TotBili-1.4
[**2162-9-27**] 11:30PM BLOOD Calcium-7.8* Phos-4.0 Mg-1.5*
.
2. Labs on discharge:
[**2162-10-12**] 05:10AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.3* Hct-30.1*
MCV-90 MCH-30.6 MCHC-34.0 RDW-18.5* Plt Ct-98*
[**2162-10-12**] 05:10AM BLOOD PT-23.6* PTT-48.8* INR(PT)-2.2*
[**2162-10-12**] 05:10AM BLOOD Glucose-84 UreaN-3* Creat-0.3* Na-136
K-3.2* Cl-105 HCO3-23 AnGap-11
[**2162-10-12**] 05:10AM BLOOD ALT-27 AST-55* AlkPhos-118* TotBili-3.5*
[**2162-10-12**] 05:10AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.5*
.
3. Imaging/diagnostics:
- Capsule endoscopy ([**2162-10-3**]): Evidence of scars from prior
banding, no varices seen. Congestion and mosaic appearance in
the stomach compatible with portal gastropathy. Abnormal in the
jejunum. No signs of active or recent bleeding. No blood or clot
seen anywhere in the lumen. Otherwise normal small bowel
enteroscopy to mid-distal small bowel (3M of scope inserted.
.
- Meckel's scan ([**2162-10-1**]): No evidence for Meckel diverticulum
.
- CTA abdomen pelvis ([**2162-10-2**]): 1. Intraluminal hyperdensity in
the cecum and the right ascending colon consistent with
gastrointestinal bleeding (the patient did not receive oral
contrast). No evidence of active bleeding or cause of
gastrointestinal bleeding is seen. 2. Cirrhotic liver with
multiple arterial enhancing lesions measuring up to 1.1 cm which
were not appreciated on the prior MRI study from [**2161-7-21**].
The differential diagnosis includes multifocal HCC vs. multiple
regenrative
nodules. Further evaluation is recommended by MRI. 3. Signs of
portal hypertension with paraesophageal, esophageal and
retroperitoneal varices, splenomegaly and small amount of
ascites. 4. Diffuse edema of the stomach wall and right colon,
most probably due to cirrhosis. Please correlate clinically. 5.
Gastric diverticulum. 6. Small left adrenal nodule which could
also be evaluated at the time of the MRI study. 7. Old fractures
at the anterior portions of ribs four and five on the right.
.
- CXR ([**2162-10-2**]): No active disease in the chest
.
- GI bleeding study #1 ([**2162-10-3**]): No active hemorrhage
.
- GI bleeding study # 2 ([**2162-10-4**]): No site of active
extravasation identified
.
- CT head w/o contrast ([**2162-10-7**]): No acute intracranial process
.
- Abdominal ultrasound with Doppler ([**2162-10-11**]): 1. Patent TIPS
shunt. Flow within the right portal vein is noted to be in the
direction of the TIPS shunt; however, flow in the left portal
vein is noted to be away from the shunt. Nodular hepatic
architecture. A single hypoechoic lesion measuring 1.1 cm is
seen in segment II corresponding with a small early enhancing
lesion seen on the recent CT of [**2162-10-2**]. 2. Moderate
amount of ascites. 3. Splenomegaly.
Brief Hospital Course:
42 yo F with alcoholic cirrhosis, complicated by variceal bleed
and ascites, transferred from OSH where she presented with
melena, s/p EGD and colonoscopy with varices banded, here for
workup of bleeding source.
.
# GI bleed/anemia: Patient had ~1 unit of pRBC requirement for
the first 5 days of admission. Capsule endoscopy showed possible
small bowel bleed but no concrete source. Meckel scan negative.
CTA on floor no acute. On hospital day 6 patient developed
large- volume melena and hematemesis. Code blue was called
though patient never developed asystole. Patient was emergent
transferred to MICU where she was intubated for airway
protection. An endoscopy in the ICU showed varices but no
evidence of recent bleed. Patient was transfused 6Uprbcs and 1U
FFP over first 24 hours ICU stay. Tagged blood scan during first
ICU day showed no active bleed. Repeat EGD showed duodenal
variceal bleed, and patient went to IR for successful TIPS and
embolization of duodenal varix. Patient remained h/d stable for
the next three days without change in her H/H. Continued to
have hematochezia during ICU stay, but gastroenterology said
this was expected even without further bleed given initial large
volume of bleed. Back on the floor, patient remained
hemodynamically stable with Hct ~28 for the remained of the
hospitalization. She was discharged with close followup with
outpatient gastroenterologist.
.
# Alcoholic cirrhosis: Patient had minimal jaundice and ascites
on admission, which did not change. She initially developed
encephalopathy after TIPS placement, which improved after
rifaximin and lactulose.
.
# Alcohol abuse: Patient has significant alcohol abuse history,
though reports on admission that she had quit recently. She was
placed on CIWA scale but never showed signs of withdrawal.
Continued thiamine and folic acid. Social work consul was
obtained. Patient will resume care with outpatient psychiatrist
on discharge.
.
# Bipolar/depression: Patient was kept on home regimen of
risperidone and trazodone prn for insomnia while taking po.
Psych was consulted after patient was extubated in the ICU and
thought she was unable to understand her medical condition. This
improved after resolution of her post-TIPS encephalopathy.
Medications on Admission:
CURRENT MEDICATIONS: (transfer meds)
calcium 500mg PO BID
Thiamine 100mg PO daily
MVI tab PO daily
Magnesium 800mg PO daily
Latulose 30cc mix c OJ PO Q4H
Iron sulfate 325mg PO BID
Lasix 40mg PO daily
Lidocaine patch to LB Q12H
Nadolol 20 mg PO daily
Omeprazole 20 mg PO BID
.
HOME MEDS:
Levaquin 500mg every other day
Lasix PO 60mg QAM 40mg Q PM
Risperidone 0.5mg [**Hospital1 **]
Trazodone 100mg PO QHS PRN
Vitamin D 8000 unit/mL daily
Folate 1 mg PO daily
Aldactone 150 mg PO BID
Lasix 40 mg PO "daily, nightly"
Omeprazole 40 mg PO daily
Amitiza 24 mcg PO BID
Calcium [**Hospital1 **]
FeSO4 325 mg PO BID
Xifaxan two tablets [**Hospital1 **]
Lactulose 30 g PO QID
Discharge Medications:
1. Outpatient Lab Work
Please check AST, ALT, Alk Phos, [**Name (NI) 3539**], INR, PTT, PT, CHEM 10
and fax to Dr. [**Last Name (STitle) 45207**] at [**Telephone/Fax (1) 45208**].
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Ok to
substitute omeprazole 40 mg qd if insurance does not cover. .
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper dastrointestinal bleed from duodenal varix
Alcoholic cirrhosis
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 45209**], you were transferred to the [**Hospital1 827**] because you had recurrent bleeding form your GI
tract. We transfused you with blood. We did many tests to try to
find the source of your bleeding. There included a small capsule
endoscopy, a Meckel's scan, and multiple upper GI endoscopies.
We found that you had a blood vessel in your small intestine
that was bleeding. We did a procedure to decrease the blood
flow to that area and the bleeding stopped.
Many medications were changed. Here is what we are sending you
home on:
LACTULOSE 30mL four times a day - make sure you have [**2-22**] bowel
movements a day. If you have less, take an additional dose.
RIFAXAMIN 550mg twice a day
PANTROPRAZOLE 40mg once a day (for acid in your stomach)
CALCIUM/VITAMIN D
THIAMINE
FOLIC ACID
You do not need to take lasix or aldactone. Dr. [**Last Name (STitle) 45207**] will
determine if you need to restart this medication.
***If you or your family notice that your thinking is unclear or
you are confusion, TAKE AN EXTRA DOSE OF LACTULOSE and call Dr.
[**Last Name (STitle) 45207**] at [**Telephone/Fax (1) 45210**].
***If you notice increase swelling in your legs or abdomen, call
Dr. [**Last Name (STitle) 45207**] at [**Telephone/Fax (1) 45210**].
Finally, you have been given a prescription to have your labs
checked. Please have them check on Monday [**10-18**] or Tuesday
[**10-19**] so they will be available when you see Dr. [**Last Name (STitle) 45207**] on
Thursday. The results will be faxed to Dr.[**Name (NI) 45211**] office.
IT IS ESSENTIAL that you never drink alcohol again as you could
die.
You were given information about relapse prevention programs
which are very important to your recovery. Please contact them
as soon as you are home to arrange for follow up.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
An appointment has been made for you with Dr. [**Last Name (STitle) 45207**] on Thursday
[**10-21**] at 3:45pm.
Address:
[**Hospital1 45212**].
[**Location (un) 47**], MA
phone: [**Telephone/Fax (1) 45210**]
fax: [**Telephone/Fax (1) 45208**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2162-10-12**]
|
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icd9cm
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[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,815
| 198,920
|
720
|
Discharge summary
|
report
|
Admission Date: [**2125-4-29**] Discharge Date: [**2125-5-29**]
Date of Birth: [**2053-11-6**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Rib pain
Major Surgical or Invasive Procedure:
Intubation
Stress MIBI
History of Present Illness:
71 y/o F w/ metastatic breast ca, w/ bone involvement, on
tamoxifen, who presents with worsening right rib pain.
.
She reports that rib pain has been a chronic problem, but has
been worse over past one week. The right side is worse, but she
also reports left sided rib pain and chest wall pain. She does
not report any trauma or heavy lifting or turning that seemed to
precipitate the pains. She was recently started on percocet for
pain which did help, but she has had to take it around the clock
without full relief.
.
ROS: denies n/v/f/c. no chest pain. + shortness of breath-
secondary to not able to take in full breaths from pain in right
side; No associated rash; + constipation.
.
In ER, given oxycodone 10mg, flexerill 10mg, and 10mg oxycontin.
However continued pain, therefore admitted for pain control
Past Medical History:
1. Hypertension
2. Glaucoma
3. Breast cancer
4. Rib pain
5. Atrial fibrillation
.
ONCOLOGIC HISTORY: Initially diagnosed in spring of [**2110**] with a
dimpling in her right breast and a positive mammogram.
Excisional biopsy demonstrated infiltrating and intraductal
carcinoma which was greater than 2 cm and she subsequently went
for a right modified mastectomy and axillary dissection. She had
negative margins and 1 positive lymph node. The tumor was ER
positive and she was subsequently stage 2, N1 disease.
Subseqeuently received adjuvant CMF chemotherapy, followed by 5
years tamoxifen. Had long disease free interval, with subsequent
recurrent disease w/ bony involvement in [**2120**]. Started on femara
at that point with good response. On progression from this she
was placed on aromasin in [**6-15**] but did not do well with this,
with increased bone pain. Most recently placed back on tamoxifen
since [**1-17**].
Social History:
Lives at home in [**Location (un) 86**] w/ husband, functional of ADLs. Former
smoker for
approximately 50 pack years, quit 10 years ago. Rare social
alcohol.
Family History:
sister died of breast ca, 56
Physical Exam:
vitals- 98.3, 162/94,76, 18, 97% RA
gen- NAd
heent- EOMI. MMM
pulm- CTA b/l
CV- RRR. no m/r/g
abd- soft,non-tender, mild distension, NABS
ext- 1+ ankle edema b/l LEs, no calf swelling, tenderness
neuro- alert and oreinted x 3, CNII-XII intact.
back/flank- no focal spinal tenderness; + tenderness to
palpation diffusely along right posterior and anterior rib cage,
also w/ tenderness on L side (R>L). + tenderness over sternum
and anterior chest wall to palpation. no associated dermatomal
rash
Pertinent Results:
CXR [**2125-4-29**]: PA AND LATERAL CHEST RADIOGRAPH: There is an
opacity within the left lung base with associated volume loss
consistent with atelectasis/consolidation. Small left pleural
effusion is present. The cardiomediastinal contour is stable.
The pulmonary vessels demonstrate mild cephalization, however
there is no frank edema. Mild loss of height is seen in
mid-thoracic spine vertebral body as well as mottled appearance
and fractures involving multiple ribs.
.
TTE [**2125-4-30**]: The left atrium is elongated. Left ventricular wall
thicknesses are normal. 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%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade II (moderate)
LV diastolic dysfunction. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated athe sinus level. The ascending aorta is mildly dilated.
The aortic arch is mildly dilated. The aortic valve leaflets are
mildly thickened. The aortic valve is not well seen. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. The mitral valve is not well
seen. Mild to
moderate ([**12-12**]+) mitral regurgitation is seen. [Due to suboptimal
image
quality, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is no pericardial effusion.
.
RIB FILMS [**2125-4-30**]: Multiple healed bilateral rib fractures and
osseous metastatic disease involving the ribs. Possible acute
fracture of lateral left sixth rib.
.
CT T-SPINE [**2125-5-2**]: CT scan of the thoracic spine which was
obtained on [**2124-5-26**], and employed contrast administration
intravenously. The study was reported by myself and Dr.
[**Last Name (STitle) 5325**] as revealing "diffusely abnormal appearing vertebral
bodies in the thoracic spine as seen on the prior MRI scan
consistent with metastatic disease. A focal lytic lesion in T5
vertebral body has progressed since [**2120**]. Anterior wedging of
T12 with an associated central lucency extending to the superior
endplate suggests pathological fracture. Heterogeneously
enlarged thyroid gland. Correlate son[**Name (NI) 5326**]." Comparison
with the prior study of [**2124-5-26**] reveals likely progression
of diffuse metastatic disease of the thoracic spine. While the
present study appears to be of higher spatial resolution than
the prior examination, there has been some progression of
compression fractures, including nearly all thoracic vertebral
bodies, most notably at T7, T8 and T12. However, there does not
appear to be retropulsion of pathologic fractures into the
central spinal canal. The T5 lytic lesion is not as clearly
discernible at this time, suggesting there may have been some
interval reactive sclerosis. There are probable small bilateral
pleural effusions, slightly more evident on the left side, as
well as multiple small wedge-shaped areas of soft tissue density
within the posterior lung fields. These pulmonary lesions were
not present on the prior spinal CT scan but were seen, at least
in part, on a recent torso CT scan. It is suggested that these
pulmonary issues be reviewed
with the chest CT service, and if deemed necessary, a followup
chest CT scan be obtained. Finally, there is no overt sign or an
epidural mass on this study, although in this regard, MR
scanning is more efficacious at detecting such an abnormality.
CONCLUSION: Apparent progression of what is likely diffuse
osseous metastatic disease, with the appearance of multiple
compression fractures as noted above.
.
[**5-14**] TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular
filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue
velocity
imaging are consistent with Grade III/IV (severe) LV diastolic
dysfunction.
Right ventricular chamber size and free wall motion are normal.
The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is an anterior
space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2125-4-30**],
the mitral
deceleration time is now shorter suggestive of more severe
diastolic
dysfunction/elevated left atrial pressures. Significant
tricuspid
regurgitation is now detected (suboptimal visualized in prior
study).
Significant pulmonary artery systolic hypertension in now
detected (unable to
assess in prior study).
Brief Hospital Course:
71 y/o F w/ metastatic breast ca, w/ bone involvement, on
tamoxifen, who was admitted with worsening chest wall pain.
.
The patient was intially admitted to the oncology service for
pain control. She was intially managed on the floor with oral
narcotic pain regimens. Rib films revealed multiple chronic and
acute rib fractures. Given persistently poorly controlled pain
despite uptitration of narcotics, CT of her T-spine was
obtained; this study revealed multiple vertebral compression
fractures. Patient was fitted with an abdominal binder for
support with ambulation. On [**5-14**] the patient developed an
episode of atrial fibrillation with rapid ventricular resonse,
and developed pulmonary edema requiring intubation and
transferred to the [**Hospital Unit Name 153**].
.
1. Respiratory failure: Due to pulmonary edema secondary to
hypertension and atrial fibrillation with underlying diastolic
heart failure. She was diuresed on a lasix gtt with
improvement. She was extubated on [**5-22**]. She did well, and
was transferred to OMED on [**5-24**], however, became quite anxious,
hypertensive and developed recurrent pulmonary edema requiring
transfer back to the ICU on [**5-25**]; her respiratory status quickly
normalized with diuresis as well as control of her anxiety and
blood pressure. She continued to improve o nthe floor, with IV
lasix 20mg [**Hospital1 **]
.
2 Hypertension, Diastolic heart failure: Patient was on regimen
of Diovan and Toprol at time of admission. These were
discontinued on the floor as her narcotics were uptitrated.
After extubation, she developed another episode of hypertension
in the setting of anxiety and was noted to have persistantly
elevated SBP, therefore her Diovan was restarted on [**5-25**]. She
was transferred to cardiology for optimization of her cardiac
regimen. Beta blocker was discontinued and her diovan was
uptitrated.
.
3 PAF: The patient has a history of paroxysmal atrial
fibrillation. Her INR was supratherapeutic at 3.5 at time of
admission on home dose of 4.5 mg qHS. On [**5-14**] the patient
developed Afib with RVR, developed pulmonary edema requiring
intubation. While in the ICU, her coumadin was discontinued due
to anticipated procedures. Several regimens for rate control
were trialed including diltiazem gtt, digoxin; the patient
flipped in and out of NSR and afib for several days, frequently
dropping her BP and requiring Neo while in Afib. EP was
consulted. She was loaded on Amio; she converted to NSR and
remained there for the remainder of her hospitalization with
intermittant brief periods of asymptomatic PAF, .
Coumadin was restarted on [**5-24**] and she reached therapeutic
levels prior to d/c.
.
4 Pain control: The pain team was consulted. The patient was
controlled with dexamethasone, tylenol, lyrica, tizanidine,
lidocaine patch, and PRN dilaudid.
.
5 Anxiety: The patient has significant anxiety which exacerbate
her HTN and atrial fibrillation. She was given ativan PRN with
good relief.
.
6 Metastatic breast cancer: The patient was continued on
tamoxifen. She will follow up with her primary oncologist for
further management.
.
7 Diarrhea: The patient developed diarrhea on [**5-24**]. She was
started empirically on PO Flagyl with improvement of her
symptoms. C Diff was negative x2. She will complete a 7 day
course of flagyl.
On the day of discharge, patient is feeling improved. She has
had good success with physical therapy, and her breathing feels
improved. Her blood pressure is well controlled and she is in
NSR.
Medications on Admission:
Diovan 40mg [**Hospital1 **]
Toprol 50mg [**Hospital1 **]
Coumadin 4.5 mg qhs
Timolol eye drops OD
Alphagan OU [**Hospital1 **]
Citrocal
Percocet 5-10mg q 4-6prn
Discharge Medications:
1. Tamoxifen 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS
(at bedtime).
9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed for pain.
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-10 units
Subcutaneous ASDIR (AS DIRECTED).
Disp:*500 units* Refills:*0*
12. Tizanidine 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
13. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
21. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
23. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
25. Outpatient Lab Work
INR check every thursday
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Rib fractures
Vertebral compression fractures
Metastatic breast cancer
Atrial fibrillation
Discharge Condition:
Afebrile, vital signs stable, tolerating POs.
Discharge Instructions:
You were admitted for pain control. You were found to have
several rib fractures, as well as multiple vertebral compression
fractures in your thoracic spine.
.
Additionally, you experienced 2 episodes of pulmonary edema
(fluid on the lungs). These may have been due to your atrial
fibrillation and hypertension.
A stress MIBI test showed normal myocardial perfusion.
Some of your medicines have been adjusted. Please take them
exactly as prescribed on the attached list.
Please take amiodarone 200mg daily
Please take valsartan 160mg twice a day.
Please continue to take the Flagyl for 3 more days to complete a
7 day course.
.
You should call Dr.[**Name (NI) 5327**] office if you are experiencing
fevers, shortness of breath, chest pain, confusion, or other
concerning symptoms.
Followup Instructions:
You should call Dr.[**Name (NI) 5327**] office to schedule a follow-up
appointment in [**6-19**] days: ([**Telephone/Fax (1) 5328**].
Please call Dr.[**Name (NI) 5329**] office at [**Telephone/Fax (1) 2936**] to make a follow
up appointment in 2 weeks.
Please follow up with Dr. [**Last Name (STitle) 5330**] in [**12-12**] weeks. Please call his
office for an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
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"284.8",
"402.91",
"733.19",
"276.1",
"787.91",
"300.00",
"564.00",
"V16.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.6",
"99.04",
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] |
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|
[
[
[]
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14104, 14119
|
8125, 11672
|
278, 303
|
14254, 14302
|
2849, 8102
|
15137, 15642
|
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|
11885, 14081
|
14140, 14233
|
11698, 11862
|
14326, 15114
|
2334, 2830
|
230, 240
|
331, 1147
|
1169, 2096
|
2112, 2273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,543
| 188,595
|
33374
|
Discharge summary
|
report
|
Admission Date: [**2178-7-27**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2095-5-7**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 83 year old with a history of HTN, glaucoma,
hyperlipidemia who presents with acute onset shortness of
breath.
Ms. [**Known lastname 77456**] was in her USOH until 4 days ago she developed acute
onset DOE associated w/ fatigue and new mild cough and feeling
as though she was gasping for air. She rested over the weekend
but on Monday decided to stay home as her sx had persisted w/ no
improvement but no worsening. She called her PCP and reported
her sx who referred her to the ED. She denies hemoptysis, sputum
production, lower extremity swelling, fever, chills, chest pain,
pleuritic pain, recent travel or any other associated sx. No
h/o prior clot, miscarriages or family h/o blood clot.
Of note, approximately 6 mo ago she suffered an L1 compression
fx which has left her sedentary w/ recommendation for bedrest.
She has had excruciating LBP and R hip pain w/ multiple recent
cortisone injections for trochanteric bursitis. She was a
previously active lady walking miles/day, working 4x/week and
athletic. She is uptodate on her cancer screening w/ colonscopy
every 3 years for colonic polyps and mammagrams.
In the [**Hospital1 18**] ED, initial vitals were: 96.8 110, 113/66, 16, 100%
on RA. Her physical exam was significant for L>R calves w/
associated tenderness. Labs were significant for d-dimer 6218,
troponin 0.05, creatinine 1.4, Hco3 20 and wbc 11.3. Given
elevated d-dimer and calf assymetry, LENIs were obtained and
revealed DVT of the left popliteal vein and a left peroneal
vein. A subsequent CTA of the chest showed saddle and segmental
PE, no pulmonary infarct and evidence of right heart strain. AN
EKG demonstrated RBBB. She was started on IV heparin with a
bolus. Blood pressures throughtout her ED stay were in the low
100s. A MICU bed was requested in the setting of saddle PE w/
R. Heart Strain. Vitals on transfer were:
This is an 83 yo F w/ no signficicant PMHx other than Fall in
[**Month (only) 404**] and has hip pain w/ limited ROM since that time. W/u for
fx has been negative. On thursday has had sudden onset dyspnea.
No orthopnea or PND. Denies lower extremity edema. No f/c. BS
are clear. HR in 80s. On exam left lower extremity was swollen
and tender. D-dimer is positive. Got a CTA and demonstrated
saddle PE + mass in renal. Started on heparin gtt w/ bolus. EKG
shows RBBB and ischemic inferior TWI which is old. Vitals on
transfer: 97.5, 109/70 85, 20, 100%ra.
On arrival to the MICU, 97.5 159/91 21 100% in 1L NC. She was
comfortable and had no complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Past Medical History:
1. Essential Hypertension
2. Hyperlipidemia
3. Severe stage glaucoma
4. Ptosis of both eyelids
5. Obesity
6. Gastritis
7. Osteopenia
8. Thalassemia
9. Cholelithiasis
10. Right Bundle Branch Block
11. Spinal Stenosis
Social History:
- Tobacco: negative
- Alcohol: negative
- Illicits: negative
- Housing: lives w/ son and has 4 children
- Employment: Works at the [**Location (un) 86**] Symphony 4days/wk
Family History:
Brother: [**Name (NI) 3730**]
Father: liver cirrhosis
Mother: Stroke
Physical Exam:
ADMISSION EXAM:
Vitals: 97.5 159/91 21 100% in 1L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: RRR no m/g/r
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: assymetric calves w/ no tenderness on palpation of the left
calf. There is a small superificial nodule likely not
representing a cord in the left posterior distal calf. no
cyanosis or edema.
Neuro: CNII-XII intact
DISCHARGE EXAM:
Vitals: 97.9, BP: 110-154/60-84, P 70-80, RR 20, 99% on RA
General: Pleasant elderly female in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Anisocoria
with left pupil 1-2mm larger than right pupil
Neck: supple, JVP not elevated, no LAD
CV: RRR no m/g/r
Lungs: Clear to auscultation bilaterally, no wheezes, faint
crackles bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm and well perfused, trace edema bilaterally, 2+ DP/PT
pulses
Neuro: CNII-XII intact, strength & sensation symmetrical
Pertinent Results:
ADMISSION LABS
[**2178-7-27**] 12:40PM BLOOD WBC-11.3*# RBC-5.38 Hgb-11.6* Hct-37.6
MCV-70* MCH-21.5* MCHC-30.8* RDW-15.9* Plt Ct-285
[**2178-7-27**] 12:40PM BLOOD Glucose-95 UreaN-35* Creat-1.4* Na-136
K-4.1 Cl-101 HCO3-20* AnGap-19
[**2178-7-27**] 12:40PM BLOOD Glucose-95 UreaN-35* Creat-1.4* Na-136
K-4.1 Cl-101 HCO3-20* AnGap-19
[**2178-7-27**] 08:35PM BLOOD CK(CPK)-48
[**2178-7-27**] 12:40PM BLOOD cTropnT-0.05*
[**2178-7-27**] 08:35PM BLOOD CK-MB-4
[**2178-7-27**] 12:58PM BLOOD D-Dimer-6218*
RELEVANT LABS:
[**2178-7-30**] 05:45AM BLOOD PT-11.3 PTT-74.7* INR(PT)-1.0
[**2178-7-31**] 06:05AM BLOOD PT-12.5 PTT-74.5* INR(PT)-1.2*
UA: large leukocytes, 29 WBCs, 1 epithelial cell
DISCHARGE LABS:
[**2178-8-3**] 06:10AM BLOOD WBC-10.4 RBC-5.65* Hgb-11.9* Hct-39.2
MCV-69* MCH-21.0* MCHC-30.3* RDW-15.9* Plt Ct-296
[**2178-8-3**] 06:10AM BLOOD PT-26.3* PTT-81.1* INR(PT)-2.5*
[**2178-8-3**] 06:10AM BLOOD Glucose-90 UreaN-16 Creat-1.2* Na-135
K-4.1 Cl-97 HCO3-27 AnGap-15
IMAGING:
CTA:
1. Saddle pulmonary embolus with bilateral pulmonary emboli
involving all segmental pulmonary arteries. Right-to-left
deviation of the interventricular septum, compatible with right
heart strain. No evidence of pulmonary infarct.
2. Exophytic left renal upper pole lesion, incompletely imaged.
Renal
ultrasound may be obtained when clinically appropriate.
3. Several locules of air inferior to the pancreas, incompletely
imaged.
4. Wedge deformity of a lower thoracic vertebral body
CXR:
1. No radiographic evidence of acute cardiopulmonary process.
Please refer to same-day chest CTA for further details.
2. Wedge deformity of a lower thoracic vertebral body, of
unknown chronicity.
LENI:
IMPRESSION: Acute DVT of left popliteal and a left peroneal
vein.
Brief Hospital Course:
HOSPITAL COURSE:
This is an 83 year old with a history of HTN, glaucoma,
hyperlipidemia who presented with acute onset shortness of
breath and was found to have saddle pulmonary embolism. She was
treated with IV heparin and ultimately transitioned to coumadin.
She incidentally was noted to have a new renal mass which was
felt to be normal variant anatomy on ultrasound.
ACTIVE ISSUES:
# Saddle Pulmonary Embolism: Saddle PE on CTA. Evidence of RLE
DVT as possible source w/ associated calf assymetry. Possible
triggers included recent immobility in setting of back pain.
Hypercoagulability of malignancy was considered, but patient up
to date on screening and renal mass felt to be normal variant
anatomy. IVC filter was considered but deferred given that she
was hemodynamically stable and not hypoxemic, and TTE of her
heart revealed an estimated PA pressure of 34. Risk factors for
mortality included troponinemia and elevated creatinine which
both resolved before discharge. She was bridged on heparin gtt
and started on coumadin [**2178-7-28**]. INR at discharge was 2.5.
She was sent home on warfarin 3 mg daily (decreased from 6mg for
initiation of TMP/SMZ antibiotics for UTI) and fondaparinaux 7.5
mg DAILY. She will be followed by the [**Hospital **] Clinic at
[**Hospital1 **] Medical Assoc and her PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) **]
#UTI: Pt complained of urinary frequency [**8-2**]. UA +leuk, WBC.
Bactrim started [**8-2**], completed 2/3 days in-house.
#Left Renal Mass: Small renal mass was noted on CTA, for which
renal ultrasound was obtained and showed likely normal variant
anatomy (parenchymal bulge) vs. focal area of pyelonephritis.
Although pyelonephritis was not consistent with her clincal
picture, a UA was sent that was normal [**7-31**].
-Patient should have repeat renal imaging in three months, which
should be discussed with PCP
#Troponemia: Progression of RBBB noted on EKG with possible mild
RV strain in setting of [**Last Name (un) **] likely cause. Cardiac enzymes were
cycled and were not consistent with ACS.
#Acute Kidney Injury: [**Last Name (un) **] in setting of saddle PE was concerning
for poor cardiac output vs hypovolemia in setting of recent
fatigue. Her ace-inh and hctz were initially held. Renal
function gradually improved, but Cr increased again and was 1.2
on discharge, likely pre-renal. Encouraged patient to increase
po hydration. Please f/u with PCP, [**Name10 (NameIs) 32385**] Cr in 1 week.
#Hypertension: Blood pressure medications were initially held
because of potential for hemodynamic instability and [**Last Name (un) **], but on
arrival to the floor hydrochlorothiazide was restarted when BPs
began to increase. Lisinopril was not restarted secondary to
[**Last Name (un) **].
#Documented history of Hyperlipidemia: She was continued on
simvastatin 10mg daily
#Documented history of GERD: She was clinically stable on
omeprazole.
#Documented history of glaucoma: she was clinically stable on
regimen of brimonidine, latanoprost and dorzolamide.
TRANSITIONAL ISSUES:
#RBBB on EKG had progressed since [**2174**] recent EKG that should be
followed
#Recheck Cr in 1 week
#repeat renal imaging in 3 months.
#DNR/I status should be confirmed at each hospitalization. No
pending labs/studies
Medications on Admission:
1. Acetaminophen 500 mg Oral Tablet 2 tablets twice a day
2. Brimonidine 0.2 % Ophthalmic Drops Instill 1 drop in both
eyes twice daily
3. Latanoprost (XALATAN) 0.005 % Ophthalmic Drops instill one
drop in each eye AT BEDTIME
4. Lisinopril 5 mg Oral Tablet 1 TABLET DAILY
5. Simvastatin 10 mg Oral Tablet 1 tablet every evening for
cholesterol
6. Hydrochlorothiazide 25 mg Oral Tablet TAKE ONE TABLET DAILY
7. Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1
capsule 30 minutes before first meal of day
8. Dorzolamide-Timolol 2-0.5 % Ophthalmic Drops 1 drop in each
eye twice daily
9. Midnite Sleep Aid (melatonin)
Discharge Medications:
1. brimonidine *NF* 0.2 % OU [**Hospital1 **]
2. Acetaminophen 1000 mg PO BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
4. Hydrochlorothiazide 25 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 10 mg PO DAILY
8. Fondaparinux Sodium 7.5 mg SC DAILY
Please administer 1 hour after discontinuing heparin drip
RX *fondaparinux 7.5 mg/0.6 mL inject 7.5 mg daily for blood
clot DAILY Disp #*7 Syringe Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 3 Days
evening [**8-2**] at 18:30
RX *Bactrim DS 800 mg-160 mg 1 Tablet(s) by mouth twice a day
Disp #*4 Capsule Refills:*0
10. Warfarin 3 mg PO DAILY16
RX *Coumadin 1 mg 3 Tablet(s) by mouth DAILY Disp #*30 Capsule
Refills:*0
11. melatonin *NF* 0 units ORAL HS
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis: Saddle Pulmonary Embolism
Secondary diagnosis: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory.
Discharge Instructions:
It was a pleasure caring for you during your hospitalization for
saddle pulmonary embolism (a blood clot in the lungs). When you
came in you were short of breath, and a CAT scan of the lungs
showed that there was a large blood clot in the blood vessels of
the lungs. In the intensive care unit you were started on
heparin, a blood thinner, which was continued on the regular
medicine floor until we started you on coumadin and your INR (a
measurement of how well blood thinners are working) was high
enough. Physical therapy saw you while you were here and felt
you would benefit from further physical therapy at home.
It is very important that you follow up with your PCP who will
be setting you up at the [**Hospital1 **] [**Hospital3 **]
so that your INR can be measured frequently. It is also
important that avoid leafy greens that can interfere with the
activity of coumadin.
The CAT scan and kidney ultrasound you had while admitted showed
a small bump on your left kidney which is most likely a normal
variation of anatomy, but you should undergo repeat ultrasound
in three months and this should be discussed with your PCP.
Followup Instructions:
1. Primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) **]
Monday, [**8-10**] at 10:50 AM
Completed by:[**2178-8-4**]
|
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"584.9",
"278.00",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11532, 11581
|
6665, 6665
|
304, 310
|
11704, 11704
|
4887, 5577
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|
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11668, 11683
|
11621, 11647
|
11719, 11817
|
3177, 3396
|
3412, 3589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,641
| 148,735
|
35944
|
Discharge summary
|
report
|
Admission Date: [**2122-11-5**] Discharge Date: [**2122-11-11**]
Date of Birth: [**2047-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2122-11-5**] Aortic valve replacement with a size 27 [**Company 1543**]
porcine tissue valve, Coronary artery bypass graft x2; left
internal mammary artery to left anterior descending artery and
saphenous vein graft to obtuse marginal.
History of Present Illness:
This is a 75 year old male with myasthenia [**Last Name (un) 2902**] with history
of moderate to severe aortic stenosis. Noted to have drop of EF
from 50-30% so referred for cardiac cath to further evaluate.
Cath revealed two vessel coronary artery disease and he was
referred for AVR/CABG.
Past Medical History:
Aortic stenosis/Coronary Artery Disease
Hypertension
Hyperlipidemia
Myasthenia [**Last Name (un) 2902**]
Prostatism
Ureter perforation(awaiting surgical repair)
History of dysphagia
s/p 3 cycles IVIG [**2119**], [**2120**]
Past Surgical History:
s/p Recent Teeth Extractions
s/p Prostate procedure - complicated by ureter perforation
s/p Penile implant
s/p Knee replacement
s/p Cataract surgery
Social History:
Occupation: Retired
Last Dental Exam: 2-3 weeks ago
Lives with: wife
[**Name (NI) **]:Caucasian
Tobacco: quit cigars/pipe 1 month ago.
ETOH: [**3-18**] drinks/week
Family History:
Father history unknown. No siblings. Mother died of cancer. No
premature CAD.
Physical Exam:
Pulse: 72 Resp: 16 O2 sat: 100% BP: 130/89
Height: 71 inches Weight: 77.3 kg
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] 3/6 SEM best heard at RUSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x] bilateral GSV very prominent and
superificial
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit transmitted murmur
Pertinent Results:
[**11-5**] Echo: PREBYASS: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is severely depressed (LVEF= 20 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr. [**Last Name (STitle) 7772**] was notified in person.
POSTBYPASS:The patient is on Epi @0.2mcg/kg/min ,
levo@.2mcg/kg/min There is now a 27 bioprosthetic valve in place
The mean gradient across the valve is 10 with no paravalvular
leaks The EF is 20%,no dissection flaps seen in the aorta. The
rest of the exam in unchanged
[**2122-11-5**] 01:16PM BLOOD WBC-17.5*# RBC-3.30*# Hgb-9.3*#
Hct-28.8*# MCV-87 MCH-28.2 MCHC-32.3 RDW-14.2 Plt Ct-148*
[**2122-11-6**] 05:07PM BLOOD WBC-11.7* RBC-2.97* Hgb-8.6* Hct-25.1*
MCV-85 MCH-28.8 MCHC-34.0 RDW-14.8 Plt Ct-101*
[**2122-11-10**] 05:35AM BLOOD WBC-8.1 RBC-3.78* Hgb-11.0* Hct-32.7*
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.2 Plt Ct-157
[**2122-11-5**] 11:49AM BLOOD PT-18.8* PTT-36.7* INR(PT)-1.7*
[**2122-11-9**] 03:24AM BLOOD PT-13.1 PTT-30.6 INR(PT)-1.1
[**2122-11-6**] 03:13AM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-134
K-4.9 Cl-108 HCO3-23 AnGap-8
[**2122-11-10**] 05:35AM BLOOD Glucose-92 UreaN-26* Creat-0.7 Na-137
K-4.2 Cl-101 HCO3-30 AnGap-10
[**2122-11-8**] 03:48AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 81628**] was a same day admit after undergoing pre-admission
work-up as an outpatient. On [**11-5**] he was brought to the
operating room where he underwent an aortic valve replacement
and coronary artery bypass graft x 2. Please see operative
report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. On post-op day one he was weaned from sedation, awoke
neurologically intact and extubated. Speech and swallow were
consulted to do patients history and rule out aspiration while
eating and drinking. He required aggressive pulmonary toilet and
multiple drips for BP support. Chest tubes and epicardial pacing
wires were removed per protocol. On post-op day 4 he was
transferred to the telemetry floor for further care. He
continued to progress and was ready for discharge home wiht
services on post operative day six.
Medications on Admission:
Aspirin 81mg daily, Lisinopril 20mg daily, Lipitor 20mg daily,
Cellcept 250mg TID, Mestinon 60mg [**Hospital1 **], MVI daily, Vit B12
1000mcg daily, Vit 1000 IU daily, Folic Acid daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): until follow up with urologist .
Disp:*60 Tablet(s)* Refills:*0*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
6. CellCept [**Pager number **] mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*0*
7. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary Artery Disease s/p coronary artery bypass graft
Acute systolic heart failure
Hypertension
Hyperlipidemia
Myasthenia [**Last Name (un) 2902**]
Prostatism
Ureter perforation (awaiting surgical repair)
History of dysphagia
s/p 3 cycles IVIG [**2119**], [**2120**]
Past Surgical History:
s/p Recent Teeth Extractions
s/p Prostate procedure - complicated by ureter perforation
s/p Penile implant
s/p Knee replacement
s/p Cataract surgery
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 17029**] in [**2-17**] weeks
Dr. [**Last Name (STitle) 1911**] in [**1-16**] weeks
These appointments have already been made for you:
[**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD Phone:[**0-0-**] Date/Time:[**2123-1-26**]
1:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2123-1-26**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2122-11-12**]
|
[
"V13.02",
"358.00",
"428.23",
"401.9",
"998.11",
"E870.8",
"V45.81",
"424.1",
"998.2",
"272.4",
"V43.65",
"V43.3",
"428.0",
"518.5",
"414.01",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"96.6",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6528, 6596
|
4220, 5128
|
333, 573
|
7106, 7112
|
2320, 4197
|
7653, 8178
|
1508, 1587
|
5363, 6505
|
6617, 6911
|
5154, 5340
|
7136, 7630
|
6934, 7085
|
1602, 2301
|
281, 295
|
601, 893
|
915, 1138
|
1327, 1492
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,317
| 116,357
|
11068
|
Discharge summary
|
report
|
Admission Date: [**2112-2-17**] Discharge Date: [**2112-2-22**]
Date of Birth: [**2037-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Mercury (Elemental) / Iodine / Magnesium
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Right upper lung nodule
Major Surgical or Invasive Procedure:
[**2112-2-17**]
OPERATIONS:
1. Right thoracotomy.
2. Lysis of adhesions.
3. Wedge resection of right upper lobe.
4. Creation of pleural tent.
History of Present Illness:
74M who presented with a surveillance chest CT scan on
[**2111-11-30**] which disclosed a new area of linear density within
the right apex. This was new when compared to a CT scan in [**Month (only) 116**].
In addition, the scan in [**Month (only) **] showed enlargement of a right
hilar node that is 3 cm in size and was not seen on previous
examination. A PET CT scan performed on [**2111-12-5**] demonstrated
the right apex linear area to be FDG avid. In addition, the
right hilar node is also FDG avid with an SUV of approximately
5.5. To evaluate his mediastinum and hilar lymph nodes
completely he underwent a combined endobronchial ultrasound
along with a cervical mediastinoscopy on [**2112-1-4**] pathology of
the mediastinoscopy revealed florid reactive follicular
hyperplasia Sinus histiocytosis with anthracosis; EBUS revealed
only atypical cells. He presents for follow up for further
options for treatment.
Past Medical History:
Non-Hodgkin's large cell lymphoma diagnosed in [**2102**] and treated
with chemotherapy.
DVT and pulmonary embolus s/p IVC filter placement [**2102**]
PAST SURGICAL HISTORY:
Bilateral inguinal hernia repairs in [**2100**] and [**2106**]
Lymph node biopsy in [**2102**].
He has also had bilateral cataracts as well.
Social History:
Remote hx of tobacco, quit 14 yrs ago. Social etOH. Denies
illicit substances. Currently married and lives with his wife.
Family History:
Non-contributory for coronary artery disease, arrhythmia or SCD.
Physical Exam:
VS: Temp: 99.7, HR 90 reg, BP 108/54, RR 20, O2 sats 93% on 3L
NC, with desaturation to 84% on 2L NC while walking. O2 sats low
90's on 3LNC while walking.
Physical Exam:
Gen: pleasant in NAD
Chest: right thoractomy site healing without redness, purulence
or drg.
Lungs: clear bilaterally t/o
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, no edema
Pertinent Results:
[**2112-2-21**] 05:53AM BLOOD WBC-7.8 RBC-2.60* Hgb-8.5* Hct-24.7*
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.6 Plt Ct-193
[**2112-2-21**] 05:53AM BLOOD WBC-7.8 RBC-2.60* Hgb-8.5* Hct-24.7*
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.6 Plt Ct-193
[**2112-2-19**] 02:20AM BLOOD WBC-8.0 RBC-2.77* Hgb-8.9* Hct-27.0*
MCV-98 MCH-32.2* MCHC-33.1 RDW-14.6 Plt Ct-194
[**2112-2-21**] 05:53AM BLOOD Plt Ct-193
[**2112-2-22**] 06:30AM BLOOD K-3.5
[**2112-2-22**] 06:30AM BLOOD Phos-1.8* Mg-1.7
[**2112-2-22**] CXR
In comparison with study of [**2-21**], the central catheter has been
removed. There is no evidence of pneumothorax. There is
decreasing right
apical and lower neck subcutaneous gas. Little change in the
appearance of
the heart and lungs.
Brief Hospital Course:
Mr. [**Known lastname 15532**] was taken to the operating room on [**2112-2-17**] where he
underwent right thoractomy and right upper lobe wedge resection
for tissue diagnosis of right upper lobe nodule. The patient
remained in the PACU and required transfer to the ICU for
hypotension and neosynephrine. He was given fluid and his
epidural for pain was eventually changed to PCA dilaudid. He was
eventually weaned off the neo and improved. He was transfered to
the floor on [**2112-2-20**]. Both chest tube were removed by [**2112-2-21**].
The patient's chest xray on [**2112-2-22**] revealed no PTX and
decreasing subcutaneous air. The patient was seen by PT and felt
to be safe to discharge home. He required oxygen, and was sent
home on 3L NC. Dr. [**First Name (STitle) **] cleared him for discharge home on [**2112-2-22**]
and will follow up with the patient in two weeks with chest xray
in clinic.
Medications on Admission:
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - [**1-23**]
Tablet(s) by mouth every four (4) hours as needed for pain no
driving, no alcohol, do not take with tylenol
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: see your PMD on [**2112-2-24**] on Wednesday for INR check and dosing
of coumadin.
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: take stool softeners while on narcotics .
8. home oxygen
3liters nasal cannula continuous pulse dose for portability. O2
sats 84% ambulating on 2Liters, but increased to >89% on 3LNC.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
right upper lobe pulmonary nodules
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Call Dr. [**First Name (STitle) **] if you have fevers >101.5, chills, shakes, sweats,
worsening shortness of breath, chest pains or any other
problems.
[**Name (NI) **]: [**Telephone/Fax (1) 2348**]
-[**Name2 (NI) **] may shower, but keep chest tube site covered with bandaid
for a few more days until healed.
-Call if your chest incision opens, drains, becomes angry red,
purulent (puss) or if you have bad pain near this area.
-Use oxygen as needed.
check.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2112-3-8**] 10:00am
on [**Hospital1 18**] [**Location (un) **] [**Hospital Ward Name 23**] center. Go to [**Location (un) **] radiology 30
minutes before your appointment.
Completed by:[**2112-2-23**]
|
[
"E878.8",
"V45.61",
"V10.79",
"V45.89",
"458.29",
"785.6",
"518.89",
"492.8",
"V12.51",
"511.0",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"40.11",
"34.99",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5197, 5280
|
3140, 4046
|
331, 475
|
5359, 5359
|
2389, 3117
|
5989, 6262
|
1926, 1993
|
4273, 5174
|
5301, 5338
|
4072, 4250
|
5504, 5966
|
1627, 1770
|
2179, 2370
|
268, 293
|
503, 1430
|
5373, 5480
|
1452, 1604
|
1786, 1910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,799
| 173,104
|
21086
|
Discharge summary
|
report
|
Admission Date: [**2151-11-19**] Discharge Date: [**2151-12-8**]
Date of Birth: [**2100-4-18**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
abdomen pain, altered mental status
Major Surgical or Invasive Procedure:
Intubation [**2151-11-19**]
Arterial line [**2151-11-20**]
Thoracentesis
Bronchoscopy
History of Present Illness:
Pt is a 51 y/o male with a PMH of etoh abuse with withdrawal
seizures 5 years ago, 4 days prior to admssion developed RUQ
pain, (prior to which he was drinking 1 quart of wine/vodka per
day). Subsequently, pt noted mild RUQ pain, nausea with 1-2
episodes per day, with 3 days of diarrhea with 5 small watery
BMs qd with very poor po intake. Also, over the last 2 days, pt
noted a frontal headache, severe in intensity attributed to his
usual severe HAs, no photophobia, no neck stiffness, no recent
head trauma, but his partner noticed increased somnolence over
the past 2 days is sleeping 16 hours per day. On day of
admission, pt noticed to have episode of tongue biting, fecal
and urinary incontinence and post-ictal confusion but the
seizure itself was not witnessed. No alcohol in the past 4 days
per pt. Pt had one episode of withdrawal seizures 5 years ago
and ?seizure this past [**Month (only) 205**] attributed to Antabuse. In the ED,
he was given IV valium X 2, Banana bag and one liter IVF. Noted
to be in NSVT with HR 200 BP 101/80. Vagal massage, adenosine
X2 given, amio loaded and IV metoprolol 25mg X1. Head CT was
negative in ED for intracranial bleed.
.
Otherwise, ROS positive for 3 week h/o cough prod of yellow
sputum, reports tested for TB 1.5 years ago, was negative per
pt.
.
History of Present Illness
Pt is a 51 y/o male with a PMH of etoh abuse with withdrawal
seizures 5 years ago, with abdominal pain x 4 days. He developed
RUQ pain, nausea with 1-2 episodes per day, with 3 days of
diarrhea with 5 small watery BMs qd with very poor po intake.
The pt's partner noted that the pt had somnolence, decreased
mental status. On day of admission, pt noticed to have episode
of tongue biting, fecal and urinary incontinence and post-ictal
confusion but the seizure itself was not witnessed. The pt
denies alcohol in the past 4 days prior to admission. Pt had one
episode of withdrawal seizures 5 years ago and ?seizure this
past [**Month (only) 205**] attributed to Antabuse.
In the ED, he was given IV valium X 2, Banana bag and one liter
IVF. Noted to have an SVT with HR 200 BP 101/80. Vagal massage,
adenosine X2 given, amio loaded and IV metoprolol 25mg X1. Head
CT was negative in ED for intracranial bleed.
Hospital course:
The was noted to be hypoxic and lethargic, he was intabated and
admitted to the [**Hospital Unit Name 153**]. He was treated for aspiration pneumonia
with IV abx since [**11-22**] ceftriaxone/azitro/clinda, switched to
levo alone [**11-24**] when sputum cx showed klebsiella,
pan-sensitive. LP was done to rule out meningitis. EEG showed
diffuse slowing, no signs of seizure activity. Pt was noted to
have a-fib for the first 2 days, which resolved. Aclaculous
cholecytitis was noted on [**11-27**], pt went for percutaneous gall
bladder drain, placed by IR. Flagyl was added to his
levofloxacin to cover anaerobes. He recieved 3 days of flagyl
before being switched to zosyn and vanco. The mental status and
respiratory status improved.
Past Medical History:
Past Psychiatric History:
No prior inpatient psychiatric admissions.
No hx of suicide attempts.
No hx of violence.
Pt began having occasional panic attacks while in college. He
believes he became depressed at that time, saw a psychiatrist a
few times, and briefly took a medication but does not recall the
name.
In the past year and a half, he has been on Zoloft X 3 months,
Prozac, Celexa, Elavil, Klonopin, and Wellbutrin for at least
six months,
prescribed by various psychiatrists he saw while living in
[**Location (un) 20180**], [**State 1727**]. None of these medications were found to be
helpful.
Took BuSpar which caused tingling sensation in hands.
Past Medical History:
PMH:
1. Panic attacks
2. GERD
3. Hypercholesterolemia
4. Suicidal ideation
5. History of withdrawal seizures in past, pt reports [**5-11**]
seizures. Last one was [**Month (only) 205**] attributed to Antabuse, and one
episode 5 years ago.
Social History:
Substance Abuse History:
EtOH: Initially reported only occasional alcohol use, and that
he drank "half a glass of wine" prior to admission. The pt has a
history of alcohol abuse since age 14, which is now alcohol
dependence, drinking upto a quart of vodka daily. H/o 1
withdrawal seizure 3 or 5 yrs ago, denies hx of DTs.
Tobacco: Smokes half pack per day
Denied illicit drug use.
He reports taking Klonopin only as prescribed, and uses no more
than 3mg po qd. He reports his drinking has increased over the
past two weeks since he has had more problems with his partner.
[**Name (NI) **] appears ambivalent about his drinking and when asked he he
considered it a problem, stated ??????I can control it.??????
Detox: twice in the past, the last was five years ago.
His longest time sober was 2 years ago when he had 5-5 months of
sobriety thorugh ??????determination.?????? He states he is ??????not wild??????
about AA. He reports he has tried to cut down and has guilty
feelings about drinking but denies feeling angry about
discussing drinking or having eye openers.
Social History:
Born and raised in [**State 350**], third of four children. His
father was physically and emotionally abusive, mother was not
very supportive. Pt. was close to his sister who died last
summer of lymphoma, he has very little contact with his other
siblings.
Graduated from [**Location 55977**]in [**Location (un) 86**], worked as a
phlebotomist for 26 years, used to play piano and sing in night
clubs. Currently unemployed.
He had been in a monogamous relationship with his previous
partner for the past 9 years, they are in the process of
breaking up.
About one year ago, Mr. [**Known lastname 55978**] and his partner moved from
[**Name (NI) 20180**], ME to [**Name (NI) 2312**], MA. They now live in his partner's
Section 8 housing in [**Location (un) 2312**].
Mr. [**Known lastname 55978**]??????s partner, [**Name (NI) **] has HIV, HCV, and ?alcohol
abuse/dependence and works as a banquet manager. Mr. [**Known lastname 55978**]
describes him as his only support, and stated ??????I??????m okay as long
as he??????s there.?????? The patient believes [**Male First Name (un) **] may be having an affair
and thinks he will be evicted form their home. The pt recalled
that last year he bought [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] because [**Male First Name (un) **] was unable to
work. Now the pt is without work and is being supported by [**Male First Name (un) **]
and wants to apply for disability.
Family History:
Mother with depression, positive h/o seizures in his niece
Physical Exam:
t97.1, bp 122/61, p 140, r 16, 93%
PERRL
OP clr, dry MMM
neck supple, no kernig's/brudzinski's
Regular s1,s2. no m/r/g
+dullness at R apex. Decreased bs at RUL
+bs, soft nt, nd.
no le edema
Pertinent Results:
[**2151-11-19**]: CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST:
IMPRESSION: No acute intracranial hemorrhage or mass effect. No
fracture.
.
[**2151-11-22**] EEG
IMPRESSION: Abnormal EEG due to marked slowing in the record
overall
with decreased voltages combined with subtle delta bursts and
runs and
one brief blunted sharp and slow wave complex involving the
central
regions predominantly with a leftsided predominance. No
definitive
discharges were, however, seen. No response to one instance of
noxious
stimulation was noted. The record suggests a diffuse mild to
moderate
encephalopathy with some suspicion of left central focality on
one
occasion. The record, otherwise, would suggest a diffuse
possibly
subcortical or deeper midline process possibly related to
hypoxia or to
medications which the patient was receiving or to a post-ictal
state.
.
CXR [**2151-11-19**]
CHEST AP: There is a consolidation involving the right upper
lobe. The heart size, mediastinal and hilar contours are
unremarkable. There are no pleural effusions. The pulmonary
vasculature is normal. The surrounding soft tissue and osseous
structures are unremarkable.
IMPRESSION: Right upper lobe pneumonia.
.
[**2151-11-27**] CXR
Extensive consolidation in the right upper lobe is present, and
this is more severe than on [**2151-11-26**]. Left lung is clear. The
heart is normal in size. An NGT terminates in the stomach, an
ETT terminates approximately 6 cm above the carina. There is no
pneumothorax.
IMPRESSION:
Worsening right upper lobe pneumonia since [**2151-11-26**].
.
Chest/Abd CT [**2151-12-1**]:
IMPRESSION:
1. Right upper lobe consolidation consistent with pneumonia.
Also seen are areas of infiltrate in the left upper and lower
lobes. Bilateral pleural effusions. Right lower lobe also
demonstrates evidence of atelectasis/collapse as well as some
consolidation.
2. No evidence of pulmonary embolus.
3. Cholecystostomy tube in good position.
4. Sigmoid diverticulosis without evidence of diverticulitis.
.
Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS
.
RUQ US [**2151-11-26**]:
IMPRESSION:
1. Findings consistent with acute cholecystitis without evidence
of definite gallstones. Sludge is present withinthe gallbladder
2. Hypoechoic area is seen near the gallbladder as described
above. Follow-up ultrasound is recommended when patient is
clinically stable.
3. Echogenic liver consistent with fatty liver. However, other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
T-Tube cholangiogram, [**2151-12-7**]:
FINDINGS: A preliminary scout view of the abdomen demonstrates a
cholecystostomy tube in the right upper quadrant. Approximately
20 cc of Optiray contrast was then gently instilled into the
drainage catheter with careful fluoroscopic monitoring. There is
prompt opacification of the cystic duct and common bile duct as
well as prompt emptying into the bowel. The common bile duct and
visualized intrahepatic ducts appear normal in caliber without
evidence of filling defects. There is no evidence of contrast
extravasation. There is a slightly bulbous configuration of the
distal common bile duct near the ampulla without evidence of
stricture.
IMPRESSION: Prompt passage of contrast from the gallbladder into
the common bile duct and into the duodenum without evidence of
significant stenosis, filling defects, or evidence of biliary
duct dilatation.
ALT/AST/LDH/CPK/Alk Phos/Amylase/T bili
.[**2151-12-7**] 05:55AM 20 17 236 121* 62 0.7
LFT ADDED [**12-7**] @ 12:40
[**2151-12-5**] 04:53AM 21 23 210 119* 60 0.7
[**2151-12-4**] 06:00AM 24 30 219 132* 0.7
ADD ON
[**2151-12-3**] 07:52AM 27 40 205 135* 52 0.6
HAPTO & TBIL ADDED [**12-3**] @ 09:42
[**2151-12-2**] 06:00AM 163 0.6 0.3 0.3
@Trough
[**2151-12-2**] 04:00AM 27 29 178 103 42 0.5
[**2151-12-1**] 03:45AM 28 23 205 87 45 0.6
[**2151-11-30**] 03:51AM 39 22 172 99 47 0.4
[**2151-11-29**] 04:45AM 57* 31 176 114 53
[**2151-11-28**] 05:24AM 91* 52* 170 141* 0.8
[**2151-11-26**] 03:56AM 123* 246* 300* 171* 46 1.5
[**2151-11-25**] 04:04AM 53* 102* 251* 111 33 1.4
[**2151-11-21**] 04:28AM 29 40 183 146 43 30 0.7
[**2151-11-20**] 02:40PM 124
[**2151-11-20**] 05:01AM 30 43* 225 185* 38* 23 0.7
ADD ON
[**2151-11-19**] 06:50PM 121
[**2151-11-19**] 06:50PM 46* 48* 229 53 24 1.4
.
Brief Hospital Course:
51 yo M h/o EtOHism and withdrawal seizures developed
klebsiella PNA requiring intubation for several days, and later
acalculous cholecystitis s/p drain [**11-27**], recuperated over the
subsequent couple of weeks, discharged to home [**12-8**] in stable,
although still recuperating condition.
.
1. Klebsiella Pneumonia:
He required a high minute ventilation, produced copious amounts
of yellow brown sputum, CXR revealed multifocal PNA, prominent
in RUL. The PNA was likely a result of aspiration in the
setting of seizure. Sputum culture revealed Klebsiella sensitive
to levofloxacin (pan sensitive). He was continued on
levofloxacin for 6 days but continued to spike fevers, so was
switched to vancomycin and zosyn to cover ventilator acquired
pseudomonas and MRSA. He continued to spike 48 hours into this
regimen but subsequent blood and soutum cultures were
unremarkable. His vancomycin was found to be subtherapeutic and
his dosing was changed to q8h. His fevers resolved, but he
continued to required significant PEEP and FiO2. He often became
agitated at which time her would desat and become hypertensive
with SBPs in the 200's. He required large amounts of versed and
fentanyl and had to be started on propofol to prevent his
extreme agitation. Given that he was not improving a CT chest
was obtained revealing bilateral pleural effusions and RUL and
RLL consolidations and collapse. A thoracentesis was performed
that yielded 900cc of exudative serous fluid classified as an
uncomplicated effusion. Given that none of his subsequent sputum
cultures revealed an organism, brochoscopy was performed to
obtain better samples and assess for obstruction. No obstruction
was noted. On Day 15 of his hospital stay he self-extubated in
the setting of agitation. He was satting 96-99% 100%
non-rebreather and appeared confortable. He continued to
maintained his O2 sats and was alert awake and oriented.
Vancomycin and zosyn were continued as he remained afebrile on
this regimen. The pt was stable and tranferred to the medicine
floor, his abx were changed to PO levo/flagyl. He was satting
well on RA at this time, breathing comfortably.
.
2. Acalculous cholecystitis:
This was identified by elevated liver ensymes on [**11-26**], noted to
have ALT/AST 123/246 alk phos 171. t bili 1.5. RUQ US on [**11-27**]
revealed findings c/w acalculous acute cholecystitis. Given the
high risk for surgery at that time, perrcutaneous gall bladder
drain was placed by IR. Flagyl was added to his levofloxacin to
cover anaerobes. He recieved 3 days of flagyl before being
switched to zosyn and vancomycin. His drain had good oputput and
subsequent Ct abdomen revealed no gall bladder wall thickening
or edema. His LFTs continued to trend down and he had no
complaints of abdominal pain. When the pt arrived at the
medicine floor, he was reevaluated by the interventional
radiology team and a plan for follow-up was established. A
surgery evaluation was obtained as well, with a plan for surgery
to be performed after several weeks. The pt was noted to have
continued output from the gallbladder drain, there was initial
concern that the output could be a sign of obstruction in the
common bile duct or ampulla, although a cholangiogram was
performd through the drainage tube which revealed no evidence of
obstruction. The gastroenterology consultants evaluated the pt
and agreed that there was no need for ERCP prior to hospital
discharge.
.
3. Acute encephalopathy:
This was orginally though to be delirium tremens vs post-ictal
state after seizure due to alcohol withdrawal v.
encephalitis/meningitis. An LP was performed and was negative
for bacterial/viral meningitis. His EEG showed marked slowing
overall with decreased voltages combined with subtle delta
bursts with left sided predominance. Diffuse mild to moderate
encephalopathy with possible left central focality thought to be
post-ictal state vs. medication induced. He was started on
multivitamin, folate, thiamine and B12. The plan was for the pt
to have a neurology follow up arranged to determine whether he
would need anti-epileptic prophylaxis. The pt continued to have
a waxing and [**Doctor Last Name 688**] mental status during his last days in the
unit which was resolving and the did resolved after the first
day on the medicine floor. The pt was noted to be at his
baseline metal status at discharge.
3. Atrial fibrillation:
On transfer to the [**Hospital Unit Name 153**] patient was in NSR. Per patient. he goes
into Afib when having withdrawals from alcohol. He was ruled out
for MI and his ECG showed no acute changes. He was initially on
diltiazem drip which was discontinued. He was continued on
telemtry and had no further episodes of afib.
.
4. Anemia:
His labs were consistent with anemia of chronic disease. His
folate and B12 were within normal limits. His iron stores were
normal. He did not require any blood transfusions as his
hematocrit remained stable in the mid to high 20's.
.
5. Reactive thrombocytosis:
The pt was noted to have an elevated platelet count which
developed during the ICU stay, and continued to rise to the
800's and once in 900's on the floor. This was assessed to be a
reactive thrombocytosis, developing after the acute illness in
the ICU. The plan was to monitor the pt as an outpatient for the
resolution of the reactive thrombocytosis.
.
6. FEN: While intubated he was started in tube feeds. He was
briefly hypernatremnic, but this resolved with increasing free
water and his sodium then remained stable
.
7. PPX: PPI, HSQ
.
8. Code: Full
.
Medications on Admission:
1. Venlafaxine HCl 37.5 mg Capsule, Sust. Release 24HR Sig:
Three (3) Capsule, Sust. Release 24HR PO once a day.
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Seroquel 25 mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for anxiety.
6. Disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Outpatient Lab Work
Please check a chem-7 and cbc weekly. Please have the results
sent to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4844**] at
phone # [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Klebsiella gram negative pneumonia
acute cholecystitis
alcohol withdrawal
stable anemia
Discharge Condition:
stable
Discharge Instructions:
Please make sure to attend all follow up appointments as
scheduled.
.
Please note that you are taking antibiotics to cover your
infection
These medications are the levofloxacin and the metronidazole
which you should continue to take for 5 days.
Followup Instructions:
1. Please call your primary care, physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4844**]
to schedule an appointment within 1-2 weeks, [**Telephone/Fax (1) 250**].
.
2. Please discuss with Dr. [**Last Name (STitle) 4844**] considering a neurology
appointment to discuss whether you should take a medicine to
prevent seizures.
.
3. Please call your psychiatry doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] to schedule
an appointment within a couple of weeks.
.
4. Please make sure to connect yourself with the alcoholics
anonymous services in your area that you are familiar with as we
have discussed.
.
5. Please note that you will be followed for your drain with the
nurse practitioner, [**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) 5545**] who will call to check up
on your progress weekly. If you have questions or need to
contact her regarding your gallbladder drain, please call
[**Telephone/Fax (1) 5546**].
.
6. You have an appointment to see the [**Name (NI) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD,
regarding the plan to have surgery to take out your gallbladder
8 weeks as we have discussed. Your appointment is at 10:00am on
[**2152-1-6**] in the [**Hospital Ward Name 23**] Building. If you have any questions,
please call ([**Telephone/Fax (1) 10820**].
|
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"427.31",
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"291.81",
"303.90",
"482.0",
"300.21",
"511.9",
"305.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.98",
"96.72",
"51.01",
"38.91",
"33.24",
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] |
icd9pcs
|
[
[
[]
]
] |
18941, 18999
|
11728, 17289
|
310, 398
|
19131, 19140
|
7258, 11704
|
19433, 20839
|
6971, 7031
|
17980, 18918
|
19020, 19110
|
17315, 17957
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2692, 3431
|
19164, 19410
|
7046, 7239
|
235, 272
|
426, 2675
|
4136, 4383
|
5486, 6955
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,268
| 194,725
|
39340
|
Discharge summary
|
report
|
Admission Date: [**2148-10-6**] Discharge Date: [**2148-10-18**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
"headache, confusion"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 89 year old woman who lives at home alone. She is a
poor historian but able to tell me that she has been recently
confused with increasing headache level [**7-27**]. She states that
her headache is frontal across the brows. She denies recent
falls, loss of consiousness, nausea, vomiting, weakness,
numbness or tingling sensation, bowel or bladder incontinence.
She
ambulates independently at home without cane or walker. She
reported that her son was concerned about her blood pressure and
brought her to [**First Name4 (NamePattern1) 86990**] [**Last Name (NamePattern1) 3549**] hospital in [**Location (un) 1110**]. CT imaging
showed a right frontal hemorrhage and she was transfered to
[**Hospital1 18**].
Past Medical History:
hypertension, increased cholesterol, chronic low back pain,
arthritis, skin CA removed on left face and over abdomen
Social History:
lives at home alone
Family History:
3 sisters with breast CA
Physical Exam:
PHYSICAL EXAM:On Admission
O: T: 97.2 BP: 140/72 HR:67 R:16 O2Sats: 92%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-2mm EOMs:intact
Abd: Soft, NT.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam but slow,
normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-19**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-22**] throughout. No pronator drift
Sensation: Intact to light touch except L5 decreased bilat,
propioception, pinprick and vibration bilaterally.
Toes downgoing bilaterally
Coordination: finger-nose-finger slower on left, rapid
alternating movements, heel to shin slightly slower on left
CT [**2148-10-6**]:right frontal CVA verses hemorhage with 7 mm midline
shift. Will need MRI with and without contrast to evaluate for
underlying lesion.
Labs:PT 11.7, PTT 24.2, INR 1.0, plat 152, NA 141, K 4.9
Exam on Discharge:
A&O x 0
PERRLA
Not following commands
Moves all extremities x 4
Pertinent Results:
ADMISSION LABS:
[**2148-10-6**] 07:30PM PT-11.7 PTT-24.2 INR(PT)-1.0
[**2148-10-6**] 07:30PM PLT COUNT-152
[**2148-10-6**] 07:30PM NEUTS-74.5* LYMPHS-17.0* MONOS-5.2 EOS-2.5
BASOS-0.8
[**2148-10-6**] 07:30PM WBC-7.4 RBC-3.57* HGB-11.7* HCT-33.5* MCV-94
MCH-32.7* MCHC-34.9 RDW-12.9
[**2148-10-6**] 07:30PM GLUCOSE-95 UREA N-39* CREAT-1.3* SODIUM-141
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
DISCHARGE LABS:
[**2148-10-16**] 09:00AM BLOOD WBC-9.8 RBC-3.20* Hgb-10.3* Hct-30.5*
MCV-96 MCH-32.2* MCHC-33.7 RDW-13.5 Plt Ct-173
[**2148-10-12**] 03:33AM BLOOD Neuts-92.7* Lymphs-5.0* Monos-2.0 Eos-0.1
Baso-0.3
[**2148-10-16**] 09:00AM BLOOD Glucose-78 UreaN-12 Creat-0.7 Na-139
K-4.2 Cl-110* HCO3-17* AnGap-16
IMAGING:
CT [**2148-10-6**] from OSH :right frontal CVA verses hemorhage with 7
mm midline
shift. Will need MRI with and without contrast to evaluate for
underlying lesion.
MRI head [**10-7**]
1. Dominant cystic-necrotic mass, largely replacing the right
frontal lobe
with predominantly cystic and acute hemorrhagic components,
involving the
rostrum and crossing the midline to involve the left forceps
minor. The lesion extends superficially with evidence of pial
transgression and probable pachymeningeal involvement.
Subependymal involvement cannot be excluded, as the lesion
effaces the right lateral ventricular frontal [**Doctor Last Name 534**]. The overall
appearance favors high-grade primary neoplasm, likely
glioblastoma multiforme.
2. Small necrotic "satellite" lesion in the right precentral
gyrus, consistent with above.
3. Subfalcine herniation, with 12mm leftward shift of midline
structures, but no evidence of uncal or more central herniation.
4. Three punctate acute infarcts in the territory of the distal
A2 and A3
segments of the right ACA, as a consequence of extrinsic mass
effect and
compression of the neighbouring vessels by the right frontal
mass. No evidence of vascular territorial infarction.
VIDEO SWALLOW [**10-16**]:
Limited examination as described above. Aspiration with
nectar-consistency barium.
Brief Hospital Course:
[**10-6**] Pt admitted to neurosurgery service to the ICU on this day
for continued blood pressure control and q1 neurochecks. She did
well on this day and plan was for MRI with and without contrast
for further evaluation of this R frontal mass. Neurology was
consulted for further recommendations and they agreed with plan
for MRI head with and without contrast and blood pressure
parameters of 100-140 systolic. She was started on dilantin
100mg every 8 hours for seizure prophylaxis and plan was to
check a level [**10-7**] a.m .
[**2059-10-7**] Pt neurological exam remained unchanged. MRI on this day
showed R frontal enhancing mass suspicious for glioma. Dilantin
level was 9.6 and she received no bolus. She was neurologically
stable. She was transferred to the floor on 9.22. Surgery was
discussed with the patient and her family. Neurologic oncology
was consulted and had a long discussion with the family and the
patient.
On [**10-10**] pt and her family were seen by the neuro-oncology team
on this day to discuss further treatment options. The results of
this discussion were to forego any agressive care including
surgery and radiation.
ON [**10-11**] pt was found to be more lethargic on exam. She was
opening eyes to voice and following intermittent commands. She
did appear to be somewhat congested and a chest x ray was
obtained for evaluation. Her chest x ray showed a RLL
consolidation and she was started on triple antibiotic therapy
for hospital aquired pneumonia. Speech and swallow evaluated her
and found her unsafe for any PO diet and felt she had been
aspirating her own secretions.She was made NPO and IV fluids
were started. The family wished to continue [**Hospital 17073**] medical
management of her pneumonia throughout the weekend and
re-evaluate her status on Monday [**10-14**] with the possibility of
CMO if she did not improve.
[**Date range (1) **] She remained on IV antibiotics and IV fluids
throughout the weekend and her exam remained stable. Palliative
care was consulted and the plan was for a family meeting on [**10-14**]
to discuss further care options.
[**10-14**] A family discussion with palliative care and the
neurosurgery team took place on this day. The final plan was to
continue [**Hospital 17073**] medical management of her pneumonia and
discharge to home with and bridge from home VNA to hospice care.
[**10-15**] Patient was switched from IV abx to PO levofloxacin and
will continue antibotics for a total of 10 days. Her exam was
improved on this day. SHe was AOx3, more awake and following
commands. Speech and swallow re-evaluated her and cleared her
for pureed diet with nectar thick liquids.
[**Date range (1) 80149**] Pt found to be more lethargic on exam and oriented
only to self. She was unable to take a PO diet or her PO
medications and she was made NPO with IV fluids and her PO
medications were held. Pt was changed to IV antibiotics and will
continue these for a total of 3 more days. Her last dose of IV
antibiotics for treatment of her pneumonia will be on [**10-18**].
After her final IV dose of antibiotics she will be discharged to
home with hospice care.
Medications on Admission:
lasix 40 mg po qd, lopressor 25 mg
[**1-20**] tablet [**Hospital1 **], lisinopril 20 mg [**Hospital1 **], niaspan 750 qd, aspirin 81
mg qd, calcium +d 1 po qd, fish oil 1200 mg [**Hospital1 **], timolo right
eye
q hs
Discharge Medications:
.
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 drops* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 .* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Until
Dexamethasone is done.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q 72 HOURS ().
Disp:*2160 Patch 72 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Right Frontal Hemorrhage
Right Frontal Tumor
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
GENERAL INSTRUCTIONS
?????? Do not lift objects over 10 pounds until approved by your
physician.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] as needed. No routine appointments are required.
Completed by:[**2148-10-18**]
|
[
"348.5",
"V66.7",
"486",
"191.1",
"716.90",
"724.2",
"790.29",
"338.29",
"272.0",
"276.7",
"401.9",
"427.89",
"430",
"432.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9427, 9476
|
5004, 8147
|
290, 296
|
9565, 9565
|
2914, 2914
|
10804, 11029
|
1243, 1270
|
8415, 9404
|
9497, 9544
|
8173, 8392
|
9743, 10781
|
3344, 4981
|
1299, 1488
|
228, 252
|
324, 1050
|
1790, 2810
|
2829, 2895
|
2930, 3328
|
9580, 9719
|
1072, 1190
|
1206, 1227
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,725
| 116,110
|
21711
|
Discharge summary
|
report
|
Admission Date: [**2206-1-25**] Discharge Date: [**2206-1-29**]
Date of Birth: [**2152-1-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea, respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 7086**] is a 54M h/o smoking, severe end-stage COPD on home
O2 of 2-5LNC, presenting with increasing dyspnea, sputum
production and transferred to MICU for need for NIPPV.
.
Roughtly one week prior to admission reports gradual onset nasal
congestion, Patient called [**Company 191**] triage on [**1-24**] with c/o that
congestion had progressed to his chest, and noted associated
thick secretions.
.
Wake this with morning with acute worsening of SOB. Progressive
symptoms prompted patient to call EMS. Sat 86% on RA per EMS, RR
30s-40s. On arrival to the ED, patient noted to be tri-poding.
Exam consistent with poor air entry and wheeze therefore
Treatment for COPD flare initiated with solumedrol 125mg,
azithro/CTX and patient placed on NIPPV; off CPAP desaturated
87% on 3L. CXR demonstrated hyperlucency of upper and mid zones
c/w severe emphysema, patchy opacities at bilateral bases,
left>right c/w crowding at emphysematic bases though cant rule
out super-imposed infiltrate. VS prior to transfer 100%02 on
CPAP 5/5 100%, RR: 18, additional VS: 139/79 HR 98.
Past Medical History:
- COPD, on 4 L home oxgyen and 10 mg prednisone every other day,
followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], no prior intubations
- Diabetes Mellitus, type 2
- Obstructive sleep apnea, followed by [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) 437**], in
process of starting therapy but not currently on non-invasive
- Likely CAD (coronary calcifications on CT)
- Depression/Anxiety
- Diverticulosis
- Scrotal hydrocele
- Dupuytren contractures
Social History:
- Tobacco: Smokes one pack per day ([**11-26**] PPD) since age 13
- Alcohol: Occasional
- Illicits: Denies
Family History:
(per chart)
Multiple family members with DM
Brother with [**Name2 (NI) 499**] cancer
No family history of lung disease
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: significantly redused air entry with distant breath
sounds, scattered wheezes. R less air entry than L.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
[**2206-1-25**] 07:00AM BLOOD WBC-9.4 RBC-4.69 Hgb-13.7* Hct-40.1
MCV-85 MCH-29.2 MCHC-34.2 RDW-12.6 Plt Ct-254
[**2206-1-25**] 07:00AM BLOOD PT-11.4 PTT-27.9 INR(PT)-1.1
[**2206-1-25**] 07:00AM BLOOD Glucose-155* UreaN-10 Creat-0.8 Na-142
K-3.8 Cl-97 HCO3-35* AnGap-14
[**2206-1-25**] 12:23PM BLOOD Type-ART Temp-37.2 pO2-154* pCO2-89*
pH-7.28* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2206-1-25**] 04:33PM BLOOD Type-ART FiO2-40 pO2-74* pCO2-78*
pH-7.34* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2206-1-25**] 10:15PM BLOOD Type-ART pO2-64* pCO2-68* pH-7.38
calTCO2-42* Base XS-11 Intubat-NOT INTUBA
[**2206-1-26**] 06:08AM BLOOD Type-ART pO2-84* pCO2-76* pH-7.36
calTCO2-45* Base XS-12 Intubat-NOT INTUBA
[**2206-1-25**] 10:15PM BLOOD O2 Sat-92
Discharge Labs:
[**2206-1-28**] 05:15AM BLOOD WBC-8.3# RBC-4.40* Hgb-12.7* Hct-37.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-12.6 Plt Ct-199
[**2206-1-28**] 05:15AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-142
K-3.7 Cl-99 HCO3-39* AnGap-8
ECGs:
Cardiovascular Report ECG Study Date of [**2206-1-25**] 8:07:40 PM
Sinus rhythm. Poor R wave progression, probable normal variant.
Non-specific lateral ST-T wave changes. Compared to the previous
tracing of [**2206-1-25**] the sinus rate is slower. The findings are
otherwise similar.
Cardiovascular Report ECG Study Date of [**2206-1-25**] 7:09:08 AM
Baseline artfact. Probable sinus tachycardia. Poor R wave
progression.
Non-specific ST-T wave abnormalities, although artifact makes
interpretation difficult. Compared to the previous tracing of
[**2204-5-10**] sinus tachycardia and artifact are new.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 0 98 [**Telephone/Fax (2) 57074**]2
IMAGING:
- Portable TTE (Complete) Done [**2206-1-27**] at 1:56:18 PM FINAL
-
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. No valvular pathology or pathologic flow
identified. Dilated ascending aorta.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on [**2203**]
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in 1 year; if
previously known and stable, a follow-up echocardiogram is
suggested in [**12-27**] years.
Brief Hospital Course:
Mr. [**Known lastname 7086**] is a 54 year old man with history of current tobacco
use, severe end-stage COPD on home O2 of 2-4L NC, admitted to
the MICU for COPD exacerbation, requiring NIPPV on presentation.
# COPD Exacerbation
Patient was admitted for COPD exacerbation, initially to MICU
for non-invasive ventilation, then transitioned back to nasal
canula over one day. Patient reports that last exacerbation was
about six months ago, for which he was not hospitalized, but he
created his own prednisone taper based on symptoms, which lasted
a couple of months. Patient was initially started on
ceftriaxone and azithromycin for treatment of potential LLL
pneumonia. Ceftriaxone was discontinued in MICU because
pneumonia was felt to be unlikely. He required albuterol
nebulizers every 2 hours in the MICU, transitioned to every 6
hours on the floor. He was also started on prednisone 60mg
daily on admission, transitioned to 40mg daily after 4 days.
Prednisone taper as follows: prednisone 40mg x 4 more days,
then decrease to prednisone 30mg x 6 days, then prednisone 20mg
x 6 days, then prednisone 10mg x 6 days, then back to home dose
of prednisone 10mg every other day. Patient may uptitrate for
symptoms if needed, but he should call primary care physician
[**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] if doing so. He would like to join outpatient
pulmonary rehab at [**Hospital1 18**] once he meets requirements for smoking
cessation. Followup appointment with Dr. [**Last Name (STitle) **] was set up.
He was also started on alendronate in setting of chronic
prednisone use.
# Tobacco Use
Patient was counseled extensively on smoking cessation. He will
use nicotine patches at home, starting with 21mg/day patches,
which he states he already has. He was seen by social work for
extra support.
# DM2
Patient was well controlled on home metformin, but had a few
elevated blood sugars while on high dose steroids. He was
maintained on insulin sliding scale during hospitalization, but
transitioned back to metformin 500mg daily on discharge. Blood
sugars should be monitored while on prednisone taper.
# Hypertension
Patient with elevated blood pressures at primary care office on
multiple occasions, not on any medications yet. Had moderately
elevated blood pressures during hospitalization, ranging
120s-160s systolic. Will defer starting low dose [**Doctor Last Name 360**] to
primary care physician.
# Depression
Patient became anxious after discussion about severity of his
COPD. Spoke with social work for extra support. Continued on
home venlafaxine.
Transitional Issues:
- smoking cessation
- dilated aortic root seen on TTE (which was done in MICU to
look for dCHF as potential etiology of shortness of breath) -->
needs followup echocardiogram in 1 year or in [**12-27**] years if
clinically stable
- monitor blood pressures
- consider starting bactrim for PCP [**Name Initial (PRE) 1102**]
Medications on Admission:
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays each
nostril once daily *** not currently taking
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhaled twice a day
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for allergic symptoms *** not currently taking
METFORMIN [GLUCOPHAGE] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth 1-3x/day as
directed, but took 50mg today, and had been taking 60 earlier
this week
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule inhaled once a day Empty
capsule into inhalation device
VENLAFAXINE - (Prescribed by Other Provider) - 225 mg Tablet
Extended Rel 24 hr - 1 (One) Tablet(s) by mouth
Discharge Medications:
1. prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO once a
day: - Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days,
- then back to your previous dosing of prednisone 10mg every
other day
.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) cap Inhalation once a day.
3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
7. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergic symptoms.
8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
9. alendronate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 5 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*0*
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) capsule Inhalation every six (6) hours
as needed for shortness of breath.
12. ipratropium bromide 0.02 % Solution Sig: One (1) capsule
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
COPD Exacerbation
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 7086**],
You were admitted to [**Hospital1 **] for a COPD
exacerbation. You were started on high dose prednisone and
given a 5 day course of azithromycin treatment. You will need
to continue prednisone for a few weeks, as listed below. As we
discussed, if you feel that the taper is too rapid, you can
increase your dose as needed, but please call Dr. [**First Name (STitle) 216**] if you
need to do this. Please also discuss smoking cessation with Dr.
[**First Name (STitle) 216**].
The following changes have been made to your medications:
* Prednisone taper as follows:
- Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days, then back to your previous dosing
of prednisone 10mg every other day
* Please also start Alendronate 10mg daily and discuss this with
your primary care physician. [**Name10 (NameIs) **] must be seated upright when
taking this medication and drink a full glass of water with it.
* Please continue taking calcium and vitamin D
* Please start using the Nicotine Patch as follows:
- nicotine patch 21 mg/day (highest dose) for 5 more weeks
- nicotine patch 14 mg/day for 2 weeks
- nicotine patch 7 mg/day for 2 weeks
(Your current prescription is only for 30 days of the 21mg/day
nicotine patch.)
While you were here you were seen by social work. She provided
you with information on smoking cessation and relaxation
techniques. It was alos recommended that you engage in out
atient therapy to help you cope with your chronic illness and
anxiety. You can contact one of the following to make an
appointment:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Street Address(2) 57075**]
[**Hospital1 8**] MA
[**Telephone/Fax (1) 57076**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 1046**]
[**Street Address(2) 57077**]
[**Hospital1 **] MA
[**Telephone/Fax (1) 57078**]
[**First Name8 (NamePattern2) **] [**Last Name (un) 41140**], [**Last Name (un) 1046**]
[**Location (un) 57079**] MA
[**Telephone/Fax (1) 57080**]
If you need more referrals or any further assistance, please
contact the social worker you saw while you were here: [**Name (NI) 636**]
[**Last Name (NamePattern1) 12471**] [**Telephone/Fax (1) 57081**]
Followup Instructions:
Please be sure to keep your followup appointments as listed
below:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-2-5**] at 10:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2206-2-13**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2206-2-13**] at 3:00 PM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"401.9",
"518.84",
"414.01",
"250.00",
"V58.65",
"569.1",
"285.9",
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"309.81",
"327.23",
"493.22",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10712, 10769
|
5399, 8006
|
331, 338
|
10862, 10862
|
2983, 2983
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262, 293
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366, 1458
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3000, 3757
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10877, 10989
|
1480, 2050
|
2066, 2175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,421
| 150,941
|
11202
|
Discharge summary
|
report
|
Admission Date: [**2137-1-29**] Discharge Date: [**2137-2-14**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year-old Italian male with a history of CAD, s/p tissue AVR,
AF (not on coumadin due to GI bleed), CKD (baseline 1.3-1.7),
HTN, HL who presents with hypotension from Rehab. The patient
was recently admitted on [**10-28**] and discharged to rehab. He
was initally treated with levofloxacin for pnuemonia and
diuresed. His coursed was complicated by MSSA bacteremia which
he was treated with a 14 day course of nafcillin (finished
[**1-5**]). His ECHO was negative for evidence of endocarditis. He
also developed c. diff colitis and was treated with flagyl
(finished [**1-8**]). The patient was discharged to [**Hospital 582**] Rehab.
The patient had complaints of weakness over the last week and
increasing loose bowel movements. He also has had poor po intake
during this same period. He was diagnosed with recurrent c. diff
on [**2137-1-23**] and started on po vancomycin 250mg QID. He
additionally, was started on pneumonia treatment with
levofloxacin 500mg daily. Although the patient and family deny
fevers, chills, cough, sputum or SOB. Today while participating
in rehab he became hypoxic to 87% RA and BP was noted to be
87/42. He was sent [**Hospital1 18**] ED for further mangement.
In the ED, 96.9 96/57 130 20 98% 2L. The patient's CXR showed a
possible left basilar opacity. He was covered with IV
Vancomycin. The patient had a WBC 8.6 and lacate of 1.2. The
patient was hypotensive to the 70's in the ED and improved with
1L IVF. His labs were also signficant for a Cr 2.4 and K 6.3
that decreased to 5.9 on repeat. He did not have ECG changes and
was given 30g of kayexalate. VS on transfer were 86 85/50 25
100% 2L.
On arrival the patient reported feeling hungry and without pain.
He denied F/C/N/V/D/abdominal pain. He also denied cough,
sputum, SOB.
Past Medical History:
1) Aortic Stenosis s/p AVR and aortic endarterectomy [**7-/2136**]
2) CAD
- Cath in [**1-/2134**] showed [**Year (4 digits) 1192**] multivessel disease
- Percutaneous coronary intervention, in [**2134-2-5**] anatomy as
follows: Selective coronary angiography of this right-dominant
system demonstrated [**Year (4 digits) 1192**] multivessel disease. The LMCA had
50% stenosis at origin. The LAD had 60% mid-vessel stenosis. The
LCX had mild disease. The RCA had 70% distal stenosis.
3) Malnutrition
4) Persistent Atrial Fibrillation: Not on warfarin [**2-20**] GI bleed
in [**2134**]
5) h/o gastrointestinal bleed as above [**2-20**] NSAIDs
6) Hypertension
7) diastolic congestive heart failure
8) Hyperlipidemia
9) Chronic Anemia - Baseline hct 29-30
10) Benign Prostatic Hypertrplasia
11) [**Month/Day (2) **] pulmonary Hypertension
12) CKD: baseline creatinine 1.3-1.7
.
Past Surgical History:
s/p rigid bronch/flex bronch/ tracheostomy #8 Portex [**2136-9-17**]
s/p EGD and PEG [**2136-9-17**]
s/p VATs [**2136-8-31**] for recurrent hemothorax
s/p AVR (25mm Magna tissue)/aortic endarterctomy [**2136-8-6**]
s/p reexploration for bleeding [**2136-8-8**]
s/p chest closure with pectoralis flaps [**2136-8-10**]
s/p cataract surgery
s/p basal cell CA excision from face
s/p Tonsillectomy
No prev problems with GA
Social History:
Currently in [**Hospital 582**] rehab
Born [**Location (un) 20338**], [**Country 2559**]
Normally lives with:wife and daughter. [**Name (NI) **] 3 other children.
Occupation:previous factory worker
Tobacco:40 pack year history previous 2/day and quit 30 years
ago
ETOH:no current
Pets - 1 dog at home
No recent foriegn travel
Family History:
Mother died suddenly at 65 years old of MI, hypertension.
Father died at 89yo of old age.
Sister died [**2-20**] ESRF was on dialysis, hypertension.
Physical Exam:
Admission:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, dry MM, poor dentition
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: healed sternal surgucal scar/ irregularly irregular, II/VI
SEM, no G/R, normal S1 S2
PULM: diminished BS at the left base otherwise 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.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission labs:
[**2137-1-29**] 01:30PM BLOOD WBC-8.6 RBC-2.62* Hgb-8.4* Hct-26.0*
MCV-99* MCH-32.2* MCHC-32.4 RDW-16.2* Plt Ct-235
[**2137-1-29**] 01:30PM BLOOD Neuts-70.3* Lymphs-24.1 Monos-3.9 Eos-1.0
Baso-0.7
[**2137-1-29**] 01:30PM BLOOD PT-14.1* PTT-21.4* INR(PT)-1.2*
[**2137-1-29**] 01:30PM BLOOD Glucose-123* UreaN-48* Creat-2.4*# Na-138
K-6.3* Cl-105 HCO3-24 AnGap-15
[**2137-1-29**] 06:50PM BLOOD Glucose-105* UreaN-48* Creat-2.4* Na-140
K-5.3* Cl-105 HCO3-26 AnGap-14
[**2137-1-29**] 01:30PM BLOOD ALT-24 AST-33 LD(LDH)-200 AlkPhos-50
TotBili-0.2
[**2137-1-29**] 01:30PM BLOOD Albumin-2.5* Calcium-8.4 Phos-5.1* Mg-2.1
[**2137-1-29**] 01:41PM BLOOD Glucose-113* Lactate-1.2 Na-135 K-6.0*
Cl-103 calHCO3-24
[**2137-1-29**] 02:35PM BLOOD K-5.9*
Urine:
[**2137-1-29**] 05:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2137-1-29**] 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2137-1-29**] 05:00PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2137-1-29**] 05:00PM URINE CastHy-[**3-23**]*
[**2137-1-29**] 05:00PM URINE Eos-NEGATIVE
[**2137-1-29**] 05:00PM URINE Hours-RANDOM UreaN-221 Creat-56 Na-33
K-89 Cl-59
[**2137-1-29**] 05:00PM URINE Osmolal-315
Microbiology:
[**2137-1-29**] URINE Legionella Negative
[**2137-1-29**] URINE URINE CULTURE-No growth
[**2137-1-29**] BLOOD CULTURE: 1/2 bottles with gram positive rods.
[**2137-2-1**] BLOOD CULTURE: No growth.
Radiology:
XR CHEST (PORTABLE AP) Study Date of [**2137-1-29**] 2:09 PM
FINDINGS: Again is seen cardiomegaly. Mediastinal and hilar
contours are unchanged. Compared to prior study, an improved
left base opacity may represent atelectasis, although an
underlying infectious process cannot be excluded. Mild vascular
congestion is also seen. Severe degenerative changes are seen at
the left shoulder. Midline sternotomy wires and prosthetic valve
are unchanged. IMPRESSION: Improved left basilar opacity may
represent atelectasis, although underlying infection cannot be
ruled out; mild vascular congestion.
CT CHEST [**2-1**]. IMPRESSION: 1. Persistent left lower lobe
atelectasis, probably has more to do with persistent [**Month/Year (2) 1192**]
left pleural effusion than airway obstruction. Left
hemidiaphragm function would require evaluation before excluding
phrenic nerve palsy. 2. Fixed deformity of the upper trachea due
to a large tortuous innominate artery (common origin of head and
neck arteries) and an enlarged thyroid gland, is probably not
clinically significant. No good evidence for
tracheobronchomalacia. 3. Coronary atherosclerosis,
predominantly right coronary and left circumflex. 4. Mild air
trapping, probably due to small airways obstruction. 5. Severe
global cardiomegaly and pulmonary hypertension, unchanged.
Brief Hospital Course:
88yoM w/ a h/o chronic diastolic CHF, chronic debilitation and
spends most of the time in bed or chair, presented to the
hospital with dehydration, acute kidney injury, aspiration and
diarrhea. He was initially treated with IV fluids, found to
have C diff and started on PO vancomycin, found to have
lactobacillus bacteremia being treated with unasyn. In addition
he became volume overloaded as a result of the rehydration and
he was diuresed for several days. The most active issue
currently is his hypervolemia which is much improved but still
requires some diuresis. He was switched to oral torsemide 40mg
po daily (he came in on 60mg po daily but was hypovolemic with
this regimen) and this will need be adjusted if needed for
further diuresis.
SEVERE C DIFF DIARRHEA: Pt was admitted with profuse diarrhea,
ARF and hypotension consistent with recurrent Cdiff. He was
initially admitted to the ICU, resuscitated and started on
Flagyl + oral Vanco. His hypotension resolved with IV fluids and
holding his diuretics. Diarrhea improved but one of his blood
cx returned positive for lactobacillus thought to have
translocated during periods of hypotension. ID recommended
treated with IV unasyn for a 14 day course and pt was covered
with treatment dose vancomycin during this time. He will
started a slow taper with po vanc after he completes the 14 day
course of unasyn. He should continue PO vancomycin at the
current dose until [**2137-3-4**] and then start a taper over roughly 2
weeks at that time.
ASPIRATION: Pt was admitted with questionable LLL opacity for
which he was being treated with levofloxacin at rehab. Repeat
imaging chest CT that suggested improving opacity and effusion.
The pulmonary team was consulted and were concerned for
recurrent aspiration pneumonina. He was placed on aspiration
precautions and had a speech and swallow evaluation. He was
found to have silent aspiration with all thin liquids on video
swallow. Pt was placed on a nectar thickened diet and family
was educated about importance of adhering to prevent recurrent
PNA.
ACUTE ON CHRONIC DIASTOLIC CHF: Previously had been on lasix
40mg po bid, this was recently switched as an outpatient to
torsemide 60mg po daily. The patient was admitted with acute
renal failure related to both diarrhea and possibly related to a
increase dose of diuretic. He was initially fluid resuscitated
and then was found to be in congestive heart failure so he was
diuresed. His creatinine increased from 1.0 to 1.2 with
diuresis from [**2-13**] to [**2-14**] so IV lasix was switched to torsemide
40mg po daily. Please measure daily weights and cardiopulmonary
exam, if he gains 3 pounds please double this dose to 40mg po
bid or 60mg po daily until weight is lost. The patient has
rales on exam at the bases ([**1-22**] way up bilaterally) with some
thigh edema but no lower leg edema. He is completely
asymptomatic currently but hopefully will slowly diurese with
this dose of torsemide. Please check electrolytes and renal
function on Saturday [**2137-2-16**]. He continues to be mildly
hypervolemic but asymptomatic so he should continue to slowly
diurese at rehab.
LACTOBACILLUS BACTEREMIA: treated with unasyn, unclear if
contaminant or pathogen, per the direction of infectious disease
this should be treated with 14 days of unasyn. Day # 1 of
treatment was [**2-6**], day # 14 to finish treatment will be [**2137-2-19**])
ANEMIA OF CHRNOIC INFLAMMATION: Pt was noted to have slowly
drifting hematocrit thought due to CKD and he received 2units of
prbcs while in house. Stools remained guaic negative and there
was no other evidence of acute blood loss. Per family, he has
been intermittently transfusion dependant over the last few
years. This will need to be monitored on an ongoing basis.
ACUTE KIDNEY INJURY: Pt with stage III chronic kidney disease
(baseline Cr 1.3-1.7) and congestive heart failure with
preserved LVEF who presented in acute renal failure thought due
to dehydration from diarrhea and overdiuresis. Diuretics were
held and he was gently rehydrated on admission. Pt was
transferred to the floor with evidence of volume overload and O2
requirement. He was gently diuresed and started back on
torsemide 40mg po daily. creatinine at the time of discharge was
1.2.
Coronary artery disease- continued on aspirin, beta-blocker, and
statin
Atrial fibrillation- not anticoagulated due to history of GI
bleed, rate-controled with metoprolol 50mg po bid. Aspirin 81mg
po daily.
Obstructive sleep apnea- continued on CPAP
Medications on Admission:
po vancomycin 250mg po QID
Levofloxacin 500mg daily
Tylenol prn
Mylanta
Dulcolax 10mg prn
Combivent TID:prn
Provigil 100mg daily
Questran 4gm x 7days
Torsemide 60mg daily
Losartan 50mg daily
Metoprolol 100mg q12
MOM
[**Name (NI) 10687**]
Heparin SQ
MVI
Nephrocaps TID
SL nitro prn
Simvastatin 20mg daily
Venlafaxine 75mg [**Hospital1 **]
Vitamin C
Vitamin D 1000 daily
ASA 81mg daily
Famotidine 20mg daily
Ferrous Sulfate 325mg [**Hospital1 **]
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): continue this dose through [**3-4**], then taper over
the following 2 weeks.
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for fever or pain.
3. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-20**] Tablet,
Delayed Release (E.C.)s PO once a day as needed for
constipation.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-20**] Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
5. modafinil 100 mg Tablet Sig: One (1) Tablet PO daily ().
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
16. ampicillin-sulbactam 3 gram Recon Soln Sig: Three (3) grams
Injection Q6H (every 6 hours): use until [**2137-2-19**].
17. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13040**] Nursing and Rehab Center
Discharge Diagnosis:
Primary:
Clostridium difficile infection
Aspiration Pneumonitis
anemia
Acute diastolic CHF
lactobacillus bacteremia
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 for low blood pressure and acute renal failure
likely due to diarrhea from C difficile infection and diuretics.
This has improved with IV fluids and more oral Vancomycin.
Because we have adjusted your diuretics it is important that you
watch for signs of fluid accumulation. Weigh yourself every
morning, call Dr. [**Last Name (STitle) 2204**] if weight goes up more than 3 lbs.
You had a video swallowing evaluation which showed that you are
aspirating on thin liquids. We recommend that you take only
thickened liquids to prevent recurrent pneumonias.
You have received blood transfusions for the chronic anemia and
will need ongoing monitoring of your blood counts.
Followup Instructions:
Department: [**State **]When: WEDNESDAY [**2137-2-13**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
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"585.3",
"600.00",
"414.01",
"276.51",
"V10.83",
"995.91",
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"272.4",
"584.9",
"427.31",
"276.7",
"285.21",
"428.33",
"V42.2",
"008.45",
"416.8",
"327.23",
"507.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14140, 14213
|
7509, 12060
|
263, 270
|
14373, 14373
|
4667, 4667
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|
3771, 3922
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14549, 15240
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2992, 3411
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3937, 4648
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212, 225
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298, 2072
|
4683, 7486
|
14388, 14525
|
2094, 2969
|
3427, 3755
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,527
| 187,511
|
39637
|
Discharge summary
|
report
|
Admission Date: [**2156-10-22**] Discharge Date: [**2156-11-2**]
Date of Birth: [**2108-7-11**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Meropenem
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Bronchoscopy and bronchoalveolar lavage [**10-23**]
History of Present Illness:
48 yo M with C4 tetraplegia s/p diving accident, trach placement
(weaned off), recent DVT on coumadin and with IVC filter
presenting from [**Hospital3 **] with altered mental status.
About 10 days ago, he started to experience altered thinking,
which was initially thought to be [**1-6**] medications (recently had
started remeron and buspar) vs poor sleep so medication doses
were reduced. On [**10-20**], mental status seemed worse, pt thought
he was holding things that werent there, or that he could walk.
WBC elevated on [**10-20**], empirically started on cipro and
linezolid for a LLL infiltrate on CXR at [**Hospital1 **]. On [**10-21**],
mental status had iproved and WBC decrased, however on AM of
admission mental status was worse. AOx3, but at [**Hospital1 **] he
thought he was walking around and is occasionally not oriented
to self.
.
About 10 days ago he also had a suprapubic catheter placed. Has
not had any fevers, chills, night sweats. No diarrhea, has
chronic constipation. Is unable to move all 4 extremities. No
recnet nausea/vomiting. Has had increased secretions and has
required more frequent suctioning at rehab, and frequent desats
to 80s. Also has increased cough with yellow sputum.
.
In ED VS were 69 125/81 27 93-94% on 2L NC. He was given
fluconazole 150 mg PO x1, ceftiraxone 1 gm IV x1. Head CT neg
for acute bleed, CXR showed small RLL opacity. On UA, moderate
yeast, few bacteria, WBC [**10-23**], Tr leuks.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
[**Doctor Last Name 79**] Parkinson White syndrome s/p ablation [**2153**]
SCI at C3-C4, has a capped trach and a g tube
DVT on coumadin, s/p IVC filter
Social History:
lives at [**Hospital3 **], has tetraplegia. Wife is very
involved in his care
Family History:
non-contributory
Physical Exam:
On admission:
VS: 97.9 120/82 55 18 97% 3L
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. Aspen collar in place,
unable to move neck. CN II-XII grossly intact.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: auscultated anteriorly, no rales, rhonchi appreciated
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+. has [**Male First Name (un) **] hose, support
boots
Skin: no rashes
Neuro/Psych: CNs II-XII intact. unable to mvoe extremities.
knows months fo the year backwards, conversational, alert and
oriented to place, date, self.
Pertinent Results:
[**2156-10-22**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-10-23**] 03:43AM BLOOD Type-ART FiO2-70 pO2-112* pCO2-70*
pH-7.26* calTCO2-33* Base XS-1 Intubat-NOT INTUBA
[**2156-10-23**] 05:35AM BLOOD Type-ART pO2-336* pCO2-51* pH-7.37
calTCO2-31* Base XS-3
[**2156-10-23**] 10:34AM BLOOD Type-ART pO2-54* pCO2-36 pH-7.52*
calTCO2-30 Base XS-5
[**2156-10-24**] 01:16PM BLOOD Type-ART Temp-36.7 Rates-/18 PEEP-10
FiO2-50 pO2-141* pCO2-55* pH-7.32* calTCO2-30 Base XS-1
Intubat-INTUBATED Vent-SPONTANEOU
[**2156-10-25**] 06:48AM BLOOD Type-ART pO2-120* pCO2-35 pH-7.46*
calTCO2-26 Base XS-2
[**2156-10-25**] 01:27PM BLOOD Type-ART Temp-37.2 Rates-16/2 Tidal V-500
PEEP-10 FiO2-40 pO2-134* pCO2-38 pH-7.42 calTCO2-25 Base XS-0
Intubat-INTUBATED
[**2156-10-26**] 03:44AM BLOOD Type-ART Temp-37.3 FiO2-40 pO2-178*
pCO2-36 pH-7.48* calTCO2-28 Base XS-4 Intubat-INTUBATED
[**2156-10-23**] 05:35AM BLOOD Lactate-1.6
[**2156-10-23**] 10:34AM BLOOD Lactate-1.6
.
Discharge labs
[**2156-11-2**] BLOOD WBC-6.7 Hgb-12.4* Hct-37.6* Plt Ct-361
[**2156-11-2**] BLOOD PT-25.7* PTT-32.0 INR(PT)-2.5*
[**2156-11-2**] BLOOD Glucose-100 UreaN-11 Creat-0.4* Na-139 K-4.2
Cl-104 HCO3-29 AnGap-10
[**2156-11-2**] BLOOD ALT-205* AST-63* AlkPhos-116 TotBili-0.2
[**2156-11-2**] BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
.
Blood Cx [**10-22**] NGTD
.
[**2156-10-22**] 2:10 pm
URINE **FINAL REPORT
[**2156-10-25**]**
URINE CULTURE (Final [**2156-10-25**]):
YEAST. >100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2156-10-22**] 3:30 pm SPUTUM
**FINAL REPORT [**2156-10-25**]**
GRAM STAIN (Final [**2156-10-22**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2156-10-25**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
STAPH AUREUS COAG +. RARE 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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2156-10-23**] 1:01 pm BRONCHIAL WASHINGS +PMNs, All Cx negative for
growth
.
[**2156-10-23**] 1:01 pm Rapid Respiratory Viral Screen & Culture-
Negative
.
[**2156-10-23**] 12:24 pm URINE legionella negative
.
Bc [**10-23**] x2 no growth
.
[**2156-10-23**] 6:49 pm URINE Source: Suprapubic.
**FINAL REPORT [**2156-10-27**]**
URINE CULTURE (Final [**2156-10-27**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
.
Radiology
.
XR CHEST (PORTABLE AP) Study Date of [**2156-10-22**] 12:35 PM
FINDINGS: A single portable semi-upright view of the chest was
obtained. An
ill defined density in the right lower lung is present. There is
no effusion
or pneumothorax. The cardiomediastinal silhouette is
unremarkable allowing
for patient position and technique. Osseous structures are
intact.
IMPRESSION: Ill defined density in right lower lung, which may
represent a
small focus of aspiration or early developing pneumonia.
.
CT HEAD W/O CONTRAST Study Date of [**2156-10-22**] 12:57 PM
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect or
major vascular territorial infarct. Ventricles and sulci are
normal in size
and symmetric in configuration. There is no shift from normally
midline
structures. [**Doctor Last Name **]-white matter differentiation is well preserved.
Mucosal
thickening is seen within scattered ethmoid air cells and there
is partial
opacification of mastoid air cells bilaterally. The remainder of
the
visualized paranasal sinuses are clear. No osseous abnormality
is identified.
IMPRESSION: No acute intracranial process. Limited exam due to
motion
artifact.
.
CT C-SPINE W/O CONTRAST Study Date of [**2156-10-22**] 6:36 PM
FINDINGS:
Compared to [**2156-9-14**], there is unchanged anterolisthesis
of C3 on C4
measuring about 7.5 mm (grade 2). Unchanged angulation of the
anterior
fixation rods with indentation on the right sided oro- and
hypo-pharynx.
Unchanged inferior displacement of the intervertebral disc
spacer. There is
increased lordosis at C2/C3, stable. Patient is status post
laminectomy at
C3/C4, unchanged kinking of the spinal cord at C3/C4.
IMPRESSION:
No significant change compared to [**2156-9-14**] with 7.5 mm
anterolisthesis
of C3 on C4.
.
XR CHEST (PORTABLE AP) Study Date of [**2156-10-25**] 2:16 PM
IMPRESSION: Lucency projected over the left hemidiaphragm is
most likely
within a loop of bowel rather than a pleural gas collection,
this may either
be subphrenic or within a diaphragmatic hernia, which could be
ellucidated
with CT, if clinically warranted.
.
CT HEAD W/O CONTRAST Study Date of [**2156-10-25**] 11:38 PM
FINDINGS: There is no evidence of hemorrhage, infarction, shift
of normally
midline structures, discrete masses, or brain edema. The
ventricles and sulci
are normal in size and configuration. Minimal mucosal thickening
is noted
within scattered ethmoid air cells. There is partial
opacification of
bilateral mastoid air cells. The remainder of the visualized
paranasal sinuses
is clear.
Again demonstrated is dramatic subluxation of C3 on C4, better
seen on the
cervical spine CT of [**2156-9-14**].
IMPRESSION: Cervical spine subluxation. Otherwise normal study.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2156-10-28**]
11:29 AM
FINDINGS IMPRESSION:
1. No evidence of pulmonary embolism as questioned.
2. Left lower lobe volume loss, with low density plugging of the
left lower
lobe bronchus.
3. Nodular opacities noted in the right lower lobe, along with
ground glass
opacity seen in the left upper lobe. Findings most likely
represent
superimposed infectious process.
.
.
Cardiology
.
ECG Study Date of [**2156-10-28**] 11:06:26 AM
Sinus bradycardia. Compared to the previous tracing the rate is
slower.
TRACING #2
.
ECG Study Date of [**2156-10-28**] 10:01:56 AM
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2156-10-25**]
no major change.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
RatePR QRS QT/QTc P QRS T
64 134 96 422/429 69 0 17
Brief Hospital Course:
48 yo M with C4 tetraplegia s/p MVA, s/p trach/peg placement,
recent DVT on coumadin with IVC filter who was admitted with UTI
and PNA and transfered to the ICU for hypercarbic respiratory
failure. Pt improved with IV cefepime/linezolid for HAP and was
treated for yeast in urine Cx with IV fluconazole. He had
another episode of respiratory decompensation on [**10-28**] likely
due LLL collapse on CXR. He improved with resp therapy,
suctioning and increased o2. Pt had a CTA on [**10-28**] with no PE
but consolidation and collapse LLL. After this episode, he
continued to improve from a respiratory standpoint.
.
# Pneumonia/Respiratory Failure: Pt was admitted with confusion
and developed acute respiratory distress requiring MICU
transfer. A bronch performed in the MICU revealed severe LLL
and LUL mucous plugging that was difficult to clear with serial
washes and he ultimately required placement on a ventilator via
trach for hypercarbic respiratory failure. Infectious work up
included a head CT that was negative and BAL cultures that were
positive for yeast and MRSA. Pt was treated with linezolid,
cefepime, and fluconazole for HAP. Pt was transferred to the
[**Hospital1 **] on [**10-27**] and had another episode of respiratory
decompensation with bradycardia on [**10-28**] that was felt likely
due to mucus plugging. His status improved with suctioning, MIE
and nebs. Pt underwent a CTA on [**10-28**] which did not show any
evidence of pulmonary embolism but there was left lower lobe
volume loss, with low density plugging of the left lower lobe
bronchus and nodular opacities noted in the right lower lobe,
along with ground glass opacity seen in the left upper lobe.
Given these persistent findings, pt was continued on IV
antibiotics to complete a 14 day course of IV cefepime and
linezolid. His respiratory status continued to improve with
aggressive respiratory therapy support, suctionning and a new
turing schedule with less time spent on his left side (1 hour on
left side and 2 hours on right) to maximize ventilation on that
side.
.
# UTI/Suprapubic cath: Patient has a suprapubic catheter and
both MRSA and yeast on UCx. Urology was consulted and did not
want to change out suprapubic catheter given that it was
recently placed and the track is likely not epithelialized. He
was treated with fluconazole, linezolid, and cefepime as above.
Fluconazole finished [**11-1**] and linezolid to finish [**11-2**]. On
[**10-28**] suprapubic catheter was noted to be leaking and urology
consult felt that could be due to bladder spasm vs UTI. By the
time of discharge, the leak had improved significantly and pt
will need to follow up with his [**Hospital1 2025**] urologist.
.
# Previous DVT on warfarin: Patient presented with an elevated
INR at 4.1 in the setting of acute illness/infection. Warfarin
was held until INR fell to ~3 and then restarted at lower dose.
His INR was very labile in house likely due to medication
interactions and LMWH was started at 1mg/kg [**Hospital1 **]. This can be
stopped when INR is >2 for over 24 hours and will need to be
reviewed at [**Hospital1 **] with daily INRs until it has stabilized.
.
# s/p C4 spinal injury: Neuro status at baseline. He requires
an Aspen collar in place at all times with Q2H turns. He was
continued on his home inhalers and PRN nebs. He is on oxycodone
PRN for pain with a bowel regimen. Turns were changed to
maximize ventilation 1hr left 2 hours on right. Pt was
continued on high flow 50% via trache mask and this will need to
be weaned at [**Hospital3 **].
.
# LFTs: Patient was noted to have mildly elevated LFTs and on
[**10-31**] the ALT had risen to c200. This was felt likely [**1-6**]
Antibiotics/fluconazole. Fluconazole was stopped on [**11-1**] as
likely offending [**Doctor Last Name 360**] and completed course. LFTs will need to
be trended at rehab to ensure resolution
.
# Poor po intake: Noted reduced po intake. PRN PEG feed.
Improved on discharge. Will need nutrition support and calorie
counting at rehab.
.
INACTIVE/CHRONIC ISSUES:
.
# Confusion: Likely secondary to infection/respiratory failure.
CT-head was performed for anisocoria and was normal. Confusion
resolved with resolution of infection. Anisocoria resolved
.
# Anemia/thrombocytosis: At baseline.
Medications on Admission:
-linezolid 600mg q12hrs
-tylenol 650 mg po q4hrs
-combivent neds q4hrs
-alendronate 70 mg daily
-calcium polycarbophil 1250mg po BID prn
-cholestyramine 4gram po BID prn
-ciprofloxacin 500mg po q12
-clotrimazole/betamet 1-0.5% top cream [**Male First Name (un) **]
-colace 100mg po BID prn
-ipratropium 0.5mg neb q4hr prn
-levalbuterol 1.25mg q4hrs prn
-lidocaine patch
-lorazepam 1mg q6hr prn
-maalox/mylanta 30ml q4hr prn
-magic bullet suppository 10mg pr daily
-midodrine 10mg po
-milk of magnesium 30ml po daily prn
-nystatin 15gm powder topical [**Hospital1 **]
-omeprazole 40mg daily
-ondansetron 4mg po TID prn
-oxycodone 10mg q3hr prn
-percocet 1 tab q4hr prn
-artificial tears both eyed QID prn
-psyllium 1 packet po daily
-senna 2 pills po BID
-theophylline 100mg po BID
-warfarin 3.5mg po daily
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever.
2. clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
3. betamethasone dipropionate 0.05 % Cream [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
4. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
Thirty (30) ML PO QID (4 times a day) as needed for abd
discomfort.
8. simethicone 80 mg Tablet, Chewable [**Hospital1 **]: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas.
9. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. magnesium hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
11. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
13. oxycodone 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q3H (every 3
hours) as needed for pain.
14. polyvinyl alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye discomfort.
15. psyllium Packet [**Hospital1 **]: One (1) Packet PO DAILY (Daily) as
needed for constipation.
16. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. cholestyramine-sucrose 4 gram Packet [**Last Name (STitle) **]: One (1) Packet PO
BID (2 times a day).
19. midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
20. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: 2-3 MLs
Miscellaneous Q6H (every 6 hours) as needed for MIE: As needed
for MIE.
21. sodium chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**12-6**] Sprays Nasal
TID (3 times a day) as needed for dry nose.
22. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebule Inhalation Q4H (every 4 hours)
as needed for shortness of breath or wheezing.
24. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) nebule
Inhalation Q4H (every 4 hours).
25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebule Inhalation Q2H (every 2 hours)
as needed for shortness of breath or wheezing.
26. linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours) for 1 days: To complete 14 days course - last day
[**11-2**].
27. enoxaparin 80 mg/0.8 mL Syringe [**Month/Year (2) **]: Eighty (80) MG
Subcutaneous Q12H (every 12 hours): To continue until INR >2 for
two days.
28. sodium chloride 0.9 % 0.9 % Parenteral Solution [**Month/Year (2) **]: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
29. cefepime 2 gram Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Injection
Q12H (every 12 hours) for 5 days: To complete 14 days to finish
[**11-5**].
30. morphine 5 mg/mL Solution [**Month/Day (4) **]: 2-4 MG Injection Q2H (every 2
hours) as needed for dyspnea, pain.
31. alendronate 70 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a week.
32. lorazepam 0.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
33. lorazepam 0.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day
as needed for anxiety. Tablet(s)
34. warfarin 1 mg Tablet [**Month/Day (4) **]: 3.5 Tablets PO Once Daily at 4 PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
Pneumonia
Respiratory failure
Urinary tract infection
Abnormal liver function tests likely due to antimicrobials
.
Secondary diagnoses:
[**Doctor Last Name 79**]-Parkinson-White syndrome
C4 tetraplegia
Deep vein thrombosis on warfarin s/p inferior vena cava filter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You came to the hospital
with confusion and breathing difficulties and were found to have
a urine infection and a lung infection. You had considerable
breathing problems and required ventilation in the ICU. You
underwent broncoscopy to help clear mucous from the lungs and to
identify the bacteria causing your pneumonia. You were treated
with broad spectrum antibiotics for the two infections and you
were weaned off the ventilator and coped well on the trache
mask. You were transferred to the medical floor where you wre
stable other than an episode of difficulty in breathing and
requiring use of your MIE and suctioning. This was likely due to
a mucus plug and resolved after the above. Other considerations
at the time included the low probability of a blood clot on the
lung which we investigated with a CT scan of your chest with
contrast to look at the blood vessels. This showed no evidence
of clot but did reveal infection and collapse at your left lung
base. In order to improve your respiratory status we instituted
a new turning regime, having less time on your left side. This
along with regular use of our MIE and respiratory therapy was
used to good effect and you improved. You were at baseline at
discharge back to [**Hospital1 **] and will complete 14 days of the
linezolid and 14 days of the IV antibiotics. There was evidence
of yeast in your phlegm and in your urine and you were treated
for a total of 7 day with the anti-fungal fluconazole. You also
noted considerable leakage from your suprapubic catheter and you
were reviewed by urology who reassured that this as not uncommon
and can be due to bladder spasm. This leakage improved during
your stay. You should follow up with your [**Hospital1 2025**] urologist
regarding your suprapubic catheter on discharge. Your INR was
initially high and your dose was reduced given your antibiotics
which can raise the level. We increased the dose and coevered
you with enoxaparin (another blood thinner) until you level is
high enough. Your INR on discharge was 2.5 and your warfarin
dose was changed back to your normal. Your liver function tests
were also found to be abnormal on transfer to the [**Hospital1 18**] and
these slightly increasd duering your stay. This is likely due to
your antibiotics and fluconazole but should be monitored at
[**Hospital1 **]. You were discharged to [**Hospital3 **] [**11-2**].
.
Changes to medications:
We continued linezolid and you have one further day
We stopped ciprofloxacin
We started IV cefepime you should continue this for more days
You were admitted on oral linezolid and should continue this for
1 more days
We added regular lorazepam at night to help with your sleep
We stopped theophylline and this should be reviewed at [**Hospital1 **]
We stopped the lidocaine patch and this should be reviewed at
[**Hospital1 **].
Your INR was erratic and thus we changed the dose of warfarin -
currently this at 4mg on [**11-1**] and decreased to home dose 3.5mg
on[**11-2**] but should be reviewed at [**Hospital1 **] with daily INR
checks.
We started enoxaparin and this should be stopped once your INR
is >2.0 for over 24 hours. You are on enoxaparin and this should
be stopped when your INR is >2 for over 24 hours.
Followup Instructions:
You should make an appointment to see your [**Hospital1 2025**] urologist on
discharge regarding your suprapubic catheter
|
[
"112.2",
"907.2",
"V44.1",
"426.7",
"V12.51",
"293.0",
"933.1",
"E849.7",
"790.6",
"276.1",
"V44.0",
"427.32",
"285.9",
"518.0",
"E912",
"E929.8",
"344.00",
"V58.61",
"486",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
21120, 21190
|
11736, 15781
|
306, 361
|
21518, 21518
|
3202, 11713
|
25094, 25219
|
2537, 2555
|
16883, 21097
|
21211, 21345
|
16052, 16860
|
21653, 25071
|
2570, 2570
|
21366, 21497
|
1867, 2247
|
245, 268
|
389, 1848
|
2584, 3183
|
21533, 21629
|
15797, 16026
|
2269, 2424
|
2440, 2521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,188
| 160,802
|
46189
|
Discharge summary
|
report
|
Admission Date: [**2177-5-14**] Discharge Date: [**2177-5-20**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y.o. female with h/o CAD, hypercholesterolemia,
diverticulosis, recent GIB c/b DVT p/w [**10-15**] SCP chest pain with
radiation to the back x 2 days. She describes it as indigestion.
She received SLNG and ASA on route. Her pain remained until she
arrived in ED at which point her CP had decreased. She has never
had this pain before.
Vitals on admission: T = 99.3, P = 46, BP = 86/30, 95% on RA
CT scan demonstrated b/l segmental pulmonary emboli and thus she
was admitted to the ICU given her age and initial vital signs.
Past Medical History:
1. GI Bleeding with Diverticulitis in [**2165**]. Recurrent GIB [**11-11**]
w/o clear source - suspect hemorrhoids vs diverticular
2. Sliding Hiatal hernia: Seen on UGI swallow in [**2164**]
3. Negative PMIBI [**7-11**] with EF 66% (multiple negative stress
tests)
4. Status post appendectomy.
5. Cataract surgery [**2167**]
6. Status post tubal ligation.
7. History of pneumonia.
8. Pap smear [**5-/2170**] with atrial thick pathology.
9. Retinacular cyst of right ring finger removed in [**2173**]
10. G4P2022
11. Mild centrilobular emphysema on CT Scan [**2171**]
12. Incidental left renal cysts on CT Scan [**2170**]
13. right popliteal DVT dx [**1-12**] s/p IVC filter
Social History:
Lives in [**Hospital3 **]. No Etoh, tob, drugs. Granddaughter =
HCP
Family History:
Brother: gastric, colonic cancer
CAD in multiple relatives
Physical Exam:
on admission, per ICU admit note:
T 97.8 hr 68 bp 144/83 rr 16 O2 97% on 2 L NC
genrl: sitting up in bed, talking on the phone
heent: perrla, eomi, no scleral icterus, MMM
neck: supple, no jvd or carotid bruits
pulmonary: lungs CTA bilaterally
CV: rrr, normal s1/2, no m/r/g
abd: soft, nt/nd, nabs, no masses/hsm
skin: no rash
neuro: a, ox3, cn 2-12 grossly intact, normal bulk/strength/tone
throughout, sensory intact to soft touch, no
nystagmus/dysarthria/tremor, FNF WNL, 2+ DTRs
Pertinent Results:
[**2177-5-14**] 12:11AM WBC-5.6 RBC-4.03* HGB-10.7* HCT-30.5* MCV-76*
MCH-26.5* MCHC-34.9 RDW-16.9*
[**2177-5-14**] 12:11AM NEUTS-47.8* LYMPHS-29.8 MONOS-17.6* EOS-4.3*
BASOS-0.6
[**2177-5-14**] 12:11AM PLT COUNT-176
[**2177-5-14**] 12:11AM PT-12.3 PTT-29.5 INR(PT)-1.1
.
[**2177-5-14**] 12:11AM cTropnT-0.05*
[**2177-5-14**] 12:11AM CK-MB-NotDone
[**2177-5-14**] 11:40AM CK(CPK)-84
[**2177-5-14**] 11:40AM CK-MB-3 cTropnT-<0.01
.
[**2177-5-14**] 12:11AM GLUCOSE-118* UREA N-22* CREAT-1.3* SODIUM-141
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
[**2177-5-14**] 12:11AM ALT(SGPT)-13 AST(SGOT)-21 CK(CPK)-93 ALK
PHOS-64 AMYLASE-206* TOT BILI-0.3
[**2177-5-14**] 11:40AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.4
.
[**2177-5-14**] 01:52AM LACTATE-0.8
.
[**2177-5-14**] 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2177-5-14**] 01:55AM URINE RBC-0-2 WBC-[**3-10**] BACTERIA-MOD YEAST-NONE
EPI-[**3-10**] TRANS EPI-0-2
.
blood cx: no growth
.
EKG [**2177-5-13**]:
Sinus rhythm
Left atrial abnormality
Early precordial QRS transition - is nonspecific
Modest nonspecific ST-T wave changes
Since previous tracing of [**2177-4-25**], atrial ectopy absent
.
CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST [**2177-5-14**]:
There is no axillary, hilar, or mediastinal lymphadenopathy.
There is an air-fluid level and focal dilatation of the mid
esophagus, which could suggest an esophageal disorder.
The heart appears normal and there are no pleural or pericardial
effusions. There is a segmental pulmonary embolism in the right
lower lobe, and an additional segmental pulmonary embolism in
the left upper lobe.
There is no evidence of aortic dissection. There is fusiform
dilatation of the entire descending aorta to 33 mm in diameter,
minimally increased since the prior study, when it measured 29
mm. Focal irregularity of the descending aorta at the
diaphragmatic hiatus is unchanged. There is mild interstitial
edema in the lungs, but no focal consolidation. There are trace
effusions. A cystic lesion in the pancreas is unchanged and
minimal prominence of the pancreatic duct is unchanged is also
again noted and similar.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Bilateral segmental pulmonary emboli. Chronic stable
opacity at the right base of 15 mm in diameter, which may
represent scar.
2. Stable cystic lesion in the pancreas.
.
KUB [**2177-5-14**]: The TrapEase filter is projecting at the level of
L3, L2 vertebra onthe right side. Incidental note is made of
levoconvex scoliosis with its tip at the level of L3. The
distribution of the bowel gas within the large bowel is
unremarkable with stool and gas noted within the sigmoid colon
and rectum. The bladder is filled with IV contrast, most likely
due to recent procedure.
IMPRESSION: Recently positioned TrapEase filter is projecting
along right side of L2- L3 in the region of the IVC.
.
BILATERAL LENIS [**2177-5-14**]:
FINDINGS: No comparisons. Grayscale, color, and pulse wave
Doppler son[**Name (NI) 1417**] were performed of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal flow,
compressibility, waveforms, and augmentation are demonstrated
bilaterally. No intraluminal thrombus is identified.
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.
.
ULTRASOUND OF IVC FILTER [**2177-5-14**]:
Ultrasound evaluation of the inferior vena cava demonstrates
linear
hyperdensities in the supraumbilical aspect of the IVC likely
represent IVC filter. Color and pulse wave Doppler exams of the
IVC proximal and distal to the filter demonstrate patent blood
flow.
IMPRESSION: Patent IVC filter.
Brief Hospital Course:
# Bilateral segmental pulmonary emboli: Diagnosed by CTA chest
in the ED. Admitted to unit for anticoagulation given
relatively recent GI bleed for close monitoring. Hematocrit
remained stable despite one guaic positive stool (but
supratherapeutic on heparin gtt at the time). Patient was
continued on an IV heparin gtt until her INR was therapeutic on
coumadin x 48 hours. Her hematocrit remained stable. Prior to
the initiation of coumadin therapy, a discussion was held with
the patient and her granddaughter to discuss the risk of a
life-threatening GI bleed with this intervention. The
alternative risk of life-threatening arrhythmia and hypotension
with a progressive pulmonary embolus was also discussed. The
granddaughter and the patient both wished to go ahead with
anticoagulation. PCP was notified via email of the plan of
treatment. Patient will follow-up with her primary care doctor
this week to follow-up her hospital admission. She will also
have daily INRs by VNA to monitor her coumadin and will have her
hematocrit rechecked in 2 days.
.
# Fusiform aortic dilation: Noted on CTA with note of
progression since her prior CT but no evidence of dissection.
Patient informed of an additional risk of aortic dissection and
life-threatening bleeding from this. She will follow-up with
her primary care doctor for continued monitoring of this
aneurysm.
.
# Esophageal dilation: Air-fluid level noted on chest CTA.
Patient denied any complaints of GERD. Her initial chest pain
that brought her in did not recur while in house. She was
continued on her sucralfate and PPI. She is s/p a recent EGD
[**11-11**] with similar evidence of a patulous esophagus.
.
# Acute renal failure: Resolved with small bolus of IVF.
.
# Anemia: Labs suggest AOCD. Hematocrit remained stable. On
iron as an outpatient. PCP to [**Name9 (PRE) 702**] for monitoring.
.
# Dispo: discharged home with services (VNA for coumadin
monitoring, medication assistance, and home safety evaluation),
cleared by PT
Medications on Admission:
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day): please dissolve in water to create a slurry (do not take
this with any of your other medications) .
Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic qd ().
Multivitamin daily
ferrous sulfate 325 mg po daily
Discharge Medications:
1. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: YOU MUST
HAVE YOUR COUMADIN LEVEL CHECKED EVERY DAY UNTIL YOUR DOSING
REGIMEN HAS BEEN ESTABLISHED.
Disp:*15 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day): please dissolve in water to create a slurry (do not take
this with any of your other medications) .
4. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic qd ().
5. Outpatient Lab Work
Please check daily PT/INR and call results to Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3510**],
phone: [**Telephone/Fax (1) 3511**]
6. Outpatient Lab Work
Please draw hematocrit, PT/INR, and PTT on [**2177-5-22**] and call
result to Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3510**], phone: [**Telephone/Fax (1) 3511**]
Discharge Disposition:
Extended Care
Facility:
Provident Skilled Nursing Center - [**Location (un) 583**]
Discharge Diagnosis:
primary:
bilateral segmental pulmonary emboli
fusiform dilation of descending aorta
esophageal dilation noted on CT
secondary:
history of GI bleed
Discharge Condition:
good: hematocrit stable, stable on room air
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience chest pain, blood in your stool, black stools,
dizziness, shortness of breath, or other concerning symptoms.
Please have your blood checked daily by the visiting nurse to
monitor your coumadin level.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 3510**] on Thursday, [**2177-5-22**] at
10:00 AM. Location: [**Last Name (NamePattern1) 98007**]. Phone: [**Telephone/Fax (1) 3511**]
|
[
"272.4",
"414.01",
"584.9",
"492.8",
"415.19",
"792.1",
"365.9",
"577.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9403, 9488
|
5973, 7987
|
225, 232
|
9680, 9726
|
2189, 5950
|
10045, 10232
|
1607, 1667
|
8436, 9380
|
9509, 9659
|
8013, 8413
|
9750, 10022
|
1682, 2170
|
175, 187
|
260, 621
|
635, 804
|
826, 1504
|
1520, 1591
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,869
| 130,526
|
53282
|
Discharge summary
|
report
|
Admission Date: [**2182-6-1**] Discharge Date: [**2182-7-3**]
Date of Birth: [**2139-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2181**]
Chief Complaint:
brought in [**12-26**] valproic acid o/d
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
HPI: 42 yo M w/ h/o HIV, bipolar disorder who initially
presented following valproic acid overdose on [**2182-6-1**]. The day
PTA, the patient was found on the floor, lying conscious and
alert, having drunk 1/2 L Bicardi, and reportedly swallowed 90
lorazepam tablets and an unknown number of depakote tablets. The
home was "trashed" with "blood everywhere." No reported LOC. He
had been part of recent 20 yr relationship with partner, had
been making homicidal/suicidal threats.
.
Initially presented combative and disoriented. Head CT, Abd CT
(-); CT C-spine showed no signs of acute injury. Intubated for
airway protection given altered mental status and
combatitiveness. During the intubation, significant edema of
upper airway was noted. Max VPA level noted in low 200's
(therapeutic <150), BZD urine/blood (-).
.
The MICU stay was complicated by RLL/RML aspiration pna which
grew MRSA in the sputum and BAL, s/p levo/clinda/vanc,
[**Date range (1) 109654**]. (Vanc [**6-4**]-current, levo/clinda [**Date range (1) 109655**]). Unasyn x
2 days was given for sinusitis noted on CT scan performed [**12-26**]
persistent fever ([**Date range (1) 87437**]). No growth on BCx. Pt has remained
persistently febrile spiking w/o pattern but at least daily, to
as high as 106F. TTE was performed as initial eval for
endocardititis, TEE performed on floor, both negative. Abd
imaging without any collections or source of fevers. Head MR
performed to r/o hypothalmic lesion.
Readmitted to MICU for fever, rigors, fluid-resistant
hypotension- T= 102-104 w/ systolic bp 80s, tachycardic to 120.
Rec'd intermittent NS boluses (total of 4L) w/ some
non-sustained improvement in bp. Repeat LP performed w/o
evidence of meningitis.
.
Past Medical History:
1) HIV: Last known cd4 [**6-16**] 543, vl 11K, no h/o OIs, ARVs d/c'd
[**12-26**] bone marrow suppression
2) Bipolar disorder, previously on depakote.
3) s/p left great toe amputation
4) s/p appendectomy
Social History:
Had been living with former partner, who recently left him for
due to physical/verbal abuse (has restraining order). Unknown
tobacco. (+) heavy EtOH.
pt has had one male sexual partner for the past 8 years. Pt
denies any time in prison. No recent foreign travel or camping.
No TB exposure, no [**Location (un) **] or animal contact
Family History:
unknown
Physical Exam:
On initial presentation to MICU:
.
Tc 99, bpc 95/61, resp 20 100%
AC, TV 600, RR 12, FiO2 100%
Gen: middle-aged male, intubated, sedated
HEENT: NC/AT, PERRL, nose with clotted blood in nares
bilaterally, OMMM, ETT in place, hard cervical collar in place
Cardiac: RRR, no M/R/G
Pulm: CTA bilaterally
Abd: mildly distended, soft, no HSM, hypoactive bowel sounds
Ext: Left great toe amputation, well-healed. No cyanosis,
clubbing, edema, 2+ DP bilaterally. Right wrist laceration.
Neuro: Moves all 4 extremities in response to painful stimulis,
2+ DTR throughout.
Skin: Multiple tattoos
Pertinent Results:
CD4 546, viral load 11,000
[**6-16**] WBC 4.9, N51 L29 M6 E1, 13% bands.
ESR 113.
BAL [**6-7**] S. aureus, no legionella, no PCP, [**Name10 (NameIs) **] fungus, no AFB,
[**6-6**] CSF non-infected, cryto antigen (-)
[**6-16**] urine, [**10-13**] RBCs 6-10 WBCs, (-)nit, leuk est, few bact, no
yeast
Hep A exposed, Hep C (-)
.
RLE u/s: Intraluminal thrombus in popliteal vein
.
Tagged WBC Scan [**6-20**]: No abnormal foci of tracer uptake
identified.
.
Chest CT [**6-18**]:
1. Cavitatory consolidation in the posterior segment of the
right upper lobe, which appears to have improved compared to the
prior CT of [**2182-6-14**], and significantly improved from the
CT of [**2182-6-6**]. Since this has a segmental distribution,
streptococcal, Legionella and Klebsiella pneumonia remain in the
differential diagnosis.
2. Multiple mediastinal and hilar lymphadenopathy with
hepatosplenomegaly.
.
Chest CT [**6-7**]
RUL and RLL infiltrate c/w pneumonia
.
TTE [**2182-6-13**]: EF 60%, no LVH.
nl valves. TRG 24-37.
.
CT chest [**6-14**]
mutliple axillary and mediastinal lymph nodes. Largest is 1.2 cm
paratracheal.
interval decrease in RLL consolidation
.
ABD CT [**6-14**]
no intra-abdominal collections
.
TEE Echo [**6-17**]: no vegatations noted.
.
[**2182-6-16**] 06:23PM BLOOD ESR-113*
[**2182-6-16**] 08:00PM BLOOD WBC-4.3 Lymph-36 Abs [**Last Name (un) **]-1548 CD3%-76
Abs CD3-1169 CD4%-35 Abs CD4-546 CD8%-38 Abs CD8-582 CD4/CD8-0.9
[**2182-6-22**] 04:22AM BLOOD Ret Aut-1.4
[**2182-6-28**] 05:05AM BLOOD Ret Aut-5.2*
[**2182-6-28**] 05:05AM BLOOD VitB12-951* Folate-7.8
[**2182-6-19**] 04:00PM BLOOD calTIBC-137* Hapto-280* Ferritn-1745*
TRF-105*
[**2182-6-7**] 03:41AM BLOOD TSH-3.7
[**2182-6-15**] 04:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
[**2182-6-17**] 09:00PM BLOOD ANCA-NEGATIVE B
[**2182-6-18**] 09:00AM BLOOD CRP-81.2*
[**2182-6-1**] 08:25PM BLOOD ASA-NEG Ethanol-59* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-6-15**] 04:21AM BLOOD HCV Ab-NEGATIVE
[**2182-6-19**] 04:00PM BLOOD PARVOVIRUS B19 DNA-Test
[**2182-6-19**] 04:00PM BLOOD EHRLICHIA ANTIBODY PANEL (HME AND HGE)-
TEST
[**2182-6-19**] 11:45AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
[**2182-6-18**] 09:00AM BLOOD Bartonella hensalae/[**Last Name (un) 7570**] IgG/IgM
Antibody Panel-Test
.
[**2182-6-27**]: PA/LAT CHEST RADIOGRAPHS: Comparison is made to [**6-26**]
and [**2182-6-23**]. A right PICC tip is in the proximal SVC. There is a dense
area of
consolidation within the posterior segment of the right upper
lobe. There is no pleural effusion or CHF. Heart size is within
normal limits.
IMPRESSION: Pneumonia in the posterior segment of the right
upper lobe.
.
[**2182-6-27**]:
PICC Line placement: IMPRESSION: Successful placement of 43 cm
total length right brachial PICC with tip in the superior vena
cava. The line is ready for use.
.
Brief Hospital Course:
A: 42 yoM w/ HIV presents s/p fall following lorazepam/depakote
OD
.
1) MRSA PNA/cavitation: The patient was intubated in the E.D.
for airway protection. During intubaton and later in MICU,
witnessed aspiration. CXR [**6-3**] and on chest CT on [**6-6**] revealed
right upper and lower lobe consolidation c/w pneumonia. Chest
CT [**6-7**] showed RUL/RLL pna which grew MRSA in the sputum and
BAL, s/p levo/clinda/vanc, [**Date range (1) 109654**]. (Vanc [**Date range (1) 109656**]
levo/clinda [**Date range (1) 109655**]). Unasyn x 2 days was given for sinusitis,
[**Date range (1) 29812**]. No growth on BCx. Demonstrated good tolerance of
CPAP/PS with adequate oxygenation and ventilation while sedated.
Fever: As the pt was being weaned from the ventilator, he began
experiencing high fevers (102-106). These continued after the
patient was weaned from the vent and continued during his brief
sojurn to the floor. During the time the pt received an
extensive work-up including multiple cultures, CT of the
abdomen, chest, and sinuses, MRI, tte and tee, multiple lumbar
punctures on the floor, and a tagged WBCC scan, all of which
failed to localize a source. On [**6-19**], a repeat cxr noted RUL
cavitary lesion and patient underwent CT scan for further
evaluation. CT revealed evolving approx 1cm x 1cm cavitary
lesion of RUL lobe w/ resolving surrounding cavitation. The
patient was started on vanco/clinda/ceftaz at this time (had
previously been maintained on vancomycin and unasyn, prior
course during ICU stay had included vanco/ceftaz). Vancomycin
was dosed more aggressively with goal troughs of 15, and the
patient defervesced within 48 hours and remained afebrile
throughout the remainder of his ICU admission. CT surgery was
consulted and felt the lesion was not amenable to either perc
drainage or surgical intevention. Plan to complete 5 wk course
of antibiotics. It was recommended that the patient have a
follow-up CT scan in [**2-27**] weeks, and patient to be scheduled for
CT Scan at the [**Hospital1 **] on [**2182-7-29**] and then have
follow-up appointments with Infectious Disease doctor [**First Name (Titles) **] [**Last Name (Titles) **]
Surgeon, Dr. [**Last Name (STitle) 952**].
.
2) DVT- patient noted to have unilateral RLE edema on [**6-22**]. U/S
revealed popliteal DVT, which apparently occurred despite
patient having been maintained on heparin sc prophylactically.
Patient started on Heparin drip for therapeutic PTT. Coumadin
started [**6-24**] with goal INR [**12-27**] (need to adjust warfarin
accordingly). After 3 days of Heparin, patient was switched to
Lovenox, which should be continued for 1-2 days after INR is
therapeutic. INR was therapeutic at 2.0 on day of discharge
([**2182-7-3**]), and patient should be continued on Lovenox 80 sc bid
for 4 more doses. INR should be checked every 3-4 days and
adjust Coumadin dose accordingly.
.
3) Valproic acid overdose: The pt's depakote levels peaked at
219 on [**6-2**]. His depakote levels were followed q4 and he was
given activated charcoal q4. Once his levels were within a
therapeutic range, his AC was d/c'd.
.
4) Hyperdynamic episodes: These were felt to most likely be due
to alcohol withdrawal, though the differential include acute
intracranial process vs. non-convulsive status. As the pt's
valproic acid levels trended down, the pt was attempted to be
weaned from sedation. He was treated with valium per CIWA and
with PRN doses for hyperdynamic episodes (HTN, Tachycardia,
tachypnea, and fever). Hyperdynamic episodes resolved routinely
with the administration of valium. Initial non-con CT head was
negative. EEG in MICU showed mild encephalopathy with no focal
epileptiform activity. Physical exam notable for ocular hippus,
muscle rigidity during acute hyperdynamic episodes. Neurology
was consulted on [**2182-6-7**]. The pt was treated with MVI,
thiamine, folate for possible alcohol related mental status
changes. The episodes resolved after approximately one week of
the above treatment.
.
5) Sinusitis- noted on ct. Asymptomatic. ENT was consulted and
a VTI maxillofacial CT was performed as preop evaluation.
Repeat CT revealing some resolution of ethmoid sinus opacities
and alternative fever source negated plans for possible
operative intervention. Patient remained asymptomatic
throughout hospital stay.
.
6) ?Bipolar disorder: The pt was seen and evaluated by
psychiatry following weaning from the vent at which point he was
also placed on a one-to-one sitter. It was felt that treatment
for the pt's ?bipolar d/o issues should be temporarily deferred.
Started on zyprexa and haldol prn following episode of
agitation on [**6-25**] during which he pulled out his PICC line. The
last 5 days of his hospital course, patient remained pleasant
without incident and PICC line stayed in place.
.
7) HIV: During admission CD4 546, viral load 11,000. The pt was
not on HAART therapy on an out-pt basis. Potential treatment has
been deferred until the pt is more stable.
.
8) Full Code
Dispo - Patient was stable and afebrile on the day of discharge
and will need to continue 5 week course of antibiotics as well
as Coumadin for DVT treatment.
Medications on Admission:
1) Depakote
2) Ativan
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-25**] Sprays Nasal
TID (3 times a day) as needed.
3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q6-8H (every 6
to 8 hours) as needed.
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO four
times a day as needed for thrush.
12. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Ceftazidime 2 g Recon Soln Sig: One (1) Intravenous three
times a day for 16 days: Please continue for 35 days total (last
dose on [**2182-7-23**]).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: Five (5)
1000mg Intravenous Q 8H (Every 8 Hours) for 16 days: Please
continue for 35 day course (last dose on [**2182-7-23**]).
15. Clindamycin in D5W 600 mg/50 mL Piggyback Sig: One (1)
Intravenous three times a day for 16 days: Please continue for
35 day course (last dose on [**2182-7-23**]).
16. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours) for 4 doses: Please continue
for 48 hours (4 more doses).
17. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
18. Outpatient Lab Work
Please have blood checked every few days to check INR level and
have Coumadin level adjusted accordingly. Your INR level was
2.0 on [**2181-7-3**].
19. Warfarin Sodium 1 mg Tablet Sig: Nine (9) Tablet PO at
bedtime: need to check INR in [**1-25**] days and adjust to goal INR
[**12-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
1. Alcohol withdrawal
2. Valproic acid overdose
3. Aspiration pneumonia
4. Bipolar disorder
Discharge Condition:
Stable
Discharge Instructions:
1. Please follow up with primary care physician
2. Please follow up with outpatient mental health professional
Followup Instructions:
- You will be scheduled to have a CT Chest without Contrast on
[**2182-7-29**]: Please call [**Telephone/Fax (1) 327**] for your appointment time and
report to [**Hospital1 69**] [**Hospital Ward Name **] in
the [**Hospital Ward Name 23**] Clinical Building, [**Location (un) 861**], Radiology.
- You have a follow-up appointment with Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
MD [**First Name (Titles) 767**] [**Last Name (Titles) **] Surgery Where: [**Hospital1 69**]:
CLINICAL CTR. - 9TH FL. HEMATOLOGY/ONCOLOGY Date/Time:[**2182-8-6**]
10:30
- Please follow-up with Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital1 1535**]: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2182-8-8**] 9:30
- Please schedule an appointment with your PCP [**Name Initial (PRE) **] 1 month after
discharge from the hospital.
Completed by:[**2182-7-3**]
|
[
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"507.0",
"482.41",
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"881.02",
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"310.0",
"996.62",
"276.5",
"303.90",
"453.41",
"E958.9",
"966.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"33.24",
"03.31",
"38.93",
"31.42",
"88.72",
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] |
icd9pcs
|
[
[
[]
]
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13632, 13710
|
6239, 11429
|
352, 357
|
13849, 13857
|
3337, 6216
|
14016, 14960
|
2707, 2716
|
11502, 13609
|
13731, 13828
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11455, 11479
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13881, 13993
|
2731, 3318
|
272, 314
|
385, 2113
|
2135, 2341
|
2357, 2691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,775
| 197,759
|
33504
|
Discharge summary
|
report
|
Admission Date: [**2192-4-20**] Discharge Date: [**2192-4-24**]
Service: CARDIOTHORACIC
Allergies:
Erythromycin / Aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion, exertional chest pain, and decreased
exercise tolerance.
Major Surgical or Invasive Procedure:
status post CABG x1/ AVR (#23 CE Magna) [**2192-4-20**]
History of Present Illness:
85 yo male with DOE, exertional CP, and decreased exercise
tolerance, work up revealed AS and single vessel CAD.
Past Medical History:
AS/CAD
COPD/asthma
Anal fissure with stricture
Prostate ca./BPH
chronic constipation
s/p melenoma removal [**12-13**]
s/p rectal fissure repair
s/p Appy. s/p T&A
s/p TURP '[**86**]
Social History:
retired MD
40 PY hx. quit "several years ago"
Family History:
nc
Physical Exam:
On admission
vs:afebrile, p:115, 110/60
general; A & Ox 3, NAD
HEENT: unremarkable
CVS:RRR, murmur noted
Lungs:CTA
ABD: benign
EXT: no C/C/E
Pertinent Results:
[**2192-4-22**] 05:27AM BLOOD WBC-10.5 RBC-3.68* Hgb-9.7* Hct-30.5*
MCV-83 MCH-26.4* MCHC-31.9 RDW-13.3 Plt Ct-179
[**2192-4-22**] 05:27AM BLOOD Glucose-110* UreaN-26* Creat-1.4* Na-135
K-4.7 Cl-99 HCO3-29 AnGap-12
RADIOLOGY Final Report
CHEST (PA & LAT) [**2192-4-22**] 12:52 PM
CHEST (PA & LAT)
Reason: assess for pnuemo
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with post CT removal post cabg
REASON FOR THIS EXAMINATION:
assess for pnuemo
PA AND LATERAL CHEST, [**4-22**]
HISTORY: Chest tube removed after CABG.
IMPRESSION: AP chest compared to [**4-20**]:
Patient has been extubated. Small bilateral pleural effusions
are unchanged and there is no pneumothorax. Bilateral lower lobe
collapse is unchanged. Postoperative cardiomediastinal
silhouette is normal and unchanged.
DR. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77682**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77683**] (Complete)
Done [**2192-4-20**] at 1:35:15 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-2-8**]
Age (years): 85 M Hgt (in): 72
BP (mm Hg): 142/90 Wgt (lb): 185
HR (bpm): 74 BSA (m2): 2.06 m2
Indication: Intraop CABG, AVR, evaluate vales, aortic contours,
ventricular function
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2192-4-20**] at 13:35 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine: 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 2.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *25 mm Hg < 20 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - Pressure Half Time: 77 ms
Mitral Valve - MVA (P [**12-7**] T): 1.8 cm2
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Complex (>4mm) atheroma in the
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Mildly dilated descending aorta.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Moderate AS (AoVA 1.0-1.2cm2) No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification. Moderate thickening of mitral
valve chordae. Torn mitral chordae. Mild valvular MS (MVA
1.5-2.0cm2). Mild to moderate ([**12-7**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient appears
to be in sinus rhythm.
Conclusions
Pre bypass: The left atrium is markedly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Right ventricular chamber size and free
wall motion are normal. The descending thoracic aorta is mildly
dilated. There is complex atheroma of the ascending, arch and
descending thoracic aorta. An epiaortic scan was conducted to
deliniate areas of least plaque/calcifcation for aortic cross
clamp and cannula prior to bypass. There is moderate aortic
valve stenosis (area 1.0-1.2cm2). No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is severe mitral annular calcification. There is calcium
extending onto a significant portion of the posterior mitral
leaflet. There is moderate thickening of the mitral valve
chordae. A torn mitral chord is present, originating from the
posteromedial papillary muscle. There is borderline mild
valvular mitral stenosis (area 1.8 cm2, 3.2 on recheck at higher
blood pressure). Mild to moderate ([**12-7**]+) mitral regurgitation is
seen, most prominent when blood pressure is in 170's systolic.
Vena contracta <.5 cm consistently.
Post byass: Preserved biventricular funciton. LVEF >55%. An
aortic valve bioprosthesis is seen (#23 magna per surgeons).
Peak gradient 12 mm Hg, Mean gradient 6 mm Hg post bypass. No
AI, no perivalvular leaks on aortic valve. Peak MR remains [**12-7**]+.
Aortic contours intact. Remaining exam is unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting ph
Brief Hospital Course:
[**2192-4-20**] Mr [**Known lastname **] was taken to the OR where he underwent
CABG x1 (SVG->PLB) and AVR (#23mm CE Magna pericardial) with Dr
[**Last Name (STitle) 914**]. Cross clamp time=104 minutes, CPB time=130 minutes.
Please refer to Dr.[**Name (NI) 9379**] operative report for further
details.Mr [**Known lastname **] was transferred to the CVICU in stable
condition, requiring Neo and Propofol to optimize blood pressure
while sedated.All drips were weaned in a timely fashion and the
patient was extubated postop night. He was transferred to the
SDU floor on POD#1.All lines and tubes were discontinued in a
timely fashion. On POD#2 Mr[**Known lastname **]'s rhythm went into a rapid
atrial fibrillation. He was beta blockaded and started on
Amiodarone po dosing.Anticoagulation was initiated with
Coumadin. Day #3 his rhythm converted to NSR in the 80s.On POD
#4 Mr [**Known lastname **] was doing well and it was felt that he was ready
for discharge to rehab for further strength and exercise
tolerance.
Medications on Admission:
Altace 5(1)
Pulmicort 2 puffs(2)
Xopenex (2)
Colace 100(2)
Pepcid 20 qhs
Ativan 0.5 prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation 1 neb [**Hospital1 **] prn () as needed for dyspnea.
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Warfarin 3 mg Tablet Sig: INR 2-2.5 Tablets PO once a day:
Dose based on INR goal 2-2.5, please check INR Mon/Wed/Fri.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day for 5 days.
15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every six (6) hours.
Discharge Disposition:
Extended Care
Facility:
[**Location **], at [**Location (un) **]
Discharge Diagnosis:
CAD/AS s/p CABG x1/AVR (#23mm CE Magna)
COPD, asthma, anal fissure, prostate ca./BPH, melanoma
removal1/08, s/pT7A, s/p appy, s/p TURP'[**86**]
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**] after discharge from rehab ([**Telephone/Fax (1) 170**]) please call
for appointment
Dr [**First Name (STitle) **] in 6weeks following discharge from rehab
([**Telephone/Fax (1) 77684**])
Dr [**Last Name (STitle) 55499**] in 4 weeks following discharge from rehab
Completed by:[**2192-4-24**]
|
[
"493.20",
"414.01",
"427.31",
"E878.1",
"424.1",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"88.72",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9752, 9819
|
7184, 8203
|
313, 370
|
10006, 10013
|
976, 1305
|
10525, 10852
|
795, 799
|
8341, 9729
|
1342, 1389
|
9840, 9985
|
8229, 8318
|
10037, 10502
|
814, 957
|
196, 275
|
1418, 7161
|
398, 512
|
534, 716
|
732, 779
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,593
| 143,480
|
877
|
Discharge summary
|
report
|
Admission Date: [**2170-10-19**] Discharge Date: [**2170-10-27**]
Date of Birth: [**2124-3-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**Known firstname 30**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Endotracheal Intubation for Respiratory Arrest secondary to
sedation
History of Present Illness:
46M h/o alcohol abuse, HCV [**3-9**] [**2141**] blood transfusion, GERD,
admitted with self-reported hemoptysis and CP, also found to be
alcohol intoxicated. Pt had attended baseball game at which he
drank about 12 beers. Afterwards, while walking home, pt
suddenly coughed up several tablespoonfuls of blood (per pt's
report to NF, he coughed one T of bright red blood). At that
time, pt also developed sudden onset L sided CP initiated and
aggravated by breathing, accompanied by SOB. Pt later reported
that this pain had changed to the R side. Pt noted no other
additional symptoms. Pt then called EMS and was brought to ED.
. ED:
# VS: T 98.1, HR 100, BP 120/76, RR 14, SaO2 96/RA
# Meds: ASA 325, nitroglycerin SL, hydralazine, metoprolol
(AFib RVR), levofloxacin (empiric Rx for PNA). Multiple pain
medications (acetaminophen, ibuprofen, morphine, Percocet,
hydromorphone). Diazepam per CIWA.
# Studies: CXR demonstrated ground glass opacities
# Clinical course: Afib + RVR (150s), spontaneous conversion
without meds to sinus tach (100s). Stable BP, asymptomatic.
.
ROS: Pt states that he was in his USOH prior to this incident
(+) Fatigue which pt attributes to longer hours at work
(-) CP, SOB, cough, hemoptysis. F/C, N/V, weight loss, sick
contacts. [**Name (NI) **] pt report to NF, prior PPD negative about ~1.5
month ago at inpatient detox.
Past Medical History:
# GERD
# Stab wounds to back ([**2141**]): R lung, kidney, liver punctured.
Seven operations necessitated c/b SBO, ruptured umbilicus,
herniated scar.
# DVT s/p knee surgery [**3-9**] athletic injury ([**2141**])
# HCV 2/2 blood transfusion ([**2141**])
Social History:
# Personal: Lives with M, F, B and B's wife, 2 nephews, in one
house.
# Professional: Carpenter
# Environmental exposures: Sawdust. 2 outdoor pet dogs.
# Alcohol: Up to 12 beers 6 times weekly
# Tobacco: Started chewing tobacco at 20y. Never smoked
tobacco.
# Recreational drugs: Pt reported experimental marijuana in
youth only. Records obtained from [**Location (un) 4047**] Detox on [**10-25**]
indicated, however, that pt had an extensive polysubstance abuse
history ([**2-6**] gallon vodka daily, up to 12 beers daily, Percocet,
and cocaine at various times). At age 45, he began snorting
crushed Oxycontin 80mg TID.
Family History:
# M a: DM2
# F a: DM2, restrictive lung disease, MI
# Siblings (1 brother, 1 sister): DM2
Physical Exam:
VS: Tm 98.9, Tc 98.1, BP 140-158/98-100, HR 78-90, R 24-26, SaO2
96/RA-98/RA
.
PE
Gen: Anxious, tremors
HEENT: NCAT, no LAD, MMM, OP clear, CN II-XII intact
CV: RRR, S1S2, no m/r/g
Chest: CTAB, equal excursion, no costochondral tenderness,
decreased inflow limited by splinting.
Abd: Soft, NTND, BS+, no HSM, no caput medusa.
Ext: No c/c/e, 5/5 strength at BUE/BLE, 2+ DP bilaterally
Pertinent Results:
Notable admission labs:
.
[**2170-10-19**] 03:17AM WBC-12.8* RBC-5.13 HGB-10.6* HCT-32.7*
MCV-64* MCH-20.7* MCHC-32.4 RDW-17.2*
[**2170-10-19**] 03:17AM NEUTS-69.6 LYMPHS-25.9 MONOS-3.9 EOS-0.4
BASOS-0.3
[**2170-10-19**] 03:17AM ASA-NEG ETHANOL-291* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2170-10-19**] 03:17AM cTropnT-<0.01
[**2170-10-19**] 09:37AM cTropnT-<0.01
[**2170-10-19**] 05:08PM cTropnT-<0.01
[**2170-10-19**] 03:17AM ALT(SGPT)-95* AST(SGOT)-71* CK(CPK)-235* ALK
PHOS-59 AMYLASE-110* TOT BILI-0.5
[**2170-10-19**] 05:05AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-10-19**] 07:00PM D-DIMER-650*
===========================================
Studies:
.
# BILAT LOWER EXT VEINS [**2170-10-19**] 6:55 PM
No evidence of DVT.
.
# CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2170-10-19**] 5:04 AM
Diffuse air space process, most likely infectious,involving the
right upper, middle and lower lobes. Small mediastinal and right
hilar lymph nodes, likely reactive. Fatty liver.
.
# CHEST (PA & LAT) [**2170-10-19**] 3:30 AM
Diffuse patchy opacity involving the entire right lung. The most
likely etiology is infectious. However, CT scan is recommended
to further assess.
.
# CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2170-10-20**] 1:00 PM
1. No pulmonary embolus.
2. Mild interval improvement in right lung patchy consolidation
and ground- glass opacity, possibly reflecting improving
infectious or inflammatory process; aspiration and pulmonary
hemorrhage are also considered.
3. 3-mm left upper lobe pulmonary nodule. If there is no known
risk factor for pulmonary malignancy, this may be followed up in
one year with chest CT.
.
# ECG Study Date of [**2170-10-19**] 12:10:46 PM
Atrial fibrillation with a rapid ventricular response. ST-T wave
abnormalities which are non-specific. Compared to tracing #1
atrial fibrillation is new.
.
# ECG Study Date of [**2170-10-19**] 12:34:48 PM
Sinus tachycardia with occasional atrial premature beats.
Compared to tracing #2 sinus rhythm has replaced atrial
fibrillation.
.
# SPUTUM Procedure Date of [**2170-10-21**]
NEGATIVE FOR MALIGNANT CELLS. Bacteria, squamous cells, and
scattered pulmonary macrophages.
.
# Cytology Report BRONCHIAL WASHINGS Procedure Date of [**2170-10-24**]
NEGATIVE FOR MALIGNANT CELLS. Reactive bronchial cells, abundant
reactive pulmonary macrophages and inflammatory cells.
.
# CHEST (PA & LAT) [**2170-10-25**] 1:10 PM
AP UPRIGHT PORTABLE CHEST: In comparison with films of [**2170-10-19**],
the patient has taken a very poor inspiration, which most likely
accounts for the prominence of the transverse diameter of the
heart. Although, the image is somewhat over-penetrated, there is
no evidence of pneumonia. Nevertheless, if there is a
significant clinical concern, a repeat study with better
inspiration and lighter technique would be recommended.
Brief Hospital Course:
46M h/o alcohol abuse, HCV 2/2 blood transfusion, admitted with
unwitnessed acute-onset hemoptysis and pleuritic CP.
.
# Hemoptysis: DDx included PE and infectious process given
diffuse multilobar opacities in R lung on imaging. Pulmonary
consult was obtained in the ED.
.
--TB rule-out: Pt was placed in isolation pending TB rule-out
based on reported history of hemoptysis. One out of three
sputum samples were reported with rare AFB on concentrated
smear. PPD was placed and was negative. Bronchoscopy was
performed to assess lungs and airways, returned no bloody fluid,
and found no masses. BAL results were negative for AFB. Final
state laboratory results reported negative M. tuberculosis.
.
--Aspiration PNA: Concern existed for possible aspiration PNA
given pt's intoxication on presentation. Levofloxacin was begun
with goal 10 day course, which was later discontinued given
possible suppressive effects on AFB. Repeat CXR on [**10-25**]
demonstrated no PNA.
.
--PE rule-out: Concern existed for possibe PE, based on elevated
DDimer, pleuritic chest pain, and episode of atrial fibrillation
which could have been chronic. Bilateral LENIs were negative
for DVT. Initial CTA chest had poor contrast timing. CTA was
repeated and demonstrated no PE.
.
--Autoimmune lung disease: Given isolated R-sided findings, low
suspicion existed for Wegener's or Goodpasture's, but ANCA and
anti-GBM were submitted and, respectively, were negative or
pending on discharge.
.
# Chest pain: Pt presented with pleuritic pain associated with
coughing and deep breathing. CE were negative and EKG
demonstrated no ischemic changes. Pt was converted to PO pain
medications and monitored for response. Pt stated repeatedly
taht . On [**10-25**], two hours
.
# Alcohol: Pt had h/o unsuccessful detox, and presented with
ethanol level of 291 on urine toxicology. Pt was highly
defensive when asked about his alcohol intake, attributing his
drinking to normal pattern with watching TV or a sports game.
Pt placed on CIWA scale with diazepam 10mg PRN, as well as
administered thiamine, folate, and MVI.
.
# Acute renal failure: Pt's Cr was noted to increase acutely
from 1.0 to 2 in a 48-hour time period, returning to 0.8
(baseline) on transfer from the MICU. As FeNa = 60, this was
attributed to either contrast-induced
.
# During day, pt repeatedly removed O2 NC; when asked why, pt
stated that it "fell off" without him knowing, despite NC being
securely in place. Overnight, per nursing, pt pulled out IV
which was securely taped, and stated that it had "fallen out" in
the shower. Second IV was placed, and securely taped with extra
tape per patient request. Pt pulled out second IV, again
claiming that it also had fallen out on its own. Later, pt took
off telemetry monitors, placed it in an empty plastic [**Location (un) 6002**]
box, taped the box closed, and then presented it to the nurse.
When asked by this examiner why pt did this, pt said it had
fallen off in the shower, and that he was "OCD" and didn't want
to lose any parts. Pt also observed to eat five [**Country 1073**]
sandwiches after completing his dinner, although he stated to
nursing that he did not have any dinner. In addition, pt
observed to be throwing objects in room (this had occured about
two nights ago as well). Pt reported to team later that he had
been thoroughly cleaning his room.
.
# AFib RVR: Pt experienced brief episode of AFib RVR in ED,
although likely [**3-9**] anxiety and pain. Pt was monitored on
telemetry and initially continued on metoprolol. On the floor,
pt had no subsequent incidents of PAF, and anticoagulation was
deferred without evidence of thrombus or PE.
.
# Sedation leading to respiratory depression leading to MICU
admission: Over the course of his hospitalization the patient
has had an escalating pain medication requirement for right
sided chest pain. Per outside records obtained by the team, the
patient was discharged from detox 1.5 months ago after an
admission for EtOH abuse and snorting 240 mg oxycontin daily. He
has been followed on a CIWA scale since admission given his
ongoing alcohol use. He received 80 mg oxycontin [**Hospital1 **] [**10-24**] and
[**10-25**] am. He received total of 60 mg prn oxycodone [**10-23**] and [**10-24**],
none [**10-25**]. He received 30 mg valium per CIWA on [**10-23**] and 10 mg
on [**10-24**], none on [**10-25**] (purposefully stopped after patient
returned from bronchoscopy with an oxygen requirement). He
received 125 mcg of fentanyl and 5 mg midazolam for the
bronchoscopy on [**10-24**]. Of note, the patient's creatinine
increased from 1.2-2.0 over the last 24 hours.
.
On the morning of MICU admission, the patient was sleepy but
arousable with stable vital signs. He was found by the nurse to
be somnolent with a RR 8-10, from presumed overdose narcotics.
After consultation with the pain service, he was given 200 mcg
narcan IM followed by repeat doses of IV narcan (total 0.88 mg)
with good result. ABG was 7.29/62/110. The patient had a room
air saturation of 96%, but he would have ongoing intermittent
periods of apnea and would desaturate to 88%. After receiving
narcan he would be a+oX 3 and appropriately answer questions. He
was transferred to the MICU for frequent narcan dosing and
nursing care.
# GERD: Pt was continued on home regimen of PPI.
.
# Full code presumed
Discharge Medications:
1. 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*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Acute Alcohol Intoxication.
2. Alcohol Withdrawal.
3. Hepatitis C Genotype 1, VL 1,560,000 IU/mL.
4. Non-MTB Mycobacterial Pulmonary Colonization - not pneumonia.
5. Narcotic Dependence.
Discharge Condition:
stable
Discharge Instructions:
Please return to the ED with fevers, chills, nausea, vomiting,
diarrhea, chest pain, or shortness of breath.
Followup Instructions:
As discussed with Dr. [**Last Name (STitle) **], [**Hospital1 18**] is committed to providing
you with optimal medical care. We want you to contact the Liver
and [**Hospital **] clinic for a follow-up appointment. It is also imperative
that you discontinue your alcohol abuse as this will lead to
further self-injury and possibly death, and make any other
medical treatments more difficult.
Liver Clinic [**Telephone/Fax (1) 2422**]
[**Hospital **] Clinic [**Telephone/Fax (1) 457**]
Alcoholic Anonymous [**Telephone/Fax (1) 6003**]
Drug and ETOH hotline 1-[**Telephone/Fax (1) 6004**]
Please see your Primary Care [**First Name8 (NamePattern2) **] [**Doctor Last Name **] as soon as possible.
|
[
"303.90",
"965.09",
"530.81",
"427.31",
"584.9",
"V02.59",
"070.54",
"486",
"E850.2",
"786.52",
"786.3",
"348.8",
"305.90",
"291.81",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12007, 12013
|
6125, 11494
|
277, 348
|
12256, 12265
|
3191, 3199
|
12422, 13121
|
2681, 2772
|
11517, 11984
|
12034, 12235
|
12289, 12399
|
2787, 3172
|
227, 239
|
376, 1745
|
3215, 6102
|
1767, 2022
|
2038, 2665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,395
| 138,508
|
54341
|
Discharge summary
|
report
|
Admission Date: [**2185-9-22**] Discharge Date: [**2185-9-27**]
Service: Neurology
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 85-year-old
right handed gentleman with hypertension, diabetes mellitus,
prostate cancer, recurrent invasive melanoma status post
excision, cataracts, status post cholecystectomy when on the
night of admission developed a right arm fine tremor that
increased in intensity over the next hour. At 7:30 p.m. he
fell forward hitting his face on the ground and became
unresponsive. When EMS evaluated the patient at 8:05 he was
nonverbal with right facial droop and questionable right arm
weakness. Twenty minutes later the patient had a grand
tonic-clonic seizure in the transport vehicle and the
patient's blood glucose was reported at 207 at the time. The
patient was intubated and brought to the Trauma Intensive
Care Unit where he was started on Dilantin and Propofol drip.
The patient had full body CT's notable for chronic bilateral
frontal subdural hygromas and nasal bone fracture. The
patient was admitted to the Trauma CTU for repair of the
nasal bone fracture, maintained on a 300 p.o. once daily dose
of Dilantin with stable vital signs and thereafter was
transferred to the Neurology Service for further management
and etiology of his new grand tonic-clonic seizure. The
patient notes that four to five weeks ago on further history
that he had a traumatic fall which may account for bilateral
subdural collection. The patient was initially seen by the
neurology consult service with Dr. [**First Name (STitle) **] [**Name (STitle) 557**] and then
transferred to the General Service for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insulin dependent diabetes mellitus.
3. Low grade prostate cancer in [**2183-1-16**] with no
treatment.
4. Recurrent invasive melanoma of the mid back status post
excision in [**2176**] and [**2180**].
5. Cataracts.
6. Appendectomy.
7. Cholecystectomy.
ALLERGIES: Niacin.
MEDICATIONS PRIOR TO ADMISSION:
1. Lisinopril.
2. Humulin insulin.
3. Avandia.
4. Aspirin.
5. Tylenol.
SOCIAL HISTORY: The patient denies use of alcohol, drugs or
cigarettes. Carries all ADLs without assistance.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.3 F. Blood pressure 120/80.
Pulse 78. Respiratory 12.
GENERAL: This is a well developed, well nourished elderly
Caucasian male extubated in gown lying on bed.
HEAD, EYES, EARS, NOSE AND THROAT: He had periorbital
hematomas. Anicteric sclerae.
NECK: Supply, no lymphadenopathy, no carotid bruits.
CARDIOVASCULAR: Normal S1/S2 with regular rate and rhythm,
no murmur.
PULMONARY: Revealed coarse breath sounds bilaterally.
EXTREMITIES: No cyanosis, clubbing or edema. Although he
did have a 1 cm open lesion on the left anterior calf.
NEUROLOGIC: The patient was awake, alert, cooperative and
attentive, following commands. The patient was able to
repeat with full speech. The patient did not have any signs
of ............, apraxia or calculation on cranial nerve
exam. Pupils are round and reactive to light. Extraocular
movements are full. Normal facial sensation and musculature.
Hearing was intact to finger rub bilaterally. The patient
had palate that rose symmetrically with tongue midline. On
motor exam the patient had 4/5 strength throughout the upper
and lower extremities in a symmetric fashion with normal tone
and bulk without adventitious movements. Strength is 4 plus
out of 5 over the course of the admission in a symmetric
fashion. The patient did have decreased vibration in both
lateral extremities. The patient on reflexes had [**12-21**]
reflexes bilaterally with upgoing toes bilaterally.
Coordination was intact on finger-to-nose and on
heel-to-shin. The patient was on bed rest and primarily
evaluated and then cleared by physical therapy to go home
with home physical therapy. The patient had normal steady
gait.
LABORATORY DATA:
White blood cell count baseline anemia with a normal MCV,
presumably due to chronic disease, hematocrit was over 12/35
on admission and [**8-16**] on discharge. The patient's blood
pressure remained stable throughout the entire neurologic
admission. The patient's coags were normal. Dip stick
urinalysis on admission showed large blood but no evidence of
any urinary tract infection. The patient did have elevated
creatinine of 1.7 on admission which normalized to 1.2 prior
to discharge presumably secondary due to rhabdomyolysis which
was cleared with intravenous fluid hydration. The patient
had an elevated CPK 254 on admission.
CPK enzymes were negative times three sets. Dilantin level
was 7.7 and 9.2 checked while patient was receiving Dilantin
in the Trauma Surgery Intensive Care Unit. Imaging studies
were performed during this admission. Initial CT showed
hemispheric bilateral chronic collections which at that time
were supposed to be either subdural hematomas or hygromas,
magnetic resonance scan later during the admission confirmed
they were hygromas and not subdermal hematomas. CT abdomen
and pelvis performed on admission showed no traumatic organ
injury or intra-abdominal hematoma. CT of the orbit showed a
nasal bone fracture with air fluid levels within the
maxillary sinuses, no other fractures identified. The
patient had magnetic resonance scan of head on [**2185-9-23**] showing no acute definite evidence of acute brain
ischemia and questionable hemorrhagic elements within the
left side subdural fluid collection. Multivariate regression
analysis showed moderate stenosis involving the precavernous
portion of the right internal carotid artery with presenting
atherosclerotic disease. There are no other areas of
hemodynamically significant stenosis or alteration. A repeat
head CT on [**9-24**] showed stable appearance of bilateral
subdural fluid collections with higher attenuation of left
cerebral collection than right. The patient was scheduled to
have magnetic resonance scan with contrast and susceptibility
imaging during this admission but refused as he was anxious
during the initial magnetic resonance scan and promised to
follow-up as an outpatient after getting open magnetic
resonance scan with primary care physician and neurology
clinic.
HOSPITAL COURSE:
The patient was admitted to the Neurology Service after
trauma he sustained for nasal bone fracture. The patient was
transitioned from Dilantin to Keppra during the admission for
seizure prophylaxis. The etiology of the patient's seizures
were unresolved at the time of discharge as they could be due
to bilateral subdural hydroma collection or possible
metastatic melanoma involving cerebrum. The patient was
informed that it would be to his advantage to have magnetic
resonance scan with contrast and susceptibility imaging while
he was an inpatient, but due to his anxiety during the first
magnetic resonance scan the patient refused this test on
three occasions and promised to have test preformed as
outpatient with appropriate follow-up. The patient had no
more seizures during the admission and was placed back on his
diabetes medication with Oxybutynin and chloride as patient
was having urinary difficulties in the two days prior to
discharge. The patient was also started on Lisinopril and
aspirin for cardiovascular and stroke prophylaxis. The
patient's diet was advanced from liquids to full consistency
without any difficulty. The patient was seen by physical
therapy and approved for discharge to home with home physical
therapy services.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: Home with physical therapy.
DISCHARGE DIAGNOSIS:
1. Grand tonic-clonic seizure of unknown etiology.
DISCHARGE MEDICATIONS: The patient was instructed to take
Humulin insulin 14 units q.a.m. as prescribed by Dr. [**Last Name (STitle) **]
his primary care physician. [**Name10 (NameIs) **] patient was also discharged
on Lisinopril 10 mg p.o. once daily. Keppra 1,000 mg p.o.
twice a day followed by 1,500 mg p.o. twice a day after two
days of use of 1,000 mg thereafter. Dilantin 200 mg to 100
mg taper over two days subsequent to discharge with
discontinue of medication on third day of discharge.
Oxybutynin and chloride 5 mg p.o. three times a day. Aspirin
325 mg p.o. once daily. Avandia 4 mg p.o. once daily.
FOLLOW-UP PLANS: The patient was ask to follow-up with
Plastic Surgery Clinic on [**2185-10-4**] for suture
removal. The patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] was called and informed about the patient's admission.
The patient was also given a prescription to obtain
outpatient head magnetic resonance scan in open setting so
that the patient does not become anxious during this
admission and refused closed myocardial infarction. The
patient also given the number to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] of [**Hospital 878**] Clinic in about four weeks to review
magnetic resonance scan findings and ascertain etiology of
seizures. Electroencephalogram performed on [**2185-9-23**]
showed abnormal electroencephalograms in awake and drowsy
states consistent with encephalopathy but no focal
epileptiform discharges.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 50783**]
Dictated By:[**Name8 (MD) 15274**]
MEDQUIST36
D: [**2185-9-29**] 12:43
T: [**2185-9-30**] 09:09
JOB#: [**Job Number 111291**]
|
[
"802.0",
"852.20",
"780.39",
"401.9",
"185",
"V10.82",
"728.89",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"21.71",
"21.81",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7711, 8307
|
7634, 7687
|
6268, 7529
|
2033, 2110
|
2244, 6251
|
8325, 9524
|
122, 1677
|
1699, 2001
|
2127, 2222
|
7554, 7613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,134
| 121,338
|
579
|
Discharge summary
|
report
|
Admission Date: [**2172-3-9**] Discharge Date: [**2172-3-14**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
1. Intubation
2. Right Radial Arterial Line
History of Present Illness:
This is an 87-year-old woman with an extensive PMH including CAD
3 vessel, HTN, CHF, mod-severe AS who presented with acute
respiratory distress requiring intubation. Ms. [**Known lastname 4602**]
developed increasing dyspnea at home since yesterday with
elevated blood pressure last evening (SBP > 200). No history of
fever, chills, cough, increased sputum or chest pain. Her
daughter found her this morning in acute respiratory distress
and consequently called EMS. At the time she was ambulating to
the bathroom.
.
In the ED, initial vs were: T 97 P 60 BP 203/97 R 30 O2 sat 74%
bag mask. Ms. [**Known lastname 4602**] was emergently intubated. She was given
lasix 60 mg IV once, per records diuresised 1150 L. Patient
dropped pressure to 60 systolic with propofol, improved with 750
cc bolus and turning off propofol. The patient was additionally
given versed and vecuronium. She received a total of 1.5 L NS,
Ceftriaxone, and Levofloxacin (empiracally for PNA). She was
transferred to the ICU.
.
Patient intubated and sedated unable to give history.
Past Medical History:
1. CAD - 3 Vessel, told to have stress test but refused several
years ago, last catheterization about 12 years ago per patient's
daughter.
2. HTN
3. Sick sinus syndrome s/p PPM [**2158**], replaced [**2169-5-9**]
4. CHF - last known echo EF >55% ([**10-12**])
5. Hypothyroidism
6. paced Afib - not anticoagulated
7. Chronic lung nodules
8. Moderate-severe aortic stenosis
Social History:
Russian speaking. Patient lives alone and is widowed. No h/o
tobacco, ETOH. Patient has help for cleaning and bathing, does
some cooking, daughter does
shopping. Walks without aid at baseline. Has frequent visitors,
daughter (health care proxy) [**Name (NI) **] lives nearby: [**Telephone/Fax (1) 4603**].
Family History:
CAD
Mother died of appendicitis
Four brothers died in [**Name (NI) 3106**]
Physical Exam:
ON ADMISSION TO ED
T: 97 P: 60 BP: 203/97 R:30 SPO2 sat 74% bag mask
General Appearance: Intubated
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: throughout)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
ON DISCHARGE:
Tm: 98.2, HR: 59, BP: 136/59, SP02: 99 2L
General: Well appearing, sitting in chair eating breakfast
Neck: Elevated JVP at about 7cm
Cardiac: Regular rate and rhythm; 3/6 systolic ejection murmur
Lungs: Crackles at bases bilaterally
Abdomen: +BS, soft, non-tender, non-distended
Peripheral Vascular: + Peripheral pulses
Extremities: Trace edema bilaterally
Skin: Warm and dry
Pertinent Results:
On admission:
[**2172-3-9**] 08:00AM BLOOD WBC-22.7* RBC-4.80 Hgb-14.7 Hct-44.8
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 Plt Ct-181
[**2172-3-9**] 08:00AM BLOOD PT-12.9 PTT-24.6 INR(PT)-1.1
[**2172-3-9**] 08:00AM BLOOD Glucose-319* UreaN-17 Creat-1.2* Na-142
K-4.8 Cl-107 HCO3-21* AnGap-19
[**2172-3-9**] 08:00AM BLOOD ALT-32 AST-33 LD(LDH)-264* CK(CPK)-63
AlkPhos-95 TotBili-0.6
[**2172-3-9**] 08:00AM BLOOD Calcium-8.6 Phos-5.9* Mg-2.4
[**2172-3-9**] 08:43AM BLOOD Type-ART Tidal V-550 FiO2-60 pO2-67*
pCO2-46* pH-7.28* calTCO2-23 Base XS--4 -ASSIST/CON
Intubat-INTUBATED
[**2172-3-9**] 08:09AM BLOOD Glucose-289* Lactate-5.9* K-4.6
.
Cardiac Enzymes:
[**2172-3-9**] 08:00AM BLOOD cTropnT-<0.01
[**2172-3-9**] 08:00AM BLOOD CK-MB-NotDone
[**2172-3-9**] 02:49PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-3-9**] 07:46PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-3-10**] 09:31AM BLOOD proBNP-1430*
.
Cardiac Echo [**2172-3-9**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size is normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2170-7-16**], the
severity of aortic stenosis has progressed.
.
CXR [**2172-3-11**]
Lung volumes are maintained following tracheal extubation.
Extensive
bilateral pulmonary consolidation is heterogeneous and also has
varied in
radiodensity to different degrees in separate areas over the
past two days. I suspect much of the abnormality is edema, but
pulmonary hemorrhage and pneumonia could be making a
contribution. Moderate cardiomegaly is stable and small
bilateral pleural effusions have developed since the earliest
studies on [**3-9**]. Transvenous right atrial and right
ventricular pacer leads in standard placements. No pneumothorax.
.
EKG [**2172-3-12**]:
A-V sequentially paced rhythm with intrinsic A-V conduction and
right
bundle-branch block configuration. Compared to the previous
tracing of [**2172-3-9**] there is no diagnostic interim change.
Brief Hospital Course:
Ms. [**Known lastname 4602**] is a pleasant 87-year-old woman with CAD, CHF,
HTN, sick sinus syndrome s/p pacer, moderate-severe AS who
presented to [**Hospital1 18**] on [**2172-3-9**] with acute respiratory distress.
Due to her poor respiratory status she was intubated in the
emergency department and admitted to the medical intensive care
unit. On [**2172-3-10**], her respiratory status had improved and she was
successfully extubated. On [**2172-3-11**], she was transferred to the
cardiology service. Her brief hospital course was notable for:
.
# ACUTE RESPIRATORY DISTRESS: Acute pulmonary edema was
suspected as the most likely etiology of the patient's acute
respiratory distress, in setting of diastolic dysfunction and
moderate-severe AS. Initially, there was concern for myocardial
infarction however, she was ultimately ruled out with three sets
of negative cardiac enzymes. There was also concern for
pneumonia and initially Ms. [**Known lastname 4602**] was put on antibiotics.
However, due to lack of fever, leukocytosis, and marked clinical
improvement, antibiotics were discontinued on [**2172-3-11**]. In the
MICU, Ms. [**Known lastname 4602**] was diuresed with 60 IV lasix x 1, and on
[**2172-3-11**] was restarted on her home regimen of 80 mg PO lasix. An
arterial line was placed on [**2172-3-9**] without incident, for close
BP observation, and this was discontinued on [**2172-3-11**], prior to
transfer to the floor. She was successfully extubated on [**2172-3-11**].
.
Upon arrival on medicine floor, Ms. [**Known lastname 4602**] was started on
Torsemide (eventually uptitrated to 40mg [**Hospital1 **]) with good urine
output and diminishment of rales on lung exam. (Patient was
diuresed with caution in light of mod-severe AS). SP02
continued to be 92-95% on 2L nasal cannula. She was also
started on Lisinopril 20mg QD for better BP control and
afterload reduction. Better BP control will help with pulmonary
edema, but without valvular repair, this issue cannot be
entirely corrected. Both the family and the patient are aware
of this.
.
# HYPERTENSION: During her hospitalization, the patient was
noted to have labile blood pressures ranging from hypo to
hypertensive. Hypotensive episodes occured in the setting of
getting propofol for sedation while intubated, and hypertensive
episodes occured primarily in the settings of anxiety, and after
extubation. In the MICU, Ms. [**Known lastname 4602**] was initially started on
captopril, but this was changed to Lisinopril on the medicine
floor. Her home clonadine was stopped; home Lopressor was
switched to Carvedilol for better alpha blockage. Torsemide
40mg [**Hospital1 **] was started as above. Ms. [**Known lastname 4602**] was also given
lorazepam prn anxiety.
.
# [**Last Name (un) **]: Creatinine increased to 1.2 from baseline 0.9 in the
setting of diuresis. It trended down to 1.0 on day of
discharge.
.
# CAD: Patient with known 3 vessel disease. No history of chest
pain and cardiac biomarkers were present. EKG did not reveal
any ST wave changes, though it did show some pacing
irregularities. ASA and simvastatin were continued. Ms.
[**Name14 (STitle) 4604**] was discharged on ASA, simvastatin, and ACE-I.
.
# MODERATE-SEVERE AORTIC STENOSIS: Ms. [**Known lastname 4602**] had increasing
dyspnea prior to admission, but no known history of chest pain
or syncope. And ECHO from [**2172-3-9**] shows an LVEF of 55% and an
aortic valve area of 0.8cm2. Ms. [**Known lastname 4602**] prefers medical
management of AS and does not want surgery. Her Imdur was
stopped during admission and she was diuresis cautiously as AS
makes her preload dependent.
.
# HYPOTHYROIDISM: Levothyroxine was continued at 50mcg daily.
.
# RATE: Ms. [**Known lastname 4602**] has a history of Afib and sick sinus
syndrome s/p PPM. Pacemaker was interrogated by EP during
admission and some changes were made. Ms. [**Known lastname 4602**] should
follow up with Device Clinic in 1 month and Dr. [**Last Name (STitle) **] on
[**2172-5-21**]. She was discharged on Amiodarone and Carvedilol.
.
#GOUT: After aggressive diuresis, Ms. [**Known lastname 4602**] complained of
symptoms consistent with gouty flare in left big toe.
Colchicine was started at 0.6mg QD and pain begam to subside.
Colchicine was continued on discharge. Outpatient management of
gout is deferred to PCP.
Medications on Admission:
meclizine 12.5mg [**Hospital1 **]
simvastatin 20 mg daily
levothyroxine 50 mcg daily
Lopressor 50 mg [**Hospital1 **],
Imdur 60 mg daily at noon
Amiodarone 200 mg daily
Aspirin 81 mg daily
Lasix 80 mg daily C
Clonidine 0.1 mg, 2 tablets in Am and 1 tablet in PM.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Oxygen
Continue oxygen by nasal cannula (1-6L) as needed. Call your
doctor [**First Name (Titles) **] [**Last Name (Titles) 4605**] worsens or your oxygen requirement
increases.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary
1. Acute pulmonary edema in the setting of high blood pressure
Secondary
1. Coronary artery disease
2. Diastolic heart failure
3. Sick sinus syndrome s/p pace maker
4. Hypothyroidism
6. Atrial fibrillation
7. Moderate-severe aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Dear Ms. [**Known lastname 4602**],
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having shortness of
breath. In the Emergency Department your oxygen level was found
to be very low and your blood pressure very high. You were
intubated (put on a ventilator) and sent to the intensive care
unit. We think that you had trouble [**Known lastname 4605**] because your
blood pressure was high which, in relation to your other cardiac
issues, ultimately caused fluid to accumulate in your lungs.
.
The following changes were made to your medications in order to
ensure better control of your blood pressure in the setting of
your aortic stenosis. We also started a medication to help with
your gout.
1. STOP taking Imdur 60mg daily
2. STOP taking Lopressor 50 mg twice a day
3. STOP taking Lasix 80mg daily
4. STOP taking Clonidine
5. START taking Carvedilol 12.5mg twice a day
6. START taking Lisinopril 20mg daily
7. START colchicine 0.6mg daily (for gout)
8. START Torsemide 40mg twice a day
.
At the rehab facility you will also receive Colace and Senna (to
help you move your bowels), Tylenol as needed for pain, oxygen,
and Heparin three times daily to prevent blood clots.
.
You will need to have your chemistry (electrolytes) checked in
one week because of some of the medications we are starting.
.
Please keep all of your doctors' appointments. Please take all
of your medications as prescribed.
.
Weigh yourself every day and call your doctor if you gain more
than 3 pounds.
.
Call your doctor or return to the hospital if you develop
shortness of breath, chest pain, severe headache, bright red
blood in your stool, abdominal pain, nausea, vomiting, diarrhea,
fever or any other concerning symptoms.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**] at [**Telephone/Fax (1) 4606**] to make an
appointment in [**1-11**] weeks after you are discharged from the
rehabilitation facility.
You will be called by the Device Clinic for an outpatient
interrogation of your pacemaker one month after discharge.
Cardiology, Dr. [**Last Name (STitle) **]: [**2172-5-21**] 09:20a
[**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
|
[
"427.31",
"518.81",
"402.91",
"424.1",
"427.81",
"428.31",
"428.0",
"584.9",
"244.9",
"V45.01",
"414.01",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11622, 11694
|
5789, 10164
|
230, 277
|
11994, 11994
|
3368, 3368
|
13970, 14438
|
2108, 2184
|
10477, 11599
|
11715, 11973
|
10190, 10454
|
12174, 13947
|
2199, 2952
|
2966, 3349
|
4016, 5766
|
183, 192
|
305, 1370
|
3382, 3999
|
12009, 12150
|
1392, 1767
|
1783, 2092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,377
| 124,202
|
12695
|
Discharge summary
|
report
|
Admission Date: [**2154-3-24**] Discharge Date: [**2154-4-11**]
Date of Birth: [**2082-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath
CABG X 4 (SVG > LAD, SVG > Ramus>diag, SVG > PDA), Maze, [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**] ligation on [**2154-3-27**]
Bronchoscopy [**2154-3-29**]
Tracheostomy [**2154-4-4**]
Bronchoscopy, repositioning of trach [**2154-4-8**]
History of Present Illness:
76yo F with h/o NIDDM, HTN, lymphoma, thrombocytopenia,
transferred from OSH with chest pain. She was then transferred
to [**Hospital 1474**] Hospital, where her pain recurred at 8/10, with her
EKG showing ST depressions in V4-6, heart rate in 140s. She
received SL NTG x 3, morphine, ASA 325, Plavix 300mg, metoprolol
and IV heparin, and was transferred to [**Hospital1 18**] for consideration
of cath.
Past Medical History:
1. DM2: on oral hypoglycemics
2. Low Grade Lymphoma: recent diagnosis, pt states has not begun
treatment yet
- Per Dr. [**Last Name (STitle) 21628**] [**Telephone/Fax (1) 39201**], to start Rituxan. Can be delayed
one month if needed for BMS/Plavix.
3. HTN
4. CKD
Social History:
retired, lives with son
Family History:
noncontributory
Physical Exam:
vitals- T 98.0, HR 54, BP 105/51, RR 15, O2sat 96% 4LNC, wt
190lbs
General- elderly woman in NAD, depressed affect
HEENT- sclerae anicteric, dry MM
Neck- no JVD visible, no carotid bruits
Lungs- bibasilar rales
Heart- irregularly irregular, no murmur
Abd- obese, soft, NT, ND, NABS
Ext- 2+ pitting edema to 1/2calf b/l, DP pulses faint b/l
Neuro- alert and oriented x 3
Pertinent Results:
[**2154-4-11**] 02:41AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.4* Hct-24.9*
MCV-91 MCH-30.8 MCHC-33.8 RDW-20.2* Plt Ct-26*#
[**2154-4-1**] 10:14AM BLOOD Neuts-56 Bands-0 Lymphs-5* Monos-37*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* Hyperse-1*
[**2154-4-11**] 02:41AM BLOOD Plt Ct-26*#
[**2154-4-11**] 02:41AM BLOOD PT-19.6* PTT-30.5 INR(PT)-1.9*
[**2154-4-11**] 02:41AM BLOOD Glucose-98 UreaN-112* Creat-1.7* Na-144
K-4.0 Cl-107 HCO3-26 AnGap-15
Brief Hospital Course:
Admitted from outside hospital on [**2154-3-24**]
Taken to cath lab on [**3-25**], found to have 90% LM & 2vCAD. IABP
placed, taken to the CCU. Went to the OR on [**2154-3-27**] for CABG X
4 (SVG>LAD, SVG>ramus>diag, SVG>PDA), Maze, LAA ligation,
(please see operative note for details). Post-operatively taken
to CSRU, on neo-synephrine for BP. Was slow to wean from
ventilator, due to sedation, and pulm. secretions. She had some
sinus rhythm post-op, but went back into AFib, with occasional
rapid ventricular rates. EP service was consulted, amiodarone
was started.
ID was consulted due to elevated WBC, empiric antibiotics were
started, but cultures were all essentially negative. She
remained on levofloxacin until [**2154-4-11**].
Hematology service was following her due to a new pre-operative
diagnosis of lymphoma, which ultimately was diagnosed as chronic
myelomonocytic leukemia, which will require frequent
transfusions of blood products.
She was extubated on POD # 8, but subsequently suffered a
respiratory arrest requiring brief CPR, and emergent
re-intubation.
She was taken to the OR on [**4-4**] whre she underwent tracheostomy
and PEG placement.
On [**4-8**], she dislodged her trach tube, requiring emergent
intubation, bronchoscopy, and replacement of the tracheostomy
tube.
She had a PICC line placed today for continued IV access and
possible transfusion of blood products.
She has remained hemodynamically stable and is ready to be
transferred to rehab for weaning from the ventilator.
Medications on Admission:
Prozac
Glipizide
Atenolol
Sulindac
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q4H (every 4 hours).
10. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) ML
Injection QMOWEFR (Monday -Wednesday-Friday) as needed for
chronic kidney disease.
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
dose daily for INR 2.0-2.5 for AFib.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD
Atrial fibrillation with rapid ventricular response
Diabetes mellitus
Hypertension
Chronic kidney disease
Chronic myelomonocytic leukemia
Discharge Condition:
stable
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
Followup Instructions:
Dr. [**Last Name (STitle) **] upon discharge from rehab.
Dr. [**Last Name (STitle) 914**] in [**2-9**] weeks
PCP and oncologist (Dr. [**Last Name (STitle) 21628**] upon discharge from rehab
Completed by:[**2154-4-11**]
|
[
"414.01",
"278.01",
"300.00",
"427.31",
"424.0",
"593.9",
"787.91",
"428.0",
"707.03",
"518.5",
"416.8",
"411.1",
"205.10",
"584.5",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"97.23",
"36.14",
"39.61",
"99.05",
"99.07",
"99.04",
"96.6",
"38.93",
"43.11",
"37.33",
"37.61",
"96.72",
"96.04",
"88.56",
"37.23",
"99.06",
"33.24",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
5354, 5426
|
2218, 3737
|
285, 556
|
5612, 5621
|
1758, 2195
|
5746, 5967
|
1336, 1353
|
3822, 5331
|
5447, 5591
|
3763, 3799
|
5645, 5723
|
1368, 1739
|
235, 247
|
584, 991
|
1013, 1279
|
1295, 1320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,685
| 122,761
|
47491
|
Discharge summary
|
report
|
Admission Date: [**2120-10-15**] Discharge Date: [**2120-10-24**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
pericardiocentesis
right heart catheterization
History of Present Illness:
85 year old with PMH of CAD s/p stent placement and meningioma
was recently admitted to [**Hospital1 18**] cardiology floor with chest pain
and fatigue. Her chest pain was thought to be noncardiac in
nature. She was discharged yesterday and felt worse overnight.
She has had mildly productive cough in the last two months but
worse overnight. She has also had chronic diarrhea ([**3-31**] BM per
day) but experienced nonbloody nonbiliary vomiting x 2
overnight. Her fatigue was worse and therefore decided to come
to the ED.
.
In ED her initial vitals were T 98.3 HR 90 (afib) BP 129/71 RR
26 85% in RA. Her oxygen satureation improved in mid 90s with
10 L NC. CT head prelim was done for vague diffuse headache
which was negative for acute process. She also had a CTA which
was negative for PE. Patient recieved Vanc 1 gram IV, Zosyn 4.5
gram IV, Flagyl 500 mg IV, zofran 4 mg IV, tylenol 1 gram PO,
KCL 40IV and 40po, and ? 2L NS. She was transfered to [**Hospital Unit Name 153**] for
further management.
.
ROS: Patient denies fever, abdominal pain, blood in stool or
urine, dysuria, hematuria, focal weakness, numbness. No other
complaints. She has pleuritic chest pain while coughing. No
PND, orthopnea, lower extremity edema.
Past Medical History:
.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post stent placement [**2117**] on
ASA and Plavix x 3 months but taken off in [**9-2**] secondary to ICH
with fall, s/p PCI 15 years ago.
2. History of bowel obstruction/volvulus [**2117-10-27**] s/p
abdominal laparatomy with LOA and extensive R colectomy c
ileocolic anastomosis [**11-1**].
3. Breast cancer.
4. Iron deficiency anemia.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. Hypothyroidism.
8. History of hyponatremia-per pt, has chronic h/o low Na, was
told by PCP to not drink too much water and is on salt tabs qid.
On d/c summary in [**11-1**] at OSH, also had hyponatremia with
likely
SIADH.
9. Intracranial hemorrhage [**2117**].
10. History of urinary tract infection.
11. Depression.
12. Hypercholesterolemia.
13. Osteoporosis with history of vertebral compression
fractures.
14. Stable meningioma.
15. Recurrent UTIs
16. Cognitive Impairment.
17. Chronic Back Pain
.
PAST SURGICAL HISTORY:
1. Extensive right hemicolectomy [**2116**].
2. Radical mastectomy [**2114**].
.
Social History:
Patient lives with husband and home health aide. Social history
is significant for the absence of current tobacco use. There is
no history of alcohol abuse.
Family History:
Brother and sister with CAD. Brother with [**Name (NI) 5895**]. There is
no family history of premature coronary artery disease or sudden
death.
Physical Exam:
On admission:
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: MMM, unable to assess JVP due to anatomy.
CARDIAC: RR normal S1, S2.
LUNGS: Bronchial BS in left base. Mild diffuse wheezes
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Reducible
perumblical hernia.
EXTREMITIES: No c/c/e.
SKIN: WWP
NEURO: Spontaneously moves all four extremities
Guaiac negative per ED signout.
.
On discharge:
HEENT: supple, no JVD appreciated
CV: RRR, no M/R/G
RESP: crackles left base with tubular breath sounds. Right clear
but decreased.
ABD: soft, NT, pos BS, mod diarrhea overnight
EXTR: no peripheral edema, pulses trace
Pertinent Results:
[**2120-10-14**] 05:55AM BLOOD WBC-11.9* RBC-3.25* Hgb-9.3* Hct-28.4*
MCV-88 MCH-28.6 MCHC-32.6 RDW-14.2 Plt Ct-212
[**2120-10-14**] 05:55AM BLOOD PT-12.4 PTT-30.2 INR(PT)-1.0
[**2120-10-14**] 05:55AM BLOOD Glucose-78 UreaN-15 Creat-0.6 Na-132*
K-4.5 Cl-93* HCO3-31 AnGap-13
[**2120-10-14**] 05:55AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9
[**2120-10-23**] 02:54AM BLOOD WBC-13.9* RBC-2.85* Hgb-8.2* Hct-24.9*
MCV-87 MCH-28.8 MCHC-33.0 RDW-15.0 Plt Ct-379
[**2120-10-24**] 05:40AM BLOOD WBC-25.9*# RBC-3.12* Hgb-8.9* Hct-27.4*
MCV-88 MCH-28.6 MCHC-32.6 RDW-14.8 Plt Ct-420
[**2120-10-24**] 05:40AM BLOOD PT-40.8* PTT-42.8* INR(PT)-4.3*
[**2120-10-23**] 07:21PM BLOOD Glucose-139* UreaN-18 Creat-1.8* Na-130*
K-5.0 Cl-88* HCO3-35* AnGap-12
[**2120-10-24**] 05:40AM BLOOD Glucose-78 UreaN-19 Creat-1.9* Na-131*
K-5.2* Cl-88* HCO3-35* AnGap-13
[**2120-10-16**] 05:32AM BLOOD ALT-18 AST-46* LD(LDH)-420* CK(CPK)-57
AlkPhos-87 TotBili-0.3
[**2120-10-15**] 05:25PM BLOOD proBNP-3303*
[**2120-10-15**] 10:15AM BLOOD cTropnT-<0.01
[**2120-10-16**] 05:32AM BLOOD CK-MB-3 cTropnT-<0.01
[**2120-10-24**] 05:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9 Iron-PND
PERICARDIAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
PLEURAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, and inflammatory cells.
.
ECHO ([**10-24**]):
The left atrium is 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. The
gradient increased with the Valsalva manuever. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. There is
abnormal septal motion/position. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is a
trivial pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
Pericardial constriction cannot be excluded.
.
IMPRESSION: Small amount of residual debris in the pericardium.
No evidence of tamponade. Constriction cannot be excluded. Small
LV cavity with hyperdynamic function, a mild LVOT gradient that
increases slightly with Valsalva.
.
Compared with the prior study (images reviewed) of [**2120-10-17**], a
septal "bounce" is seen on the current study. This is a
non-specific finding but can be seen with effusive/constrictive
physiology. There is minimal pericardial fluid left with some
organized elements at the RV apex and RV outflow tract. The
other findings are similar.
.
CT chest s contrast: 1. Unchanged large bilateral pleural
effusions with associated atelectasis, somewhat improved on the
left.
2. Persistent cardiomegaly with decreased pericardial effusion.
3. Multilevel degenerative anterior wedge compression fractures
as before.
.
RIGHT HEART CATH:
COMMENTS:
1. Resting hemodynamics demonstrated elevated right and left
sided
filling pressures, with equalization of RA, RV, PCWP, and
pericardial
pressures (RA mean 19 mm Hg, RVEDP 21 mm Hg, PCWP mean 22 mm Hg,
and
pericardial pressure 20 mm Hg). There was a blunted y descent.
The
cardiac index was normal (2.7 l/min/m2). The pulmonary vascular
resistance was mildly elevated (218 dynes-sec/cm5). After
removal of 400
cc serosanguinous fluid, a y descent was present. However,
pericardial
pressure remained mildly elevated.
.
FINAL DIAGNOSIS:
1. Pericardial tamponade.
2. Biventricular diatolic dysfunction.
.
CXR ([**10-23**]):
IMPRESSION: AP chest compared to [**10-11**] through 26:
Right lung is clear. Large cardiac silhouette unchanged, left
lower lobe
atelectasis and bilateral pleural effusions are improving. No
pneumothorax. Upper mediastinum is widened by extremely
tortuous vessels.
Brief Hospital Course:
85 year old with PMH of CAD s/p stent placement and meningioma
was recently admitted to [**Hospital1 18**] with chest pain and fatigue.
Thought to be non-ischemic. Had an echo and CTA which showed a
left pleural effusion & a small pericardial effusion w/ possible
diastolic dysfunction.
.
She was also dx w/ a UTI and d/c'd on bactrim [**10-14**]. She came
back [**10-15**] after having a large increase in cough and sob. She
has also had chronic diarrhea ([**3-31**] BM per day) plus vomiting x 2
overnight. CT of chest shows worsening pleural effusion and
pericardial effusion, etiology unknown. TTE showed evidence of
tamponade w/ RV diastolic collapse. The patient was transferred
to the CCU for pericariocentesis and drain placement as well as
thoracentesis. Also had new onset Afib this admission treated
w/ IV Amiodarone now transitioned to PO. Has improved sats
after diuresis and drainage of effusions.
.
# effusions - Unclear etiology; could be viral vs. cardiac
etiology. Thoracentesis revealed high LDH but otherwise
transudative in nature. Cultures/cytology negative. However,
given patient's elevated WBC, treated c 7 day course of vanc +
ceftriaxone. S/p pericardiocentesis with drain placement and
removal. Improved with diuresis, and after drainage.
- Repeat TTE in [**4-1**] weeks to reassess pericardial fluid.
.
# hypoxia: No signs of pneumonia or PE on CTA. Most likely due
to a combination of pleural and pericardial effusion/atelectasis
on imaging and exam. Influenza negative.
.
# atrial fibrillation: In atrial fibrillation on admission with
no prior history. Has since converted to NSR spontaneously. On
warfarin therapy. Since INR 4.3 on discharge, temporarily
holding.
- Continue amiodarone, BB, warfarin. Note that since patient is
on amiodarone will likely need less dose of warfarin to reach
therapeutic INR -- titrate to INR 2.0 - 3.0.
- Note that patient's discharge meds do not presently include
warfarin because her INR was supratherapeutic on day of
discharge.
.
# Leukocytosis: stable; unclear etiology but infectious etiology
remains a possibility although no organism identified to date.
Finished 8 day course of vanc + CTX, abx were stopped. Pt has
elevated WBC on discharge but otherwise stable, likely [**1-29**] UTI.
- Discharging on cipro (renally dosed) x 7 days to treat
presumed UTI.
.
# CAD: No signs of ischemia on EKG or CEZ.
-Continue ASA, Statin, BB
.
# Hyponatremia: improved with diuresis. Known chronic
hyponatremia. ?chronic SIADH. [**Month (only) 116**] have dCHF contributing to her
current worsening of hyponatremia. Currently improved and
stable.
- continue home salt tablets
.
# HTN: pt has been hypotensive recently.
.
# Hypothyroidism - Continue home levothyroxine. TSH pending
today to assess now amiodarone load complete.
Medications on Admission:
Amlodipine 5 mg daily
Aspirin 325 mg daily
Atenolol 50 mg daily
Calcium Carbonate 500 mg [**Hospital1 **]
Cholecalciferol (Vitamin D3) 400 unit q8h
Donepezil 10 mg daily
Levothyroxine 100 mcg daily
Loratadine 10 mg daily
Nitroglycerin 0.3 mg Tablet, Sublingual PRN
Omeprazole EC 40 mg daily
Simvastatin 40 mg daily
Sodium Chloride 1 gram Tablet daily
Trimethoprim-Sulfamethoxazole 160-800 mg [**Hospital1 **] for 6 days
.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
8. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
11. Psyllium Packet Sig: One (1) Packet PO twice a day.
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Pleuritic chest pain.
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1)
application Topical as needed () as needed for superficial skin
breakdown.
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: First day [**2120-10-15**].
20. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
*** 21. warfarin should be restarted once INR no longer
supratherapeutic to maintain target INR 2.0 - 3.0 (4.3 on
discharge)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Atrial Fibrillation with rapid ventricular response
Pericardial Effusion with tamponade
Pleural effusion
Acute Renal Failure
Leukocytosis
Hyponatremia
Hypertension
Discharge Condition:
stable
Discharge Instructions:
You had a collection of fluid around your heart that was drained
out. It has not reaccumulated. You also have atrial
fibrillation, a heart rhythm problem that resolved with
medicine. You were started on amiodarone and coumadin because of
this rhythm to prevent strokes. You were treated with
antibiotics for a possible pneumonia. Your kidney function is
worse because your are dehydrated. You should drink plenty of
fluids. Medication changes:
1. Stop taking amlodipine and Atenolol
2. Start taking ciprofloxacin for a possible urinary infection
3. Start taking albuterol and atrovent nebs as needed for
trouble breathing.
4. Start taking Ibuprofen for any chest pain from the tube
5. Stop taking Mirtazipine for now as you have been sleepy here
and not breathing enough.
6. Start Amiodarone to control your heart rhythm
7. Start Metoprolol to slow your heart rate.
8. Start Metamucil to control your diarrhea
Followup Instructions:
UROLOGY UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2120-10-30**] 8:30
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2120-11-4**]
9:30
Gastroenterology:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2121-5-5**] 10:30
Pulmonary:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58318**], MD Phone: ([**Telephone/Fax (1) 513**] Date/Time: [**11-27**] at
2:30pm.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Phone: ([**Telephone/Fax (1) 32215**] Phone: [**11-13**] at
3:30pm. [**Hospital6 2910**].
Completed by:[**2120-10-24**]
|
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68,140
| 190,006
|
18625
|
Discharge summary
|
report
|
Admission Date: [**2157-1-19**] Discharge Date: [**2157-2-16**]
Date of Birth: [**2073-4-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Transfer from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] NH for hypotension and hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1683**] is an 83 YOM with dementia, Type 2 Diabetes Mellitus,
bladder cancer s/p resection and BCG treatment, and recently
discharged for UTI who was at his nursing home yestderday when
found to be having chills and lower extremity numbness. His
vitals were taken and was found to be afebrile 95.7, hypotensive
(79/57), tachycardic (120) and hypoxic (O2SAT: 81% on RA). His
bilateral LE were found to be cold and purple. He was warmed up
and put into bed and his BP stabilized in 110s, he was placed on
nonrebreather and his O2 sats came up only to 87%. Per records
he did not have any mental status changes.
.
Of note, OSH records from Mr [**Known lastname 1683**] previous D/C summary in OMR
report he has had multiple recent UTIs over the past few months
including multi drug resistent enterobacter on [**2156-12-12**], Proteus
on [**2156-12-20**], as well as Klebsiella in [**Month (only) 359**]. Mr. [**Known lastname 1683**] was
recently discharged from [**Hospital1 **] on [**2156-12-31**] for UTI with pseudomonas
resistent to cipro. This admission was complicated by delirium
and LE DVT for which an IVC filter was placed due to concurrent
hematuria. He is not currently anticoagulated. He was discharged
on meropenem for 6 days. On [**2157-1-18**] (the day prior to admission)
he presented to the ED b/c of hematuria and passage of clots. He
was seen by urology and foley irrigation was performed and he
was sent out on Levofloxacin with plans to undergo cystoscopy
with bladder biopsies and possible
resection of TURBT as an outpatient. However, the following day
he had his hypotensive event described above and was sent to the
ED.
.
In the ED his vitals were 98.0 110 130/60 18 99. However, his BP
dropped to 90/60 BP with sats in the 80s and a lactate of 6. CXR
showed no acute pulmonary process. He was given vanc and
meropenem and, had an IJ placed, 6 L fluid, and foley showed
gross hematuria. He was transfered to the MICU with concern for
urosepsis where his pressure stabilized and he did not require
pressors. He was transfered to the medicine floor.
.
Upon ariving to the floor vitals were 99.2 122/60 91 20 97% on
RA.
.
ROS: Difficult to understand pt, unsure if from dementia or
adentulous. Pt alert but oriented only to self, knew he was in
[**Location (un) 86**] but could not name hospital. Denied pain, SOB, but stated
he was cold and thirsty.
Past Medical History:
1. Pulmonary Embolism ([**2156-12-24**], IVC filter, not on
anticoagulation)
2. Pancreatitis
3. Dementia
4. Type 2 Diabetes Mellitus
5. Hypertension, but not on antihypertensives
6. BPH
7. Bladder Cancer
- s/p transurethral resection in [**7-31**]
- completed [**3-29**] BCG treatment (missed treatment 5 [**1-25**] UTI)
8. s/p Stab Wounds
9. h/o RPR - treated in [**2119**]
10. s/p Penile Implant
11. Osteoarthritis
Social History:
Per previous records, patient could not complete full history
with me due to his delirium and dementia.
Home: lives in [**Location 4367**] [**Hospital3 400**] Facility
Occupation: retired long-distance truck driver
EtOH: remote history of social alcohol use; denies EtOH in > 45
years
Tobacco: remote history of 1 PPD smoking history, could not tell
me when he quit
Drugs: denies
Family History:
Could not complete due to patient's dementia.
Physical Exam:
VS: 100.4 133/74 76 20 98% RA
General: Alert, oriented to self only, lying comfortably in bed
HEENT: Dry mucous membranes, edentulous, pupils equal and
reactive
Neck: supple, JVP not elevated, no LAD. Right IJ in place,
appears clean and dry.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: 2+ pitting edema in left LE and 1+ on right, chronic venous
stasis changes to skin of both LEs; DPs difficult to palpate,
but feet are warm
Neuro: CN grossly intact. Uses both upper extremities
purposefully.
Foley with red urine in bag. Responded to questions, but
difficult to make out his answers, mildly agitated, not really
holding coherent conversation.
Pertinent Results:
LABS ON ADMISSION:
[**2157-1-18**] 10:00AM BLOOD WBC-11.7* RBC-4.20* Hgb-10.4* Hct-32.8*
MCV-78* MCH-24.8* MCHC-31.7 RDW-14.7 Plt Ct-257
[**2157-1-18**] 10:00AM BLOOD Neuts-82.9* Lymphs-11.6* Monos-4.7
Eos-0.4 Baso-0.3
[**2157-1-18**] 10:00AM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2*
[**2157-1-18**] 10:00AM BLOOD Glucose-138* UreaN-33* Creat-1.3* Na-144
K-3.9 Cl-100 HCO3-30 AnGap-18
[**2157-1-19**] 05:25PM BLOOD ALT-17 AST-16 LD(LDH)-268* AlkPhos-76
TotBili-0.3
[**2157-1-19**] 05:25PM BLOOD Lipase-68*
[**2157-1-19**] 05:25PM BLOOD cTropnT-<0.01
[**2157-1-19**] 07:43PM BLOOD Hgb-8.4* calcHCT-25 O2 Sat-91
[**2157-1-19**] 08:48PM BLOOD Glucose-133* Lactate-1.2
[**2157-1-19**] 05:22PM BLOOD Lactate-6.0* K-5.0
LABS ON DISCHARGE:
[**2157-2-14**] 05:53AM BLOOD WBC-6.6 RBC-3.38* Hgb-7.9* Hct-26.0*
MCV-77* MCH-23.2* MCHC-30.2* RDW-18.1* Plt Ct-423
[**2157-2-15**] 06:56AM BLOOD WBC-8.0 RBC-3.57* Hgb-8.2* Hct-27.5*
MCV-77* MCH-23.0* MCHC-29.8* RDW-17.5* Plt Ct-421
[**2157-2-15**] 06:56AM BLOOD Glucose-141* UreaN-12 Creat-0.6 Na-136
K-4.5 Cl-99 HCO3-29 AnGap-13
[**2157-2-15**] 06:56AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6
[**2157-2-16**] 05:43AM BLOOD WBC-7.6 RBC-3.50* Hgb-8.2* Hct-26.6*
MCV-76* MCH-23.5* MCHC-30.9* RDW-18.0* Plt Ct-495*
[**2157-2-16**] 05:43AM BLOOD Glucose-144* UreaN-11 Creat-0.6 Na-134
K-4.3 Cl-97 HCO3-30 AnGap-11
[**2157-2-16**] 05:43AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8
********
CXR [**2157-1-20**]: FINDINGS: Lung volumes are markedly diminished with
resultant bronchovascular
reorientation at the lung bases. No consolidation or edema is
evident. Tortuosity of the thoracic aorta is slightly
accentuated due to the low lung volumes. Similarly, cardiac size
is mildly accentuated, but remains overall within normal limits.
No definite effusion or pneumothorax is seen. Extensive
degenerative changes are again seen throughout the thoracic
spine. There are multiple bilateral rib deformities, presumably
due to remote trauma, relatively stable when compared to the
prior exam. IMPRESSION: Markedly low lung volumes with no acute
pulmonary process identified.
RENAL U/S: FINDINGS: The right kidney measures 11.0 cm. The left
kidney measures 13.1 cm. No stones, hydronephrosis or solid mass
is identified. Within the lower pole of the right kidney is a
1.6 cm simple-appearing cyst. There is also a 1.6 cm
simple-appearing cyst within the upper pole of the left kidney.
No perinephric fluid collection is identified.
Limited views of bladder reveal Foley catheter, with the bladder
decompressed. There is a heterogeneous 6.7 cm mass in the
bladder with vascular waveforms obtained, compatible with the
patient's known bladder mass.
IMPRESSION:
1. No evidence of hydronephrosis.
2. No evidence of perinephric abscess or fluid.
CXR [**2-9**]: Cardiomediastinal silhouette is stable. Right PICC
line tip is at the level of superior SVC. Heart size is normal.
Mediastinal contour is unremarkable. There is questionable new
small focal opacity at the mid portion of the left lung that
might represent subpleural atelectasis/nodule seen on the chest
CT from [**2157-1-29**], with no new consolidations
demonstrated. The known pulmonary nodules are partially imaged
on the current study due to the suboptimal sensitivity of this
portable chest radiograph. Multiple rib fractures, bilateral,
are unchanged since the prior study. The IVC filter is in place.
.
CT CHEST WITHOUT IV CONTRAST: There are numerous pulmonary
nodules throughout all lobes of the lungs consistent with
metastatic disease, presumably from the patient's known bladder
cancer unless there is an additional unknown primary neoplasm.
These are larger in the lung bases, measuring up to 12 mm
bilaterally (2:36, 2:34). There is no significant pleural
effusion. There is bilateral mild subsegmental dependent
atelectasis. The trachea and bronchi are patent to the
subsegmental levels. There is no mediastinal lymphadenopathy.
Note is made of multiple slightly prominent axillary lymph
nodes, which are not pathologically enlarged by size criteria.
There are numerous coronary artery calcifications, as well as
calcification of the aortic arch. A right upper extremity PICC
terminates with the catheter tip in the lower SVC. Limited axial
imaging of the upper abdomen is fairly unremarkable, although
numerous renal hypodensities are again seen, which are most
consistent with cysts, although better demonstrated on prior
imaging studies. The superior most aspect of an infrarenal IVC
filter is seen (2:56). Small hiatal hernia is present.
Osseous structures demonstrate numerous left-sided chronic rib
fractures at T1-9 as well as right-sided rib fractures at T1-6.
No suspicious lytic or sclerotic lesions are seen. There is mild
degenerative change of the thoracic spine.
IMPRESSION: 1. Innumerable bilateral pulmonary nodules
consistent with metastatic disease.
2. No mediastinal lymphadenopathy.
3. Chronic rib fractures bilaterally.
4. Renal hypodensities most consistent with cysts, better
demonstrated on
prior studies.
Brief Hospital Course:
83yo gentleman with h/o bladder cancer, recurrent UTIs, and
dementia called out from the MICU for continuing treatment of
urosepsis. Hospital course by problem as follows.
.
# Urosepsis: Patient received 7 L IVF with improvement in blood
pressure, never needed vasopressor support. He was started on
meropenem given prior urine cx sensitivities. He was transferred
to the floor the following morning. His renal function returned
to baseline after volume repletion. UCx pseudomonas 10-100k,
sensitive to cefepime, ceftaz, gent, [**Last Name (un) 2830**], [**Doctor Last Name **], tobra.
Recurrent UTIs across last several months with documented
history of proteus, enterobacter, klebsiela and pseudomonas,
current urine cx showing pseudomonas. No other clear source of
infection as he did not have infiltrate on CXR, no cough, no
abdominal pain, BCx NGTD, and no lines on admission. PICC line
placed and he was treated for 14days with meropenem. Urology
consulted. Recurrent UTI's likely [**1-25**] bladder cancer and
urinary retention. A Foley catheter was placed at admission.
This was taken out overnight on [**2-15**]. He passed his trial of
void with a 100 cc residual volume. He was noted to be
incontinent of urine at baseline.
.
# Bladder cancer, hematuria: Urology took for cystoscopy-> 7cm
tumor, unable to resect via scope. CT to assess for invasion/
lymph node involvement-> no clear evid of invasion or LN
involvement however mult lung nodules concerning for metastatic
disease. Med onc consulted-> Rec chest CT for accurate
staging, bx for tissue diagnosis, and agreed to follow when
outpatient. Given massive DVT and need for anticoagulation,
discussion had with family/urology/ radiation oncology about
possible palliative procedures to stop hematuria and allow for
anticoagulation. Decision was made to proceed with palliative
radiation tx as family wished to avoid any further invasive
procedures. Palliative care also consulted. Patient underwent
palliative radiation in attempt to control hematuria so that he
could have anticoagulation given his large lower extremity DVT
as below.
.
# DVT: h/o PE [**1-25**] DVT with IVC in place not anticoagulated due
to history of hematuria. Patient noted to have swollen L leg->
LENI-> DVT from L common fem to L popliteal. CT scan done for
staging as above showed DVT extended up to DVT filter.
Anticoagulation attempted however was d/c'd as hematuria
increased and patient dropped his hct. Palliative radiation
therapy was given with the goal to control hematuria, however
the patient did continue to bleed with anticoagulation. Given
that he bled enough to require multiple transfusions during this
admission, it was ultimately felt that anticoagulation should be
held with the decision to re-start deferred to the outpatient
setting.
.
# Low grade fevers: Following treatment with meropenem for
urosepsis as above, patient developed recurrent low grade
fevers. No clear source. UCx, BCx, and CXR negative for
infection. WBC stable. In the end, thought likely due to DVT.
By discharge, still having once daily temperatures to 99 F.
.
# Delirium : Continued on aricept. MS waxed and waned however
never returned to baseline. He frequently became agitated,
pulling at his PICC line and foley. He frequently required soft
restraints to prevent him from injuring himself and occasionally
required haldol (ECG checked and QTc wnl). After his catheter
was removed the restraints were removed and he was overall much
more calm.
.
# Anemia: baseline Hct 32-35, current Hct 25, likely [**1-25**]
hematuria. Iron studies were consistent with underlying anemia
of chronic disease. Guiac was negative. He was transfused a
total of 5 units of PRBCs during this admission given blood loss
from his friable bladder tumor. His Hct was stable around 26
prior to discharge.
.
# Hypernatremia, Mild, Asymptomatic: likely [**1-25**] poor PO water
intake. Encouraged PO intake of water and this resolved on its
own.
.
# Type 2 DM: controlled with ISS in house.
Medications on Admission:
Imipenem 750mg [**Hospital1 **] IM started [**2157-1-3**] for 3 days
Ertapenem 1gm IM Qday x 4 days, started [**2157-1-3**]
Decubrite 1 tab Qday
tylenol 650mg Q4H PO PRN
Lasix 30mg PO qday
Levaquin 250mg PO x 7 days, started [**2157-1-18**]
Donepezil 5mg HS
Gabapentin 300mg Qday
Imdur 30mg Qday
Famotidine 20mg PO BID PRN itch
Novalog SSI
Senna 1-2 tabs [**Hospital1 **] PRN
Vitamin D3 400mg, 2 tabs Qday
Colace 100mg [**Hospital1 **]
Citaloprom 20mg Qday
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*30 Tablet(s)* Refills:*2*
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily). Tablet(s)
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dryness.
Disp:*1 bottle* Refills:*2*
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Insulin Instructions
Please continue to take your Humalog Insulin --Sliding Scale as
taken during this admission. A full sliding scale regimen is
outlined below for the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] nurses to follow. To be
taken as needed at meal times and at bed time
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
1. Urosepsis
2. Bladder Cancer
3. Deep venous thrombosis
SECONDARY:
1. Dementia / deliriium
2. Type 2 Diabetes Mellitus
3. Hypertension, but not on antihypertensives
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness: Lethargic but arousable
Activity Status: Bedbound
Discharge Instructions:
It was a pleasure taking care of you during your admission at
[**Hospital1 69**]. You were admitted for a
urinary tract infection. You were treated with antibiotics. You
had a catheter in your bladder for some time, but we took this
out and you were able to urinate on your own.
You received a course of radiation to help improve your bladder
cancer symptoms.
You have a previous diagnosis of left lower leg blood clot. We
were unable to give you anticoagulant medications for this as
you continued to have significant blood in your urine, requiring
blood transfusion, after receiving these.
We have changed some of your medications during your admission.
Please continue, start, or stop your medications as below:
- Continue Citalopram 20 mg daily
- Continue Donepezil 5 mg daily
- Continue Famotidine 20 mg twice daily
- Continue polyethylene glycol for constipation as needed
- Continue Senna for constipation prevention
- Continue Vitamin D 800 units daily
- Stop Fexofenadine
- Continue Colace 100 mg twice daily
- Continue Tylenol as needed for pain/fever as written
- Continue using Humalog Insulin as needed with a sliding scale
at meal times and bedtime as taken prior to this admission
- Stop Lasix; discuss re-starting this medication as an
outpatient.
- Continue getting subcutaneous heparin three times daily while
in [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] and Dr. [**Last Name (STitle) 10351**] from
urologic oncology on [**3-10**] at 1 pm.
.
Dr.[**Name (NI) 51133**] office was called and notified that you will be
going back to The [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Upon return to the [**First Name4 (NamePattern1) 2299**]
[**Last Name (NamePattern1) **] you will be seen by her nurse practitioner, Jiyan [**Doctor Last Name **]
(#[**Telephone/Fax (1) 608**]). Ms. [**Name13 (STitle) **] will help to coordinate your next
visit with Dr. [**Last Name (STitle) 4321**] at your facility.
Completed by:[**2157-2-16**]
|
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"599.71",
"799.02",
"276.1",
"285.1",
"788.20",
"401.9",
"276.2",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"57.32",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15600, 15673
|
9661, 13678
|
395, 402
|
15892, 15892
|
4623, 4628
|
17453, 18129
|
3680, 3727
|
14185, 15577
|
15694, 15871
|
13704, 14162
|
16024, 17430
|
3742, 4604
|
241, 357
|
5354, 9638
|
430, 2825
|
4643, 5335
|
15906, 16000
|
2847, 3265
|
3281, 3664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,733
| 122,526
|
54239+59607
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-1-24**] Discharge Date: [**2141-1-29**]
Service:
CHIEF COMPLAINT: This is an 83 year old lady with a history
of congestive heart failure, atrial fibrillation on
anticoagulation and recent placement of a biventricular
pacemaker on [**2141-1-19**]. She presented through the Emergency
Room status post two falls at home. The patient had been
feeling well until the day prior to admission. At that time,
the patient had a fall while going to the bathroom, during
which she reports she slipped on the tile and fell onto her
back. On the day of admission, the patient again fell in the
kitchen, saying that she slipped on a piece of food. The
patient denied any loss of consciousness, dizziness,
palpitations or head trauma. In addition, she denied fevers,
chills, cough, rashes, shortness of breath, and chest pain.
In the Emergency Department, the patient had a chest x-ray
which showed near complete opacification in the left
hemithorax with mild shift of the trachea and mediastinum to
the right. The right lung was clear. A CT scan was
subsequently performed to correlate these findings. It
showed a high attenuation of fluid filling the left
hemithorax. There was minimal linear scarring in the right
posterior medial lung base. These findings were suggestive
of a large left hemithorax which reaches a slightly higher
attenuation in the apex, suggesting a bleed adjacent to this
location. However, there was no clear active extravasation
at this site. There was also a small hematoma visualized
adjacent to the pacemaker insertion site. At that time, the
patient was admitted to the medical Intensive Care Unit for
further care.
PAST MEDICAL HISTORY:
1. Congestive heart failure. Echocardiogram performed on
[**2141-1-23**] showed an ejection fraction of 45%. The left and
right atrium were mildly dilated. Overall left ventricular
systolic function was mildly depressed. There was mild to
moderate 1 to 2+ mitral regurgitation. Moderate to severe 3+
tricuspid regurgitation. A small to moderate sized
pericardial effusion was visualized. There was no evidence of
tamponade.
2. Atrial fibrillation. The patient was anticoagulated on
admission.
3. Status post placement of biventricular pacemaker on
[**2141-1-19**].
4. Hypertension.
5. Depression.
6. Status post cholecystectomy.
7. Status post appendectomy.
ALLERGIES: Penicillin which causes hives.
MEDICATIONS:
1. Co-Reg 25 mg p.o. twice a day.
2. Lisinopril 10 mg p.o. q. day.
3. Lasix 40 mg p.o. q. day.
4. Prilosec 20 mg p.o. q. day.
5. Wolfram.
6. Lomoxin.
7. Spironolactone.
8. Multi-vitamin tablets.
9. Aspirin 81 mg p.o. q. day.
10. Nitroglycerin patch .1 at night.
11. Salicylate 500 mg twice a day.
12. Lexapro 10 mg p.o. q. day.
SOCIAL HISTORY: The patient lives alone downstairs from her
son. She is widowed. She is working part time at a
laboratory in [**Hospital3 1810**]. She denies tobacco,
alcohol or illicit drugs.
PHYSICAL EXAMINATION: Temperature 96.4; heart rate 80; blood
pressure 94/34; respiratory rate 20; oxygen saturation 97% on
six liters nasal cannula. General: Pleasant, elderly lady,
lying in bed, in no acute distress. HEAD, EYES, EARS, NOSE
AND THROAT: Normal cephalic, atraumatic. Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements intact. Clear moist oropharynx. Neck: JVP at 9
cm, supple, without bruits. Cardiac: Regular rate and
rhythm; soft; 2/6 systolic ejection murmur best heard at the
base. Pulmonary: Clear to auscultation bilaterally with
decreased breath sounds at the left base. Abdomen: Soft,
nontender, non distended. Positive bowel sounds.
Extremities: 1+ edema of the ankles bilaterally.
LABORATORY DATA: White blood cell count of 21.3; hematocrit
of 31.3; platelets 224. Differential showed 88 neutrophils,
8 lymphocytes and 3 monocytes. Chemistry revealed a sodium
of 135; potassium of 4.4; chloride of 96; bicarbonate of 24;
BUN 26; creatinine 2.0, elevated from a baseline of .8 and
glucose of 142. CK 188; CK MB 13; troponin T 0.75.
HOSPITAL COURSE:
1. Hemothorax. The patient was found to have a large, left
sided hemothorax on CT scan. On the evening of admission,
she was admitted to the medical Intensive Care Unit for
further treatment. Her anticoagulation was reversed at that
time. The case was discussed with both interventional
pulmonary and CT surgery. On [**2141-1-24**], the patient went for a
VATS procedure and was placed at the left sided chest tube.
There was almost immediate drainage of 2.7 liters of
serosanguinous fluid. The chest tube continued to drain
slowly over the next two days. During the VATS procedure, [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] was visualized in the subclavian vein, which was thought
to be the source of the patient's hemothorax in the setting
of her anticoagulation. The chest tube was removed on the
evening of [**2141-1-26**]. The patient tolerated the chest tube
well. A small, apical, left sided pneumothorax was
visualized on chest x-ray which resolved after the chest tube
was removed. The patient's anticoagulation was held
throughout the admission, in light of her hemothorax.
2. Hypotension. The patient was hypotensive on admission
with systolic blood pressures in the 90's. This resolved
with intravenous fluids and transfusion obtained of packed
red blood cells. Following the VATS procedure, the patient
was restarted on her antihypertensive medications.
Subsequently, she once again became hypotensive. This
resolved with discontinuation of the blood pressure
medication and intravenous fluids. On [**2141-1-25**], she was
started back on her Co-Reg and her ace inhibitor was
restarted on [**2141-1-26**]. These were slowly titrated up as
tolerated, to control blood pressure throughout the remainder
of the admission.
3. Congestive heart failure. This was not an active issue
for the patient during her admission. She was continued on
her Digoxin. Her beta blocker and Lasix were re-added as her
blood pressure allowed.
4. Atrial fibrillation. The patient is status post
placement of a biventricular pacemaker on [**2141-1-19**]. She had a
regular paced rhythm throughout admission. Anticoagulation
was reversed and then held in the setting of her hemothorax.
5. Acute renal failure. The patient had acute renal failure
on admission to the hospital. This was thought to be
secondary to dehydration. Her creatinine trended down to
baseline with intravenous fluids.
6. Diarrhea. The patient developed diarrhea on the evening
of [**2141-1-26**]. A Clostridium difficile has been sent and is
currently pending.
7. Status post falls. Question whether her falls are
mechanical in nature, as the patient describes or secondary
to possible orthostatic hypotension. Physical therapy and
occupational therapy are currently evaluating the patient for
home services versus rehabilitation.
8. Fluids, electrolytes and nutrition. The patient was on a
cardiac diet throughout the admission. Her electrolytes were
repleted as needed.
9. Prophylaxis. PPI's, bowel regimen, Pneumoboots.
[**First Name11 (Name Pattern1) 8207**] [**Last Name (NamePattern4) 8208**], M.D.
[**MD Number(1) 8209**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2141-1-27**] 02:53
T: [**2141-1-27**] 16:22
JOB#: [**Job Number 111132**]
Name: [**Known lastname 18311**], [**Known firstname 18312**] Unit No: [**Numeric Identifier 18313**]
Admission Date: [**2141-1-24**] Discharge Date: [**2141-1-30**]
Date of Birth: [**2057-9-4**] Sex: F
Service:
This discharge summary addendum is from [**2141-1-29**] to [**2141-1-30**].
HOSPITAL COURSE:
1. Left hemothorax. The patient is status post VATS and
evacuation status post chest tube removal likely secondary
to pacer placement and anticoagulation, holding all
anticoagulation.
1. Acute renal failure, prerenal resolved with IV fluids.
1. Hypertension. Continued on Coreg for heart rate and blood
pressure control.
1. Status post pacemaker placement. She was to followup with
Device Clinic after D/C from rehab.
1. Congestive heart failure, well compensated. Currently
continue current Lasix dosing.
DISPOSITION: Discharge to rehab today.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Digoxin 125 mcg p.o. q.d.
3. Celexa 10 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d.
5. Carvedilol 25 mg p.o. b.i.d.
6. Flagyl 500 mg p.o. t.i.d. x2 weeks.
7. Lisinopril 10 mg p.o. q.d.
8. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. prn for two
weeks.
9. Lasix 20 mg p.o. q.d.
FOLLOW-UP PLANS: Patient is to followup with [**Name6 (MD) 3812**]
[**Name8 (MD) 18314**], NP on [**2141-1-31**] at 3:30 p.m. The patient is also to
followup with [**First Name8 (NamePattern2) 18315**] [**Location (un) **], a nurse from her primary care
provider's office. She is to followup in the Device Clinic
with nurse practitioner, Doust on [**2141-2-9**] at 10 a.m.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 18316**]
Dictated By:[**Last Name (NamePattern1) 5109**]
MEDQUIST36
D: [**2141-5-2**] 15:48:32
T: [**2141-5-3**] 05:12:48
Job#: [**Job Number 18317**]
|
[
"427.31",
"424.0",
"511.8",
"276.5",
"512.1",
"998.11",
"285.1",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.59",
"34.09",
"39.41",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8389, 8701
|
7763, 8366
|
2993, 4083
|
8719, 9316
|
102, 1681
|
1703, 2771
|
2788, 2970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,678
| 109,128
|
9176+56005+56008
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-14**]
Date of Birth: [**2072-3-4**] Sex: F
Service: VSU
CHIEF COMPLAINT: Right thigh wound.
HISTORY OF PRESENT ILLNESS: This 70-year-old female, with
known peripheral vascular disease and is status post multiple
vascular surgeries, presents to Dr.[**Name (NI) 1392**] office with a
right knee-thigh pain since [**2142-11-10**], and acute
right thigh drainage today, bloody in character. Outside work-
up included knee films which were negative, intra-articular
cortisone injection without improvement to the knee, an MRI
of the spine which demonstrated disk disease. Patient was to
get an epidural injection, but this was not done secondary to
her current symptoms. Patient denies fevers, chills, sweats.
She denies glucose changes. She was seen by her primary care
physician and started on ciprofloxacin 500 mg on [**2142-12-28**]. There had been no changes in the right knee pain. She
is now admitted for post incision and drainage in the office
for IV antibiotics and wound care.
PAST MEDICAL HISTORY:
ALLERGIES: Benadryl--manifestations unknown; aspirin--GI
bleed.
MEDICATIONS: Protonix 40 mg once daily, Zoloft 50 mg once
daily, Lasix 80 mg once daily, lisinopril 20 mg once daily,
Lipitor 80 mg once daily, warfarin 3 mg on Tuesdays,
Thursdays, Saturdays and Sundays, warfarin 2 mg on Monday,
Wednesday and Friday, Humulin-N 50 units q. a.m. and Humulin-
N 35 units at bedtime, with a Humalog sliding scale before
meals and at bedtime, Slow-Iron daily.
ILLNESSES: Include coronary artery disease status post
coronary angioplasty with stenting of the right coronary
artery in [**2141-12-16**], history of congestive heart failure--
compensated, history of hypertension--controlled, history of
hypercholesterolemia on a statin, history of upper GI bleed
secondary to aspirin--asymptomatic, history of MRSA sepsis in
[**2142-2-13**].
PREVIOUS SURGERIES: A cholecystectomy in [**2096**],
aortobifemoral bypass in [**2128**] with a right AK popliteal
bypass in [**2134**], bilateral right and left femoral popliteals
in [**2127**], a fem-fem bypass with a right SFA endarterectomy in
[**2127**], removal of the fem-fem bypass with vein patch
angioplasty to the PFA in [**2128**], a redo common femoral BK [**Doctor Last Name **]
with 8-mm PTFE in [**2139-11-15**], also a thrombectomy of the
common femoral artery at the same time, a left temporal
biopsy in [**2141-3-16**] which was negative, a jump graft of
right fem [**Doctor Last Name **] to BK [**Doctor Last Name **] with PTFE, and endarterectomy of the
popliteal artery in [**2142-2-13**].
SOCIALLY: The patient lives with her husband. She ambulates
with a cane. She denies smoking or alcohol use.
PHYSICAL EXAM: VITAL SIGNS: 138/70, 68, 16, O2 sat 96% in
room air. HEENT EXAM: There is no JVD, a left carotid bruit,
carotids are palpable 2 plus bilaterally. Lungs are clear to
auscultation. Heart has a regular rate and rhythm without
murmur, gallop or rub. Abdominal exam is soft, nontender,
bowel sounds x4. There are no bruits or masses. Peripheral
vascular exam: The right thigh is with a 2x2 opening with
surrounding erythema and warmth to palpation. Pulse exam
shows on the right radial artery palpable 1 plus, femoral 2
plus, DP and PT palpable at 2 plus. On the left, the radial,
femoral, dorsalis pedis, posterior tibial are all palpable at
2 plus. NEUROLOGICAL EXAM: Patient is oriented x3, nonfocal.
HOSPITAL COURSE: The patient was admitted to the vascular
service. She was placed on bed rest. Wound cultures were
obtained. Routine labs were obtained. Antibiotics of
vancomycin, levofloxacin and Flagyl were instituted. Blood
cultures and urine cultures were obtained. For diabetes, we
continued her current regime. Hemoglobin A1C was obtained. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult was obtained. A urinalysis was done to rule
out a UTI. The patient was continued on her antihypertensive
medications. Electrocardiogram was checked initially with no
acute changes. Coumadinization was held in anticipation for
potential further surgical intervention versus diagnostic
procedure. Initial swab grew oxacillin resistant staph, coag-
positive, heavy growth. Sensitivities to Bactrim were
requested, and this was sensitive to vancomycin, Bactrim,
tetracycline and gentamicin. The anaerobe cultures were no
growth. Blood cultures: Initial cultures grew [**1-17**] Staph coag-
positive, oxacillin resistant. The patient's repeated blood
cultures x3 were no growth and finalized. The patient had
urine cultures. She required several samplings until we
obtained an adequate urine for culture which was no growth.
On hospital day #2, patient complained of chest discomfort.
She was alert. Vital signs were stable. EKG during chest pain
showed no acute changes. There was some mild ST depression in
III, AVF, V1 and V2, as compared with the EKG on [**2142-3-18**]. Nitroglycerin relieved the symptoms within 3 minutes. A
repeat EKG was without change.
[**Last Name (un) **] followed the patient during her hospitalization for
diabetic management. Her hemoglobin A1C was 7.9. Infectious
disease was consulted for recommendations for appropriate
antibiotic therapy and length of therapy. Patient was
continued on current therapy. A vascular lab ultrasound
secondary to carotid disease and no follow-up in 2 years.
This showed a moderate plaque in the right internal carotid
artery and the left, the right being greater with narrowing
of the right of 40-59%, and on the left 60-69%. There was
normal left vertebral antegrade flow, and the right vertebral
was occluded. Patient had an MR of the lumbar spine obtained.
There were no abnormal signals within the vertebral bodies.
There was some loss of signal in L3-L4, L4-5, L5 and S1.
Intervertebral disk indicates some degenerative changes with
minimal loss of height in 3 and 4, with no significant
bulging of the disk. Significant disease was noted in L5 and
S1 with intervertebral disk loss and focal right base
protrusion and herniation into the spinal canal causing
displacement and compression of the S1 nerve root sleeve.
There was mild compression of the thecal sac at this level.
There was no abnormal signal within the disk to suggest
diskitis. The vertebral bodies demonstrate normal signal.
There is no evidence for abscess, or other fluid collections.
The patient's aortobifemoral graft was identified.
The patient had an MRA of the aorta and pelvic vessels and
the right leg vessels. The abdominal aorta was unchanged in
appearance. Renal arteries: Right there were 2, on the left
it was singular and were patent. The celiac and superior
mesenteric were patent. Aortobifemoral bypass was widely
patent throughout, originating from the distal infrarenal
aorta proximally and midway between the origin of the renal
arteries and the native bifurcation. The graft shows no
narrowing into its anastomosis with the common femoral
arteries bilaterally, where there are clip artifacts. There
are no collaterals to suggest high-grade stenosis. The native
distal aorta to graft origin remains patent with some
irregularity. There was irregularly, as well, within the
bilateral common iliacs which remain patent until the level
of the bifurcation. No internal iliac arteries could be
identified. On the right lower extremity, there is a
pseudoaneurysm of the right common femoral just beyond the
insertion to the right aortobifemoral artery graft which has
increased in size. It now measures 13-mm in diameter and 60-
mm in length. Previously, it was a 9x16. The profunda on the
right is patent. The right fem above-knee popliteal graft
shows mild narrowing proximally just distal to the
pseudoaneurysm, and it returns to normal caliber within the
proximal thigh. It is widely patent to the distal thigh where
the jump graft originates. Jump graft from the fem above-knee
popliteal graft to below-knee popliteal graft is completely
thrombosed. Throughout its entire extent, there is extensive
enhancement surrounding the occluded graft which occluded
distally at its anatomosis to below-the-knee popliteal and
medially at its origin which extends into the surface of the
skin where the patient's ulcer is located. This is highly
suggestive of infectious cause with an infected graft.
It is uncertain, however, whether these areas are infected,
and which have reactive enhancement from thrombosis. There is
no drainable fluid collection seen within this area. The
abnormal enhancement extends around the femoral above-knee
popliteal graft at the site of the jump graft origin, and the
femoral above-knee popliteal graft remains patent. At this
area through moderately narrowed proximally 50% to the
femoral, above-knee popliteal graft was patent to its
anastomosis with the above-knee popliteal, and the above-knee
popliteal artery is patent to the top of the prior
pseudoaneurysm just beyond the femoral condyle. Collaterals
are not well seen around the jump graft or the above-knee
popliteal artery occlusions. The anterior tibial and
posterior tibial arteries appear to be patent. The anterior
tibial and common peroneal and posterior tibial trunk is
reconstituted by collaterals. The anterior tibial does not
fill the DP. However, the posterior tibial does remain patent
into the foot. The peroneal artery is minimally patent
proximally, and does not extend beyond the midcalf. Left
lower extremity, the aortofemoral graft is patent throughout
its anastomosis with the femoral artery. The origin of the
profunda femoris is patent; however, there is a small
pseudoaneurysm at its origin measuring 8-mm in diameter which
is slightly increased in size from prior study. The left fem
below-knee popliteal artery graft is widely patent throughout
its course without evidence of focal stenosis. There is mild
narrowing of the native left anterior tibial artery without
high-grade stenosis. The common peroneal, posterior tibial
trunk is widely patent, and the posterior tibial artery is
widely patent throughout its course. The peroneal artery is
patent proximally and extends to the distal calf where it
gives off some collateral branches to both posterior tibial
and anterior tibial arteries. The anterior tibial artery
fills the dorsalis pedis which is diminutive but patent. The
posterior tibial artery fills plantar arteries with a
dominant lateral plantar branch that is patent. There is
edema within the vastus lateralis bilaterally and adjacent
muscles that is nonspecific. There is no other significant
muscle edema except for in the areas around the affected jump
graft and packed cavity.
Patient was evaluated by the cardiology service for
perioperative risk assessment. They felt that a Persantine-
MIBI was not indicated at this time, as there is probably
100% chance that it would be positive. Its only value would
be to determine size of ischemic defect, probably not small,
from EKG changes. The patient is at a high risk, but surgery
is unavoidable. Recommendations to transfuse to correct
anemia for hematocrit greater than 30, maintain her systolic
pressure in 120s-130s, maintain pulse rate in the 60s or
less, and proceed with surgery known at a higher risk.
Patient underwent on [**2143-1-7**] an excision of the PTFE
jump graft and wound debridement. She tolerated the procedure
well and was transferred to the PACU in stable condition. She
required 2 units of packed red blood cells for a
postoperative hematocrit of 21.4. She remained
hemodynamically stable and was transferred to the VICU for
continued monitoring and care.
Postoperative day 1, post-transfusion crit was 22.6.
Initially ran [**Company 5249**]-max of 100.1-99.9. The initial wound was
repacked and dressed. Patient remained in the VICU, Swan'd,
transfused 2 units of packed red blood cells. The glycemic
control was excellent. Serial CKs were flat. Troponins were
0.18, 0.18, 0.23. EKG was without further change. Patient was
continued on current management. Patient continued to be
followed by [**Last Name (un) **] service. Patient required IV nitroglycerin
for systolic hypertension. Post-transfusion crit was 26.9.
Patient's diet was advanced as tolerated. Diuresis was
continued. Patient was continued on antibiotics and remained
in the VICU for continued monitoring and care.
On postoperative day 3, T-max was 1003. The patient's Swan-
Ganz was converted to a triple-lumen. Diuresis was continued.
She was transfused another unit of packed red blood cells,
and electrolytes were repleted. Post-transfusion crit was
30.6. Diuresis was continued with IV Lasix. Reglan was begun
p.o. The patient was continued to be followed by infectious
disease.
Postoperative day 4, the levofloxacin and Flagyl were
discontinued. Patient continued to be diuresed. Her
hematocrit was 33.0 and stable. Her exam was unremarkable.
She had a Dopplerable DP and PT on the left, and a
Dopplerable DP on the right. Ambulation to chair was begun.
She was tolerating p.o.'s. IV fluids were Hep-Locked. She had
an excellent urinary output. Foley was discontinued at
midnight. She continued to be diuresed. O2 sats were
monitored, and O2 weaned. With adjustments in her insulin
dosing, her hyperglycemia improved. Final recommendations
from ID was that the patient should continue for a total of 6
weeks of IV vancomycin from the date of removal of the graft,
which was [**1-7**]. The vanco trough should be monitored
weekly along with a CBC, diff, BUN and creatinine. The trough
goal is [**10-4**]. These results should be faxed to the
infectious disease department at [**Telephone/Fax (1) 1419**]. Patient has
been instructed to follow-up with infectious disease clinic
in [**Month (only) 958**], and the number has been given to the patient to
call for an appointment time. A PICC line was placed on
[**2143-1-11**] for continued antibiotic therapy.
Remainder of the hospital course was unremarkable. The
patient was discharged to rehab in stable condition.
DISCHARGE MEDICATIONS: Acetaminophen 325 mg tablets [**12-17**] q. 4-
6 h. p.r.n., hydrocodone/acetaminophen 5/500 mg tablets [**12-17**]
q. [**3-21**] h. p.r.n., Zoloft 50 mg daily, amlodipine 5 mg daily,
atorvastatin 80 mg daily, Citalopram 5 mg tablets [**12-17**] at
bedtime p.r.n. as needed, Protonix 40 mg once daily,
Lopressor 50 mg t.i.d., Reglan 5 mg before meals and at
bedtime, hydromorphone 2 mg tablets [**12-17**] q. [**2-16**] h p.r.n.
severe pain, warfarin 3 mg daily. Maintain an INR between 2.0-
3.0 for graft patency. Patient's PICC line should be flushed
according to protocol of the hospital or VNA service that the
patient's care is under. Patient will continue vancomycin at
750 mg q. 12 h. for a total of 6 weeks, starting from [**2143-1-7**] to [**2143-2-18**]. Patient's NPH Insulin we will
continue at 42 units in the morning and 20 units at bedtime.
Humalog sliding scale as directed. Please see enclosed scale.
DISCHARGE DIAGNOSES: Methicillin resistant Staphylococcus
aureus right wound graft infection, Methicillin resistant
Staphylococcus aureus bacteremia, blood loss anemia transfuse
corrected, history of coronary artery disease status post
percutaneous transluminal coronary angioplasty with stenting
with the right coronary artery in [**2141-12-16**], history of
congestive heart failure--compensated, history of
hypertension--controlled, history of hypercholesterolemia on
statins, history of Methicillin resistant Staphylococcus
aureus sepsis previously, history of peripheral vascular
disease and multiple bypasses, history of gastrointestinal
bleed secondary to aspirin, history of gallbladder disease
status post cholecystectomy.
MAJOR SURGICAL PROCEDURES: Debridement of the right leg
wound and excision of infected jump graft on [**2143-1-7**], peripherally inserted central catheter line placement
on [**2143-1-11**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2143-1-11**] 14:12:49
T: [**2143-1-11**] 15:57:06
Job#: [**Job Number 31545**]
Name: [**Known lastname 1198**],[**Known firstname 732**] M Unit No: [**Numeric Identifier 5480**]
Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-22**]
Date of Birth: [**2072-3-4**] Sex: F
Service: SURGERY
Allergies:
Benadryl
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2143-1-14**] Patient's planned discharge was defered secondary to
development of increasinf foot ischemia.Patient had PVR's aof
fore foot done and graft duplex done.
[**2143-1-16**] rt. bka
[**2143-1-17**] POD#1 inital dressing removed. wound without cellulitis.
diet advanced and PCA continued.[**Last Name (un) 616**] continued to follow
patient. She did require adjustment of insulin dosing for
hypoglycemia.
[**2143-1-18**] Episode of trnasint confusion. ABG no hypoxia, reglan
discontinued. Temp Max 102.2 blood c/s multiple obtained, no
growth so far. Urine c/s >100,000 organisms, repeat U c/s
pending of [**2143-1-20**]. CXR no infiltrates.Diflucan started.
[**2143-1-19**] continued with temp 101.0 wound with mild anterior flao
discoloration and erythema. Continued on antibiotics
Continued to be followed by physical thearphy.
[**2143-1-20**] T max 100.5 confusin improved.
[**2143-1-21**] wound stump improved. afebrile.
[**2143-1-22**] Transfered to rehab. Wound clean dry skin edges well
approximated. Patient to f/up [**Hospital 5481**] clinic as directed. Iv
Vanco will continue for 6 weeks from amputation date, may
require long term antibiotic suppression which will be decided
on followup with ID. Patient should followup with [**Doctor Last Name **] in 4
weeks. Skinclips remain in place until seen in followup by Dr.
[**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2143-1-22**] Name: [**Known lastname 1198**],[**Known firstname 732**] M Unit No: [**Numeric Identifier 5480**]
Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-22**]
Date of Birth: [**2072-3-4**] Sex: F
Service: SURGERY
Allergies:
Benadryl
Attending:[**First Name3 (LF) 231**]
Addendum:
please do a peak and trough [**2143-1-23**] goal trough 15-20. peak >30
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2143-1-22**]
|
[
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"041.11",
"413.9",
"250.72",
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"584.9",
"682.6",
"428.0",
"440.23",
"790.7",
"790.92",
"998.31",
"996.62",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"86.22",
"99.07",
"89.64",
"84.15",
"99.04",
"88.72",
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icd9pcs
|
[
[
[]
]
] |
18523, 18761
|
14941, 17826
|
14001, 14919
|
3484, 13977
|
2766, 3412
|
3431, 3466
|
152, 172
|
201, 1065
|
1088, 2750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,482
| 101,161
|
4920
|
Discharge summary
|
report
|
Admission Date: [**2153-1-20**] Discharge Date: [**2153-2-19**]
Date of Birth: [**2084-11-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Heparin Agents / Motrin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
shoulder pain
Major Surgical or Invasive Procedure:
S/P ACD
S/P POSTERIOR CERVICAL RECONSTRUCTION
History of Present Illness:
68 M PMH thyroid ca with mets to bone and liver, history of
intrathecal narcotics requirement, who p/w increased pain. The
pain is located in the L shoulder scapular to humoral region,
with no obvious radation, and was [**2156-9-14**] in severity. He also
describes other chronic pains, including leg and some chest pain
with heavy coughing, but these have been stable. He was seen by
Dr. [**Last Name (STitle) 19**] on [**1-16**], where he was also noted to have some L sided
weakness, and was sent for an MRI to evaluate for metastatic
disease, which as noted below showed no new changes. He was
attempting to increase his decadron as indicated by Dr. [**Last Name (STitle) 19**],
when he couldn't handle the pain this AM, and came to the ED.
He has also described some diffuse paresthesias of both
fingertips, although primarily on the L--no apparent pattern.
Otherwise, he denies focal weakness, numbness, incontinence of
stool or urine, urinary retention, HA, as well as any F/C/NS,
LH, appetite changes, SOB, N/V, or abdominal pain. He has a
chronic cough [**3-9**] radiation, and also noted poor fluid intake
over the past few days, although no apparent reason. He
requires a walker to ambulate, but notes no change over the past
few days.
.
In the ED, given dilaudid 4mg IV x 2, with pain that was not
completely revolved, but "tolerable."
Past Medical History:
Thyroid ca s/p thyroidectomy [**2147**], with mets to bone and liver
-s/p implanted epidural narcotics on prior admission; hx of
infected Port-A-Cath system
S/p carboplatin [**1-9**]
S/p cyperknife to T1 [**7-10**]
Clear cell ca of L kidney s/p L nephrectomy [**6-6**]
S/p appy
Social History:
History of smoking cigarettes, 1 pack-per-day, for 10
years--stopped in [**2126**]. Occasional alcohol, 1-2 drinks per
week. He does not use any illicit drugs.
Family History:
His mother died of tuberculosis at age 36 in [**2085**]. His father
died at age 73 from coronary artery disease.
His brother died of smoking-related lung cancer. His sister and
his children are healthy.
Physical Exam:
Vitals: T 98.8
BP 150/91
HR 93
R 20
Sat 97% RA
*
PE: G: NAD, WN, WD
HEENT: Clear OP, MMM
Neck: Supple, No LAD, No JVD
Lungs: BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: No edema. 2+ DP pulses BL.
Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. Strength UE [**6-9**] R, 4/5 L throughout--no
pattern and pt denies pain limiting, [**6-9**] BL LE. 2+ reflexes,
equal BL. Ungoing toes BL. Past-pointing on L UE, NL on R.
Pertinent Results:
MR [**Name13 (STitle) 2853**] [**2153-1-17**]: There is no change from [**2152-2-12**]. There is
metastatic disease at C7-T1 and T2 with collapse of T1 and
resultant kyphosis. There is stable epidural disease. There
have been posterior laminectomies and there is no spinal cord
compression, although there is probably some myelomalacia and
atrophy at the level of the surgery, unchanged.
*
L Shoulder/humerus Plain film: Read pending; no obvious
fracture, ? metastatic involvement.
.
CXR [**1-22**]: Patchy opacities most prominent in the right lower
lobe, worrisome for pneumonia.
.
CT spine [**1-23**]: Progression of the lytic osseous and epidural
metastases, with progressed malalignment. Fracture through the
T2 pedicle screws bilaterally
.
CTA [**1-23**]: 1) Right lower and right middle lobe air space
consolidation consistent with pneumonia. There appears to be
narrowing of the bronchus intermedius.
2) Left lower lobe atelectasis and patchy multifocal bilateral
generalized foci of air space disease most likely reflecting
consolidations though metastases are not excluded.
3) Progression of osseous vertebral and hepatic metastasis.
4) No evidence of PE.
5) Possible cervical instability.
.
Bone scan [**1-23**]: 1) No abnormal uptake in the left upper
extremity. 2) Uptakecorresponding to known metastases in the
sternum, cervical spine as above. The new uptake in the left
11th and 12th rib ends likely post-traumatic.
Brief Hospital Course:
68M thyroid ca to bone + liver p/w increased pain L shoulder/
humerus. Pt was admitted to the Medicine service and treated
for the following problems:
.
# pneumonia: Patient had altered MS and low grade fevers [**1-22**]
and CXR performed which suggested pna. Started on levo/flagyl
with concern for aspiration. [**1-23**], patient had new hypoxia and
hemoptysis. Hematocrit has remained stable. CTA negative for PE
but did confirm significant pneumonia. No fevers since starting
levo/flagyl.
.
#L shoulder/humerus pain: Evaluated by radiation oncology who
felt that risks of radiation in setting of multiple prior
episodes was quite high especially given instability.
Neurosurgery consulted for cervical spine. His pain was
initially difficult to control, but was ultimately dramatically
improved when he was changed to a dilaudid PCA--he did not have
relief from fentanyl patch, likely b/c of soft tissue wasting
and future efforts at long acting medications should be PO.
.
#thyroid ca, metastatic disease: progressive in spine and
likely contributing to current complaints. Levothyroxine was
continued. consider neupogen. Will d/w attending Oncologist
.
# thrush: The patient was admitted with thrush which was
succesfully treated with nystatin S&S.
Neurosurgery team asked to eval this pt on [**2153-1-23**] and was
transferred to our service for spinal deformity which was noted
on upper level of images (CT chest) to r/o PE. CT of cervical
thoracic spine was obtained and results of T1 collapse noted.
Pts family, at that time wanted to continue care with prior
Neurosurgeon/Dr. [**Last Name (STitle) 1327**]. This was communicated to this
neurosurgery team. Some short time later the family wished
against transfer out to Dr.[**Name (NI) 1334**] care and decided that they
would want surgery to correct spinal deformity/kyphosis here.
The pt was placed in [**Last Name (un) 20482**] Halo traction at 30lbs of traction.
This was in attempt to reduce kyphotic deformity for
pre-operative optimization. A CT scan of the spine was obtained
in traction and good reduction of the deformity was noted. The
pt was then medically optimized and pre-op'd and taken to the OR
on [**2153-2-8**] for C7 T1 T2 corpectomies/ anterior approach. There
was a lot of bleeding during the initial anterior approach / the
case lasting approximately 7 hours. It was decided that the pt
would remain intubated and return to the OR on the 5th (the next
day for continuation of the case. The second portion of the
case was completed that day (the 5th). Thoracic surgery
assisted because of mediastinal mass / we needed sternotomy to
control bleeding and complete ant. approach. The total EBL was
7.5 liters with the pt being given 22 units of PRBC's. He had a
chest tube placed on the left side intraoperatively. This was
removed on approx 1/7/7. Postoperatively he was started on
Fondiparinox on [**2-13**] as he is HIT positive. On [**2153-2-14**] he had a
peg tube place. His postoperative head CT and spine CT's were
stable. His neurological status postoperatively was stable. All
extremeties are antigravity and his mentation is intact. His
course complicated by intermittent low HCT's for which he was
transfused. Temps as high as 102.+ for which he was started on
Zosyn. On [**2153-2-16**] his left upper extremity was noted to be
swollen and son[**Name (NI) **] noted LUE DVT. On the 14th, the halo ring
that was initially placed for use of cervical traction and for
potential halo vest placement was removed. He remains in a
cervical collar and had been OOB to chair. The patient required
prolonged ventilation he had difficulty clearing his secretions.
His family was offered a trach but they felt the patient had a
difficult post operative course and was suffering they did not
want to the patient to under go further procedures. The patient
had made his wishes clear to his family not to be dependent or
on a ventilator for a prolonged period. After a long discussion
with the family and Dr [**Last Name (STitle) **] they decided to extubate the
patient and see if he could tolerate being extubated, he quickly
passed away in a few minutes with his family at his side.
Medications on Admission:
gabapentin 300/300/900,
hydromorphone 4-8 mg Q8H PRN,
tizanidine 2mg t.i.d.,
fentanyl patch 75 mcg per hour every three days,
lidoderm patch 50, 3 patches a day
lorazepam 0.5mg Q4-6H PRN
levothyroxine 0.125 qd
protonix 40 qd
folic acid
decadron 2mg [**Hospital1 **] (incr to 4mg in AM today)
Discharge Medications:
N/A
Discharge Disposition:
Extended Care
Discharge Diagnosis:
cervical spine harware failure
s/p cervical spine stabilization
metestatic disease
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2153-2-19**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"03.4",
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icd9pcs
|
[
[
[]
]
] |
9061, 9076
|
4500, 8691
|
303, 351
|
9203, 9212
|
3038, 4477
|
9264, 9298
|
2230, 2437
|
9033, 9038
|
9097, 9182
|
8717, 9010
|
9236, 9241
|
2452, 3019
|
250, 265
|
379, 1734
|
1756, 2036
|
2052, 2214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
538
| 191,596
|
23230
|
Discharge summary
|
report
|
Admission Date: [**2161-10-28**] Discharge Date: [**2161-11-16**]
Date of Birth: [**2088-12-5**] Sex: F
Service: MEDICINE
Allergies:
Dristan Cold
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy [**2161-10-29**]
Percutaneous GJ tube placement [**2161-11-5**]
Radiation therapy [**Date range (3) 59717**]
History of Present Illness:
72yo woman with h/o newly diagnosed metastatic cancer (lung vs
esophageal primary) with mass compressing the esophagus and left
hip met presented [**2161-10-28**] with hemoptysis, melana, tachycardia.
Cancer diagnosed 3 weeks prior after patient noted progressive
dysphagia. Pt seen by Dr. [**Last Name (STitle) 952**] as outpatient who felt patient
was not an operative candidate for curative resection. Patient
was started on weekly Taxol/[**Doctor Last Name **] and XRT treatment(palliative
chemo regimen). EGD [**2161-10-9**] showing nonulcerated submucosal
mass. Patient also treated for H. pylori [**9-24**]. Three days
prior to presentation the patient noted onset of a nonproductive
cough without fevers, chills, chest pain. On the morning of
admission at 1AM, she awoke with cough productive of bloody
sputum. Later that morning she passed a large loose black stool
x 2. She has had poor po intake for the past week secondary to
mass limited her ability tolerate solid food. When she
presented earlier today to [**Hospital **] clinic, she complained of
dizziness/lightheadedness and was found to be tachycardic and
orthostatic, and was referred to the ED for further evaluation.
In the ED, HR 128, BP 151/49, and Hct noted to be 29.5 (baseline
36-39), INR also elevated to 1.5. She developed a transfusion
reaction with fever. She was pretreated with benadryl and
tylenol, and then transfused one unit PRBC. She also received
3L NS.
GI service was consulted and reported that endoscopy would put
the patient at further risk for bleeding due friable esophagus
secondary to XRT, and limited therapeutic benefit in face of
bleed due to tumor or radiation. Thoracic surgery consulted and
recommended palliative esophageal stenting after acute bleed
resolved, but not acute surgical management of tumor burden.
Today [**2161-11-1**], patient stable to be called out of ICU setting
to regular medical floor to be followed by the oncology team.
Past Medical History:
Cancer- esophageal vs lung, mets to left hip
Hypertension
Hypercholesterolemia
PVD s/p bypass [**2148**]
Basal cell skin ca
h/o polio as a child
H. pylori
h/o heartburn
Social History:
widowed x 2 with 4 grown children
tob: 1/2ppd x 40yrs, quit 12yrs ago
EtOH: occasional
illicits: none
Family History:
mother d. CHF
father d. MI
1 Brother d. leukemia
1 brother d. CVA
1 brother [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8751**]
1 sister with CAD
Physical Exam:
Physical Exam on Admission [**2161-10-28**]:
T 97.7 HR 118 BP 123/45 RR 16 95% 2Lnc
Gen: comfortable, lying in bed, NAD
HEENT: PERRL, anicteric, MMM with blood in OP
Neck: supple, no LAD
CV: tachycardic, regular rhythm, no m/r/g
Resp: decreased breath sounds with crackles R base to 1/2 up
GI: +BS, soft, NT, ND, no masses, no HSM, vertical midline scar
Back: NT
Rectal: little stool in vault, guiaic negative
Skin: no rashes
Neuro: CN II-XII intact, motor and sensation intact grossly
Physical Exam on transfer to OMED [**2161-11-1**]:
VS: T 98.8 HR 126 BP 143/67 RR 18 O2 93% on
Gen: elderly F sitting in bed with faint voice NAD, nasal canula
O2 on.
HEENT:PERRL. EOMI. MM dry. no cervical/ supraclavicular LAD
CV: tachycardic, regular. no m/r/g. some mild tenderness over
lower right anterolateral ribs, mostly over intercostal muscles
Lungs: decreased BS lower [**11-21**] R lung. no crackles.
Abd: hypoactive BS. soft. NT, ND. no palpable HSM.
Extr: warm PT 2+ b/l. no palpable cord. no asymmetry. no edema
Back: nontender.
Skin: dry. no visible rashes.
Neuro: CN 2-12 grossly intact, toes downgoing. no focal motor or
sensory deficits noted.
Labs:
Pertinent Results:
Endoscopic Ultrasound ([**2161-10-7**]):
A 35 x 41 mm heterogeneous mass with irregular borders was
identified at 28 cm on the oposite site from the aorta in the
mediastinum. The mass could not be traversed with an EUS
endoscope. No adenopathy was noted. FNA x 3 with a linear
endoscope was performed--> cytology consistent with non-small
cell carcinoma.
EGD ([**2161-10-7**]):
A submucosal mass 31 to 28 cm which could be traversed with an
endoscope with resistance.
Chest x-ray([**2161-10-28**]):
Extensive consolidation in right middle and right lower lobes
and to a lesser degree in the right upper lobe and posterior
segment of left
lower lobe. These findings may be due to massive aspiration,
infectious
pneumonia, or pulmonary hemorrhage. A more chronic process such
as
bronchoalveolar cell carcinoma cannot be excluded. Follow up
radiographs and clinical correlation suggested.
CT([**2161-10-28**]):
1) Hyperenhancing focus superior to the esophageal mass which
abuts the
carina, right main stem bronchus and esophagus which could
reflect hemorrhage.
2) Large lower esophageal mass displacing the left atrium.
3) Mediastinal and right hilar adenopathy.
4) Extensive alveolar opacities most pronounced in the right
lower lobe which
could reflect aspiration or hemorrhage.
5) Unremarkable aortic bypass graft with no evidence of
aortoenteric fistula.
Transthoracic Echo [**2161-10-29**]: EF 60%. normal LV. trivial mr. [**First Name (Titles) **] [**Last Name (Titles) 33904**]l effusion.
Brief Hospital Course:
72yo woman with newly diagnosed metastatic nonsmall cell cancer
(esophageal vs lung primary) presenting with hemoptysis, melana,
tachycardia.
1. Hemoptysis: The patient initially presented with hemoptysis
and the DDx included esophageal tumor invading trachea or
bronchi, lung cancer, pneumonia vs. aspiration from UGIB. Her
CT scan on admission was concerning for a hemorrhagic lesion,
and CXR for an aspiration event. Treatment options were limited
per thoracic surgery. She was transfused 4 units PRBC to
maintain a Hct >30, and Hct stabilized on the second day of
admission. The patient suffered a tranfusion reaction
consisting of tachycardia, tachypnea, and decreased oxygen
saturation that resolved with benadryl and tylenol. She was
pretreated for all subsequent transfusions. She had one
treatment of XRT [**2161-10-29**]; chemotherapy was held. She underwent
bronchoscopy on the second day of admission which showed
extrinsic compression of bronchi, blood in the RLL c/w
aspiration. Patient continued to cough up sputum with dried
blood, felt to be from aspiration. Transferred to the floor in
stable condition.
2. Melena: Patient presented with apparent UGIB by history,
but was guiaic negative on exam. GI was consulted and initially
deferred endscopy unless emergent given risk of bleeding with
friability of gastroesophageal mucosa secondary to XRT and
limited therapeutic options. The DDx included esophageal tumor,
mucositis secondary to XRT, PUD, esophagitis, [**Doctor First Name 329**]-[**Doctor Last Name **]
tear. All services agreed that most likely etiology was tumor.
Hct remained stable after PRBC transfusion. She was continued
on IV protonix. Diet was advanced to clears on hospital day 2,
but she tolerated little in the way of a po diet given the tumor
burden on her esophagus.
- continue to guaic stools.
- will request repeat endoscopy from GI tomorrow to evaluate if
tumor has grown.
3. Squamous Cell Cancer of Unknown Primary Source (lung vs
esophageal): The patient's palliative treatment regimen
consisted of XRT and weekly chemo on admission. She received
one XRT treatment on [**2161-10-29**]. Chemotherapy has been held per
Dr. [**Last Name (STitle) 3274**] and Dr. [**First Name (STitle) **].
- Will continue to address with Dr. [**Last Name (STitle) 3274**] when/if plan to
resume chemotherapy.
- Will request Dr. [**Last Name (STitle) 3274**] continues to discuss prognosis with
family.
4. Coagulopathy, INR 1.5 on admit: Coagulopathy was thought to
be nutrional given the patient's poor po intake. A DIC panel
was negative. Tranfusion of FFP was attempted but failed due to
tranfusion reaction. As the patient's level of coagulopathy was
not so severe as to cause spontaneous bleeding, she was treated
with SQ vitamin K and monitored. INR has remained stable
1.4-1.5 since admit.
5. Tachycardia: The patient presented with tachycardia that
was felt to be due acute blood loss causing hypovolemia. She
ruled out for MI. Echocardiogram showed normal LV function and
no pericardial spread of disease causing pericardial effusion.
She was fluid rescuscitated but continued to be tachycardic. It
was then felt that her tachycardia may be associated with the
low grade fevers she experienced and anxiety. She continued in
sinus rhythm with HR 100-120s on transfer to the floor. On the
third night of admission, she developed acute pulmonary edema
secondary to 4-5 Liters IVF boluses for treatment of
tachycardia. She was subsequently diuresed approximately 3
liters and her oxygenation and tachypnea improved by later that
day.
- continue aggressive diuresis, goal negative 500cc-1L.
6. ARF: Creatitine on admission was 1.1 from baseline 0.6, and
was thought to be prerenal associated with her acute blood loss.
It resolved by the second day of hospitalization after fluid
rescusitation.
7. HTN: Patient has a history of HTN treated with HCTZ. She
was normotensive on admission. Anti-hypertensives have been
held out of consideration for continued blood loss. In the ICU,
the patient has continued to be normotensive to mildly
hypertensive with SBP 140-150s during her hospitalization.
- Monitor blood pressure. COnsider resuming anithypertensives
if Hct remains stable.
8. Pulmonary:
Aspiration Pneumonia: On admission, a large RLL infiltrate was
noted on CXR that was concerning for aspiration pneumonitis,
pneumonia, lymphangetic spread versus hemorrhage. Today [**4-27**] of
antibiotics (levofloxacin/clindamycin) for possible aspiration
pneumonia. Her WBC has improved. She continues to have
occasional low grade fevers. CXR today not sig changed from
yesterday
- continue to monitor respiratory rate, fever and wbc count.
- continue nasal canula, wean O2 as tolerated.
CHF: pulm edema likely related to IVF boluses, improving with
diuresis.
9. Nutrition: On admission, the patient was kept NPO. Her diet
has been advanced to clears, however she is taking little po per
report of ICU team.
- continue mainenance IVFs.
- once pt stabilized, will discuss with thoracic surgery the
possibility of palliative esophageal stent.
10. Pain: continue to manage pain with fentanyl patch and
morphine iv for breakthrough
11. Dispo: Per ICU team, the patient is full code. Her son,
[**Name (NI) **], is designate [**Hospital **] health care proxy. We will continue to
address code status given prognosis is poor.
Medications on Admission:
1. [**Doctor Last Name **]/Taxol
2. Lipitor 10mg daily
3. ASA
4. HCTZ 12.5mg daily
5. Folate
6. MVI
7. Xalatan eye drops
8. Fentanyl patch
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Per GJ tube.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Morphine Sulfate 10 mg/5 mL Solution Sig: Five (5) mg PO Q6H
(every 6 hours) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
8. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Metastatic adenocarcinoma of unknown primary ICD-9 199
Pelvic metastatic disease
Pulmonary hemorrhage
Melena
Volume depletion
Acute blood loss anemia
Esophageal compression with dysphagia
Hematemesis
Discharge Condition:
Stable. Ambulating well with assistance. Tube feeds via GJ tube
are at goal. Patient is afebrile.
Discharge Instructions:
Call Dr. [**Last Name (STitle) 3274**] if you have a fever > 101.4, lightheadedness,
dizziness, trouble breathing or blood in your stool or black
stool.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3274**]:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2161-12-1**] 9:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2161-12-1**]
9:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"401.9",
"197.8",
"578.0",
"276.8",
"162.9",
"584.9",
"507.0",
"286.9",
"428.0",
"999.8",
"578.1",
"285.1",
"198.5",
"530.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"92.29",
"43.11",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11971, 12048
|
5626, 11042
|
286, 410
|
12292, 12391
|
4104, 5603
|
12592, 13120
|
2729, 2892
|
11239, 11948
|
12069, 12271
|
11068, 11216
|
12415, 12569
|
2907, 4085
|
236, 248
|
438, 2400
|
2422, 2592
|
2608, 2713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,350
| 199,224
|
40448
|
Discharge summary
|
report
|
Admission Date: [**2171-7-16**] Discharge Date: [**2171-7-27**]
Date of Birth: [**2119-9-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Extubation [**2171-7-19**] (patient was transferred into the hospital
intubated)
Insertion of post-pyloric feeding tube [**2171-7-22**]
History of Present Illness:
51 y/o male with CAD, alcohol abuse, h/o pancreatitis (last
episode 8 months ago), initially presented to [**Location (un) **] on [**2171-7-3**]
with abdominal pain, nausea, and vomiting x 1 day. The
abdominal pain was diffuse, beginning first as cramps, and
associated with foul-smelling, bilious vomiting, nausea, and
profuse sweating. In addition, he had some vague chest pain
associated with the epigastric area that was relieved with one
tablet of sublingual nitroglycerin. He did not have any bouts
of diarrhea or constipation. Furthermore, he did not endorse any
history of fever, chills, shortness of breath or palpitations.
.
In the emergency room at the outside hospital, he was found to
have a white blood cell count of 13,000, an amylase level of
1201, and a lipase level of >[**2160**]. The patient was afebrile and
had a clear chest and abdominal x-ray; however, he was found to
have pancreatitis upon further investigation by CT scan of the
abdomen. IV fluids (rate of 150cc/hr) and pain management were
started immediately, and a regimen of imipenem initiated.
Unfortunately, due to his worsening tachypnea and evidence of
respiratory failure, his IV fluids were increased to 200cc/hr
and he was transferred to the ICU; there, his antibiotics were
changed to Zosyn, and he was given 250 mcg of fentanyl and 25 mg
of Versed. He was also intubated and sedated for delirium
tremens.
.
In the outside ICU, septic work-up (blood and urine cultures)
were negative until [**2171-7-16**], and stool samples for C. Diff.
also returned negative. Another CT scan of his abdomen was
performed on [**2171-7-16**] to investigate the underlying cause of
his fever, revealing pancreatic necrosis. After this diagnosis,
he was transferred to the [**Hospital1 18**] for further management and
admitted to the ICU. His course is outlined by problem below:
.
1. Necrotizing pancreatitis - He was seen by both surgery and
GI, who recommended supportive care with NPO status, IVF and
initiation of enteral feeds. CT-guided pancreatic aspiration
was discussed, however, as patient improved clinically, this was
deferred. His course was notable for hypervolemia and
third-spacing [**2-13**] pancreatitis, which has since improved. He
has clinically improved; culprit felt to be alcohol with
gallstones and TG as possible contributers. He was not given
antibiotics here as he completed a 12-day course of
zosyn/imipenem at OSH. He had a PPFT placed 2 days ago which he
self d/c'd, so this was replaced today by IR. Plan for TEN, and
initiate po's per GI.
.
2. ARF - He also developed ARF with peak Cr of 1.6. This
improved over the next few days and he has been auto-diuresing
heavily approximately 60-200 cc/hour. This is felt to be
secondary to post-ATN diuresis. Improved to baseline. Now
diuresing massively with 200 cc/hr. Monitoring lytes, UOP with
goal I/O = even, fluid boluses being given as needed.
.
3. Fever - since initial presentation with negative infectious
work-up at OSH and here. Felt to be [**2-13**] necrotizing
pancreatitis.
.
4. Diarrhea - occuring over last few days; cdiff at OSH negative
x 1. Not sent here. No abd pain, n/v.
.
5. Tachycardia - sinus, felt to be [**2-13**] hypovolemia, fever, benzo
w/d. On BB, IVF prn. Now in 100s-110s, improved from
120s-130s.
.
6. Alcohol withdrawal c/b delirium tremens - Extubated and off
vent [**2171-7-19**]. Was on maximal doses of fentanyl and versed while
intubated. Once extubated, he was converted to IV methadone to
help taper requirments. Now on 10 mg IV methadone with plans to
taper off by tomorrow. Was on high doses of midazolam as well,
now on valium as needed (required 2 doses over 24 hours).
.
Currently, patient feels well with only c/o diarrhea since the
weekend. No f/c/s, abd pain, n/v. No tremors. No CP/SOB.
Still has foley. Feels weak and deconditioned.
.
10-pt ROS otherwise negative in detail except for as noted
above.
Past Medical History:
- Coronary artery disease --> post-MI (12 years ago) with stent
x 3
- Hypertension
- Hyperlipidemia
- Pancreatitis (last episode 8 months ago)
- Alcohol abuse
Social History:
- Former firefighter, now part-time bartender
- Divorced with three children
- Tobacco: None
- Alcohol: Heavy drinker, drinks heavy liquor and beer regularly
(approximately [**3-17**] drinks a day); last drink was the day prior
to admission
- Illicits: None
Family History:
Family History:
- Father: Alive at age 76, with history of brain cancer,
cardiovascular disease, and stroke
- Mother: Passed away at age 55 of myocardial infarction;
history of diabetes mellitus
- Siblings: [**Name (NI) **] brother with history of cardiovascular
disease and hyperlipidemia; older brother is healthy
Physical Exam:
Vitals: Tm=99/T=98.5, HR=106, BP=135/82, RR=18, SpO2: 96% on
room air
General: Patient was lying comfortably in bed with a
post-pyloric feeding tube inserted; able to communicate clearly
and completely, oriented to time, person and place
HEENT: Sclera aninteric, MM dry, OP clear
Neck: supple, JVD normal, no LAD
Chest: CTA-B, no w/r/r
CV: RR tachycardic, no m/g/r, normal S1 S2
Abdomen: soft, non-tender, non-distended abdomen with bowel
sounds present; there was no rebound tenderness or guarding, no
organomegaly
GU: foleys catheter inserted, no edema
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis; no
peripheral edema
Neurological: Ao x 3, non-focal
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2171-7-22**] 04:45AM BLOOD WBC-10.9 RBC-2.55* Hgb-7.9* Hct-23.4*
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.8 Plt Ct-581*
[**2171-7-19**] 03:41AM BLOOD WBC-14.0* RBC-2.39* Hgb-7.5* Hct-22.6*
MCV-95 MCH-31.4 MCHC-33.2 RDW-13.9 Plt Ct-535*
[**2171-7-16**] 10:13PM BLOOD WBC-10.9 RBC-2.47* Hgb-7.7* Hct-23.5*
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.1 Plt Ct-475*
[**2171-7-16**] 10:13PM BLOOD Neuts-83.5* Lymphs-9.3* Monos-3.1 Eos-3.8
Baso-0.2
[**2171-7-22**] 04:45AM BLOOD Glucose-110* UreaN-27* Creat-1.1 Na-145
K-3.4 Cl-110* HCO3-22 AnGap-16
[**2171-7-18**] 04:15PM BLOOD Glucose-106* UreaN-32* Creat-1.5* Na-145
K-4.2 Cl-112* HCO3-25 AnGap-12
[**2171-7-16**] 10:13PM BLOOD Glucose-100 UreaN-32* Creat-1.5* Na-150*
K-4.5 Cl-113* HCO3-25 AnGap-17
[**2171-7-16**] 10:13PM BLOOD ALT-24 AST-32 LD(LDH)-508* AlkPhos-65
Amylase-34 TotBili-0.8
[**2171-7-16**] 10:13PM BLOOD Lipase-59
[**2171-7-22**] 04:45AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.1
[**2171-7-16**] 10:13PM BLOOD Albumin-2.9* Calcium-8.7 Phos-4.4 Mg-2.4
[**2171-7-16**] 10:13PM BLOOD Triglyc-198*
[**2171-7-17**] 02:35AM BLOOD Type-ART pO2-77* pCO2-33* pH-7.50*
calTCO2-27 Base XS-2
[**2171-7-17**] 11:52PM BLOOD Type-ART Temp-37.3 Rates-/32 PEEP-5
FiO2-40 pO2-111* pCO2-32* pH-7.46* calTCO2-23 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2171-7-19**] 03:53AM BLOOD Type-ART pO2-88 pCO2-47* pH-7.35
calTCO2-27 Base XS-0
[**2171-7-16**] 10:14PM URINE Hours-RANDOM UreaN-474 Creat-43 Na-131
K-32 Cl-95
[**2171-7-17**]: Urine culture --> negative
[**2171-7-16**]: MRSA Screen + Blood culture --> both negative
Brief Hospital Course:
51 yo M with HTN, HLD, CAD, alcoholism admitted with necrotizing
pancreatitis, alcohol withdrawal and acute renal failure.
The patient presented with severe, necrotizing pancreatitis to
an outside hospital. He had a lipase>[**2160**] and CT imaging with a
pancreatic phlegmon. This was felt due to alcohol abuse. He also
was found to have non-obstructive gallstones and
hypertriglyceridemia with levels >1000; both of which may have
contributed to his pancreatitis. The patient was started on
broad spectrum antibiotics and completed a 2 week course of
Zosyn. While at the outside hospital, the patient received
aggressive IV fluids and developed respiratory distress
requiring intubation prior to transfer.
After transfer, he slowly improved. He was successfully
extubated and after a short course of post-pyloric [**Last Name (un) **]-enteral
feeding, the patient was advanced to clear liquids and then a
regular diet without problems. [**Name (NI) **] was counselled extensive on
the need for alcohol cessation and was started on crestor and
niacin for triglyceride control. Consideration can be made as an
outpatient for cholecystectomy as passed gallstone may have
contributed to his presentation (though EtOH abuse seems to be
the more likely, predominant cause of his symptoms, he does have
gallstones confirmed on outside hospital ultrasound).
His hospital course was complicated by alcohol withdrawal and
delirium tremens requiring high doses of benzodiazepines. He
ultimately improved and the withdrawal symptoms resolved.
He had acute renal failure initially and this resolved with
volume rescucitation.
The patient had diarrhea throughout much of his hospitalization.
Multiple stool studies were sent for C Diff and all were
negative. This may be related to the pancreatitis. He was given
anti-diarrheals as needed. The diarrhea improved on a regular
diet towards the end of his hospitalization.
The patient continued to have fever spikes to 100 throughout his
hospitalization even after completing his antibiotic. He had no
findings of a new acute infection and this seemed to be related
to the pancreatitis. His fever curve trended down and he had no
temperatures above 99 in the days prior to discharge.
The patient had a sinus tachycardia to 100-120 for much of his
hospitalization. This seemed most related to relative
hypovolemia and anemia. He received volume rescucitation and 1
unit PRBC transfusion with improvement though he continues to
have some asymptomatic tachycardia with exertion up to 120. The
patient should have a repeat Hct measured at his follow-up
appointment and may require further transfusion as an
outpatient.
Anemia. The patient has anemia of chronic disease and probable
iron deficiency anemia. He was started on iron supplements. He
received 1 unit of PRBC's. On discharge he was persistently
anemic to 23. The patient should have a repeat Hct measured at
his follow-up appointment and may require further transfusion as
an outpatient.
The patient has chronic HTN, HLD and continues on beta-blocker,
ACEi and statin therapy.
He was counselled extensively on the need for alcohol cessation.
Medications on Admission:
- Metoprolol 12.5 mg daily
- Lisinopril 20 mg daily
- Crestor 10 mg daily
- Fish oil & multivitamins
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*5*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*4*
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
Disp:*30 Tablet(s)* Refills:*4*
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*4*
6. multivitamin with folic acid 200 mcg Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Blood draw: CBC. To be drawn at your follow-up appointment.
Discuss the results with your primary care doctor. Please
discuss whether or not you need additional transfusion for
anemia.
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing pancreatitis
Alcohol abuse
Alcohol withdrawal
Hypertriglyceridemia
Cholelithiasis
Acute renal failure
Diarrhea
Sinus tachycardia
Anemia of chronic disease
Probable iron deficiency anemia
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of severe inflammation of your
pancreas. This was due to alcohol use. You must stop using
alcohol. You also have gallstones and very high triglycerides
and these may have contributed to the pancreas inflammation.
Please discuss gallbladder removal with your primary care
doctor. In addition, take the prescribed medications (Crestor
and Niacin) to reduce your triglyceride levels.
Your hospitalization was complicated by several other problems
including alcohol withdrawal and anemia. Please follow-up with
your primary care doctor to continue discussing alcohol
cessation and to have your blood counts checked - you may
require transfusion in the near future. Take iron supplements as
prescribed to aid in new red blood cell production.
Followup Instructions:
Location: [**Location **]
With: URGENT CARE CLINIC
Address: 1400 VFW PARKWAY, [**Location **],[**Numeric Identifier 16354**]
Phone: [**Telephone/Fax (1) 19336**]
When: Wednesday [**7-31**] at 2PM
|
[
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"401.9",
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,017
| 194,481
|
39312+39336
|
Discharge summary
|
report+report
|
Admission Date: [**2186-9-26**] Discharge Date: [**2186-9-29**]
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cipro
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
worsening speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 85-year-old man with history of a left
posterior pariet-occipital hemorrhagic stroke in [**2185-8-23**],
DM, HTN, CAD s/p 2 stents, and HLD, recently admitted to
neurology service [**Date range (1) 86934**] with new speech difficulties
(nonsensical speech and word-finding difficulty) and found to
have a new left parietal intraparenchymal hemorrage, and
discharged to rehab [**9-14**] on aspirin 81 mg daily with exam at
that
time notable for dysarthria, right field cut, and Wernicke
aphasia.
At 5 PM this afternoon while eating dinner he was noted to have
worsening speech from baseline, worse right facial droop and
dysarthria. His speech continued to become more garbled and
right arm weakness was noted. BP at the time was 142/60 and he
was transferred to [**Hospital1 18**] for further eval.
Past Medical History:
DM, type 2
HTN
CAD, s/p 2 stents
Hyperlipidemia
Hemorrhagic stroke ([**8-/2185**])
Eczema
Basal cell carcinoma of nose s/p excision
Allergic reactions:
1. Penicillin reaction ("severe rxn" of unknown tpye)
2. Sulfa
3. Ciprofloxacin
Social History:
Lives in [**Location 2251**], MA with wife and son. History heavy tobacco
use and alcohol use, but quit both many years ago. Denies
history of drug use. He is ambulatory at home and able to
perform all ADLs.
Family History:
Father had emphysema. No history of stroke or other neurological
illnesses. No history of bleeding, clots, or miscarriages.
Physical Exam:
HEENT; NC/AT, mucous membranes moist, oropharynx clear
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, NT, ND
Extr; no edema
Neuro;
MS; Eyes open spontaneously. Speech is dysarthric, nonfluent,
and incoherent. Able to state name but unable to comprehend
place. Unable to name objects or repeat a sentence. Follows
commands such as closing eyes and squeezing hands.
CN; PERRL 3mm-->2mm, EOMI, no nystagmus. Decreased blink to
threat in R visual field. R facial drooop. Palate elevatese
symmetrically. Does not protrude tongue to command.
Motor; normal bulk and tone. Uncooperative with formal strength
testing but holds left arm antigravity for ten seconds and right
arm with drift but sustains antigravity. Holds legs antigravity
for at least 5 seconds with mild (4+ weakness) proximally on
right compared to left.
Sensory; Grimaces to noxious on left but diminished reaction on
right arm and leg.
Reflexes; 2+ at biceps and brachioradialis bilaterally.
Paratonia when attempting to assess patellar reflexes. 0 at
achilles. Toes are equivocal.
Coordination; uncooperative with assessment
Gait; deferred
Pertinent Results:
[**2186-9-26**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2186-9-26**] 07:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2186-9-26**] 07:10PM GLUCOSE-154* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15
[**2186-9-26**] 07:10PM WBC-11.4*# RBC-3.95* HGB-12.7* HCT-36.8*
MCV-93 MCH-32.2* MCHC-34.5 RDW-13.0
[**2186-9-26**] 07:10PM PLT COUNT-455*#
[**2186-9-26**] 07:10PM PT-12.5 PTT-24.4 INR(PT)-1.1
CT brain on [**2186-9-26**]:
IMPRESSION: New large left frontoparietotemporal hemorrhage with
surrounding vasogenic edema and sulcal effacement. 4-mm
rightward shift of midline structures, increased from prior. No
evidence of downward herniation. The previously known left
parietotemporal hemorrhage is decreased in size on this
examination. MRI with gadolinium may be performed to evaluate
for the presence of underlying lesions.
Brief Hospital Course:
Mr [**Known lastname **] was admitted for worsening speech. He was recently
discharged with a stable left parietal hemorrhage. On
re-evaluation he was found to have worsening speech. He had
nonsensical speech. Otherwise he also had a right sided field
cut and initially had right sided weakness that resolved by
24hours. He was also found to be hypertensive initially and was
placed on nicardipine drip. This was stopped and he was placed
on losartan and metoprolol. This was titrated to proper blood
pressure control. He had a repeat CT scan of his head and had a
stable neurological examination. He was transferred to the wards
for further care.
On the wards, patient remained neurologically stable on
examination. He has stable Wernicke's type aphasia and right
homonymous hemianopia. Pt will not be started on aspirin again
after this as the risk for further bleeds is too high. He was
restarted on subcutaneous heparin for DVT ppx on 3rd day of
admission. He will follow up with stroke clinic.
Medications on Admission:
-ASA 81 mg daily
-lantus 15 units SC qhs
-lispro 5 units q breakfast and lunch
-lispro sliding scale
-losartan 25 mg daily
-metoprolol 25 mg [**Hospital1 **]
-zocor 20 mg daily
-multivitamin
-omeprazole 40 mg daily
-trazodone 25 mg qhs prn sleep
-ceftriaxone 1g q24 (last dose due [**9-28**]) for e coli UTI
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
5. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary
- Hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro status: receptive aphasia, does not blink to threat on
right
Discharge Instructions:
You were sent to [**Hospital1 18**] ER for speech difficulties. You had a CT
scan of your had which showed new bleeding and you were
hypertensive. You were in the ICU and were started on
medications to control your hypertension. Your aspirin was
stopped to prevent further bleeding in the brain.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD
Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2186-10-30**] 1:30
[**Hospital Ward Name 23**] Clinical Centr [**Location (un) **]
Unit No: [**Numeric Identifier 86981**]
Admission Date: [**2186-9-26**]
Discharge Date: [**2186-9-29**]
Sex: M
Service:
ADDENDUM: CAT scan of the brain from [**9-26**] showed a new
left frontotemporal parietal intraparenchymal hemorrhage.
This measured 4.3 x 3.2 cm. There was some subarachnoid
extension, surrounding vasogenic edema, sulcal effacement
and 4 mm of rightward shift. There was also compression of
the left lateral ventricle. The marked vasogenic edema
and compression of the left lateral ventricle were clinically
significant. Mr. [**Known lastname **] presented on [**9-26**] with new
aphasia (receptive more than expressive aphasia). He also
presented with new right homonymous hemianopsia and right arm
weakness. These deficits were related to the vasogenic edema and
also the left frontotemporal parietal hemorrhage.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern4) 86982**]
MEDQUIST36
D: [**2186-11-24**] 10:52:00
T: [**2186-11-24**] 11:59:14
Job#: [**Job Number 86983**]
|
[
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"277.39",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6169, 6241
|
3939, 4939
|
287, 293
|
6314, 6314
|
2938, 3916
|
6876, 8212
|
1657, 1783
|
5298, 6146
|
6262, 6293
|
4965, 5275
|
6556, 6853
|
1798, 2919
|
231, 249
|
322, 1158
|
6329, 6532
|
1180, 1415
|
1431, 1641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,065
| 180,479
|
9478
|
Discharge summary
|
report
|
Admission Date: [**2196-9-30**] Discharge Date: [**2196-10-11**]
Date of Birth: [**2125-5-11**] Sex: M
Service: VSURG
Allergies:
Lisinopril / Cozaar
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
disabling claudication
Major Surgical or Invasive Procedure:
aorto- [**Hospital1 **] femoral by pass graft w left accesory renal artery
embolectomy and reimplantation [**2196-9-30**]
History of Present Illness:
Patient well known to Dr. [**Last Name (STitle) **].who presents with
progressive bilateral leg claudication which limits his
activities. Has reconsidered the option of revascularization and
now admitted for aortobifemoral bypass for his aorto-iliac
disease and abdominal aaa.
Past Medical History:
aortoiliac, aaa
carotid stenosis bilaterally 60-69%
gout
coronary artery disease
history of congestive heart failure
chronic renal insuffiency ( 2.0-2.8)
Social History:
smoker current
previous alcohol use( heavy) discontinued
Family History:
unknown
Physical Exam:
Vital Signs: b/p 155/58 pulse 61 oxygen saturation 99% on room
air
general: alert
HEENT bilateral caroits bruits, carotids palpable bilaterally
Lungs: clear to ausculation bilaterally
Heart: regular rate rythmn
abdominal: begnin
Extremities: no edema.
Pulse exam: femoral pulses palpable bilaterally,left pedal
pulses monophasic signal only. right dp palpable
Neuro: intact
Pertinent Results:
[**2196-9-30**] 11:02PM TYPE-ART PO2-145* PCO2-38 PH-7.31* TOTAL
CO2-20* BASE XS--6
[**2196-9-30**] 11:02PM LACTATE-1.3
[**2196-9-30**] 09:27PM TYPE-ART PO2-170* PCO2-46* PH-7.28* TOTAL
CO2-23 BASE XS--4
[**2196-9-30**] 09:10PM GLUCOSE-128* UREA N-58* CREAT-2.3* SODIUM-141
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14
[**2196-9-30**] 09:10PM CALCIUM-7.4* PHOSPHATE-4.4 MAGNESIUM-1.4*
[**2196-9-30**] 09:10PM WBC-15.1*# RBC-3.83* HGB-11.8* HCT-32.7*
MCV-85 MCH-30.9 MCHC-36.1* RDW-16.5*
[**2196-9-30**] 09:10PM PLT COUNT-139*
[**2196-9-30**] 08:02PM TYPE-ART PO2-183* PCO2-46* PH-7.27* TOTAL
CO2-22 BASE XS--5
[**2196-9-30**] 08:02PM LACTATE-1.5
[**2196-9-30**] 08:02PM HGB-10.5* calcHCT-32
[**2196-9-30**] 07:50PM WBC-9.5 RBC-3.45* HGB-10.1* HCT-30.1* MCV-87
MCH-29.4 MCHC-33.7 RDW-16.7*
[**2196-9-30**] 07:50PM PLT COUNT-161
[**2196-9-30**] 07:50PM PT-13.9* PTT-31.7 INR(PT)-1.2
[**2196-9-30**] 07:25PM TYPE-ART PO2-176* PCO2-47* PH-7.26* TOTAL
CO2-22 BASE XS--5
[**2196-9-30**] 07:25PM GLUCOSE-131* LACTATE-2.4* NA+-137 K+-4.1
CL--109
[**2196-9-30**] 07:25PM HGB-10.7* calcHCT-32 O2 SAT-97
[**2196-9-30**] 07:25PM freeCa-1.01*
[**2196-9-30**] 06:33PM TYPE-ART PO2-207* PCO2-44 PH-7.23* TOTAL
CO2-19* BASE XS--8
[**2196-9-30**] 06:33PM GLUCOSE-125* LACTATE-1.2 NA+-137 K+-3.6
CL--112
[**2196-9-30**] 06:33PM HGB-9.2* calcHCT-28
[**2196-9-30**] 06:33PM freeCa-1.06*
[**2196-9-30**] 04:37PM TYPE-ART PO2-274* PCO2-46* PH-7.31* TOTAL
CO2-24 BASE XS--3
[**2196-9-30**] 04:37PM GLUCOSE-107* K+-3.9 CL--105
[**2196-9-30**] 04:37PM HGB-10.9* calcHCT-33 O2 SAT-97
[**2196-9-30**] 01:25PM TYPE-ART PO2-99 PCO2-38 PH-7.36 TOTAL CO2-22
BASE XS--3
[**2196-9-30**] 01:25PM TYPE-ART PO2-99 PCO2-38 PH-7.36 TOTAL CO2-22
BASE XS--3
[**2196-9-30**] 01:25PM GLUCOSE-103 LACTATE-0.8 NA+-137 K+-4.0
CL--106
[**2196-9-30**] 01:25PM HGB-10.3* calcHCT-31
[**2196-9-30**] 01:25PM HGB-10.3* calcHCT-31
Brief Hospital Course:
[**2196-9-30**] admitted to preoperative holdi;ng area. S/P
aortobifemoral bypass graft, left accessory renal artery
embolectomy with reimplantation.Transfered to PACU in stable
condition. Remained intubated secondary for need of fluid
resusitation.
[**2196-10-1**] POD#1 afebrile hemodynamically stable. Extubated.
Abdominal exame mild distention but bowel sounds present.NTG
discontinued. remains NPO. Epidural for analgesic controll.
perioperative kefzol continued. Transfered to VICU.
[**2196-10-2**] POD#2 remaines in VICu stable afebrile. Moblilzation of
fluids.
9/13/04POD#3 gout attack given colchicine and rhematology
consulted.s/p joint aspiration wich was consistant with pseudo
gout.predisone started.
[**2196-10-4**] POD# 4 epidural catheter removed.Continues with rt.
elbow and left knee pain.
elbow fluid culture no growth,bood cultures x2 no growth, CVL
tip gram stain with grampositive cocci.
[**2196-10-5**] POD#5 swan discontinued. foley discontinued . ambulation
to chair began. Physical theraphy evaluation recommended
rehablititaion when medically stable.
[**2196-10-6**] POD#6 afebrile. stool c. diff negative. Repeat blood
cultures obtained for temerature elevation.
[**Date range (1) 14449**] POD#[**7-1**] continued to work with physical
thearphy.Keflex started for wound changes. normal saline wet to
dry [**Hospital1 **] dressing changes began for right groin
infection.discharged to home.
Medications on Admission:
atenolol 10mgm daily
norvasc 10mgm daily
hydralizine 40mgm qid
allopurinol 150mgm daily
ASA
lipitor 20mgm daily
prazosin 4mgm [**Hospital1 **]
colchicine 6mgm q 48 hrs
folic acid 1mgm daily
procrit 5000u every 4 days
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
5. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: start [**Date range (1) 32271**].
Disp:*3 Tablet(s)* Refills:*0*
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: start [**Date range (1) 32272**]
then d/c.
Disp:*3 Tablet(s)* Refills:*0*
13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day:
do not start until [**2196-11-4**].
Disp:*30 Tablet(s)* Refills:*2*
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 weeks.
Disp:*2 Capsule(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
Bostonian - [**Location (un) 86**]
Discharge Diagnosis:
symptomatic aortoiliac disease
abdominal aortic aneyrysm
pseudo gout
right groin wound infection
Discharge Condition:
stable
Discharge Instructions:
call if wound does not improve, or becomes more red, swollen or
drainage changes
call if develope fever >101.5
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 3121**]
Completed by:[**2196-10-11**]
|
[
"440.21",
"593.9",
"440.1",
"275.49",
"440.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.16",
"81.91",
"39.25"
] |
icd9pcs
|
[
[
[]
]
] |
6390, 6455
|
3387, 4808
|
301, 425
|
6596, 6604
|
1416, 3364
|
6764, 6886
|
998, 1007
|
5075, 6367
|
6476, 6575
|
4834, 5052
|
6628, 6741
|
1022, 1397
|
239, 263
|
453, 731
|
753, 908
|
924, 982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,507
| 189,506
|
50716
|
Discharge summary
|
report
|
Admission Date: [**2126-7-12**] Discharge Date: [**2126-7-31**]
Date of Birth: [**2055-11-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
dental abscess s/p I&D
Major Surgical or Invasive Procedure:
incision and drainage of dental abscesses X 2 by OMFS
History of Present Illness:
Ms [**Known lastname 81697**] is a 70 year-old female with pmh of chronic
vertigo secondary to a concussion, hypertension, and depression
who was admitted on [**7-12**] after undergoing I&D of a dental
abscess. She states she developed right lower, back gum pain
last Tuesday which worsened over the course of the week. She
felt it starting invovling her "glands" in her neck, first on
the right side, but then progressively to her left side. She
admits to pain with swallowing. She denies history of dental
abscess, fevers, chills, or other symptoms.
She went for the I&D of her abscess by OMFS without
complication. She was admitted to trauma surgery afterwards,
however since her infection was not traumatic, she was
transferred to medicine for further care.
Currently she admits to occasional pain which responds to
morphine as well as pain with swallowing and nausea. She also
has occasional SOB, but no CP. Slight cough.
Review of Systems:
(+) Per HPI
(-) Denies chest pain or tightness, palpitations. Denied
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. No numbness/tingling in extremities.
No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
HTN
HLD
Depression
Chronic vertigo secondary to a head inury sustained 20 years
while playing volleyball
Social History:
She lives alone. She is unable to work due to her chronic
vertigo. She smokes [**3-6**] cigarettes per day. Denies drug or
alcohol use.
Family History:
NC
Physical Exam:
Vitals: T 99.7 BP 106/56 P 90 RR 18 Sat 93% on RA
General: Middle-aged female lying in bed in NAD
HEENT: PERRL, EOMI, bruise present over her left upper neck,
bandage in place. packing present in the back, right lower
portion of her mouth.
Neck: no JVD
Heart: RRR no m/r/g
Lungs: Patient is breathing comfortably. Crackles present
bilaterally halfway up her lung fields.
Abd: +BS, NTND, soft
Ext: no edema
Neuro: Alert and appropriate
Pertinent Results:
[**2126-7-12**] 04:43PM LACTATE-1.4
[**2126-7-12**] 04:30PM GLUCOSE-102* UREA N-29* CREAT-1.9* SODIUM-138
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2126-7-12**] 04:30PM WBC-15.3*# RBC-4.41 HGB-13.9 HCT-40.6 MCV-92
MCH-31.5 MCHC-34.2 RDW-13.2
[**2126-7-12**] 04:30PM NEUTS-87.0* LYMPHS-8.5* MONOS-3.8 EOS-0.6
BASOS-0.2
[**2126-7-12**] 04:30PM PLT COUNT-263
CT neck [**7-19**]
FINDINGS: A large heterogeneous collection in the submandibular
space has
decreased in size. The largest rim-enhancing pocket measures 4.3
x 0.9 cm,
decreased from 5.0 x 1.6 cm. There is edema surrounding this
lesion,
decreased from prior. Additional drains have been instilled in
the interval. Posterior and leftward shift of the airway
persists, although decreased and difficult to exactly determine
now the patient is intubated. Air-fluid level is in bilateral
maxillary sinuses. A likely orogastric tube is also seen.
Retropharyngeal tissues are difficult to assess status post
intubation. No mediastinal fat stranding or area of focal
consolidation is seen in the lung. No cervical lymph nodes are
pathologically enlarged. No thrombosis of the neck vessels is
demonstrated. There are no osseous findings to suggest
osteomyelitis.
IMPRESSION: Interval decrease in large submandibular abscess
with apparent
decrease, but persistent displacement of the airway which is now
intubated. For the detection of osteomyelitis, MR is more
sensitive.
CT neck [**7-12**]
FINDINGS: There is a hypodense collection containing foci of air
immediately adjacent and medial to the right submandibular gland
and lateral to the right mylohyoid muscle consistent with an
abscess, with the largest pocket measuring 12 x 16 x 29 mm.
There is no evidence of odontogenic infection or sialolith.
There is no evidence of retropharyngeal abscess. The airways
appear patent. There is some fluid within the right pyriform
sinus.
No cervical lymph nodes meet CT size criteria for pathologic
enlargement. The carotid vessels and their branches appear
unremarkable. The great vessels appear unremarkable. There is no
mediastinal or hilar lymphadenopathy.
The visualized lungs show mild emphysematous changes.
Degenerative changes are seen within the cervical spine, most
prominent at
C4-C5, C5-C6. There is no evidence of prevertebral soft tissue
swelling.
IMPRESSION:
1. Abscess, medial and adjacent to the right submandibular gland
and lateral to the right mylohyoid. No definite odontogenic
infection or sialolith identified.
2. Fluid within the right piriform sinus.
3. Degenerative changes at C4-C5 and C5-C6 with no prevertebral
soft tissue swelling.
CXR [**7-22**]
FINDINGS: Cardiomediastinal contours are unchanged. Endotracheal
tube has
been removed and other support devices are unchanged in
position. Worsening of bibasilar atelectasis and persistent
small bilateral pleural effusions.
Microbiology
[**2126-7-21**] 9:37 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2126-7-23**]**
GRAM STAIN (Final [**2126-7-21**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2126-7-23**]):
Commensal Respiratory Flora Absent.
ENTEROBACTER CLOACAE. MODERATE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
YEAST. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
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
[**2126-7-16**] 9:41 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2126-7-20**]**
GRAM STAIN (Final [**2126-7-16**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2126-7-19**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
[**2126-7-12**] 10:50 pm SWAB RIGHT SUBMANDIBULAR ABSCESS.
GRAM STAIN (Final [**2126-7-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2126-7-16**]):
VIRIDANS STREPTOCOCCI. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2126-7-17**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES. RARE GROWTH.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
Blood cultures 6/11 Coag neg staph, otherwise neg
Urine cultures: NEG
[**2126-7-27**] 4:26 pm SWAB Source: R cheek.
**FINAL REPORT [**2126-7-30**]**
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2126-7-30**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
[**2126-7-25**] 7:49 am BLOOD CULTURE
**FINAL REPORT [**2126-7-31**]**
Blood Culture, Routine (Final [**2126-7-31**]): NO GROWTH.
Labs at discharge:
[**2126-7-31**] 09:46AM BLOOD Hct-28.1*
[**2126-7-31**] 05:48AM BLOOD WBC-5.7 RBC-2.62* Hgb-8.1* Hct-23.8*
MCV-91 MCH-30.9 MCHC-34.1 RDW-14.7 Plt Ct-412
[**2126-7-31**] 05:48AM BLOOD Glucose-98 UreaN-19 Creat-1.4* Na-142
K-3.3 Cl-107 HCO3-21* AnGap-17
[**2126-7-31**] 05:48AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.1
Brief Hospital Course:
Ms [**Known lastname 81697**] is a 70 year-old female with pmh of chronic
vertigo secondary to a concussion, hypertension, and depression
admitted on [**7-12**] after undergoing I&D of a dental abscess.
# Peridontal abscess: Ms [**Known lastname 81697**] was transferred to medicine
after incision and drainage of her peridontal abscess by OMFS
the night of admission. She tolerated the procedure well
without complication. She was treated with clindamycin 600 mg
IV tid for initially days. Blood cultures and abscess cultures
were sent and became positive for strep viridans. She also
rinsed twice daily with chlorhexidine oral rinse. She initially
did well after the first drainage, however she continued to have
pain with swallowing and her drain began draining pus. On [**7-15**]
due to concern for worsening of her swallowing, she underwent a
neck CT which showed presistent collection. She was taken back
to the OR and underwent further extraoral and intraoral I&D,
with placement of four pimrose drains and removal of two teeth.
It was decided to keep her intubated overnight and she was
monitored in the MICU. Abscess cultures grew out strep
viridans, and an ID consultation was obtained. She was started
on unasyn and her clindamycin was discontinued on ID's
recommendation. She remained intubated for 6 days for severe
swelling of her airway secondary to the abscess and surgical
swelling. Tube feeds were initiated. She was extubated on [**7-21**]
after manipulation of her nasotracheal tube finally demonstrated
a cuff leak. She remained stable after extubation and was
transferred to the floor. However, at the time of transfer she
remained unable to tolerate POs due to the primrose drains
continuing to have significant drainage. She was placed on NG
tube feeds until [**2126-7-29**]. Close f/u with OMFS and subsequent CT
imaging of her abscesses revealed that these were decreasing in
size.
# Hypoxia: After her initial surgery she became hypoxic to the
high 80's on RA, requiring 2-3L of NC. Her lung exam revealed
crackles halfway up her lung fields and her CXR looked wet, but
without evidence of pneumonia. Given her acute renal failure,
diuresis was initially held and she was allowed to auto-diurese.
She was also encouraged to use incentive spirometry. She was
gently diuresed on the floor.
During her MICU stay, she had a sputum culture which grew out H.
influenza and Enterobacter that was negative for beta-lactamase.
This was adequately covered with the unasyn which the patient
was being treated with for her abscess. Because she continued to
have low-grade fevers, her Abx therapy was broadened to
Vanc-Zosyn for concerns over VAP. Her respitatory status
improved gradually to discharge.
# Acute renal failure: The patient's Cr decreased from 1.9 to
1.3 with IVF. She likely had prerenal ARF due to decreased po
intake in the setting of painful swalling due to her dental
abscess. Her creatinine trended down during her
hospitalization. Her creatinine increased slighlty after
stopping her tube feeds. However, her PO intake increased
quickly during the next days as her pain decreased.
# Postive blood culture: Her admission blood culture [**2-4**] grew
out gram positive cocci. She was started on vacomycin while
awaiting speciation. The gram positive cocci grew out to be
coag negative staph which was thought to be a contaminant so the
vancomycin was stopped. Several surveillence blood cultures
were sent and showed no growth to date.
# Hypertension: Patient is hypertensive at baseline, but on
transfer to MICU had low blood pressures. Her pressures
remained stable and she was re-initiated on Atenolol and
Amlodipine and HCTZ. Her Amlodipine was increased to 10mg daily
because of ongoing HTN.
# Hyperlipidemia: Her statin was initially held due to pain
with swallowing, but was restarted prior to discharge.
# Anemia: Hcts downtrended during admission, though initially to
be due to surgical blood losses/hemodilution. This improved
prior to discharge
# Depression: She was continued on wellbutrin.
Medications on Admission:
Amlodipine 5mg daily
HCTZ 25mg daily
Atenolol 50mg daily
Lovastatin 40mg qHS
trazadone 1-2 tabs qHS
wellbutrin 150mg daily
ASA 81 [**Hospital1 **]
Fish oil 1 tab [**Hospital1 **]
ibuprophen prn
benadryl prn
Ca and vit D
MVI
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): swish and spit.
Disp:*300 mL* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO Daily.
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for allergy symptoms.
7. Lovastatin 40 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO qHS PRN as
needed for insomnia.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6 hrs if needed as needed for pain: Sedating
medication. Do not take before driving or operating machinery.
Disp:*15 Tablet(s)* Refills:*0*
10. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
11. Outpatient Lab Work
Check chem 7 on [**2126-8-6**]. Fax results to Dr. [**Known firstname **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 21392**].
12. Valtrex 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for herpes simplex outbreak on neck for 3 days: Take if
herpes outbreak on neck worsens or recurs.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Peridental abscesses
Acute renal failure
pneumonia
Secondary:
Rash
Depression
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
.
You were admitted to the hospital after undergoing an incision
and drainage of an abscess (infected area) of your mouth and
neck. You tolerated the procedure well and were monitored
afterwards in the hospital. You required 2 separate draining
procedures and were followed closely by you oral-maxillofacial
surgeons during your stay.
.
During your stay you developped a fever and you were treated
with antibiotics to treat both your dental abscesses and a
presumed respiratory infection. Because of the dental
operations, you had signifiant pain and were unable to swallow
appropriately. You were given a nasogastric tube and were fed
through this tube for several days. You also had significant
pain during you stay and were treated with a combination of oral
and intravenous medications. Over time, you fevers dissipated
and your pain decreased and we were able to pull your feeding
tube. We are pleased with your recovery and have switched your
intravenous antibiotic to an oral antibiotic.
.
During your stay you also developped a rash on your neck that
was due to Herpes Simplex Virus, type 1. You were successfully
treated with an antiviral medication. You have been given a
prescription for Valtrex to take if you develop another
outbreak.
You should continue to take this antibiotic
"Augmentin/Amoxicilin Clavulanate" as prescribed for 7 days
after your discharge.
You should continue to use Chlorhexidine Gluconate 0.12 %
Mouthwash as prescribed to minimize infections in your oral
cavity.
You can also continue to take your pain medications
"Oxycodone-Acetaminophen" as prescribed if you have pain related
to your surgery. Note that this medication includes
acetaminophen and should not be combined with Tylenol or any
other medications that contain acetaminophen. Do not drive or
participate in any other hazardous activities after taking
Percocet.
You laboratory test showed some evidence of kidney disfunction.
Due to this, your hydrochlorothiazide was stopped for now. You
will need to have some labs checked on [**2126-8-6**] to recheck your
kidney function. Due to your kidney dysfunction, you should not
take any ibuprofen, Motrin, Aleve, Naproxen, or other related
medications until instructed to do so by your doctor.
During your stay we changed some of your home medications.
START chlorhexidine mouthwashes
START amoxicillin for 7 days
STOP ibuprofen due to kidney dysfunction.
STOP hydrochlorothiazide due to low intake of food and liquids.
This will help you avoid dehydration. Talk to Dr. [**Last Name (STitle) **] about
restarting this medication when you see her in clinic.
INCREASE amlodipine from 5mg to 10mg daily
.
You should continue to take all your other home medications as
previously prescribed by your physician.
Followup Instructions:
Primary Care Physician Appointment
When: WEDNESDAY, [**8-14**], 2PM
Name: DR. [**Known firstname **] [**Doctor Last Name **]
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Oral and Maxillofacial Surgeon
With: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 24902**] Yawkey Building [**Location (un) **]
Phone: [**Telephone/Fax (1) 28910**].
Appointment: Thursday [**2126-8-1**] 10:30am
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,990
| 113,207
|
45969
|
Discharge summary
|
report
|
Admission Date: [**2184-9-9**] Discharge Date: [**2184-9-19**]
Date of Birth: [**2137-5-6**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Acetaminophen / Ultram / Oxycontin / Zantac /
Levofloxacin
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions,
small bowel resection, primary repair of recurrent ventral
hernia, placement of left femoral vein triple lumen central
venous line, placement of PICC.
History of Present Illness:
The patient is a 47-year-old female with end
stage renal disease on hemodialysis, status post epigastric
ventral hernia repair in the distant past, who was noted
recurrence of the ventral hernia but without any symptoms.
The day PTA, during hemodialysis, she developed abdominal
discomfort and nausea, and thereafter, severe pain at the
side of the recurrent epigastric ventral hernia. She came to
the emergency room where a CT scan of the abdomen revealed a
small omental fat- containing ventral hernia above the
umbilicus with mild adjacent inflammatory fat stranding.
Adjacent to this region, there were multiple prominent loops
of small bowel with fecalization of bowel contents and
surrounding inflammatory fat stranding and fluid locally. The
loops of bowel distal to these prominent loops appeared
decompressed and the findings were suggestive of a recent
reduction of an incarcerated hernia with high grade
obstruction. She now presents for exploratory laparotomy.
Past Medical History:
1. Significant for end-stage renal disease secondary to
glomerulonephritis possibly secondary to IgA diagnosed in
[**2165**], and the patient has been on hemodialysis since [**2170**].
She is anuric and is on Monday, Wednesday, and Friday
dialysis schedule.
2. The patient has had bilateral below-the-knee amputations
secondary to calciphylaxis in [**2181-1-19**] as well as
multiple finger amputations during the same year.
3. She is status post a parathyroidectomy for previous
admissions for hypercalcemia.
4. The patient is status post a left arteriovenous fistula on
her left upper extremity placed in [**2179**], which became
injured during a fistulogram in [**2183-3-22**].
5. She has chronic pain.
6. She is status post a mitral valve replacement in [**2180-3-21**] with a mechanical Carbomedics 29-mm valve for
rheumatic heart disease; and she is on Coumadin for this
valve. She also has a history of endocarditis.
7. History of hypertension.
8. Anxiety.
Social History:
The patient smokes one-third of a pack per
day. She denies any EtOH and is disabled.
Family History:
Non-contributory
Physical Exam:
On admission:
99.8 100 90/49 19
A&Ox3 in obvious pain
MMM, w/o JVD
RRR, tachy, no murmur
CTAB
soft +BS, epigastric TTP, voluntary gaurding, non-distended, no
rebound
guaiac negative
s/p bilat BKA
Pertinent Results:
[**2184-9-17**] 01:10PM BLOOD WBC-4.6 RBC-3.30* Hgb-9.9*# Hct-28.9*
MCV-88 MCH-30.0# MCHC-34.2# RDW-18.4* Plt Ct-176
[**2184-9-15**] 06:05AM BLOOD WBC-6.3 RBC-2.66* Hgb-7.2* Hct-23.1*
MCV-87 MCH-26.9* MCHC-31.0 RDW-18.5* Plt Ct-148*
[**2184-9-14**] 06:48AM BLOOD WBC-5.6 RBC-2.72* Hgb-7.4* Hct-23.9*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.0* Plt Ct-142*
[**2184-9-13**] 08:10AM BLOOD WBC-6.2 RBC-2.69* Hgb-7.5* Hct-23.8*
MCV-89 MCH-27.8 MCHC-31.3 RDW-18.3* Plt Ct-146*
[**2184-9-13**] 05:39AM BLOOD WBC-5.9 RBC-2.73* Hgb-7.5* Hct-24.5*
MCV-90 MCH-27.4 MCHC-30.6* RDW-18.1* Plt Ct-135*
[**2184-9-12**] 06:15AM BLOOD WBC-6.9 RBC-2.99* Hgb-8.5* Hct-26.8*
MCV-90 MCH-28.6 MCHC-31.9 RDW-17.9* Plt Ct-127*
[**2184-9-11**] 03:03AM BLOOD WBC-7.2 RBC-3.17* Hgb-8.9* Hct-27.5*
MCV-87 MCH-28.2 MCHC-32.4 RDW-17.9* Plt Ct-120*
[**2184-9-10**] 07:43PM BLOOD Hct-30.2*
[**2184-9-10**] 03:08AM BLOOD WBC-12.5* RBC-3.66* Hgb-10.1* Hct-31.1*
MCV-85 MCH-27.6 MCHC-32.6 RDW-18.1* Plt Ct-118*
[**2184-9-9**] 02:15PM BLOOD WBC-16.1* RBC-3.51* Hgb-9.7* Hct-29.0*
MCV-83 MCH-27.7 MCHC-33.6 RDW-18.2* Plt Ct-114*
[**2184-9-9**] 08:00AM BLOOD WBC-15.9* RBC-3.61*# Hgb-10.0*#
Hct-31.1*# MCV-86 MCH-27.7 MCHC-32.2 RDW-18.6* Plt Ct-107*
[**2184-9-8**] 09:40PM BLOOD WBC-11.5*# RBC-5.47* Hgb-15.5 Hct-46.2
MCV-84 MCH-28.3 MCHC-33.5 RDW-17.9* Plt Ct-138*
[**2184-9-17**] 09:30AM BLOOD PT-23.8* PTT-49.4* INR(PT)-4.1
[**2184-9-16**] 05:40AM BLOOD PT-24.5* PTT-59.0* INR(PT)-4.4
[**2184-9-15**] 09:12PM BLOOD PT-23.6* PTT-48.0* INR(PT)-4.0
[**2184-9-15**] 06:05AM BLOOD PT-27.4* PTT-56.0* INR(PT)-5.5
[**2184-9-14**] 06:48AM BLOOD PT-24.3* PTT-54.4* INR(PT)-4.3
[**2184-9-13**] 08:55PM BLOOD PT-23.1* PTT-50.8* INR(PT)-3.9
[**2184-9-13**] 05:39AM BLOOD PT-22.9* PTT-104.3* INR(PT)-3.8
[**2184-9-12**] 06:15AM BLOOD PT-18.0* PTT-58.2* INR(PT)-2.3
[**2184-9-11**] 03:03AM BLOOD PT-16.8* PTT-56.5* INR(PT)-1.9
[**2184-9-8**] 07:00AM BLOOD PT-18.9* INR(PT)-2.5
[**2184-9-16**] 05:40AM BLOOD Glucose-68* UreaN-22* Creat-5.0*# Na-141
K-3.4 Cl-96 HCO3-28 AnGap-20
[**2184-9-15**] 06:05AM BLOOD Glucose-68* UreaN-43* Creat-7.3*# Na-141
K-3.7 Cl-102 HCO3-23 AnGap-20
[**2184-9-14**] 06:48AM BLOOD Glucose-86 UreaN-35* Creat-6.0*# Na-144
K-4.0 Cl-102 HCO3-25 AnGap-21*
[**2184-9-12**] 06:15AM BLOOD Glucose-70 UreaN-45* Creat-6.6*# Na-144
K-4.3 Cl-100 HCO3-24 AnGap-24*
[**2184-9-11**] 03:03AM BLOOD Glucose-92 UreaN-32* Creat-5.3*# Na-143
K-4.4 Cl-102 HCO3-24 AnGap-21*
[**2184-9-10**] 03:08AM BLOOD Glucose-74 UreaN-46* Creat-6.7* Na-139
K-4.5 Cl-98 HCO3-22 AnGap-24*
[**2184-9-9**] 02:15PM BLOOD Glucose-89 UreaN-37* Creat-5.9* Na-140
K-4.6 Cl-99 HCO3-25 AnGap-21*
[**2184-9-9**] 08:00AM BLOOD Glucose-141* UreaN-33* Creat-5.5* Na-141
K-4.2 Cl-100 HCO3-25 AnGap-20
[**2184-9-8**] 11:20PM BLOOD Glucose-142* UreaN-28* Creat-5.7* Na-141
K-4.5 Cl-94* HCO3-27 AnGap-25*
[**2184-9-8**] 09:40PM BLOOD Glucose-119* UreaN-25* Creat-5.7*# Na-139
K-4.7 Cl-90* HCO3-30 AnGap-24*
[**2184-9-8**] 09:40PM BLOOD ALT-66* AST-41* AlkPhos-468* Amylase-415*
TotBili-0.5
[**2184-9-16**] 05:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.4*
[**2184-9-15**] 06:05AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.5*
[**2184-9-14**] 06:48AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.7
[**2184-9-13**] 08:10AM BLOOD Albumin-3.0* Calcium-8.7 Phos-5.8* Mg-1.7
UricAcd-6.7*
[**2184-9-12**] 06:15AM BLOOD Calcium-8.9 Phos-5.2* Mg-1.7
[**2184-9-11**] 03:03AM BLOOD Calcium-9.3 Phos-5.1* Mg-1.9
[**2184-9-10**] 03:08AM BLOOD Calcium-8.4 Phos-5.2* Mg-1.5*
[**2184-9-9**] 02:15PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.5*
[**2184-9-9**] 08:00AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.5*
[**2184-9-8**] 09:40PM BLOOD Albumin-4.9* Calcium-10.0 Phos-4.8*
Mg-1.8
[**2184-9-10**] 11:25AM BLOOD freeCa-1.14
[**2184-9-9**] 02:22PM BLOOD freeCa-1.15
[**2184-9-9**] 06:33AM BLOOD freeCa-1.04*
[**2184-9-9**] 05:23AM BLOOD freeCa-1.04*
Brief Hospital Course:
Pt admitted to surgery from the ED.
Ct showed:
1. Prominent loops of proximal small bowel adjacent to an
omental fat containing ventral hernia with fecalization of bowel
contents, adjacent inflammatory fat stranding, and small amount
of fluid and extraluminal air consistent with bowel ischemia and
contained perforation. There also is apparent caliber change
just below the level of the ventral hernia within the small
bowel loops, as the distal loops of small bowel are markedly
collapsed. All these findings are suggestive of interval
reduction of an incarcerated hernia with high-grade bowel
obstruction. At this time, no bowel loops are demonstrated
within the ventral hernia.
2. Patent mesenteric vessels.
3. 2, low-density lesions within the spleen, likely representing
hemangiomas.
4. Stable appearance of simple hepatic cyst within the dome of
the liver.
5. Diffuse increase in density of the osseous structures
consistent with renal osteodystrophy.
6. Collateral vessels within the right lateral chest wall. These
findings are suggestive of a right subclavian vein stenosis.
Clinical correlation is recommended.
Pt taken to the OR for operation. Taken to the ICU intubated.
Renal consulted for HD and recs. Pt extubated on POD1. Renal
was consulted for continuation of her hemodialysis, which went
on with out complication. She was kept NPO until bowel function
resumed on POD 3, She transferred out of the ICU once extubated
on POD 1. She was kept on heparin gtt due to her need for
anti-coagulation. Once she had resumed POs, coumadin was
started, and she was brought up to her normal coagulation level
of 2.5-3. She will follow up in the coumadin clinic and
hemodialysis for follwing her INR. Through the remained of her
postoperative course, she was advnced through sips, to clears,
fulls, then to a regular diet which she tolerated well. By POD
10, she was tolerating regular diet, having bowel movements and
her coumadin was theraputic. She was d/c'ed home.
Medications on Admission:
xanax
MS [**First Name (Titles) **]
[**Last Name (Titles) **]
protonix
fentanyl
levoxyl
dilaudid
coumadin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO daily ().
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent ventral hernia with small
bowel obstruction and compromised bowel.
Chronic renal failure
Discharge Condition:
good
Discharge Instructions:
You may resume your home medications, please take all new
medications as prescribed.
You may resume your regular activities. You may shower, pat the
wound dry. Do not soak the wound for one week. The staples
will be removed at your follow up appointment. Please refrain
from driving while taking narcotic pain medication.
Please call your physician or return to the hoptial if you
experience:
- Increasing pain
- Fever (>101.5)
- Inability to eat/persistant vomiting
- Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. Call ([**Telephone/Fax (1) 10820**] to make
an appointment.
Completed by:[**2184-9-19**]
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66,929
| 128,790
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4068
|
Discharge summary
|
report
|
Admission Date: [**2117-2-12**] Discharge Date: [**2117-2-25**]
Date of Birth: [**2069-9-4**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin Analogues / IV Dye, Iodine Containing / Ace
Inhibitors / Benadryl
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever, respiratory distress
Major Surgical or Invasive Procedure:
Already intubated on transfer from OSH
A line
Esophageal balloon
History of Present Illness:
47-year old patient of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with a 15-year history of
Hodgkin's Disease, previously treated with chemotherapy
complicated by bleomycin lung and two allogenic bone marrow
transplants (2 and 6 years ago) complicated by heart failure and
radiation fibrosis who presents as a transfer from an outside
hospital after being intubated in the setting of a bleed during
a bronchoscopy with subsequent development of ARDS.
Patient was in usual state of health until this past [**Month (only) **]
when she presented to clinic with a fever and cough. A sputum
culture from [**12-25**] was noted to have sparce growth of
aspirgillus fumigatus and terreus. Galactomannan and beta glucan
negative. BAL deferred at patient's request. Treated with
Azithromycin and Cefpodoxime.
She did well and returned to work. She was given a DLI on [**1-14**].
On [**1-25**], she presented to [**Hospital **] Medical Center with worsening
fevers and shakiness for 48 hours. Chest imaging showed what was
felt to be worsening of her infiltrate (although it is unclear
what this was compared to) and pneumonitis. They performed a
bronchoscopy on [**2117-1-26**] which was complicated by an extensive
bleed leading to intubation. She later developed ARDS and was
started on IV steroids and pressors. She was started on an
antibiotic regimen which eventually included Linezolid,
Meropenem, Voriconazole and Acyclovir (prophylaxis dose).
She developed worsening hypercarbia on [**2-9**] and underwent a
workup for embolic disease. A CTA was negative for PE but showed
b/l pleural effusions R>L and a new left upper lung nodule of
1.4cm. In addition, diffuse ground glass opacities are present.
A right gastrognemius thrombus and a left cephalic thrombus was
found. An MRI of the brain showed a new left parietal lobe
infarcation. A CT also showed old infarction. Given abscence of
positive cultures per records at the time, antibacterials were
stopped on [**2-8**] and [**2-9**]. Voriconazole was continued. Atovaquone,
Acyclovir ppx was continued. The patient was started on high
dose Methylprednisolone 60mg Q8h on [**2-9**]. A pigtail catheter
drainage of R chest loculated effusion was planned for [**2-11**] but
was not done.
From the VS it appears that the patient was hypotensive on
[**11-19**]. No record of a fever. WBC up to 20,000.
She was transferred to [**Hospital1 18**] for further evaluation and
management given her extensive past medical care at [**Hospital1 18**]. She
arrived in the [**Hospital Unit Name 153**] intubated, sedated and in no apparent
distress. VS on arrival as below.
Past Medical History:
1. Hodgkin's lymphoma, nodular sclerosing, diagnosed in [**2101**];
radiation to the mediastinum in [**2102**] and to the lymph nodes in
[**2115**]
2. Autologous bone marrow transplant in [**2103**]
3. Non-myeloablative allogeneic stem cell transplant in [**2110**],
MUD on [**2115-9-20**] ATG conditioning c/b serum sickness; Cellcept
discontinued in [**2115-5-8**], only on low dose Prednisone recently
(increased transiently to 20mg for pruritus)
4. Cardiomyopathy, chemotherapy induced.
5. Depression/anxiety
6. Urinary incontinence
7. GVHD related to transplant with dry eyes and occasional oral
involvement
8. Herpes Zoster, [**2-13**]
9. PCP infection in [**8-/2114**] and remains on Bactrim
10. CMV viremia [**9-14**]
11. EBV viremia [**2115-11-7**] MMF discontinued
12. BK viremia and viruria- [**2115-11-7**]
13. RSV infection in [**2116-2-7**]
.
.
46 yo female with a long history of nodular sclerosing Hodgkin's
disease, s/p autologous SCT [**2101**], s/p sibling donor allogenic
transplant [**2110**], and s/p unrelated allogenic SCT with D 0 on
[**2115-9-20**]. Her post transplant course was notable for "serum
sickness" thought related to ATG with fevers, rash, and joint
pains. She was started on prednisone for control of the symptoms
and the steroids have subsequently been discontinued. She had a
relatively uncomplicated post-transplant course until she
developed CMV viremia with CMV viral load on [**2115-9-30**] noted at
4000. [**Doctor First Name 16883**] was started on IV ganciclovir. On [**2115-10-8**], she was
switched to valganciclovir for continued treatment. Subsequent
CMV viral loads on [**2115-10-6**] revealed a level of 9000, and
repeat on [**2115-10-11**] was 14,500. At this point, [**Doctor First Name 16883**] was switched
back to IV ganciclovir, and she was discharged to the local
apartments on [**2115-10-16**]. Unfortunately, her CMV viral load
increased further and she was readmitted for IV Foscarnet on
[**2115-10-24**]. With improvement in her CMV viral load, she was
discharged to the apartments on [**2115-11-9**] on IV ganciclovir. She
was switched to Valganciclovir 900 mg twice per day in mid
[**Month (only) 359**]. Her dose was decreased to 900 mg once per day as of
[**2115-12-5**]. She developed a macular papular rash and was seen by
Dermatology on [**2115-11-13**]. Biopsy was consistent with a drug
hypersensitivity reaction, possibly related to Foscarnet or
Bactrim. She also was treated for a short period of time with
Keflex for possible infected SK on her hand. Her Bactrim was
switched to Atovaquone and her Keflex was discontinued. She has
recently been noted for slowly decreasing counts thought related
to her Valcyte. However, [**Doctor First Name 16883**] was noted for increasing EBV
level of 400 and with concern for PTLD, she was admitted on
[**2115-12-15**] for evaluation and followup. Subsequent EBV viral
loads were < 8 and CT of the neck showed decreasing adenopathy.
CT of the torso showed stable adenopathy within the abdomen.
Bone marrow biopsy was negative for lymphoma. [**Doctor First Name 16883**] was
discharged on [**2115-12-19**]. Her counts have been recovering.
.
- Dx [**10/2101**] IIE HD. Treated with 6 cycles of MOPP/ABV
hybrid followed by XRT.
- Recurred in [**4-/2103**] with minimal disease and went to autologous
transplant in 4/[**2103**].
- [**12/2109**] noted for recurrent disease, received Gemzar as single
[**Doctor Last Name 360**].
- s/p nonmyeloablative allogeneic stem cell transplant from a
sibling donor on [**2110-5-8**] with evidence for recurrent disease.
- s/p 3 cycles of gemcitabine and Navelbine completed on
[**2110-12-15**] followed by donor lymphocyte infusion on [**2110-12-26**]
at a dose of 1 x10 to the 7th T cell per kilogram.
- s/p 3 cycles of CEPP chemotherapy with the first cycle given
without procarbazine and completed on 03/[**2111**].
- s/p DC/DLI infusion on [**2111-6-5**] on the DC/DLI protocol with
DLI dose of 3 x10 to the 7th T-cell per kilogram.
- Evidence for disease recurrence in [**8-/2111**] and status post
four weeks of Rituxan, last given on [**2111-10-7**], supported with
Leukine injections.
- s/p donor lymphocyte infusion at a dose of 1 x10 to 8th T-cell
per kilogram on [**2111-10-22**].
- s/p enrollment on [**Company 2860**] study involving anti-CTLA-4 antibody
with donor lymphocyte infusion in 05/[**2112**].
- Evidence for recurrent disease while on protocol and status
post two cycles of Navelbine and gemcitabine.
- s/p DLI at a dose of 0.79 x10 to the 8th T-cell per kg on
[**2112-11-25**].
- Evidence for recurrent disease in [**1-/2113**] and status post
single [**Doctor Last Name 360**] Velcade starting in [**1-/2113**] given for two cycles,
however, complicated by fevers and abdominal pain requiring
admission at [**Hospital **] Medical Center.
- Began Gemzar, Navelbine once again on [**2113-3-16**], s/p 4 cycles
supported with Leukine injections for the second, third and four
cycles.
- Status post DLI at a dose of 1.15 x10 to the 8th T-cell per
kilogram on [**2113-7-7**].
- Noted for progressive disease in [**2114-4-7**] and now s/p 2
cycles of Gemzar/Navelbine in [**Month (only) 547**]/[**2114-6-7**] with C2D8 on
[**2114-6-20**].
- Plan to move forward with two more cycles of Gemzar/Naveline
but developed fever, shortness of breath and increasing white
count requiring admission in NY and then follow up admission at
[**Hospital1 18**] for presumed infection.
- Treated for PCP infection with IV Bactrim and currently on
Bactrim prophylaxis.
- Persistent elevation in white blood count with increased
abdominal adenopathy and began treatment with Methotrexate for
two doses with minimal response.
- Treated with three cycles of ICE chemotherapy, last cycle in
1/[**2115**]. The 1st cycle was given at 75% dosing and 2nd and 3rd
cycles were given with 50% dosing.
- Plan had been to move forward with possible allogeneic
transplant from an unrelated donor but noted for progression of
disease in cervical adenopathy and abdominal areas with
increasing white count and fevers. She was given high dose
steroids and then treated with three cycles of DHAP starting of
[**2115-4-17**], with 3rd cycle on [**2115-6-3**]. She had initial response
after two cycles with normalization of white count and
resolution of cervical adenopathy but this grew again, and she
received the 3rd cycle of DHAP. She received a 4th cycle of DHAP
on [**2115-8-5**] for further treatment while undergoing workup for
allogeneic transplant.
- Received dose of Velban on [**2115-8-30**] due to increased white
count and to temporize her disease prior to her admission.
- Admitted for 2nd allogeneic stem cell transplant from an
unrelated donor with ATG/TLI conditioning. D 0 was [**2115-9-20**].
Social History:
Worked for a state senator in [**Location (un) **], NY, No Hx of EtOH or
tobacco, currently living in the apartments with her mother.
Lives in [**State 531**].
Family History:
Non-contributory.
Physical Exam:
VS: 97.2 118/74 88 32 92/FiO2 55%
GEN: sedated, no acute distress
HEENT: PERRL, sclerae anicteric, neck supple, MMM
CV: RRR, normal S1, S2, no R/G/M
LUNGS: coarse, no wheeze, intubated
GI: soft, non-tender, non-distended, +BS, greenish-brownish
liquid stool
EXT: warm and well perfused, trace edema bilaterally, 2+ DP
pulses palpable bilaterally
SKIN: no erythema, rash, no jaundice
NEURO: moving all extremities, reacts to painful stimuli
Pertinent Results:
Admission labs:
[**2117-2-12**] 05:30PM BLOOD WBC-9.2 RBC-2.89* Hgb-9.2* Hct-27.1*
MCV-94 MCH-31.9 MCHC-34.1 RDW-16.8* Plt Ct-150
[**2117-2-12**] 05:30PM BLOOD Neuts-88.1* Lymphs-5.5* Monos-6.3 Eos-0.1
Baso-0.1
[**2117-2-12**] 05:30PM BLOOD PT-12.5 PTT-21.8* INR(PT)-1.1
[**2117-2-12**] 05:30PM BLOOD Glucose-137* UreaN-39* Creat-0.6 Na-142
K-4.3 Cl-96 HCO3-45* AnGap-5*
[**2117-2-12**] 05:30PM BLOOD ALT-53* AST-31 LD(LDH)-295* AlkPhos-220*
TotBili-0.7
[**2117-2-12**] 05:30PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.4 Mg-2.0
.
Other labs:
[**2117-2-13**] 05:38AM BLOOD Fibrino-365
[**2117-2-13**] 05:38AM BLOOD DirBili-0.4*
[**2117-2-13**] 05:38AM BLOOD calTIBC-255* Hapto-280* TRF-196*
[**2117-2-16**] 04:17AM BLOOD Triglyc-183* HDL-54 CHOL/HD-3.9
LDLcalc-120
[**2117-2-18**] 04:48AM BLOOD Triglyc-222*
[**2117-2-23**] 04:26AM BLOOD Triglyc-227*
[**2117-2-15**] 07:53PM BLOOD Vanco-24.7*
[**2117-2-16**] 07:03AM BLOOD Vanco-16.5
[**2117-2-12**] 05:49PM BLOOD Lactate-1.1
[**2117-2-15**] 05:03AM BLOOD Lactate-1.0
[**2117-2-16**] 04:48AM BLOOD Lactate-0.8
[**2117-2-17**] 01:20AM BLOOD Lactate-0.5
[**2117-2-17**] 10:15AM BLOOD Glucose-125* Lactate-1.1
[**2117-2-20**] 06:00PM BLOOD Lactate-0.6
[**2117-2-21**] 04:01AM BLOOD Lactate-0.6
[**2117-2-21**] 03:31PM BLOOD Lactate-0.9
[**2117-2-22**] 04:31AM BLOOD Lactate-0.8
[**2117-2-22**] 07:55PM BLOOD Lactate-1.3
.
ABGs:
[**2117-2-12**] 05:49PM BLOOD freeCa-1.18
[**2117-2-21**] 04:01AM BLOOD freeCa-1.20
[**2117-2-22**] 07:55PM BLOOD freeCa-1.18
[**2117-2-12**] 05:49PM BLOOD Type-CENTRAL VE Temp-36.1 Rates-32/ Tidal
V-250 PEEP-5 FiO2-70 pO2-45* pCO2-88* pH-7.37 calTCO2-53* Base
XS-20 Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-12**] 08:43PM BLOOD Type-ART Rates-32/ PEEP-5 FiO2-55 pO2-60*
pCO2-59* pH-7.51* calTCO2-49* Base XS-19 Intubat-INTUBATED
Vent-CONTROLLED
[**2117-2-13**] 03:39AM BLOOD Type-ART Temp-36.2 Rates-28/2 PEEP-5
FiO2-55 pO2-69* pCO2-54* pH-7.54* calTCO2-48* Base XS-19
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-13**] 05:01PM BLOOD Type-ART Temp-36.3 Rates-28/0 Tidal V-270
PEEP-5 FiO2-55 pO2-83* pCO2-75* pH-7.35 calTCO2-43* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2117-2-13**] 08:03PM BLOOD Type-ART Temp-36.3 Rates-8/0 PEEP-10
FiO2-55 pO2-77* pCO2-72* pH-7.33* calTCO2-40* Base XS-8
Intubat-INTUBATED Vent-CONTROLLED Comment-DRIVING PR
[**2117-2-14**] 12:22AM BLOOD Type-ART Temp-36.2 Rates-28/0 PEEP-10
FiO2-55 pO2-101 pCO2-79* pH-7.31* calTCO2-42* Base XS-8
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 02:37AM BLOOD Type-ART Temp-36.1 Rates-30/0 PEEP-10
FiO2-50 pO2-94 pCO2-74* pH-7.30* calTCO2-38* Base XS-6
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 07:12AM BLOOD Type-ART Rates-30/0 PEEP-10 FiO2-50
pO2-68* pCO2-84* pH-7.30* calTCO2-43* Base XS-11
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 12:51PM BLOOD Type-ART Rates-3/ Tidal V-220 PEEP-3
FiO2-60 pO2-76* pCO2-98* pH-7.26* calTCO2-46* Base XS-12
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 02:30PM BLOOD Type-ART Rates-30/ Tidal V-220 FiO2-55
pO2-99 pCO2-89* pH-7.28* calTCO2-44* Base XS-11
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 07:12AM BLOOD Type-ART Rates-30/0 PEEP-10 FiO2-50
pO2-68* pCO2-84* pH-7.30* calTCO2-43* Base XS-11
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 12:51PM BLOOD Type-ART Rates-3/ Tidal V-220 PEEP-3
FiO2-60 pO2-76* pCO2-98* pH-7.26* calTCO2-46* Base XS-12
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 02:30PM BLOOD Type-ART Rates-30/ Tidal V-220 FiO2-55
pO2-99 pCO2-89* pH-7.28* calTCO2-44* Base XS-11
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 04:12PM BLOOD Type-ART Temp-36.1 Rates-32/ Tidal V-220
PEEP-10 FiO2-55 pO2-71* pCO2-91* pH-7.31* calTCO2-48* Base XS-15
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-14**] 06:34PM BLOOD Type-ART Temp-37.1 Rates-32/ Tidal V-230
PEEP-5 FiO2-60 pO2-100 pCO2-73* pH-7.39 calTCO2-46* Base XS-14
-ASSIST/CON Intubat-INTUBATED
[**2117-2-15**] 05:03AM BLOOD Type-ART Temp-37.2 FiO2-60 pO2-120*
pCO2-87* pH-7.38 calTCO2-54* Base XS-21 Intubat-INTUBATED
[**2117-2-15**] 09:14AM BLOOD Type-ART Temp-36.8 Rates-32/ Tidal V-230
PEEP-5 FiO2-50 pO2-63* pCO2-63* pH-7.44 calTCO2-44* Base XS-15
-ASSIST/CON Intubat-INTUBATED
[**2117-2-15**] 05:09PM BLOOD Type-ART Temp-36.7 PEEP-5 pO2-78*
pCO2-85* pH-7.34* calTCO2-48* Base XS-15 Intubat-INTUBATED
[**2117-2-15**] 08:09PM BLOOD Type-ART pO2-86 pCO2-91* pH-7.38
calTCO2-56* Base XS-23 Vent-CONTROLLED
[**2117-2-16**] 12:29AM BLOOD Type-ART FiO2- O2 Flow-50 pO2-89 pCO2-82*
pH-7.39 calTCO2-52* Base XS-20 Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-16**] 04:48AM BLOOD Type-ART Temp-37.2 FiO2-50 pO2-71*
pCO2-84* pH-7.44 calTCO2-59* Base XS-27 Intubat-INTUBATED
Vent-CONTROLLED
[**2117-2-16**] 07:44AM BLOOD Type-ART Rates-33/ PEEP-5 FiO2-50 pO2-59*
pCO2-85* pH-7.43 calTCO2-58* Base XS-26 -ASSIST/CON
Intubat-INTUBATED
[**2117-2-16**] 11:50AM BLOOD Type-ART Rates-32/ Tidal V-270 PEEP-5
FiO2-50 pO2-69* pCO2-83* pH-7.41 calTCO2-55* Base XS-22
-ASSIST/CON Intubat-INTUBATED
[**2117-2-16**] 03:38PM BLOOD Type-ART Temp-37.9 Rates-35/ Tidal V-230
PEEP-5 FiO2-50 pO2-88 pCO2-84* pH-7.36 calTCO2-49* Base XS-17
-ASSIST/CON Intubat-INTUBATED
[**2117-2-16**] 08:45PM BLOOD Type-ART Temp-37.2 pO2-80* pCO2-82*
pH-7.37 calTCO2-49* Base XS-17 Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-17**] 12:52AM BLOOD Type-ART pO2-242* pCO2-74* pH-7.37
calTCO2-44* Base XS-14 Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-17**] 01:20AM BLOOD Type-ART Rates-32/ Tidal V-300 FiO2-50
pO2-70* pCO2-71* pH-7.37 calTCO2-43* Base XS-11
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-17**] 04:32AM BLOOD Type-ART Temp-37.4 Rates-32/ Tidal V-300
PEEP-5 FiO2-50 pO2-77* pCO2-77* pH-7.36 calTCO2-45* Base XS-13
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-17**] 10:15AM BLOOD Type-ART pO2-69* pCO2-85* pH-7.31*
calTCO2-45* Base XS-12
[**2117-2-17**] 10:20AM BLOOD Type-CENTRAL VE
[**2117-2-17**] 04:14PM BLOOD Type-ART Temp-36.3 Rates-32/ Tidal V-200
PEEP-5 FiO2-50 pO2-114* pCO2-77* pH-7.33* calTCO2-42* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2117-2-17**] 11:06PM BLOOD Type-ART Temp-36.8 PEEP-5 pO2-69*
pCO2-70* pH-7.35 calTCO2-40* Base XS-9 Intubat-INTUBATED
Vent-CONTROLLED
[**2117-2-18**] 05:08AM BLOOD Type-ART Temp-36.4 PEEP-5 FiO2-50 pO2-62*
pCO2-66* pH-7.38 calTCO2-41* Base XS-10 Intubat-INTUBATED
Vent-CONTROLLED
[**2117-2-18**] 01:57PM BLOOD Type-ART Temp-36.9 Rates-32/2 PEEP-5
FiO2-50 pO2-69* pCO2-83* pH-7.29* calTCO2-42* Base XS-10
Intubat-INTUBATED
[**2117-2-18**] 04:40PM BLOOD Type-ART Temp-36.7 Rates-32/ PEEP-5
FiO2-50 pO2-110* pCO2-83* pH-7.27* calTCO2-40* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2117-2-18**] 07:40PM BLOOD Type-ART Temp-36.2 PEEP-5 FiO2-50
pO2-106* pCO2-76* pH-7.30* calTCO2-39* Base XS-7
Intubat-INTUBATED
[**2117-2-19**] 12:01AM BLOOD Type-ART Temp-36.0 PEEP-5 FiO2-50 pO2-67*
pCO2-59* pH-7.38 calTCO2-36* Base XS-7 Intubat-INTUBATED
[**2117-2-19**] 03:57AM BLOOD Type-ART Temp-36.9 PEEP-5 FiO2-50 pO2-87
pCO2-73* pH-7.35 calTCO2-42* Base XS-10 -ASSIST/CON
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-19**] 09:41PM BLOOD Type-ART pO2-92 pCO2-77* pH-7.38
calTCO2-47* Base XS-15
[**2117-2-20**] 06:32AM BLOOD Type-ART pO2-71* pCO2-86* pH-7.34*
calTCO2-48* Base XS-16
[**2117-2-20**] 12:28PM BLOOD Type-ART Temp-36.1 Rates-32/ pO2-68*
pCO2-85* pH-7.34* calTCO2-48* Base XS-15
[**2117-2-20**] 06:00PM BLOOD Type-ART Temp-36.8 Rates-32/2 PEEP-2
FiO2-50 pO2-91 pCO2-85* pH-7.35 calTCO2-49* Base XS-16
-ASSIST/CON Intubat-INTUBATED
[**2117-2-21**] 04:01AM BLOOD Type-ART pO2-64* pCO2-92* pH-7.33*
calTCO2-51* Base XS-17
[**2117-2-21**] 11:31AM BLOOD Type-ART pO2-66* pCO2-98* pH-7.31*
calTCO2-52* Base XS-17
[**2117-2-21**] 02:48PM BLOOD Type-ART pO2-67* pCO2-118* pH-7.27*
calTCO2-57* Base XS-20
[**2117-2-21**] 03:31PM BLOOD Type-ART Temp-36.6 Rates-32/ PEEP-4
FiO2-50 pO2-82* pCO2-93* pH-7.35 calTCO2-54* Base XS-20
-ASSIST/CON Intubat-INTUBATED
[**2117-2-21**] 06:36PM BLOOD Type-ART pO2-89 pCO2-93* pH-7.36
calTCO2-55* Base XS-21
[**2117-2-21**] 10:56PM BLOOD Type-ART pO2-85 pCO2-86* pH-7.39
calTCO2-54* Base XS-21
[**2117-2-22**] 04:31AM BLOOD Type-ART pO2-67* pCO2-86* pH-7.41
calTCO2-56* Base XS-24
[**2117-2-22**] 11:19AM BLOOD Type-ART Temp-37.3 Rates-32/0 PEEP-4
FiO2-50 pO2-69* pCO2-87* pH-7.40 calTCO2-56* Base XS-23
Intubat-INTUBATED Comment-PS34
[**2117-2-22**] 07:55PM BLOOD Type-ART Temp-35.3 Rates-32/0 FiO2-50
pO2-64* pCO2-78* pH-7.45 calTCO2-56* Base XS-24
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-23**] 03:22AM BLOOD Type-ART Temp-37.6 Rates-32/ PEEP-4
FiO2-50 pO2-69* pCO2-87* pH-7.43 calTCO2-60* Base XS-27
Intubat-INTUBATED Vent-CONTROLLED
[**2117-2-23**] 03:31PM BLOOD Type-ART pO2-72* pCO2-88* pH-7.39
calTCO2-55* Base XS-22
[**2117-2-23**] 09:00PM BLOOD Type-ART pO2-72* pCO2-74* pH-7.44
calTCO2-52* Base XS-20
[**2117-2-24**] 05:43AM BLOOD Type-ART pO2-75* pCO2-75* pH-7.43
calTCO2-51* Base XS-20
.
.
Microbiology
[**2117-2-13**] 05:38
VORICONAZOLE
Test Concentration
---- -------------
Antifungal Drug Level
Voriconazole 0.30 ug/ml
Comments: There are no established reference ranges for
voriconazole,
however, levels of <1.0 ug/ml may be sub-optimal while levels
>6.0 ug/ml
may be associated with toxicity, visual disturbances, and/or
elevated
liver function tests.
.
[**2117-2-13**] 14:17
B-GLUCAN
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
.
[**2117-2-13**] 14:17
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
RESULT INTERPRETATION:
An Index <0.5 is considered to be negative.
An Index >=0.5 is considered to be positive.
.
[**2117-2-12**] 5:30 pm BLOOD CULTURE
**FINAL REPORT [**2117-2-18**]**
Blood Culture, Routine (Final [**2117-2-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2117-2-14**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
[**2117-2-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
-ve
[**2117-2-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2117-2-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B -ve
[**2117-2-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2117-2-12**] URINE URINE CULTURE-FINAL
.
[**2117-2-13**] 6:03 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Site:
A LINE
Source: Line-A.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2117-2-13**] 6:03 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2117-2-16**]**
Respiratory Viral Culture (Final [**2117-2-16**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2117-2-14**]):
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.
.
[**2117-2-14**] 11:10 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2117-2-14**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2117-2-16**]):
RARE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2117-2-15**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2117-2-15**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
.
[**2117-2-15**] BLOOD CULTURE Blood Culture, Routine -ve
[**2117-2-14**] BLOOD CULTURE Blood Culture, Routine -ve
[**2117-2-14**] BLOOD CULTURE Blood Culture, Routine -ve
.
[**2117-2-16**] 4:17 am Immunology (CMV) Source: Line-Aline.
**FINAL REPORT [**2117-2-17**]**
CMV Viral Load (Final [**2117-2-17**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
.
[**2117-2-21**] URINE URINE CULTURE -ve
[**2117-2-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2117-2-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
-ve
[**2117-2-16**] STOOL OVA + PARASITES -ve
.
[**2117-2-21**] 10:37 pm BLOOD CULTURE Source: Line-aline.
Blood Culture, Routine (Preliminary):
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..
SENSITIVE TO Daptomycin AT MIC 1.0 MCG/ML, Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final [**2117-2-22**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
[**2117-2-23**] URINE URINE CULTURE -ve
.
.
Cardiology:
ECG Study Date of [**2117-2-12**] 8:07:40 PM
Sinus tachycardia. Compared to the previous tracing of [**2116-2-22**]
the rate is
increased.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
134 128 68 282/411 56 59 34
.
ECG Study Date of [**2117-2-12**] 8:42:10 PM
Sinus tachycardia. Compared to the previous tracing there is no
change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 124 68 348/432 37 47 55
.
Portable TTE (Complete) Done [**2117-2-15**] at 9:00:00 AM
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Very mild global left ventricular systolic
dysfunction. Mild mitral regurgitation. Mild pulmonary
hypertension.
.
Portable TTE (Focused views) Done [**2117-2-23**] at 3:55:40 PM
Conclusions
Biventricular systolic function appears grossly preserved
(regional wall motion not assessed).
Two agitated saline injections were performed at rest. These
revealed no evidence of intracardiac shunt. There was trace late
contrast in the left ventricle consistent with a probable slight
pulmonary arteriovenous shunt.
.
.
Radiology:
XR CHEST (PORTABLE AP) Study Date of [**2117-2-12**] 8:03 PM
IMPRESSION: AP chest read in conjunction with chest CT on
[**12-28**]
compared to the most recent prior chest radiograph, [**2-19**].
Moderate right pleural effusion and large areas of consolidation
in both lungs
are new since a year ago. Whether this is multifocal pneumonia
or pulmonary
edema is radiographically indeterminate.
ET tube ends just above the upper margin of the clavicles, but
only 2 cm above
optimal placement due to shortening of the tracheal length
because of marked
pulmonary radiation fibrosis. Nasogastric tube is coiled in the
stomach. An
infusion line ends in the SVC. Large calcified lymph nodes are
treated
lymphoma. No pneumothorax.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-14**] 5:23 AM
The position of the ET tube, central venous line and the NG tube
is unchanged.
The newly placed esophageal device tip is at the proximal
stomach
approximately 5 cm below the GE junction. The purpose of this
device is
unclear: temperature probe ? feeding tube ? There is no
significant interval
change in bibasal consolidations, bilateral pleural effusions,
partially
loculated on the left and mediastinal calcified lesion
representing
post-treatment changes of lymphoma.
.
UNILAT UP EXT VEINS US LEFT Study Date of [**2117-2-14**] 11:04 AM
FINDINGS: Suboptimal scan; patient unable to cooperate and
suboptimal
positioning of the left upper extremity.
There is wall-to-wall flow and normal compressibility in the
left jugular
vein. Wall-to-wall flow is seen in the left subclavian vein.
There is normal
compressibility of the left axillary vein. There is normal
compressibility in
the left brachial vein with wall-to-wall flow. There is normal
compressibility in the left basilic and left cephalic vein.
IMPRESSION:
Suboptimal scan due to positioning; patient unable to cooperate.
No convincing evidence of deep venous thrombosis in the left
upper extremity.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-15**] 4:37 AM
IMPRESSION: AP chest compared to [**2-12**] through 9:
The improvement in widespread pulmonary opacification between
[**2-13**] and 9
has stabilized. While this may have been due to edema, the
residual
consolidation raises a possibility of multifocal pneumonia.
Heart size is top
normal. Moderate right pleural effusion is stable. ET tube is in
standard
placement. The esophageal manometer ends in the upper stomach
alongside the
looped nasogastric tube. A left subclavian infusion port ends in
the region
of the superior cavoatrial junction and right internal jugular
line in the
upper SVC.
The large calcified central lymph nodes reflect treated
lymphoma.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-16**] 5:50 AM
FINDINGS: The left venous infusion catheter ends near the
cavoatrial
junction. The right IJ catheter ends in the mid SVC. The ET tube
ends 4 cm
above the carina. The NG tube is within the stomach but coiled
on itself and
pointing towards the GE junction. The small left and moderate
right pleural
effusions are unchanged. There is unchanged right pleural
thickening or
loculated effusion. There is no significant overall change in
the appearance
of the bilateral lung opacities, consistent with edema versus
multifocal
pneumonia. The bulky hilar and mediastinal calcified
lymphadenopathy is
unchanged.
IMPRESSION:
1. Persistent bilateral lung opacities, consistent with edema
and/or
multifocal pneumonia.
2. Unchanged small left and moderate right pleural effusions.
Possible
loculated component of right effusion.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) PORT Study Date of [**2117-2-16**] 10:12
AM
FINDINGS: Color and [**Doctor Last Name 352**]-scale son[**Name (NI) **] was performed on the
bilateral lower
extremities. There is a segmental occlusive echogenic thrombus
in the right
posterior tibial vein, which does not extend proximally. The
right common
femoral, superficial femoral, popliteal veins are normal in
compressibility
and waveform.
There is no left-sided deep vein thrombosis. The left common
femoral,
superficial femoral, popliteal veins are normal in
compressibility,
augmentation and Doppler waveforms. The left-sided calf veins
are patent and
compressible.
IMPRESSION:
1. Occlusive segmental deep vein thrombosis in the right
posterior tibial
vein, without proximal extension to other deep veins.
2. No left-sided DVT.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-17**] 3:21 PM
FINDINGS: The NG tube has been replaced with a feeding tube that
ends near
the GE junction. A new tracheostomy tube ends less than 1 cm
from the carina.
The left venous infusion catheter ends near the cavoatrial
junction. The
small left and moderate right pleural effusions are unchanged.
Possible
loculated component of right effusion and/or pleural thickening
is unchanged.
There is no significant change in the appearance of the
bilateral lung
opacities, consistent with edema versus multifocal pneumonia.
Mediastinal and
hilar calcified lymphadenopathy is unchanged.
IMPRESSION:
1. New feeding tube tip near the GE junction.
2. Tracheostomy tube ending less than 1 cm above the carina.
3. Persistent bilateral lung opacities, consistent with edema
and/or
multifocal pneumonia.
4. Unchanged small left and moderate right pleural effusions.
Possible
loculated component of right effusion.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-17**] 7:58 PM
FINDINGS: Nasogastric tube is no longer visualized. A larger
bore tube
remains in place, possibly representing a feeding tube, and has
been advanced
further into the stomach since the prior radiograph. However,
there is
apparent coiling of this device more proximally in the upper
thorax above the
level of the thoracic inlet. At the time of this dictation, a
separately
dictated chest x-ray has been performed and documents subsequent
removal of
this device. With the exception of the change in tube positions,
the
appearance of the chest is relatively similar compared to the
prior study of
earlier the same date except for slight worsening of diffuse
pulmonary
opacities.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-17**] 11:26 PM
FINDINGS: Feeding tube has been removed and replaced with a
nasogastric tube,
which terminates in the distal stomach. Other indwelling devices
are
unchanged in position including a relatively low lying
tracheostomy tube.
Widespread pulmonary opacities affecting the right lung to a
greater degree
than the left, appears slightly improved in the interval.
Extensive calcified
lymphadenopathy and upper lobe volume loss with associated
pleural and
parenchymal scarring are again demonstrated as well as a
moderate-sized
partially loculated right pleural effusion superimposed upon
pleural
thickening. Within the imaged portion of the upper abdomen, a
single dilated
loop of small bowel is present in the left upper quadrant and is
of uncertain
etiology.
IMPRESSION: Newly placed nasogastric tube in standard position.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-18**] 6:35 PM '
The current study re-demonstrates tracheostomy with its tip
being relatively
low, 1.3 cm above the carina, unchanged. Cardiomediastinal
silhouette is
stable. Extensive parenchymal opacities are unchanged as well.
Large
mediastinal calcifications are re-demonstrated. The Port-A-Cath
catheter tip
is at the level of low SVC. The NG tube tip is in the stomach.
IMPRESSION: No interval change since the prior study.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-19**] 5:42 AM
Portable AP chest radiograph was reviewed in comparison to prior
study
obtained on [**2117-2-18**].
The position of tubes and lines is unchanged. There is no change
in
multifocal opacities and loculated bilateral small-to-moderate
pleural
effusion, right more than left.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-21**] 5:20 AM
One view. Comparison with the previous study of [**2117-2-19**].
Multifocal
pulmonary opacities and bilateral pleural effusions, greater on
the right,
persist. Mediastinal structures are unchanged. Calcified
mediastinal and
hilar lymph nodes are redemonstrated. A right internal jugular
catheter has
been removed. A tracheostomy tube, left IJ line and MediPort
catheter remain
in place.
IMPRESSION: Removal of right internal jugular catheter. No other
definite
change.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-22**] 5:03 AM
Comparison film [**2117-2-21**]. The position of the various lines and
tubes is
unchanged. Multifocal opacities are again noted, probably little
changed
since the prior chest x-ray, allowing for differences in
penetration.
IMPRESSION: No change.
.
XR CHEST (PORTABLE AP) Study Date of [**2117-2-24**] 5:56 AM
IMPRESSION: AP chest compared to [**2-17**] through 17:
Since [**2-22**], the diffuse opacification in the left lung
has improved except for the apex. On the right, the multifocal
consolidation is unchanged. The interval change might be
remission of edema, and the large scale
consolidation could be multifocal pneumonia or a non-recoverable
component of
edema such as ARDS. The moderate right pleural effusion which
has been
present since admission is unchanged. Heart size top normal and
stable. The
heavily calcified mediastinal lymph nodes are treated lymphoma.
An infusion port ends in the low SVC, nasogastric tube passes to
the distal
stomach and a tracheostomy tube is in standard placement. No
pneumothorax.
Brief Hospital Course:
Ms [**Known lastname 17914**] is a 47 year old woman with refractory Hodgkin's
disease s/p autologous and two allogenic transplants presenting
with respiratory failure from an OSH after BAL and airway
hemorrhage.
.
# Respiratory Failure: Hypercarbic respiratory failure.
Etiology: ARDS in setting of likely infection after hemorrhagic
bleed during bronchoscopy in woman with poor underlying
respiratory status due to previous radiation/chemotherapy vs
aggressive Hodgkins recurrence. On arrival to the ICU patient
had already been intubated for 18days. Decision made to undergo
tracheostomy on [**2-17**]. Respiratory failure refractory to broad
spectrum antibiotics including anti-fungals as well as stress
dose steriods. Patient unable to undergo repeat chest imaging
due to peristent instability. Decision made to transition care
to comfort measures only after extensive discussion with family
regarding poor prognosis. Patient with terminal extubation on
[**2-25**]. Family agreed to post-mortem examination.
.
# Parietal Stroke: Found on head MRI on [**2117-2-11**] at OSH. Neurology
was consulted and imaging reviewed. Per neurology and
neuroradiology imaging consistent with embolic events. TTE with
bubble ordered which revealed no evidence of intracardiac shunt.
Patient anticoagulated with heparin gtt (48hrs after
tracheostomy performed). Heparin gtt was later transitioned to
Lovenox
.
# History of Deep Venous Thrombosis: Per outside hospital
records patient with right gastrocnemius thrombus, left cephalic
thrombus found on recent imaging. Repeat upper and lower
extremity ultrasound in house. No convincing evidence of deep
venous thrombosis in the left upper extremity on repeat imaging.
Lower extremity study revealed occlusive segmental deep vein
thrombosis in the right posterior tibial
vein, without proximal extension to other deep veins. No
left-sided DVT. Patient was placed on heparin gtt 48hrs after
placement of tracheostomy. No IVC filter was placed.
Medications on Admission:
Voriconazole 200 mg PO Q12H
Acyclovir 200 mg PO Q8H
MethylPREDNISolone Sodium Succ 60 mg IV Q8H
Midodrine 5 mg PO BID
Atovaquone
Citalopram 10 mg
Albuterol MDIs
Ipratropium MDIs
Vitamin D 400 UNIT PO/NG DAILY
Fentanyl
Midazolam
cycloSPORINE *NF* 0.05 % OU [**Hospital1 **]
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercarbic respiratory failure
Hodgkins Disease
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2117-3-4**]
|
[
"V58.65",
"E933.1",
"287.5",
"453.42",
"518.81",
"E879.8",
"357.82",
"425.9",
"285.9",
"434.11",
"201.58",
"279.50",
"276.3",
"V49.86",
"787.91",
"E879.2",
"V66.7",
"996.85",
"508.1",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.29",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
38477, 38486
|
36139, 38121
|
371, 437
|
38578, 38588
|
10556, 10556
|
38639, 38807
|
10062, 10081
|
38444, 38454
|
38507, 38557
|
38147, 38421
|
38612, 38616
|
10096, 10537
|
22999, 23900
|
23944, 36116
|
22778, 22963
|
304, 333
|
465, 3096
|
10573, 11084
|
3118, 9869
|
9885, 10046
|
11097, 21416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,393
| 199,176
|
4764
|
Discharge summary
|
report
|
Admission Date: [**2164-1-5**] Discharge Date: [**2164-1-10**]
Date of Birth: [**2096-9-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bradycardia, hypotension, during bronchoscopy, then with ST
elevations and increasing troponin after epinephrine
administration during resuscitation
Major Surgical or Invasive Procedure:
aborted rigid bronchoscopy [**2164-1-5**]
History of Present Illness:
67 y/o Russian-speaking F with PMH of metastatic renal cell ca
with a h/o ST elevations during a similar tumor debulking
procedure in [**12-1**]. The [**Month (only) **] procedure was aborted [**2-28**]
hypotension and bradycardia--the patient was taken emergently to
the cath lab where she was found to have 100% clean coronaries,
but had troponin elevation related to coronary artery vasospasm.
Now admitted today [**1-5**] again for rigid bronch for tumor
debulking. As the bronchoscopy was undertaken, the scope was
advanced into the LUL which was found to be completely
obstructed by tumor. As the Argon Plasma Coagulator was
activated, the patient became bradycardic to the 40's,
hypotensive with SBP of 40. Did not respond to atropine, neo,
phenylephrine and therefore was given 200 mcg of epi and became
HTN. The procedure was aborted and the patient was taken to the
PACU, slowly weaned off neo, was extubated, but still was tachy
to 140's. EKG's done in the OR and PACU with diffuse ST
elevations in leads V3-V6.
Past Medical History:
1. Renal cell carcinoma, clear cell, diagnosed [**1-27**], status post
left nephrectomy and left lower lobe resection
2. Status post TAH, uterine prolapse repair
3. Hyperlipidemia
Social History:
married, denies smoking or alcohol use
Family History:
non-contributory
Physical Exam:
PE: 96.7, pc 125, bpc 117/80, resp 22, 99% 100% shovel mask
Gen: sitting in bed, NAD
HEENT: dark glasses, no JVD, MMM
Cardiac: tachy, regular, no M/R
Pulm: mild wheezing anterior, coarase breath sounds at left
Abd: NABS, soft, NT/ND
Ext: warm without edema
Pertinent Results:
CT CHEST W/CONTRAST [**2164-1-6**] 11:18 AM
IMPRESSION:
1. Interval worsening of mediastinal and hilar lymphadenopathy;
persistent postobstructive collapse of the left upper lobe. Mass
effect upon the SVC and right middle lobe bronchus are evident
as well.
2. Subsegmental pulmonary embolus within a right lower lobe
anterior pulmonary artery branch. This finding was communicated
to Dr. [**Last Name (STitle) **] at 2:00pm.
3. Interval increase in size of left lower lobe mass.
4. Interval increase in size of mass within the left nephrectomy
bed.
5. Stable appearance of hypervascular metastatic focus within
the right lobe of the liver.
6. New small pericardial effusion.
[**2164-1-5**] 04:40PM GLUCOSE-133* UREA N-9 CREAT-0.6 SODIUM-138
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2164-1-5**] 04:40PM CK(CPK)-20*
[**2164-1-5**] 04:40PM CK-MB-NotDone cTropnT-0.04*
[**2164-1-5**] 04:40PM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.6
[**2164-1-5**] 04:40PM WBC-12.3* RBC-3.45* HGB-9.5* HCT-28.3* MCV-82
MCH-27.5 MCHC-33.5 RDW-15.0
[**2164-1-5**] 04:40PM PLT COUNT-527*
[**2164-1-5**] 04:40PM PT-13.5 PTT-25.4 INR(PT)-1.2
[**2164-1-5**] 03:35PM TYPE-ART PO2-322* PCO2-33* PH-7.48* TOTAL
CO2-25 BASE XS-2
[**2164-1-5**] 03:35PM GLUCOSE-154* LACTATE-3.0* NA+-134* K+-3.5
CL--104
[**2164-1-5**] 03:35PM HGB-8.5* calcHCT-26
[**2164-1-4**] 03:50PM UREA N-15 CREAT-0.8
[**2164-1-5**] 03:35PM freeCa-1.12
[**2164-1-4**] 03:50PM WBC-8.4 RBC-3.50* HGB-9.5* HCT-29.0* MCV-83
MCH-27.3 MCHC-32.8 RDW-15.6*
[**2164-1-4**] 03:50PM PLT COUNT-543*
[**2164-1-4**] 03:50PM GRAN CT-6450
Brief Hospital Course:
67 y/o F with metastatic renal cell ca, with bradycardia during
debulking, hypotension, and recurrent ST elevations / coronary
vasospasm.
1. Metastatic RCC with LUL collapse [**2-28**] compression: Tumor
progression since last month and pt seems unable to tolerate
debulking procedure. Repeat CT chest performed on [**2164-1-6**]
showed progression of disease burden and incidental finding of a
subsegmental RML PE. Heparin IV started, head CT with IV
contrast did not show any evidence of brain metastesis, and the
patient was transitioned to coumadin. However, given evidence of
small but enlarging pericardial effusion on TTE, anticoagulation
was discontinued prior to discharge given concern for high risk
of bleeding into a potentially malignant effusion. Her
outpatient oncologist followed her throughout the course of her
admission; he reported that there was no systemic therapy left
that would likely alter the course of her disease. He
recommended that she be evaluated by radiotherapy to determine
whether collapse of the left lung and obstruction of the SVC
could be forstalled by radiation. She was evaluated while
in-house by the radiation oncology team, with whom she will
follow-up as an outpatient.
2. Cardiac: Inferior ST elevations seen on EKG following
administration of epinephrine for bradycardia and hypotension.
CE positive, likely reflecting coronary vasospasm post
epinephrine, with peak trop at 0.48 on [**2164-1-6**]. Cardiology was
consulted on [**2164-1-5**] and the patient was started on a
nicardipine drip to treat coronary vasospasm. On [**2164-1-6**], per
cardiology, patient started on ASA, CCB PO, Lisinopril and
statin. Beta blocker was held to allow for reflex tachycardia in
setting of PE.
3. Full Code.
Medications on Admission:
Lipitor 10 mg PO daily
Protonix 40 mg PO daily
Avastin per oncology
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*1*
2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for shortness of breath or wheezing.
Disp:*30 Tablet(s)* Refills:*0*
9. spacer
use as directed
Disp: one spacer
Refills: 0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: myocardial infarction
Secondary: pulmonary embolism, metastatic renal cell carcinoma,
left lower lobe collapse
Discharge Condition:
Fair
Discharge Instructions:
1) Please take all your medications as prescribed. Because you
had a myocardial infarction (heart attack), your atorvastatin
dose was increased to 20 mg daily, and lisnopril, aspirin, and
nifedipine were added to your regimen.
2) Please follow-up with your primary care physician or the
emergency room if you develop shortness of breath, chest pain,
lightheadedness, or other symptoms that you find concerning
Followup Instructions:
1) Cardiology/Primary care
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]
([**Telephone/Fax (1) 4606**]) Monday [**2164-1-16**] at 9:30 a.m.
2) Oncology
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-18**] 2:30
Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2164-1-18**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19988**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-18**] 3:00
3) Radiation Oncology
-- Dr. [**Last Name (STitle) 3929**] ([**Telephone/Fax (1) 9710**]) [**2164-1-16**] at 9 a.m. Located at
[**Hospital3 **], [**Hospital Ward Name **], [**Hospital Ward Name 332**] building basement
Completed by:[**2164-5-2**]
|
[
"518.0",
"458.29",
"276.1",
"285.9",
"V10.52",
"415.19",
"197.0",
"197.7",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.28",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6680, 6738
|
3732, 5480
|
417, 461
|
6902, 6908
|
2100, 3709
|
7368, 8430
|
1789, 1807
|
5598, 6657
|
6759, 6881
|
5506, 5575
|
6932, 7345
|
1822, 2081
|
229, 379
|
489, 1513
|
1535, 1717
|
1733, 1773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,805
| 169,311
|
3852+3853+55510+55515
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2106-4-2**] Discharge Date: [**2106-4-26**]
Date of Birth: [**2070-7-23**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 35 year old
male status post gastric bypass surgery in [**2100-12-15**] who
presents with a nonhealing gastric ulcer at his
gastrojejunostomy anastomosis. The patient had had
gastrointestinal bleed from this which required transfusions
at an outside hospital.
PAST MEDICAL HISTORY: 1. Nephrolithiasis; 2.
Gastroesophageal reflux disease recalcitrant to Prilosec; 3.
Gastrointestinal bleed secondary to ulceration at the
Roux-en-Y but no history of hypertension, diabetes, renal or
hepatic disease.
PAST SURGICAL HISTORY: Gastric bypass in [**2100-12-15**] and
cholecystectomy in [**2105-6-14**].
ALLERGIES: Zantac
MEDICATIONS ON ADMISSION: Multivitamin and Prilosec 40 mg
p.o. q.d.
PHYSICAL EXAMINATION: On physical examination the blood
pressure was 115/82, pulse 52. Weight was 165 at a height of
5 foot 7 inches. In general he is a well developed man in no
acute distress. Head, eyes, ears, nose and throat,
atraumatic, normocephalic, anicteric. No lymphadenopathy.
No thyromegaly. Neck was supple. Chest was clear to
auscultation bilaterally. Cardiac, regular rate and rhythm,
normal S1 and S2. Abdomen was soft, nontender. Striae with
well healed midline incision. Liver edge palpable. Bowel
sounds are present. Extremities, no cyanosis, clubbing or
edema.
HOSPITAL COURSE: The patient was admitted on [**2106-4-2**]
and underwent gastric bypass revision with a ventral hernia
repair. The patient was transferred to the floor.
Immediately postoperatively the patient did well and had good
urine output. On postoperative day #1 in the evening, the
patient had a tachycardia to the 150s and 160s with blood
pressure systolic in the 90s and he was complaining of
dizziness. A stat hematocrit was sent and was found to be
18. At that point the patient was transfused 2 units of
packed red blood cells and was transferred to the Intensive
Care Unit for further monitoring. The patient was also
transfused fresh frozen plasma and was given vitamin K in the
Surgery Intensive Care Unit. A central line was placed for
better intravenous access. After 6 units of packed red blood
cells, it was decided that the patient should return to the
Operating Room on [**4-5**] for endoscopy to look at the
anastomosis. The anastomosis was injected with epinephrine
and blood clots were removed from small bowel decompression.
The patient was then transferred back to the Intensive Care
Unit for further monitoring. On [**2106-4-6**], the
patient's hematocrit was 24.1 with an INR of 1.1. The
patient was transferred to the floor. On [**2106-4-7**], the
patient was advanced to a Stage 2 diet. On postoperative day
#6 and 3, [**2106-4-8**] the patient was advanced to a Stage
3 diet and his intravenous fluids were hep blocked. Due to
abdominal distention the patient's gastrostomy tube was
unclamped. Due to a leakage of Roxicet around the patient's
gastrostomy tube with a white count increased to 25, the p.o.
diet was discontinued and the patient was started on tube
feeds via the tube. The tube feeds were ramped up to goal
and the patient was placed on Vancomycin, Levofloxacin and
Flagyl. Due to a wound infection, the patient's wound was
opened and dressing changes t.i.d. were started. The patient
was continued on the Vancomycin, Levofloxacin and Flagyl and
a PICC line was placed. On [**2106-4-13**], Fluconazole was
started as the culture from the [**Location (un) 1661**]-[**Location (un) 1662**] drain put out
yeast by culture. On [**2106-4-14**] the patient became
tachycardiac in the AM. A stat chest x-ray was taken and
left-sided pleural effusion was found. Stat chest x-ray
showed a left-sided pleural effusion. The patient was taken
down to the Interventional Radiology Suite for an ultrasound
guided tap of his left-sided pleural effusion. However, due
to some miscommunication a sample is what was taken from the
pleural effusion and the patient returned to the
Interventional Suite on [**2106-4-15**] for a therapeutic tap of
the pleural effusion. A catheter was left in for free
drainage on [**2106-4-15**]. On [**2106-4-16**], a vacuum dressing
was applied to the patient's abdominal wound. On [**2106-4-17**], the patient's pigtail from his left chest was removed.
The patient's white blood cell count which had been 29
trended down to 19.6. The Vancomycin, Levofloxacin, Flagyl
and Fluconazole were continued. On [**2106-4-19**], a
computerized tomography scan was repeated to look for any
undrained collection due to continued fever spikes to 101.5
and above. No further drainable collection was found. At
this time, Methylene Blue dye was instilled into the
patient's tube feeds to look for a leak. On [**2106-4-20**] blue
dye was found in the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain. The tube
feeds were discontinued. The patient was started on total
parenteral nutrition. The patient was made NPO. In the
following days the patient's white count and fevers came
down. The patient was continued NPO for bowel rest on total
parenteral nutrition. The patient's Vancomycin was
discontinued on day #14. The patient's Fluconazole was also
discontinued on a course of 14 days. The patient was to
continue on Levofloxacin and Flagyl for a full six week
course.
The patient was discharged to rehabilitation on [**2106-4-26**]
on the following medications.
DISCHARGE MEDICATIONS:
1. Total parenteral nutrition
2. Fluconazole 200 mg intravenously q. 24 hours
3. Pantoprazole 40 mg intravenously q. 24 hours
4. Levofloxacin 500 mg intravenously q.d.
5. Flagyl 500 mg intravenously q. 8 hours
DISCHARGE INSTRUCTIONS: The patient was also discharged with
vac changes every three days. The patient was to follow up
with Dr. [**Last Name (STitle) **] in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2106-4-24**] 17:58
T: [**2106-4-24**] 16:41
JOB#: [**Job Number 17286**]
Admission Date: [**2080-2-12**] Discharge Date: [**2106-5-8**]
Date of Birth: [**2070-7-23**] Sex: M
Service:
STAT ADDENDUM to previous discharge summary of [**2106-4-26**].
HOSPITAL COURSE: Since previous discharge summary, the
patient remained NPO until [**2106-5-4**]. During that time, the
patient was receiving nutrition through TPN. He was
continued on a 14 day course of fluconazole, 14 day course of
vancomycin and those were discontinued once he had finished
his course. He was continued on intravenous levofloxacin and
Flagyl for what will be a course of six weeks. On [**2106-5-4**],
the patient had a G-tube study under fluoroscopy which was
negative for leak. He also underwent a swallow study under
fluoroscopy which was also negative for leak. Due to the
results of these tests, the patient was given a stage 1 diet
with methylene blue in his water. The patient drank this the
evening of [**2106-5-4**] and on the morning of [**2106-5-5**], it was
found that the patient had blue dye in his JP drain. At this
time, the patient was made NPO. The JP bulb was changed.
The tubing was flushed and after several hours of clear
drainage, the methylene blue was added to his tube feeds
which were restarted. The patient continued on tube feeds
with methylene blue for a total of 36 hours before developing
methylene blue in the JP bulb yet again. At this time, the
patient was again made strict NPO and the tube feeds were
stopped. His G-tube was placed to gravity. The patient was
restarted on his TPN. The VAC dressing was removed on
[**2106-5-6**] and it was decided that the wound had sufficient
granulation tissue to continue with only [**Hospital1 **] wet to dry
dressing changes. On [**2106-5-7**], the patient was restarted on
his TPN and plans were made for discharge on [**2106-5-8**] with
home VNA services. The patient was discharged on the
following medications.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg intravenous q 24 hours for a total of
14 more days
2. Flagyl 500 mg intravenous q8h for a total of another 14
more days
3. Benadryl 25 mg intravenous q6h prn
4. Heparin flushes 100 units per ml, 1 ml intravenous qd
prn, 10 ml normal saline followed by 1 ml of heparin
The patient's dressing changes were to be done [**Hospital1 **], wet to
dry to his abdominal wound. He was to be strictly NPO and he
had instructions for TPN. The patient was to follow up with
Dr. [**Last Name (STitle) **] in two weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-331
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2106-5-7**] 08:25
T: [**2106-5-7**] 08:32
JOB#: [**Job Number 17287**]
Name: [**Known lastname 2729**], [**Known firstname **] Unit No: [**Numeric Identifier 2730**]
Admission Date: Discharge Date:
Date of Birth: [**2070-7-23**] Sex: M
Service:
ADDENDUM: Since the previous discharge summary done on [**2106-5-8**], the patient had his [**Location (un) 2021**]-[**Location (un) 2022**] drain removed per
Dr. [**Last Name (STitle) **]. It was decided at this time that his leak was
probably small enough that he could be fed orally. The
patient was advanced to a Stage 1 diet and remained afebrile.
The patient was then advanced to a Stage 2 diet on [**2106-5-12**]. The patient tolerated this well and on [**2106-5-13**]
the patient was advanced to a Stage 3 diet. The patient
remained afebrile through this. The patient was weaned off
of his total parenteral nutrition on [**2106-5-14**] and plans
were to be made for his discharge home on p.o. Levofloxacin
with dressing changes b.i.d. The patient spiked, however, to
a temperature of 104 on [**2106-5-14**] and he was brought
downstairs for a computerized tomography scan.
Dictated By:[**Last Name (NamePattern1) 2731**]
MEDQUIST36
D: [**2106-5-14**] 19:40
T: [**2106-5-15**] 07:47
JOB#: [**Job Number 2732**]
Name: [**Known lastname 2729**], [**Known firstname **] Unit No: [**Numeric Identifier 2730**]
Admission Date: [**2080-2-12**] Discharge Date: [**2106-5-17**]
Date of Birth: [**2070-7-23**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM: The CT scan done on [**2106-5-14**]
was notable for a stable appearance of his left pleural
effusion, persistent collection of gas in hepatic gastric
reflex however there was no evidence for an abscess. The
patient had been complaining of some mild irritation at his
PIC line insertion site. It did appear to be mildly
erythematous; the PIC line was subsequently removed. The
patient defervesced subsequent PIC line tip cultures and
blood cultures were both negative. The patient remained
afebrile throughout the remainder of his hospital course, had
no associated nausea or vomiting, was making good urine and
had adequate po intake. The patient was discharged on [**2106-5-17**] in stable condition with instructions to follow up with
Dr. [**Last Name (STitle) **] in two weeks.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg po q day.
2. Protonix 40 mg po q day.
The patient will be receiving VNA services for management of
his [**Hospital1 **] wet to dry dressing changes to his abdominal wound.
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D. [**MD Number(1) 2750**]
Dictated By:[**Last Name (NamePattern1) 2751**]
MEDQUIST36
D: [**2106-5-17**] 13:18
T: [**2106-5-17**] 13:39
JOB#: [**Job Number 2752**]
|
[
"530.81",
"997.4",
"511.9",
"552.21",
"E878.2",
"998.11",
"531.40",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"53.51",
"45.02",
"44.31",
"45.11",
"54.12",
"99.15",
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11320, 11799
|
826, 869
|
6472, 8182
|
5832, 6454
|
703, 799
|
892, 1463
|
159, 438
|
461, 679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,016
| 130,106
|
22915
|
Discharge summary
|
report
|
Admission Date: [**2126-1-23**] Discharge Date: [**2126-1-27**]
Date of Birth: [**2086-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
generalized tonic-clonic seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture ([**2126-1-23**])
Open Reduction Internal Fixation of comminuted right ankle
fracture ([**2126-1-25**])
History of Present Illness:
39 y/o M with PMH notable for seizures staring as a child
presented [**2125-1-20**] to the ER from group home (without any
records) with witnessed tonic-clonic seizures per EMT and was
supposedly post-ictal post seizures. The patient supposedly
stopped his dilantin ~5 mo ago per EMS sheet and rest of hx not
obtainable per pt. ED staff described pt as hallucinating and
pulling at lines/agitated. ED gaven 1g IV dilantin, Ativan 2mg
IV x1, Valium 30 mg IV x 1. By the time of the initial MICU
eval, the patient was sedated. Head CT was negative for
hemorrhage. R. Ankle x-ray + for oblique slightly comminuted
fracture of distal R. fibula extending into ankle mortise with
disruption of mortise. Ortho eval'd in ED- put in splint, but
plan is to take to the OR for fixation.
*
ED course (no bed until [**2125-1-22**]) notable for continuing DIlantin
and CIWA scale; the patient required valium q1 hr in the ED. Pt
was also hydrated as he had rhabdomyolysis from the sz,
presumably.
*
MICU course notable for continued hydration for rhabdo,
continued dilantin and other ancillary ICU management (PPI,
RISS, nutrition). The patient was also noted to be febrile and
Ancef was started for question of cellulitis although DTs and
fracture can also cause fever. CXR today also concerning for
aspiration PNA. Plan per ortho is to take for ORIF on Friday. Pt
not requiring ICU level of care-- valium q3hours and VSS.
Past Medical History:
?sz disorder
EtOHism with DT
Social History:
Lives in group home, significant recent alcohol abuse although
initially denied to rooming house and evaluating physicians.
Estranged from his family but has a friend that he can call.
Used to work in masonry. Used to live with GF but that situation
ended
Family History:
noncontrib
Physical Exam:
last temp: 99.8/ HR 78/ BP 131/77 / 18// 98% RA
Gen: Malorodrous, tatooed middle-aged man, awakened from sleep
for exam. NAD, alert and oriented/
HEENT: EOMI, PERRL, poor dentition, MMM, no thrush
Neck: supple, no lad
Heart: RR, no m/g/r
Chest: L nipple and environs erythematous, warm and tender. Area
outlined in pen.
Lungs: CTAL, r with basilar rhonchi
Abd: soft, nt/nd, no hsm
Ext: Right LE in splint, left no c/c/e, 2+ dps b/l. B/l hnand
swelling with area of erythema on medial side of LUE.
Neuro: CN2-12 intake, full strength in LLE, UEs: diminished grip
strength in left hand (isolated to 3 middle fingers), exam
limited by pain and cooperation
Pertinent Results:
LABS ON DISCHARGE:
WBC 7, Hct 13.6, MCV 94
Plt 208
Glucose-97 UreaN-8 Creat-0.8 Na-142 K-3.9 Cl-104 HCO3-30*
AnGap-12
Mg 2.0
CK 8383, [**Numeric Identifier 59204**], 2387
ALT 108, 116, 147
AST 146, 162, 120
AP 70, 230
Tbili 0.7
Amylase 33, Lipase 13
Albumin 3.4
HbA1C 4.9
Phenytoin 15.8, 13.8, 6, 4.2
URINE:
URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
CSF:
WBC-2 RBC-7* Polys-5 Lymphs-80 Monos-15
Total protein 36, glucose 108
MICRO:
CSF ([**2126-1-22**]): no growth
Blood cx ([**2126-1-22**]): no growth to date
urine ([**2126-1-22**]): no growth
IMAGING:
CHEST (PORTABLE [**2126-1-22**]): No infiltrates, effusions, pulmonary
edema, cardiomegaly, or pneumothorax
ANKLE (AP, MORTISE & LAT) RIGHT [**2126-1-21**]: FILM AND REPORT NOT
AVAILABLE TO ME AT DISCHARGE, BUT per report: R. Ankle x-ray +
for oblique slightly comminuted fracture of distal R. fibula
extending into ankle mortise with disruption of mortise.
HAND (AP, LAT & OBLIQUE) RIGHT PORT [**2126-1-23**]: IMPRESSION: No
acute fracture of the right hand.
WRIST(3 + VIEWS) RIGHT PORT [**2126-1-23**]: NO FX
U/S UPPER EXT, BILAT: No evidence of left OR RIGHT upper
extremity deep vein thrombosis.
FOREARM (AP & LAT) LEFT- NO ACUTE FX
HUMERUS (AP & LAT) LEFT - NO ACUTE FX
ANKLE (AP, MORTISE & LAT) RIGHT [**2126-1-25**] - Three intraoperative
radiographs of the right ankle. Since exam [**0-0-0**], the
patient has had a plate and screws placed across the distal
fibular fracture. The ankle mortise is congruent with the talus.
Brief Hospital Course:
39 yo M with hx of sz d/o off dilantin for 5 months and alcohol
abuse admitted for generalized tonic-clonic sz in the setting of
?EtOH withdrawl and untreated seizure d/o. Seizure complicated
by comminuted right ankle fracture and rhabdomyolysis without
renal failure. Hospital course outlined below by problem:
##seizure- etiology felt to be two-fold: etoh withdrawl and
untreated seizure d/o. The patient had not been taking his
dilantin for the last 5 months and admitted to drinking 120oz
alcohol/day when he became more conscious. In the ED he weas
noted to be hallucinating and picking at things in the air. He
was loaded on dilantin (1g IV dilantin, Ativan 2mg IV x1, Valium
30 mg IV x 1and required frequent dosing of valium for CIWA
>20). Head CT was negative for intracranial bleed related to
fall. LP was negative for bacterial meningitis. He was
admitted to the MICU for monitoring but did not require
intubation and had no further seizure episodes. By HD 4, his
CIWA scores improved and he no longer required valium. Dilantin
levels were initally therapeutic but became persitently low
which was felt to be consistent with his long term alcohol use.
He was loaded on Keppra and will need to continue taking 1g PO
bid. This can be adjusted by a neurologist who he will see in
an outpatient setting. He was seen by social work for his
alcohol use while here and will be returning to his group home
on discharge.
##Rhabdomyolysis: Peak CK were 10K with no evidecne of renal
insuficiency. He was aggressively hydrated and maintained good
UOP throughout his hosptial course. CK were downtrending to
[**2121**] before he was discharged.
##Comminuted right ankle fx: Complication of his seizure with
trauma after falling down his stairs. R. Ankle x-ray + for
oblique slightly comminuted fracture of distal R. fibula
extending into ankle mortise with disruption of mortise.
He was taken to the OR for ORIF after his neurologic status was
cleared. During the procedure it was noted that his bone was
very poor, and it is recommended that he take calcium and vitd
supplementation. He will need to be nonweight bearing for at
least 12 wks in a hard cast with crutches. He will need to
avoid NSAIDs as these impair bone healing and conglomeration to
the internal fixation rods. He will need to schedule an
appointment with Dr. [**First Name (STitle) 4223**], orthopedist, for follow up.
##Left finger numbness: The patient was noted to have numbness
and weakness in his left hand consistent with distal median
nerve compression. He has no history or risk factors for carpel
tunnel. Phalen sign negative. A large ecchymosis was noted on
the medial aspect of his left arm and it is thought that he
experienced blunt trauma to his median nerve. Plain films of
his humerous and forearm showed no fracture and the patient had
no clinical signs for fracture. It is interesting that he has
symptoms of DISTAL median nerve involvment rather than both
proximal and distal. He will be followed in the neurology
clinic for both these symptoms and his seizure d/o. The
symptoms will likely improve over the next week.
Medications on Admission:
?prozac ?neurontin ?trazodone ?dilantin
stopped dilantin on own 5 months ago
Discharge Medications:
1. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day
for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day for 2
doses: take one pill at night [**2126-1-27**] and one in the morning
[**2126-1-28**].
Disp:*2 Tablet(s)* Refills:*0*
8. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day:
start the evening of [**2126-1-28**].
Disp:*120 Tablet(s)* Refills:*2*
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-17**]
hours for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Seizure, alochol withdrawl
Seizure d/o
Secondary:
Substance abuse
Alcoholism
Discharge Condition:
good
Discharge Instructions:
continue to take your medications
*****DO NOT BEAR ANY WEIGHT ON YOUR INJURED RIGHT LEG FOR 12
WEEKS FROM THE TIME YOUR WERE CASTED. USE CRUTCHES. DO NOT GET
CAST WET.
Followup Instructions:
please contact [**Name (NI) 191**] clinic, [**Telephone/Fax (1) 250**], to make an appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4460**] within 2-4 weeks of your hospital
discharge.
please contact [**Hospital 878**] Clinic, [**Telephone/Fax (1) 44**], to make an
appointment within 1-2 weeks of your hospital discahrge. You
will see them for your seizures and numbness in your fingers.
Please contact the orthopedic clinic, ([**Telephone/Fax (1) 55088**], to
schedule a follow up appointment within 2 weeks of your hospital
discharge, with Dr. [**First Name (STitle) 4223**], please call this week for appt.
|
[
"733.09",
"790.6",
"V15.81",
"291.0",
"584.9",
"276.5",
"560.1",
"728.88",
"354.1",
"780.39",
"E880.9",
"682.4",
"824.4",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"03.31",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
8911, 8969
|
4537, 7673
|
345, 467
|
9099, 9105
|
2949, 2949
|
9323, 9973
|
2248, 2260
|
7800, 8888
|
8990, 9078
|
7699, 7777
|
9129, 9300
|
2275, 2930
|
273, 307
|
2968, 4514
|
495, 1907
|
1929, 1959
|
1975, 2232
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,387
| 132,348
|
29967
|
Discharge summary
|
report
|
Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-16**]
Date of Birth: [**2086-11-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p MVA vs tree
Major Surgical or Invasive Procedure:
1. Anterior cervical discectomy with C6 C7 corpectomy with graft
2. IVCF
3. bronchospcopy
4. Tracheostomy placement
5. Percutaneous endoscopic gastrostomy tube placement
History of Present Illness:
HPI:19 yr old male unrestrained driver s/p car vs tree at
reported high rate of speed. Per reports pt has not moved his
lower extremities. Pt brought from scene to [**Hospital1 18**] for further
evaluation. Pt was paralyzed, sedated and intubated in the
trauma bay upon arrival.
Past Medical History:
None
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
on arrival
PHYSICAL EXAM:
T: BP:122/72 HR:71 RR: 16 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Hard cervical collar on
Lungs: CTA bilaterally
Cardiac: NSR on monitor
Abd:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated
Reportedly pt moving upper extremities spontaneously upon
arrival
w/ no movement of LE. Per EMS report they also did not see any
movement of lower extremities. Decreased rectal tone. Pt
currently difficult to examine as he is paralyzed and sedated.
Motor:
Moves upper extremities spontaneously; follows some simple
commands on upper extremities, no movement of lower extremities
spontaneosly or to painful stimuli
CURRENTLY
Afebrile, vital signs stable
Gen: WD/WN, comfortable, NAD.
HEENT: PERRLA, EOMI.
Neck: Tracheostomy site clean, intact. ACDF incision clean,
dry, intact; staples removed.
Lungs: CTA bilaterally
Cardiac: NSR
Abd: Soft, NT, ND.
Extrem: Warm and well-perfused.
Neuro: Sensation to nipple level; none below.
Mental status: Alert & oriented x3, follows commands.
Motor:
IP Q AT G [**Last Name (un) 938**]
R 0 0 0 0 0
L 0 0 0 0 0
D B T Grip
R 4+ 5 3+ 5
L 4+ 5 4- 4+
Pertinent Results:
[**2106-2-14**] 04:01AM BLOOD WBC-9.2 RBC-2.96* Hgb-8.5* Hct-25.5*
MCV-86 MCH-28.8 MCHC-33.4 RDW-13.5 Plt Ct-327
[**2106-2-14**] 04:01AM BLOOD Glucose-105 UreaN-16 Creat-0.7 Na-143
K-3.9 Cl-106 HCO3-29 AnGap-12
[**2106-2-14**] 04:01AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.4*
Brief Hospital Course:
Pt was admitted through the emergency department to the ICU on
[**2106-2-5**]. He was brought to the operating room on [**2-5**] for
anterior cervical discectomy with corpectomies of C6 and 7 with
cage and plates placed. A rigid cervical collar was re-applied
postoperatively. He was returned to the ICU where his VS and
neurological exam were followed closely.
He was weaned and extubated on [**2-6**] and transferred to step down
neuro ICU. Additional imaging of the spine to include MRI of T
and L spine were ordered. An MRA of the Cervical spine was also
ordered to r/o vertebral artery dissection. The pts diet was
advanced and he was tolerating PO intake without emesis or
difficulty. His exam postoperatively was that he was paraplegic
to B/L LE's with patchy and inconsistent sensation to lower
thorax and legs.
Approx 12 MN on [**2-7**] into [**2-8**] the pts mother, who was at the
bedside felt that her son was not doing as well. Pt was seen
and evaluated. He was febrile now to 101.8 with slight inc in
resp's. His oxygen saturation was 96-98%. Approx one hour later
he was re-evaluated and found to be more dysnpneic with
tachypnea to the low 40's. ABG/CXR/ and cultures were obtained
as his temp had risen to 103.8 axillary. He was transferred
back to the TICU within the hour. He was monitored closely and
supportive care was given.
His resp status declined and the pt ultimately required
re-intubation at approx 3am on [**2-9**]. Repeat CXR was concerning
for hemothorax and also showed partial collapse of left lung. CT
chest showed no evidence of PNA and was suggestive of mucoid
impaction. He had a bronchscopy at the bedside which yeilded a
large mucus plug. He self extubated later that day and was
supported with suplimental O2. MRI of the T-spine was obtained,
demonstrating s/p C5-T1 fusion for spinal injury with cord
transection at C6 levels, a small amount of subarachnoid
hemorrhage in the lumbosacral canal, and L5-S1 central disc
protrusion, with known nerve root impingement.
[**2-10**] CXR: Interval near complete drainage of left-sided pleural
effusion.
No pneumothorax identified on this upright radiograph.
[**2-11**] IVC placed and positioning confirmed via CXR. Tracheostomy
and PEG also placed.
[**2-12**] CTA C-spine: No vertebral artery dissection.
[**2-13**]: arterial line discontinued and tip sent for culture (no
growth). C-collar removed while patient in bed.
[**2-14**]: Patient mobilization begun (out of bed with assist).
[**2-15**]: C-spine and T-spine films obtained. Patient prepared for
discharge to extended care facility in [**Location (un) 9012**]. Patient was
stable at time of discharge summary completion, with no active
acute care issues.
Medications on Admission:
unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain for 7 days.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 3952**] Center
Discharge Diagnosis:
1. s/p C6 spinal cord injury
2. respiratory failure
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Have a your incision checked daily for signs of infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] UPON RETURN TO THE GREATER [**Location (un) **] AREA.
PLEASE OBTAIN AP & LATERAL X-RAYS OF YOUR C-SPINE AND T-SPINE IN
6 WEEKS. PLEASE FAX A COPY OF THE REPORT TO DR.[**Doctor Last Name **] OFFICE.
Completed by:[**2106-2-15**]
|
[
"E816.0",
"E878.8",
"518.0",
"518.81",
"806.09",
"802.0",
"884.0",
"997.3",
"872.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"96.72",
"43.11",
"80.99",
"96.6",
"18.4",
"81.62",
"38.7",
"84.51",
"31.1",
"86.59",
"81.02"
] |
icd9pcs
|
[
[
[]
]
] |
6391, 6451
|
2465, 5194
|
336, 508
|
6547, 6555
|
2171, 2442
|
7736, 8064
|
897, 914
|
5252, 6368
|
6472, 6526
|
5220, 5229
|
6579, 7713
|
955, 1185
|
280, 298
|
536, 820
|
1970, 2152
|
842, 848
|
864, 881
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,157
| 131,297
|
12902
|
Discharge summary
|
report
|
Admission Date: [**2175-5-6**] Discharge Date: [**2175-5-17**]
Date of Birth: [**2108-8-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
66F with hx of [**Hospital **] transferred from [**Location (un) 620**] after having
worst HA of life at 4p while at church.
Major Surgical or Invasive Procedure:
Endovascular coiling of 3mm Acom aneurysm
History of Present Illness:
HPI:66F with hx of [**Hospital **] transferred from [**Location (un) 620**] after having
worst HA of life at 4p while at church. She denied N/V, CP, SOB,
LOC. Was found to have SAH at OSH, Dilantin loaded and started
on
Nimodipine. She was then transferred here for further
evaluation.
Past Medical History:
HTN
Social History:
Quit smoking years ago, drinks glass wine/[**Doctor Last Name 6654**]/night
Family History:
Hx of embolic stroke, no hx aneurysm
Physical Exam:
T:98.1 BP:132/74 HR:61 RR 16 O2Sats 99
Gen: WD/WN, comfortable, NAD.
HEENT:atraumatic, normocephalic Pupils: PERRL EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-25**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
CTA HEAD W&W/O C & RECONS Study Date of [**2175-5-6**] 8:37 PM:
1. 3-mm anterior communicating artery aneurysm with projection
of
the aneurysmatic sac inferiorly. With associated previously
identified
perimesencephalic subarachnoid hemorrhage.
2. Slightly more prominent occipital ventricular horns compared
to 3.5 hours
prior, continued close followup is recommended. Trace of
intraventricular
hemorrhage layering in the occipital ventricular horns,
apparently new since
the prior study.
3. Unchanged 11 x 7 mm right orbital intracoronal soft tissue
mass, the
differential for this lesion includes hemangioma, varix,
lymphangioma.
CT HEAD W/O CONTRAST Study Date of [**2175-5-7**] 4:28 AM:
1. Diffuse subarachnoid hemorrhage centered in the
perimesencephalic space
appears similar to that seen initially. However, since then
there has been
interval slight increase in the occipital and temporal horns
bilaterally
consistent with mild hydrocephalus, as seen on later CTA head.
Also mild
bilateral intraventricular hemorrhage.
2. The right intraconal soft tissue nodule appears separate from
the optic
nerve. Differential again include hemangioma, varix, or
lymphangioma.
CAROT/CEREB [**Hospital1 **] Study Date of [**2175-5-7**] 9:23 AM:
CT HEAD W/O CONTRAST Study Date of [**2175-5-8**] 10:20 AM:
Unchanged extensive subarachnoid hemorrhage. Unchanged moderate
ventricular dilatation.
CTA [**5-12**]
IMPRESSION:
1. Findings consistent with interval evolution of extensive
subarachnoid
hemorrhage with decrease in blood products layering sulci,
basilar cistern as well as intraventricular blood products.
Stable ventricular size and
configuration.
2. Possible mild left posterior cerebral artery and A1 and A2
segment of left anterior cerebral arteries vasospasm without
definite correlate on CT
perfusion. Recommend clinical and Transcranial Doppler
correlation.
3. Unchanged 11-mm right orbital intraconal soft tissue nodule,
differential continues to include hemangioma, varix, or
lymphangioma.
Brief Hospital Course:
Pt. admitted to the neurosurgical service on [**5-6**] for [**9-30**]
headache that was the result of a ruptured 3mm ACOM aneurysm. On
[**5-7**] three coils were placed in the aneurysm endovascularly. The
procedure was uncomplicated and the patient was extubated in the
ICU.
[**5-8**] suvalience CT was negative for the development of
hydrocephalus.
[**5-9**]: Head CT negative for hydrocephalus. Continuing to monitor
for development of hydrocephalus or vassospasm.
[**5-10**]: Patient's diet was advanced as tolerated and neuro checks
were decreased to every two hours.
On [**5-12**] she had a CTA which showed Possible mild left posterior
cerebral artery and A1 and A2 segment of left anterior cerebral
arteries vasospasm without definite correlate on CT perfusion.
She was then transferred to the floor.
She continued to do well neurologically and worked well with
PT/OT.
On [**5-16**] she denied diplopia and HA and has not clinical findings
of diplopia. She was then cleared by PT to go home. Her son
[**Name (NI) 39664**] will stay with her on [**Location (un) **] for a couple of days and
then bring her back to [**State 760**] with him.
Upon discharge she was neurologically intact without deficit.
Medications on Admission:
Diovan 80mg/12.5, Omeprazole 20mg,
Lexapro?, Calcium, ASA 81mg'.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-23**]
Tablets PO Q4H (every 4 hours) as needed for Headache: Please do
not take Tylenol with this medication.
Disp:*80 Tablet(s)* Refills:*0*
3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
3mm Anterior Communicating Artery Aneurysm
UTI
Discharge Condition:
Neurologically stable
Discharge Instructions:
Angiogram with Embolization
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What 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
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. You will need a
cerebral angio at that time. Please call the office at
[**Telephone/Fax (1) 1669**] to schedule an appointment.
Completed by:[**2175-5-17**]
|
[
"V15.82",
"430",
"401.1",
"285.9",
"435.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6045, 6106
|
4242, 5459
|
441, 484
|
6197, 6221
|
2206, 4219
|
8184, 8408
|
936, 975
|
5574, 6022
|
6127, 6176
|
5485, 5551
|
6245, 7242
|
7268, 8161
|
990, 1185
|
277, 403
|
512, 799
|
1437, 2187
|
1200, 1421
|
821, 826
|
842, 920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,316
| 193,823
|
36362
|
Discharge summary
|
report
|
Admission Date: [**2127-7-21**] Discharge Date: [**2127-7-26**]
Date of Birth: [**2044-8-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass x1(Left internal mammary artery grafted
to left anterior descending artery)/Mitral Valve repair (#28mm
CG annuloplasty ring)-[**2127-7-21**]
History of Present Illness:
82 year old female with known mitral regurgitation who
has been experiencing worsening shortness of breath and
orthopnea. She is followed closely by Dr. [**Last Name (STitle) 5017**] who has been
adjusting her diuretic therapy. Despite medical therapy, she
continues to experience heart failure symptoms. She was seen in
clinic by Dr. [**Last Name (STitle) **] on [**2127-6-12**] and now presents for
preadmission testing in preparation for surgery.
Past Medical History:
Chronic Diastolic Congestive Heart Failure/Mitral Regurgitation
Questionable History of Myocardial Infarction [**2125-1-22**]
Hypertension
Obesity
Osteoarthritis, Left Knee - requires Cortisone shots
Polymyositis
Gout
Small Splenic Aneurysm
Hiatal Hernia
Cataracts
Hypothyroidism
Social History:
Occupation: Retired Waitress
Last Dental Exam : Full dentures
Lives with: Husband
[**Name (NI) 1139**]: never
ETOH: never
Family History:
Family History: Brother - heart attack at age 49
Physical Exam:
Physical Exam
Pulse: 92 Resp: 16 O2 sat: 95%
B/P Right: 142/80 Left: 135/85
Height: 65" Weight: 180
General: Elderly obese female in no acute distress
Skin: Dry [x] intact [x], No C/C
HEENT: PERRLA, EOMI, NCAT, OP Benign, Edentulous
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**3-28**] holosytolc murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Pertinent Results:
[**2127-7-22**] 03:00AM BLOOD WBC-15.6* RBC-3.70* Hgb-11.0* Hct-33.2*
MCV-90 MCH-29.7 MCHC-33.2 RDW-13.4 Plt Ct-148*
[**2127-7-21**] 03:25PM BLOOD WBC-15.9*# RBC-3.60* Hgb-10.4*# Hct-30.6*
MCV-85 MCH-29.0 MCHC-34.1 RDW-13.9 Plt Ct-156
[**2127-7-21**] 03:25PM BLOOD PT-15.2* PTT-38.2* INR(PT)-1.3*
[**2127-7-21**] 02:07PM BLOOD PT-16.4* PTT-36.6* INR(PT)-1.5*
[**2127-7-23**] 05:25AM BLOOD WBC-13.2* RBC-3.28* Hgb-9.7* Hct-29.7*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.6 Plt Ct-118*
[**2127-7-21**] 03:25PM BLOOD PT-15.2* PTT-38.2* INR(PT)-1.3*
[**2127-7-23**] 05:25AM BLOOD Glucose-104 UreaN-29* Creat-1.2* Na-139
K-4.8 Cl-107 HCO3-21* AnGap-16
[**2127-7-25**] 05:30AM BLOOD UreaN-21* Creat-0.8 K-3.9
pre-CPB: 82 yr old female w/ pmhx of htn and CAD whose
intraoperative echocardiogram showed normal left ventricular
function with an EF> 55% and no evidence of abnormal wall
motion. There was severe mitral regurgitation with myxomatous
degeneration of both leaflets and partail flail. The vena
contracta was > 7 mm.
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good
(>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. A catheter or pacing wire is seen
in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (?#). Trace
AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Partial mitral
leaflet flail. MR vena contracta is >=0.7cm Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the
procedure. The patient was 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.
post-CPB: patient was weaned from bypass with 1 mcg/kg/min of
phenylehrine. There was no evidence of new regional wall motion
abnormalities and EF was > 55%. A well seated mitral
annuloplasty ring was seen with interrogation via Doppler
revealing minimal residual regurgitation in the settinag of a
mean gradient of 4 mm Hg. All findings discussed with surgeons
at the time of the exam.
Conclusions
The left atrium is dilated. No mass/thrombus is seen in the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses and
cavity size are 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are myxomatous. There is partial
mitral leaflet flail. The mitral regurgitation vena contracta is
>=0.7cm. Severe (4+) mitral regurgitation is seen. There is no
pericardial effusion.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-7-23**] 12:32
?????? [**2121**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**7-21**] Ms.[**Known lastname **] was taken to the operating room and underwent
coronary artery bypass grafting x1(left internal mammary artery
grafted to the left anterior descending artery)/Mitral Valve
repair (#28mm CG annuloplasty ring). Cross clamp time = 56
minutes. Cardiopulmonary Bypass time= 74 minutes. Please refer
to Dr[**Last Name (STitle) **] operative report for further details. She was
transferred in critical but stable condition to the CVICU. She
awoke neurologically intact and was extubated without
difficulty. All lines and drains were discontinued in a timely
fashion. Beta-blocker and diuretic was initiated. She continued
to progress and was transferred to the step down unit on POD#1
for further monitoring. Physical therapy was consulted and
evaluated the patient. Ms.[**Known lastname **] postoperative course was
essentially uneventful. She continued to progress and was
cleared by Dr.[**Last Name (STitle) **] for discharge to rehab on POD #5. All
follow up appointments were advised.
Medications on Admission:
Lasix 40 qd
Levothyroxine 25 qd
Lisinopril 10 qd
Metoprolol Succ 25 qd
Pepcid
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. Tab
Sust.Rel. Particle/Crystal(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Coronary artery disease/Mitral Regurgitation
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) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 5424**] in 1 week, please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2127-7-26**]
|
[
"710.4",
"274.9",
"244.9",
"414.01",
"401.9",
"715.36",
"424.0",
"278.00",
"428.0",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.63",
"88.72",
"39.61",
"35.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8844, 8959
|
6427, 7448
|
340, 506
|
9048, 9055
|
2224, 6404
|
9567, 9932
|
1460, 1495
|
7577, 8821
|
8980, 9027
|
7474, 7554
|
9079, 9544
|
1510, 2205
|
281, 302
|
534, 985
|
1007, 1288
|
1304, 1428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,617
| 192,629
|
16535
|
Discharge summary
|
report
|
Admission Date: [**2200-10-13**] Discharge Date: [**2200-10-18**]
Date of Birth: [**2164-6-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**10-13**] Minimally Invasive Mitral Valve Repair (30mm annuloplasty
ring)
History of Present Illness:
36 year old female, developed palpitations this past summer, in
evaluation there was a new murmur noted. She had echocardiogram
which revealed moderate-severe mitral regurgitation
Past Medical History:
Benign lumpectomy
Social History:
Lives with husband and three children, social worker, denies
tobacco, ETOH 1 glass wine daily
Family History:
Uncle and paternal grandmother hx of HF
Physical Exam:
Admission
Vitals HR 84 RR 12 B/P 116/63 wt 102 lbs
Skin intact
Neck supple no JVD full ROM
Chest clear to auscultation
Heart RRR, [**1-27**] holosystolic murmur
Abdomen soft, nontender, nondistended, + bowel sounds
Ext: warm, well perfused, no edema, pulses +2
Pertinent Results:
[**2200-10-17**] 06:02AM BLOOD WBC-5.1 RBC-2.60* Hgb-8.2* Hct-24.0*
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.2 Plt Ct-202
[**2200-10-13**] 01:31PM BLOOD WBC-15.5*# RBC-2.42*# Hgb-7.9*#
Hct-22.1*# MCV-91 MCH-32.6* MCHC-35.7* RDW-13.4 Plt Ct-131*#
[**2200-10-17**] 06:02AM BLOOD Plt Ct-202
[**2200-10-15**] 06:51AM BLOOD PT-13.2* PTT-31.5 INR(PT)-1.2*
[**2200-10-13**] 01:31PM BLOOD Plt Ct-131*#
[**2200-10-13**] 01:31PM BLOOD PT-17.5* PTT-56.7* INR(PT)-1.6*
[**2200-10-17**] 06:02AM BLOOD Glucose-99 UreaN-7 Creat-0.5 Na-139 K-4.3
Cl-105 HCO3-28 AnGap-10
[**2200-10-13**] 02:00PM BLOOD UreaN-7 Creat-0.4 Cl-115* HCO3-21*
[**2200-10-14**] 08:49PM BLOOD ALT-13 AST-49* AlkPhos-36* Amylase-47
TotBili-0.4
[**2200-10-14**] 08:49PM BLOOD Lipase-14
Brief Hospital Course:
Admitted and went to operating room for minimally invasive
mitral valve repair. Please see operative report for further
detail. She was transferred to the cardiac surgery recovery
unit. In the first 24 hours she awoke neurologically intact and
was weaned from all vasopressors. On postoperative day 1 she
was transferred to [**Hospital Ward Name **] 2. Chest tube remained in place due to
pneumothorax. She has continued to have a small right apical
pneumothorax, as well as some subcutaneous air at the right
chest wall area, without shortness of breath nor oxygen
requirement. These have remained unchanged in 3 days by repeat
chest x-rays. She had a brief episode of (non-sustained) VT on
[**10-16**], with no symptoms, and no recurrence. She continued to
progress on postoperative day 5 she was ready for discharge home
with VNA services.
Medications on Admission:
MVI
Antibiotics dental prophylaxis
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Mitral regurgitation s/p MV repair
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for 2 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) 1290**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46948**] in [**11-25**] week ([**Telephone/Fax (1) 46949**]) please call for
appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-25**] weeks please call for appointment
Completed by:[**2200-10-18**]
|
[
"427.1",
"424.0",
"512.1",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3761, 3810
|
1845, 2696
|
292, 370
|
3889, 3896
|
1087, 1822
|
4301, 4706
|
749, 790
|
2781, 3738
|
3831, 3868
|
2722, 2758
|
3920, 4278
|
805, 1068
|
240, 254
|
398, 580
|
602, 622
|
638, 733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,532
| 154,654
|
54529
|
Discharge summary
|
report
|
Admission Date: [**2194-10-12**] Discharge Date: [**2194-10-17**]
Date of Birth: [**2138-12-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD, Angiography x 2
Colonoscopy
History of Present Illness:
55F with history of diverticulosis c/b multiple episodes of
diverticular bleed and AAA status post EVAR [**7-26**] with revision
[**8-25**] for endoleak presents with 2 episodes of bright red blood
per rectum this evening. The patient states that bleeding began
at 9:30 pm. The bleeding is painless. It is associated with
fatigue, mild lightheadedness, and chills. She denies fevers,
chest pain, shortness of breath, abdominal pain, dysuria or
hematuria. She has not experienced any nausea,
hematemasis/coffee ground emesis. She states that she had BRBPR
in the past secondary to diverticuli.
.
In the emergency department, VS: BP 107/64 HR 102 RR 22 Sat
95%/RA. EKG showed sinus at 92 normal axis normal intervals
poor R-wave progression similar to prior. The patient was seen
by gastroenterology, who recommended a CTA. She received one
unit of PRBCs for active bleeding. She did not undergo NG
lavage in the ED. Had episode of BRBPR just prior to transfer
to floor (a couple of cups in volume per patient).
.
On the floor, VS: 98.6 97 115/81 --> 78/62 17 100%RA.
Patient complaining of fatigue. Denies dizziness. No further
episodes of BRBPR.
Past Medical History:
Past Medical History:
Diverticulosis c/b diverticular bleed x4 - first one in [**2185**]
requiring sigmoidectomy with colostomy (now s/p hartmann's
takedown) and diverticulitis - all hospitalizations at [**Hospital1 34585**]
HTN
pancreatitis
anemia
obesity
ventral hernia
h/o positive PPD
.
PSH: Hartmann's/takedown
Social History:
lives with family, independent in ADLs
Tobacco - denies
ETOH - denies
Ilicit substances - denies
Family History:
n/c
Physical Exam:
Admission Physical Exam:
VS: 98.6 97 115/81 --> 78/62 17 100%RA
Gen: Alert, oriented; fatigued; NAD
HEENT: Sclera anicteric; MMM
Card: tachycardic S1, S2, no murmurs, rubs or gallops
Resp: clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended; + BS
Ext: non-edematous;
Skin: dry; without rashes
Neuro: CN II - XII grossly intact; moving all extremities
.
Discharge Physical Exam:
O:VS: 98.8 HR 95, 113/67, 18, 97% RA
Gen: Alert, oriented x3; NAD
HEENT: Sclera anicteric; MMM
Card: RRR, nl S1, S2, soft [**2-20**] early systolic murmur best at USB
no rubs or gallops
Resp: clear to auscultation bilaterally, with good air movement
Abd: Soft, non-tender, non-distended; + BS
Ext: no c/c/e. Right groin no bleeding, no concerning features,
no bruit.
Skin: dry; without rashes
Neuro: Non-focal
Pertinent Results:
adm labs:
[**2194-10-11**] 10:50PM BLOOD WBC-8.0 RBC-3.82* Hgb-10.1* Hct-27.5*
MCV-72* MCH-26.5* MCHC-36.9* RDW-15.7* Plt Ct-284
[**2194-10-11**] 10:50PM BLOOD PT-12.8 PTT-25.0 INR(PT)-1.1
[**2194-10-11**] 10:50PM BLOOD Glucose-155* UreaN-22* Creat-0.9 Na-141
K-3.5 Cl-102 HCO3-30 AnGap-13
[**2194-10-12**] 06:49AM BLOOD Type-[**Last Name (un) **] pH-7.37 Comment-GREEN TOP
[**2194-10-12**] 06:49AM BLOOD freeCa-1.06*
[**2194-10-13**] 04:00AM BLOOD WBC-6.4 RBC-3.17* Hgb-9.1* Hct-25.2*
MCV-79* MCH-28.7 MCHC-36.1* RDW-15.6* Plt Ct-152
[**2194-10-13**] 04:00AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.0
[**2194-10-13**] 04:00AM BLOOD Plt Ct-152
[**2194-10-13**] 03:15AM BLOOD Glucose-117* UreaN-10 Creat-0.6 Na-141
K-4.2 Cl-111* HCO3-25 AnGap-9
[**2194-10-13**] 03:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
[**2194-10-13**] 04:30AM BLOOD Type-[**Last Name (un) **] pH-7.42
[**2194-10-13**] 04:30AM BLOOD freeCa-1.14
Reports:
CTA: IMPRESSION:
1. No evidence of aortic-enteric fistula.
2. Persistent progressive pooling of intravenous contrast within
the
dependent portion of the cecum represents a site of active
bleeding.
3. Infrarenal abdominal aortic aneurysm, similar in size since
recent
examination from [**2194-7-7**]. Persistent type 2 endoleak
feeding from a
lower lumbar artery.
4. Ventral hernia containing nonobstructed small bowel.
5. Diverticulosis.
.
TTE: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
CXR: Single AP view of the chest shows a right upper extremity
PICC
whose tip terminates at the atriocaval junction. No pneumothorax
or pleural
effusion. Cardiac silhouette is normal. No focal consolidation.
IMPRESSION: Appropriately positioned right upper extremity PICC
.
d/c labs:
[**2194-10-17**] 05:57AM BLOOD WBC-6.0 RBC-3.68* Hgb-10.8* Hct-30.2*
MCV-82 MCH-29.2 MCHC-35.7* RDW-15.7* Plt Ct-225
[**2194-10-15**] 03:05AM BLOOD PT-12.6 PTT-25.3 INR(PT)-1.1
[**2194-10-17**] 05:57AM BLOOD Glucose-112* UreaN-14 Creat-0.6 Na-143
K-3.3 Cl-106 HCO3-30 AnGap-10
[**2194-10-17**] 05:57AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.9
[**2194-10-13**] 04:30AM BLOOD Type-[**Last Name (un) **] pH-7.42
[**2194-10-13**] 04:30AM BLOOD freeCa-1.14
Brief Hospital Course:
55 year old woman with a history of diverticulosis and aortic
aneurism with recent endoleak admitted with BRBPR.
.
#MICU Course: Patient admitted with tachycardia in the setting
of 2 episodes BRBPR. Prior to transfer to ICU, the patient had
a 3rd episode of large BRBPR. She was transfused 1 unit PRBCs
in ED. CTA showed pooling of extravasated blood in the cecum,
extensive diverticulosis, and no evidence of aorto-enteric
fistula. On transfer to the floor, she became hemodynamically
unstable, requiring multiple units PRBCs. She underwent
emergent angiography that did not reveal the source of bleed.
On the first day of admission, she received 6 units PRBCs. In
the evening, she once again became hemodynamically unstable with
large BRBPR and returned to angiography. Second angiogram did
not reveal source of bleed. The patient underwent EGD that did
not show evidence of upper GIB. Colonoscopy revealed no
bleeding to cecum but could not pass the scope into the terminal
ileum. Multiple diverticuli were seen on right side of colon,
no AVMs, and a 2.5cm polyp was tattooed that will need removal
as an outpatient. She was seen by the Surgery team, who felt
that if she continued to bleed, she would require a total
abdominal colectomy, given that her bleeding appeared to be
originating in the right colon and she had a large polyp
concerning for malignancy in the left colon. The frequency of
her bleeding then decreased and her hematocrit remained stable,
so she was transferred from the MICU to the floor. She received
a total of 8 units PRBCs, 2 units FFP, 1 unit platelets.
.
#[**Hospital1 139**] Wards Course: The patient was received hemodynamically
stable, without complaints. She did not have any bleeding, and
her hematocrit remained stable without transfusions. She had an
isolated drop in hematocrit that was stable at repeat without
transfusion or other intervention. She had a normal bowel
movement 2 days prior to discharge. She tolerated a regular
diet well, after being advanced slowly from a clear liquid diet.
A social work consult was obtained for help with coping. On
day 3 of being on the floor, the patient was discharged home,
after being consented by surgery and anesthesia for surgery the
week after discharge. The plan was for a colectomy to remove
the suspected source of bleeding and the polyp concerning for
malignancy. The patient was stable and without complaint prior
to discharge. She preferred not to stay in the hospital until
her elective surgery, and there was no medical reason to keep
her as she had been stable with no further bleeding or
hematocrit drop, and was tolerating a regular diet well.
.
##Surgery: Patient was offered surgical management of GI
bleeding as an outpatient, and agreed to return to the hospital
next week for subtotal colectomy, colorectal anastomosis, and
possible stoma. Anesthesia was contact[**Name (NI) **] for pre-operative
work-up, the appropriate labs and studies were identified, and
the patient signed the consent form. The surgery will be
scheduled for [**2194-10-23**]. The patient will call the surgery office
at [**Telephone/Fax (1) 94579**] to confirm the time. She will complete a colon
prep consisting of GoLytely the night before surgery. A
prescription for GoLytely was provided at discharge.
.
**********
Chronic Issues:
#HTN: Chronic, on amlodipine, lisinopril/hydrochlorothiazide as
an outpatient. Given her hypotension secondary to her GI bleed,
her home medications were held on admission. Her SBPs were
stable in the 110 range for the 3 days on the floor, so she was
sent home off of these medications.
.
#AAA with recent type II endoleak: Chronic, s/p EVAR in [**7-26**] and
repair of type 2 endoleak in [**8-25**]. Stable per CTA. No evidence
of aorto-enteric fistula. On admission, vascular was made aware
of the patient's admission, and stated it was safe to hold
aspirin given her GI bleed and the possibility of surgery.
.
**************.
Transitional issues:
.
# After her surgery, pt will need her anti-hypertensives
restarted if indicated. She may also need her aspirin to be
restarted given her history of AAA repair.
.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other
Provider)-
20 mg-25 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth DAILY (Daily)
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. Golytely 236-22.74-6.74 gram Recon Soln Sig: Four (4) liters
PO night before surgery for 1 doses: Please drink 8oz every 10
minutes until 4 liters are consumed.
Disp:*4 liters* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulosis
Lower GI bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 111557**],
You were admitted for blood in your stool. You were evaluated
by the GI doctors and by the surgeon. You had a colonoscopy
that showed diverticulosis which you had been diagnosed with
previously, and a polyp (a small protrusion of bowel that can
sometimes turn into cancer). Everyone agrees that your bleeding
was likely related to diverticulosis in your colon. After
speaking with the surgeons, it was decided to have an operation
to remove your colon to prevent future bleeding and to remove
the polyp.
.
Your blood counts were monitored closely, and were stable prior
to discharge.
.
You should follow the directions given to you by the surgeons
about how to prepare for the surgery. If you have questions,
please call their office.
.
Please note that you should STOP taking:
AMLODIPINE 5 mg daily
LISINOPRIL-HYDROCHLOROTHIAZIDE 20 mg-25 mg daily
ASPIRIN 81 mg daily
.
You should stop these three medications because your blood
pressure was normal without them, and we do not want to put you
at risk for bleeding again before your surgery.
.
Please follow-up with your primary care docotor after your
surgery.
Followup Instructions:
Please contact the surgery office at [**Telephone/Fax (1) 94579**] to confirm the
date and time of your upcoming colon surgery.
Completed by:[**2194-10-17**]
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52,953
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44270+58697
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Discharge summary
|
report+addendum
|
Admission Date: [**2135-4-18**] Discharge Date: [**2135-5-3**]
Date of Birth: [**2100-6-1**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Phenytoin / Ancef / Zosyn / Meropenem / Vancomycin /
Levofloxacin / Metronidazole
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
shortness of breath, RUQ pain
Major Surgical or Invasive Procedure:
intubation
CVL placement
arterial line placement
open cholecystectomy
History of Present Illness:
4 yo M with h/o AVM as a child with resultant left hemiparesis,
VP shunt, spinal stenosis who presented to an OSH on [**4-18**] with
acute respiratory distress and RUQ pain. He was transferred to
[**Hospital1 18**], where he was intubated in the ER for respiratory fatigue.
Pan CT scan showed distended gallbladder with sludge/multiple
small layering gallstones without pericholecystic fluid or fat
stranding. He was covered broadly with vancomycin/meropenem and
was admitted to the MICU on [**2135-4-18**]. On [**4-19**], a RUQ ultrasound
was performed that showed a perforated gallbladder. Flagyl was
added and he urgently went to the OR for open cholecystectomy on
[**4-19**].
.
In the OR, 3L bloodly fluid evacuated from abdomen
(hemoperitoneum), and the GB was removed. He was admitted to the
trauma ICU post-op, still intubated. Antibiotics were narrowed
to vancomycin/levofloxacin/flagyl. On [**4-20**], he was transfused 2
U pRBCs for post-op HCT 21.3. He had an episode of hypotension
and hypoxia, which improved with suctioning. He was febrile on
[**4-21**], and pan-cultures, including bile, showed no growth. He
exhibited difficulty with weaning from the ventilator, so on
[**4-22**], a dobhoff was placed and TF were started. It was noted
that he was as high as 17 liters positive LOS, and so a lasix
gtt was started with good effect, and propofol was added to
precedex for sedation. On [**4-23**], he received a lasix bolus and
became hypotensive, was given 2 L crystalloid. Continued to
desat with turning. On [**4-24**], CPAP increased to [**9-11**]. Pan
cultures were re-sent for fever. LENIs were negative. Zosyn was
added to the vanc/levo/flagyl, in order to broaden coverage. He
was given mucomyst by ETT for mucus plugs. On [**4-25**], zosyn was
switched to meropenem. IP was consulted and felt that he did not
need a bronch, but could need a trach. A family meeting with
multiple providers was held on [**4-26**], and the family expressed
strong wishes against tracheostomy, as the patient has tracheal
stenosis as a complication of a prior tracheostomy. A PICC line
was placed. He also had diarrhea, and stool was sent for c.diff.
He was vigorously autodiuresing up to 400cc/hr. He was weaned
down to PSV 5/5 and transferred to MICU-7 for continued
ventilator weaning and eventual extubation.
.
Currently, he is intubated and sedated, but responding to
stimuli. He appears comfortable.
Past Medical History:
1. Anoxic brain injury secondary to an AVM.
2. History of seizure disorder.
3. Obstructive sleep apnea: BiPAP at night and during day PRN
4. VP shunt with multiple revisions.
5. Acne
6. Obesity
7. Status post-tracheostomy with tracheal narrowing.
8. Left hemiplegia.
9. Spinal stenosis.
10. Self harm - bites right arm when frustrated or agitated
Social History:
Lives in group home with one other male occupant and 24 hour
nursing. No alcohol, tobacco or illicit drugs.
Family History:
n/a
Physical Exam:
VS: 99.7 94 117/74 21 99% on PSV 5/5/0.4 (ABG: 7.48/39/93/30)
Gen: Intubated, sedated but opens eyes, responds to stimuli
HEENT: pupils not examined; large habitus. Doboff in place
NECK: CVL line c/d/i
CV: regular rate, rhythm, no audible murmurs
Pulm: Coarse BS with transmitted upper airway sounds and
scattered rhonchi, otherwise clear without wheezing; symmetric
expansion
Abd: obese, soft, non-tender, surgical staples and drain site
appear well healing with no erythema/induration. Normoactive.
GU: Foley in place
Ext: WWP with 2+ DP pulses
Pertinent Results:
CBC:
[**2135-4-18**] 01:40PM BLOOD WBC-11.5*# RBC-6.38* Hgb-18.3* Hct-53.4*
MCV-84 MCH-28.7 MCHC-34.3 RDW-13.8 Plt Ct-230
[**2135-4-19**] 04:37AM BLOOD WBC-16.5* RBC-5.20 Hgb-15.2# Hct-43.9
MCV-85 MCH-29.2 MCHC-34.5 RDW-14.0 Plt Ct-245
[**2135-4-19**] 09:53AM BLOOD WBC-11.6* RBC-3.93* Hgb-11.8*# Hct-32.7*#
MCV-83 MCH-30.1 MCHC-36.2* RDW-14.4 Plt Ct-195
[**2135-4-20**] 01:42AM BLOOD WBC-9.0 RBC-2.94* Hgb-8.7* Hct-24.6*
MCV-84 MCH-29.8 MCHC-35.6* RDW-14.6 Plt Ct-154
[**2135-4-21**] 02:10AM BLOOD WBC-8.1 RBC-2.85* Hgb-8.7* Hct-24.0*
MCV-84 MCH-30.4 MCHC-36.1* RDW-14.4 Plt Ct-153
[**2135-4-22**] 02:06AM BLOOD WBC-7.0 RBC-2.74* Hgb-8.1* Hct-23.0*
MCV-84 MCH-29.5 MCHC-35.2* RDW-14.7 Plt Ct-199
[**2135-4-23**] 01:39AM BLOOD WBC-6.4 RBC-2.74* Hgb-8.4* Hct-23.5*
MCV-86 MCH-30.8 MCHC-35.8* RDW-15.9* Plt Ct-206
[**2135-4-25**] 03:48AM BLOOD WBC-7.6 RBC-2.71* Hgb-8.0* Hct-23.9*
MCV-88 MCH-29.6 MCHC-33.5 RDW-15.3 Plt Ct-259
[**2135-4-26**] 03:06AM BLOOD WBC-6.9 RBC-2.81* Hgb-8.5* Hct-24.7*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.5 Plt Ct-288
[**2135-4-27**] 02:36AM BLOOD WBC-8.6 RBC-3.00* Hgb-8.8* Hct-26.3*
MCV-88 MCH-29.2 MCHC-33.3 RDW-16.0* Plt Ct-324
[**2135-4-28**] 04:33AM BLOOD WBC-7.9 RBC-3.35* Hgb-9.5* Hct-29.2*
MCV-87 MCH-28.5 MCHC-32.6 RDW-15.7* Plt Ct-343
[**2135-4-29**] 03:26AM BLOOD WBC-6.7 RBC-3.34* Hgb-9.6* Hct-29.2*
MCV-87 MCH-28.8 MCHC-33.0 RDW-15.8* Plt Ct-378
CHEMISTRY:
[**2135-4-18**] 01:40PM BLOOD Glucose-112* UreaN-12 Creat-0.9 Na-141
K-5.9* Cl-98 HCO3-30 AnGap-19
[**2135-4-29**] 02:41PM BLOOD Glucose-99 UreaN-6 Creat-0.6 Na-142 K-3.6
Cl-108 HCO3-26 AnGap-12
LFTs
[**2135-4-18**] 01:40PM BLOOD ALT-397* AST-397* LD(LDH)-717*
AlkPhos-159* Amylase-59 TotBili-2.2*
[**2135-4-19**] 09:53AM BLOOD ALT-411* AST-296* AlkPhos-123
TotBili-5.2*
[**2135-4-20**] 01:42AM BLOOD ALT-378* AST-242* AlkPhos-105
TotBili-4.4* DirBili-4.0* IndBili-0.4
[**2135-4-27**] 02:36AM BLOOD ALT-65* AST-39 AlkPhos-129 TotBili-1.1
==============================
MICRO:
all negative (multiple blood, sputum, and urine) except:
[**2135-4-20**] 11:26 am BILE
**FINAL REPORT [**2135-4-28**]**
GRAM STAIN (Final [**2135-4-20**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2135-4-23**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2135-4-28**]):
PROPIONIBACTERIUM SPECIES.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
==============================
IMAGING:
[**4-18**] CT HEAD
IMPRESSION: No acute intracranial hemorrhage. Stable appearance
of marked
encephalomalacia of majority of the right cerebral hemisphere.
No acute
findings.
[**4-18**] CT-A C/A/P
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bibasilar atelectasis/pneumonia/aspiration.
3. Markedly distended gallbladder with layering sludge/small
gallstones.
There is no pericholecystic fat stranding or fluid. However,
this could
represent acute cholecystitis in the appropriate setting. Please
correlate
clinically and consider ultrasound for further evaluation.
4. Diffuse fatty infiltration of the liver.
[**4-19**] RUQ U/S
IMPRESSION: Apparent perforation of the gallbladder as there is
loss of
normal gallbladder wall and complex material extending from the
gallbladder fossa into the subhepatic space. This appearance is
dramatically different from the appearance of the gallbladder on
the chest CT dated [**2135-4-18**]. No biliary dilatation seen.
Simple ascites fluid seen in the lower quadrants.
[**4-25**] Bilateral LENI:
IMPRESSION: No evidence of DVT
[**2135-4-28**]: Multiple chest x-rays taken during the period of
intubation, the most recent of which was [**4-28**] showing continued
RLL/RML atelectasis and otherwise stable findings.
[**2135-5-3**]: CXR done on day of discharge at request of family.
Preliminary read: no new cardiopulmonary pathology.
==============================
PATHOLOGY (from tissue obtained intra-op on [**2135-4-19**]):
1. Liver, needle core biopsy (A):
A. Acute cholangitis; see note.
B. Marked predominantly macrovesicular steatosis without
intracytoplasmic hyalin involving >66% of the core (Score 3).
C. Minimal portal and lobular mixed cell inflammation (Score
1).
D. Rare balloon cell degeneration is seen (Score 1).
E. Trichrome stain shows mild periportal and sinusoidal
fibrosis (fibrosis stage 2).
F. Iron stains show no increased iron deposition.
2. Gallbladder (B-D): Gangrenous cholecystitis with perforation
and cholelithiasis, mixed-type.
Note: The liver findings are consistent with toxic-metabolic
injury. If NASH, the NAS score is [**4-9**]. The differential
diagnosis for the acute cholangitis includes ascending infection
and generalized sepsis, among others.
Brief Hospital Course:
34 yo M with h/o AVM as a child with resultant left hemiparesis,
VP shunt, spinal stenosis who presented to an OSH on [**4-18**] with
acute respiratory distress and RUQ pain. He was transferred to
[**Hospital1 18**], where he was intubated in the ER for respiratory fatigue.
Pan CT scan showed distended gallbladder with sludge/multiple
small layering gallstones without pericholecystic fluid or fat
stranding. He was covered broadly with vancomycin/meropenem and
was admitted to the MICU on [**2135-4-18**]. On [**4-19**], a RUQ ultrasound
was performed that showed a perforated gallbladder. Flagyl was
added and he urgently went to the OR for open cholecystectomy on
[**4-19**].
In the OR, 3L bloodly fluid evacuated from abdomen
(hemoperitoneum), and the GB was removed. He was admitted to the
trauma ICU post-op, still intubated. Antibiotics were narrowed
to vancomycin/levofloxacin/flagyl. On [**4-20**], he was transfused 2
U pRBCs for post-op HCT 21.3. He had an episode of hypotension
and hypoxia, which improved with suctioning. He was febrile on
[**4-21**], and pan-cultures, including bile, showed no growth. He
exhibited difficulty with weaning from the ventilator, so on
[**4-22**], a dobhoff was placed and TF were started. It was noted
that he was as high as 17 liters positive LOS, and so a lasix
gtt was started with good effect, and propofol was added to
precedex for sedation. On [**4-23**], he received a lasix bolus and
became hypotensive, was given 2 L crystalloid. Continued to
desat with turning. On [**4-24**], CPAP increased to [**9-11**]. Pan
cultures were re-sent for fever. LENIs were negative. Zosyn was
added to the vanc/levo/flagyl, in order to broaden coverage. He
was given mucomyst by ETT for mucus plugs. On [**4-25**], zosyn was
switched to meropenem. IP was consulted and felt that he did not
need a bronch, but could need a trach. A family meeting with
multiple providers was held on [**4-26**], and the family expressed
strong wishes against tracheostomy, as the patient has tracheal
stenosis as a complication of a prior tracheostomy. A PICC line
was placed. He also had diarrhea, and stool was sent for c.diff.
He was vigorously autodiuresing up to 400cc/hr. He was weaned
down to PSV 5/5 and transferred to MICU-7 for continued
ventilator weaning and eventual extubation.
In the MICU from [**Date range (1) 38269**], he was diuresed and easily weaned
down to minimal support settings. He was extubated uneventfully
on [**4-28**] and was weaned down to room air. His arterial line was
removed. He passed a speech and swallow evaluation and tolerated
a regular diet. Flagyl was stopped on [**4-29**] after a 10 day
course, but vancomycin/meropenem/levofloxacin were continued for
possible VAP, with coverage due to finish on [**5-2**].
On return to the floor, he completed an antibiotics course on
[**5-2**] as above. He continued to receive furosemide for diuresis
until [**5-1**], and was converted to HCTZ (home dosing) on [**5-2**]. His
breathing improved and he appeared comfortable on room air with
good air entry on clinical exam. A chest x-ray was taken on the
day of discharge at the request of his family, which showed
(prelim read) continued right basal atelectasis with elevated
hemidiaphragm, some mild congestion (improved from prior),
resolving infiltrate, and no effusion. His recovery was
complicated by the development of two new pressure sores (stage
II/unstageable) on the buttocks. He was evaluated by the wound
consult team at the time of discharge and recommendations were
passed to staff at his group home. He also developed diarrhea
(C. difficile negative) which was attributed to his recent
antibiotics. He was treated symptomatically with
diphenoxylate-atropine while in-house and discharged on
loperamide, which he uses PRN as outpatient. Finally, on the
evening prior to discharge, he began to develop a rash along his
left flank. This progressed the following morning [**5-3**] to a
maculopapular morbilliform rash covering most of the trunk and
also in patches on the lower extremities consistent with a drug
reaction. The most likely agents to have caused this were his
recent IV antibiotics (meropenem perhaps most likely; patient
also received vancomycin, levofloxacin, and metronidazole for
10-day courses; he received also a few doses of Zosyn while in
the ICU). As antibiotics were already stopped on the morning of
presentation, the patient was treated with Benadryl and group
home staff instructed to watch for worsening symptoms. The
patient has also been asked to follow up with his PCP to discuss
resumption of full-dose aspirin (held during this admission) as
well as proper follow up for his liver biopsy findings (NASH vs.
toxic-metabolic injury).
Medications on Admission:
- Diprolene 0.05 % Lotion apply to right forearm twice a day as
needed for for increased redness on intact skin do not use on
open areas
- Imodium Advanced 2 mg-125 mg Chewable Tab 2 Tablet(s) by mouth
prn give 2 caps after initial diarrhea, may repeat 1 cap with
each subsequent loose stool not to exceed 4 in 24 hours
- [**Last Name (un) 18774**] Vaporub Ointment apply to chest at bedtime as needed for
for nasal congestion
- Preparation H 0.25 %-50 % Topical Gel may apply externally to
rectum twice a day as needed for for rectal
itching/redness/swelling
- Senna 8.6 mg Tab 1 (One) Tablet(s) by mouth once a day
- Artificial Tears 0.1 %-0.3 %-0.2 % Eye Drops one drop each eye
twice a day as needed for any time during day that eyes are
noticed to be dry
- Triple Antibiotic 3.5 mg-400 unit-[**Unit Number **],000 unit/g Ointment apply
topically to skin twice a day as needed for to superficial open
areas/redness
- Saline Spray 0.9 % spray 2 puffs each nostril twice a day for
nasal dryness
- Aspirin 325 mg Tab, Delayed Release 1 (One) Tablet(s) by mouth
once a day
- Acetaminophen 325 mg Tab 2 Tablet(s) by mouth every four (4)
hours as needed for for temperature >100.0
- Milk of Magnesia 400 mg/5 mL Oral Susp 30 mL Suspension(s) by
mouth every 2 days if no BM as needed for constipation
- Albuterol Sulfate 2.5 mg/3 mL (0.083 %) Neb Solution 1 vial(s)
nebulized every AM and every 3pm and up to 4 times daily as
needed for sluggishness, inability to breathe/speak, head
drooping, fatigue
- ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 inhalation po
QID as needed as needed for prn when out and nebulizer not
available
- Xanax 0.25 mg Tab 1 Tablet(s) by mouth once in the morning prn
anxiety
- Hydrochlorothiazide 12.5 mg Tab 1 Tablet(s) by mouth every
morning as needed for fluid retention
- Multi-Vitamin W/Minerals Cap 1 (One) Capsule(s) by mouth once
a day
- Timolol 0.5 % Eye Gel Forming Soln 1 drop(s) both eyes q AM
- Potassium Chloride SR 10 mEq Tab, Particles/Crystals 3 Tab(s)
by mouth twice a day do not crush
- Clotrimazole 1 % Topical Cream apply to groin rash twice a day
- Peridex 0.12 % Mouthwash use 15 mL orally and rinse mouth for
30 seconds twice a day
- PreviDent 5000 Plus 1.1 % Cream apply to toothbrush and brush
teeth twice a day
- Tegretol XR 200 mg 12 hr Tab 1 (One) Tablet(s) by mouth twice
a day do not crush no substitute, medically necessary
- Benzac AC 10 % Topical Gel apply to face, chest and back once
a day as needed for acne, irritated skin
- Neurontin 100 mg Cap one Capsule(s) by mouth three times a day
brand name only no substitutions
- Loratadine 10 mg Tab 1 Tablet(s) by mouth once a day as needed
for allergies
- Gold Bond 0.15 %-1 % Topical Powder apply to groin and back
twice a day for sweating
- Ipratropium Bromide 0.03 % Nasal Spray 2 (Two) sprays in each
nostril up to four times a day as needed for runny nose
associated with a cold
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Please hold for loose stool.
2. Artificial Tear(dxtrn-HPM-gly) 0.1-0.3-0.2 % Drops Sig: One
(1) drop Ophthalmic twice a day as needed for dry eyes: to both
eyes.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-8**]
hours as needed for fever or pain: Not to exceed 4 g (4000 mg)
daily.
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Timolol Maleate 0.5 % Gel Forming Solution Sig: One (1) drop
Ophthalmic QAM: to both eyes.
6. Tegretol XR 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO twice a day: do not crush;
no substitutions.
7. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: brand name only, no substitutions.
8. Gold Bond 0.15-1 % Powder Sig: One (1) application Topical
twice a day as needed for sweating: to groin and back.
9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for groin rash.
10. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: Two (2)
sprays Nasal every six (6) hours as needed for runny nose
associated with cold: to each nostril.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation QAM and Q3PM, up to 4
times daily as needed for shortness of breath or wheezing.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation four times a day as needed for shortness of
breath or wheezing: for use when out or nebulizer not available.
13. [**Last Name (un) 18774**] Vaporub Ointment Sig: One (1) application Topical
at bedtime as needed for nasal congestion: apply to chest.
14. Saline Spray 0.9 % Aerosol, Spray Sig: Two (2) puffs
Miscellaneous twice a day as needed for nasal dryness: to each
nostril.
15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO every other day as needed for constipation: Do not
co-administer with Neurontin. Hold for diarrhea/loose stool;
give if no BM in 2 days.
16. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
17. Peridex 0.12 % Mouthwash Sig: Fifteen (15) ml Mucous
membrane twice a day: Rinse mouth for 30 seconds.
18. PreviDent 5000 Plus 1.1 % Cream Sig: One (1) application
Dental twice a day: apply to toothbrush and brush teeth twice
daily.
19. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
20. Imodium Advanced 2-125 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO 2 caps after initial diarrhea, may repeat 1
cap with each additional loose stool not to exceed 4 in 24 hours
as needed for diarrhea.
21. Aspiration precautions
1. PO diet of small straw sips of thin liquid and regular solids
2. Pills whole w/ thin liquid as tolerated. 3. 1:1 supervision
to assist w/ feeding and maintain aspiration. 4. Please feed
slowly, giving pt adequate time to chew and swallow. 5.
Alternate bites and sips. 6. If pt is seen w/ coughing on thin
liquids, please downgrade to nectar-thick liquid. 7. TID oral
care.
22. Discontinue medications
Please STOP USE of diprolene and Preparation H. If the symptoms
for which these medications were prescribed return, please call
your primary care doctor.
23. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO QAM as needed
for anxiety.
24. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day: do
not crush.
25. Benzac AC 10 % Gel Sig: One (1) application Topical once a
day as needed for acne, irritated skin: to face, chest, and back
.
26. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching or worsening rash: if rash continues
to worsen or becomes bothersome to patient despite this
medication, please call PCP.
[**Name Initial (NameIs) **]:*30 Capsule(s)* Refills:*0*
27. Activity
Please avoid vigorous activity until after your follow up
appointment with Dr. [**Last Name (STitle) **]. Please confirm activity
recommendations with Dr. [**Last Name (STitle) **] at that time.
28. Respiratory
Please continue to use nebulizer as before (without oxygen is
acceptable).
29. Respiratory equipment
Please provide patient with new tubing and mask for CPAP machine
every six months and with the occurrance of any infection.
30. Vitals
Please check patient's vital signs including oxygen saturation
daily or if he develops new symptoms.
31. Incentive spirometer
Please provide patient with an incentive spirometer and instruct
in proper use. Patient should use this device 10 times an hour
while awake (or as frequently as possible) to maintain good
aeration of lungs.
32. respiratory
Please continue BIPAP on prior home settings.
33. Triple Antibiotic 3.5-400-5,000 mg-unit-unit/g Ointment Sig:
One (1) application Topical twice a day as needed for open sores
or cuts.
34. Ancillary
Please continue all other patient care orders as prior to this
admission.
35. Mepilex AG 6 X 6 Bandage Sig: One (1) dressing Topical
every seventy-two (72) hours: To sacral ulcers as directed by
wound care recs.
[**Last Name (STitle) **]:*30 * Refills:*2*
36. Critic-Aid Clear AF 2 % Ointment Sig: One (1) application
Topical once a day as needed for sacral ulcers: Please use as
directed by wound care recs.
[**Last Name (STitle) **]:*1 unit* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
- Gangrenous cholecystitis with ruptured gall bladder
- Ventillator-associated pneumonia
- Macrovesicular steatosis on liver biopsy (Score 3)
- Mild periportal and sinusoidal fibrosis on liver biopsy
(fibrosis stage 2)
Discharge Condition:
Mental Status: Confused - always (history of anoxic brain
injury)
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were transferred to [**Hospital1 69**]
with difficulty breathing and abdominal pain. You were intubated
to help your breathing, and you received antibiotics to treat a
possible infection in your lungs and diuretics to help remove
fluid from your lungs. It was also found that you had a ruptured
gall bladder, and you were taken to surgery to have it removed.
You recovered well from your surgery and breathing problems.
We have made the following changes to your medication regimen:
- STOP TAKING diprolene and Preparation H as these medictions
are not needed at this time
- STOP TAKING aspirin unless/until directed to resume by your
primary care doctor
- BEGIN TAKING diphenhydramine (Benadryl) 25 mg by mouth every
6-8 hours as needed for rash spreading/itching. If your rash
becomes markedly worse or bothersome despite use of this
medication, or if you develop problems with mouth/lip/throat
swelling, shortness of breath, or rash developing into open
sores, contact your doctor right away or return to the hospital
for further evaluation.
Please keep your follow up appointments as scheduled below.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2135-5-9**] at 1:50 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
- Please ask your doctor to examine your rash and make changes
to your medications as needed
- Please discuss use of aspirin (and appropriate dose) with your
doctor and follow his instructions regarding use
- Please review all medications with your doctor at this visit
- Please ask your doctor to examine your lungs and assess your
volume status; if needed, your doctor will recommend seeing your
pulmonologist sooner than otherwise scheduled. Your doctor will
also make any necessary changes to your diuretic regimen.
- Discuss your liver biopsy results and make a plan with your
doctor for follow up
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2135-5-9**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
- Discuss best diet and activity orders with your doctor at this
time
- Discuss staple removal with your doctor at this visit (your
doctor will most likely remove staples at this time)
Department: [**Hospital3 249**]
When: WEDNESDAY [**2135-6-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2135-6-15**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY/[**Hospital Ward Name **] 503
When: THURSDAY [**2135-6-23**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5285**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2135-5-3**] Name: [**Known lastname 15022**],[**Known firstname **] F Unit No: [**Numeric Identifier 15023**]
Admission Date: [**2135-4-18**] Discharge Date: [**2135-5-3**]
Date of Birth: [**2100-6-1**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Phenytoin / Zosyn / Meropenem / Vancomycin /
Levofloxacin / Metronidazole
Attending:[**First Name3 (LF) 175**]
Addendum:
The patient's mental status on discharge was clear, alert and
interactive.
The patient does not have 24 hour home care.
Social History:
Lives in group home with one other male occupant. No alcohol,
tobacco or illicit drugs.
Discharge Disposition:
Home
Discharge Condition:
Mental Status: Clear, cognitive status at baseline
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**]
Completed by:[**0-0-0**]
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77,664
| 170,240
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37317
|
Discharge summary
|
report
|
Admission Date: [**2195-1-17**] Discharge Date: [**2195-1-25**]
Date of Birth: [**2131-12-16**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Fevers and malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **]
63M with no significant PMH presents with unexplained febrile
neutropenia. The pt was recently diagnosed with an abcess in
left axilla nine days ago. The pt noted swelling, fluctuance,
erythema and pain, however no purulence noted. The pt was placed
on Bactrim on [**2195-1-8**] by an urgent care physician for suspected
MRSA (per pt). The pt states that he began experiencing fevers
two days ago, nightsweats and a pink truncal rash. The pt noted
the swelling in his left axilla improved over this time period.
No I and D performed. The pt today re-presented to urgent care
at [**Hospital1 **]. Upon arrival home the pt was told of
abnormal lab values (WBC of 0.9) and subsequently presented to
the ED. Of note the pt works at [**Hospital **] Hospital in JP in the
Mental Health Division. Pt has been previously immunized to HBV
and has had several negative HIV tests. Of note pt had a WBC of
6.6 [**2194-5-1**].
.
In the emergency department 98.6 76 19 99, while in the ED exam
notable for rigors. Initial labs significant for K 5.8. ECG with
RBBB and sinus bradycardia. The pt received Calcium Gluconate
1gm, 1Amp of bicarb, 1 amp of D50, 4 units of Insulin,
Kayexelate 15gm which improved K to 4.5. The pt received doses
of Vancomycin 1gm and Cefepime 2gm IV as well as 3L NS prior to
transfer. Prior to transfer the pt was noted to have rigors
102.5 133/55 60 20 98% on RA.
.
REVIEW OF SYSTEMS:
(+)ve: fever, chills, night sweats, loss of appetite (of [**2-4**]
days duration)
.
(-)ve: fatigue, chest pain, palpitations, rhinorrhea, nasal
congestion, cough, sputum production, hemoptysis, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting,
diarrhea, constipation, hematochezia, melena, dysuria, urinary
frequency, urinary urgency, focal numbness, focal weakness,
myalgias, arthralgias
Past Medical History:
- Anxiety
- L axillary abcess
- staph skin infection that resolved with keflex in [**9-/2194**]
- s/p wrist surgery
Social History:
Married. Lives in JP with Wife. Two sons age 35, 36. [**Name2 (NI) 1403**] at
[**Hospital **] Hospital in JP as a social worker. [**Name (NI) **] ETOH, tobacco or
IVDU. No Pets. No tattoos. No known exposures to HIV. Never been
incarcerated.
Family History:
Mother 86 - healthy. Father Deceased MI age 82. Two sisters
healthy. [**Name2 (NI) **] family history of heme malignancies.
Physical Exam:
EXAM ON ARRIVAL TO ICU:
T=101 BP=100/46 HR=56 RR=16 97%O2=RA
PHYSICAL EXAM
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 6
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Left axilla with two contiguous areas of mild
fluctuance with central darkening, no purulence visiualized.
Mildly tender. No edema or calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: Scant light pink blanching rash on chest.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-3**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2195-1-17**] 08:30PM WBC-0.5* RBC-4.50* HGB-13.5* HCT-40.5 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.3
[**2195-1-17**] 08:30PM NEUTS-0* BANDS-0 LYMPHS-80* MONOS-8 EOS-6*
BASOS-0 ATYPS-6* METAS-0 MYELOS-0
[**2195-1-17**] 08:30PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2195-1-17**] 08:30PM PLT COUNT-570*
[**2195-1-17**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2195-1-17**] 08:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-1-17**] 08:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
DISCHARGE LABS: [**2195-1-25**]
WBC 18.2 / hct 36.3 / Plt 505
Granulocyte Count [**Numeric Identifier 83953**]
Pertinent Labs:
[**2195-1-17**] 08:30PM URINE GR HOLD-HOLD
[**2195-1-17**] 08:30PM URINE HOURS-RANDOM
[**2195-1-17**] 08:30PM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-2.8
MAGNESIUM-2.3
[**2195-1-17**] 08:30PM ALT(SGPT)-22 AST(SGOT)-53* LD(LDH)-441* ALK
PHOS-49 TOT BILI-0.2
[**2195-1-17**] 08:30PM GLUCOSE-88 UREA N-34* CREAT-1.7* SODIUM-130*
POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-21* ANION GAP-20
[**2195-1-17**] 08:52PM LACTATE-2.7*
[**2195-1-17**] 10:23PM LACTATE-1.8
MICROBIOLOGY:
[**2195-1-17**] Blood Cx negative
[**2195-1-17**] Urine Cx negative
[**2195-1-18**] Blood Cx negative
STUDIES:
[**2195-1-17**] CXR No previous images. Hyperexpansion of the lungs is
consistent with chronic pulmonary disease. However, no evidence
of acute pneumonia, vascular congestion, or pleural effusion
Brief Hospital Course:
63 year old male presenting with febrile neutropenia, elevated
creatinine in setting of right axillary abcess while on Bactrim.
1. Neutropenia: Initial differential included post-infectious,
drug-induced/agranulocytosis, primary immune disorders or
hypersplenism. The association with recent Bactrim placed
drug-induced agranulocytosis higher on the differential,
although a rare condition. The patient was placed on neutropenic
precautions and admitted to the ICU. The patient was continued
on Vancomycin and Cefepime for febrile neutropenia coverage. He
was ultimately given leucovorin and G-CSF with improvement in
his neutrophil count, and he was no longer neutropenic. As his
neutrophil count improved, he was transitioned to PO
doxycycyline. He was monitored for 24 hours with normal WBC and
on PO doxycycline only, and he remained stable. He was
discharged with plans for a CBC count within 3 days of
discharge.
2. Fever: Initial differential included left axilla abcess, drug
induced, occult infection (transient bacteremia secondary to gut
translocation). He continued to spike fevers while on Bactrim as
outpatient (although it is unclear if Bactrim is cause or effect
of fevers at this stage). Blood and urine cultures were sent.
Incision and drainage of abcess was considered but not felt to
be necessary as patient's fevers subsided and no fluctuant areas
were noted.
3. Acute Renal Failure: Unknown baseline creatinine. Patient
had good urine output. Pt received 1L of NS while in ED. Cr from
1.7 to 1.4 to 1.1 following total of 6 lites of normal saline.
Nephrotoxins were avoided.
4. Hyponatremia: Appeared to be clinically intravascularly
depleted with Na of 130, improved to 135 with 1L NS. This is
further supported by elevated BUN/Cr ratio. Thus was likely
hypovolemic hyponatremia.
5. Hyperkalemia: Elevated on admission. Received Kayexelate,
Calcium, Bicarb, D50 in emergency department, potassium
improved.
6. Sinus Bradycardia: HR 40-50s. Stable per prior outside ECGs.
Pt with occasional asymptomatic sinus pauses while sleeping.
7. Left Axillary Abscess:
His abscess was thought possibly related to MRSA infection. His
bactrim was discontinued, and he was transitioned to vancomycin
initially. As his WBC count improved, he was transitioned to PO
doxycycyline. Even after his neutrophil count improved, his left
axillary abscess remained without fluctuance or significant
drainage. He was discharged with plans to have follow-up with
his PCP [**Name Initial (PRE) 176**] 3 days of discharge and then follow-up with his
infectious disease team within 2 weeks of discharge. He is to
continue on doxycycline for at least 10 days with plans to have
weekly follow-up of his infection. If his infection persists or
does not improve, he may need surgical evaluation for incision
and drainage and/or antibiotic regimen changes.
Medications on Admission:
Bactrim - discontinued
Doxycycline - prescription never filled
Discharge Medications:
1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*30 grams* Refills:*2*
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10-14 days: Please continue this
medication for at least the next 10 days. At that time, your
physicians can help you decide what kind of further treatment
you need.
Disp:*28 Capsule(s)* Refills:*0*
3. Outpatient Lab Work
Please check patient's CBC and differential.
Discharge Disposition:
Home
Discharge Diagnosis:
Agranulocytosis
Febrile Neutropenia due to bactrim
Left axillary abscesses
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 with a very low white blood
cell count and fevers. You also had an elevated potassium level
and decreased kidney function. You were initially admitted to
the ICU for monitoring. Your potassium level and kidney
function quickly improved with IV fluids. It was thought that
bactrim led to your low white blood cell count and possibly your
fever. The infection in your left armpit also may have led to
your fever. You were started on two strong antibiotics,
Vancomycin and Cefepime, and were then transferred out of the
ICU to the medicine floor.
While on the medicine floor your white blood count began to
improve, and your fevers stopped. You were transitioned to an
oral antibiotic, doxycycline, which will need to be taken for at
least the next 10 days. No other changes were made to your home
medications.
Followup Instructions:
We would like to have you seen at least once a week for the next
several weeks to continue to monitor your infection.
We would recommend that you follow-up with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 41875**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within the next three days to have
your CBC checked and your axillary infection monitored.
You will also have follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13895**], your
infectious disease physician. [**Name10 (NameIs) 357**] call his office at
[**Telephone/Fax (1) 457**] for this appointment time. This appointment will
likely be within the next 2 weeks at which time your infection
can be further monitored and your CBC can again be checked.
Please continue your doxycycline for at least the next 10 days.
If your infection improves on this medication alone, your
infection will have been treated. If your infection persists or
worsens, you may need further antibiotic and/or surgical
treatment of your abscess.
|
[
"041.12",
"E931.0",
"288.03",
"780.61",
"682.3",
"584.9",
"276.7",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8839, 8845
|
5369, 8226
|
296, 302
|
8964, 8964
|
3746, 3746
|
9982, 11067
|
2641, 2766
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8340, 8816
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8866, 8943
|
8252, 8317
|
9109, 9959
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4448, 4544
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1817, 2226
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238, 258
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330, 1798
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3762, 4432
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8978, 9085
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4560, 5346
|
2248, 2366
|
2382, 2625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,369
| 162,773
|
6986
|
Discharge summary
|
report
|
Admission Date: [**2182-8-25**] Discharge Date: [**2182-9-1**]
Date of Birth: [**2111-7-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Tremors, chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
77 yo M w/ h/o DM type 2, HTN, dyslidemia, NASH cirrhosis/HCC
s/p liver [**First Name3 (LF) **] who presents w/ tremors and chest pain. Pt
reports was in usual state of health until around 11:30pm night
prior to presentation. At that time noted "rope-like" pain
around his chest while watching TV on the couch. Pain lessened
and he was able to go upstairs and go to sleep. He awoke 1 hour
later w/ tremors and shaking of his "entire body" and worsened
chest discomfort of the same quality, now [**2180-7-24**] in severity.
Reported shallow breathing but denied SOB, nausea, diaphoresis,
vomiting, sweats. Felt cold and was shivering. Wife saw husband
shaking and called 911 and was transported to [**Hospital1 18**].
In the ED, initial vitals were 98.1 95 112/55 14 99% RA. Pt
initially reported tremors and chest pain w/ onset in ED, but on
further questioning noted that CP may have started at home. EKG
was done which showed ST elevations in I, aVL, and V2 w/
infero-lateral ST depressions. Patient was given aspirin 325,
heparin bolus, and nitroglycerin and immediately transported to
the cath lab for STEMI. Labs were notable negative troponin and
creatinine of 2.0.
In the cath lab, patient recieved 600 mg of plavix and 5 mg of
lopressor. Cath was notable for right dominant system w/ 100%
occlusion of mid LAD which was stented w/ a BMS. Also showed 70%
LCx lesion and diffuse disease of the RCA- 50-60%. Pt tolerated
the procedure well and was transported to the CVICU.
On arrival to the floor, patient appeared comfortable and denied
any symptoms of CP, SOB, abd pain, nausea or vomiting. Reported
a little bit of "acid taste" in his mouth.
Past Medical History:
-cirrhosis [**1-17**] NASH
-HCC s/p liver [**Month/Day (2) **] [**4-19**]
-post-operative course complicated by bile duct ischemia,
strictures, requiring bilateral biliary percutaneous drains,
left drain removed [**2179-1-18**] due to leak
-re-placed on liver [**Year (4 digits) **] list
-cardiac tamponade, required pericardiocentesis in [**8-/2178**]
-DM2 > 10 years
-HTN
-parathyroid adenoma s/p parathyroidectomy [**8-21**]
-CRI, recent baseline cr 1.6-1.9, from DM and HTN
-Squamous cell carcinoma in situ of face
Social History:
Very rare Alcohol use, stopped smoking [**2148**]. Retired, was
previously director of Health Services for the Prison Service.
He has three children, and is married
Family History:
Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.
Physical Exam:
ADMISSION EXAM:
VS: T= afebrile BP= 120/65 HR= 89 RR= 17 O2 sat= 97% on 2L
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
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, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site w/ dressing c/d/i. No hematoma or
bruit. No c/c/e.
SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT
DISCHARGE EXAM:
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
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, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site c/d/i. No hematoma or bruit. No c/c/e.
SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT
Pertinent Results:
ADMISSION LABS:
[**2182-8-25**] 08:35PM GLUCOSE-288* UREA N-41* CREAT-2.0* SODIUM-134
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-19* ANION GAP-15
[**2182-8-25**] 08:35PM ALT(SGPT)-60* AST(SGOT)-156* CK(CPK)-633* ALK
PHOS-100 TOT BILI-4.6*
[**2182-8-25**] 08:35PM CK-MB-55* MB INDX-8.7* cTropnT-5.01*
[**2182-8-25**] 08:35PM %HbA1c-6.8* eAG-148*
[**2182-8-25**] 08:35PM tacroFK-6.5
[**2182-8-25**] 08:35PM WBC-5.5 RBC-3.32* HGB-10.9* HCT-32.9* MCV-99*
MCH-32.9* MCHC-33.3 RDW-15.6*
[**2182-8-25**] 12:36PM GLUCOSE-274* LACTATE-1.7 K+-3.5
[**2182-8-25**] 12:36PM freeCa-1.18
[**2182-8-25**] 12:09PM CK-MB-56* MB INDX-7.3* cTropnT-2.98*
[**2182-8-25**] 05:41AM CK(CPK)-34*
[**2182-8-25**] 05:41AM cTropnT-0.01
[**2182-8-25**] 05:41AM CK-MB-2
Left Heart Catheterization [**2182-8-25**]: R dominant system. LMCA w/
mild disease. LAD w/ 100% mid stenosis --> stented (BMS) --> 0%
residual; LCX: separate ostia from right cusp --> 70% mid; RCA:
50-60% disease, diffuse.
2-D ECHOCARDIOGRAM [**2181-8-25**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). The right ventricular
cavity is mildly dilated The aortic root is mildly dilated at
the sinus level. The ascending aorta and aortic arch are mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
PERTINENT DISCHARGE LABS:
[**2182-9-1**] 07:10AM BLOOD WBC-4.4 RBC-2.69* Hgb-9.1* Hct-26.3*
MCV-98 MCH-33.6* MCHC-34.4 RDW-15.6* Plt Ct-109*
[**2182-9-1**] 07:10AM BLOOD Glucose-126* UreaN-65* Creat-2.6* Na-134
K-4.2 Cl-105 HCO3-16* AnGap-17
[**2182-9-1**] 07:10AM BLOOD ALT-38 AST-49* AlkPhos-515* TotBili-4.5*
[**2182-9-1**] 07:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5
Brief Hospital Course:
71 yo M w/ h/o NASH cirrhosis and HCC s/p liver [**Month/Day/Year **], DM
type 2, HTN, and dyslipidemia who presented w/ tremors and CP,
found to have STEMI.
#) Anterior STEMI: Pt presented w/vague h/o CP and was found to
have ST elevations in V1-V2 on EKG w/ reciprocal lateral
depressions. TnT on presentation in ED was negative, but
subsequently peaked at 5.63 and MB peaked at 56 during his
hospitalization. He was loaded with plavix 600mg and taken
urgently to the cath lab and found to have 100% stenosis of the
mid-LAD and 70% stenosis of the mid-circumflex. This was
treated with a BMS to the mid-LAD. Repeat echo showed mild
symmetric left ventricular hypertrophy with preserved regional
and global biventricular systolic function (EF>55%). Dilated
thoracic aorta. Mild mitral regurgitation. Borderline pulmonary
artery systolic hypertension. He was also treated medically
with Aspirin (325mg), Prasugrel 10mg QD, Atorvastatin (ok to use
high dose, per Hepatology), and Metoprolol 25mg PO BID, and
continued his home Terazosin 10mg QHS and cilostazol 100mg PO
BID.
#) CKD: Pt w/ CKD likely [**1-17**] to DM type 2 w/ creatinine at
baseline of 2.0. Did receive 110 mL of contrast during cath and
concern for development of contrast induced nephropathy. He was
given IVF, diuretics were held, and all medications were renally
dosed. His Cr increased to 3.7 during this admission, in the
setting of getting IV contrast during the cath. Nephrology was
consulted and thought this was likely [**1-17**] IV contrast
nephropathy. He was treated with IVF and then diuresis and Cr
was 2.6 on discharge and will be reevaluated on [**9-4**] at his
cardiology f/u appointment.
#) On [**8-28**] he spiked a fever to 102.1 and c/o shaking and
chills. Blood and urine cx were sent and his plasmapheresis
line was removed. The catheter tip and blood cx gram stains
were positive for GNR and grew out Enterobacter cloaca in
culture sensitive to Ciprofloxacin. He was initially treated
with Cefepime and meropenem after consultation with Infectious
Disease. He will be treated for a total of 14 days of
Ciprofloxacin to be discontinued on [**9-10**].
#) NASH Cirrhosis s/p Liver [**Month/Year (2) 1326**]: s/p cadaveric liver
[**Month/Year (2) **] in [**2175-4-16**]. He is currently a candidate for a second
[**Year (4 digits) **] due to biliary strictures in his transplanted liver
though notes he is low on the list. MELD is 20. Dr. [**Last Name (STitle) 497**], his
hepatologist was contact[**Name (NI) **] during this admission and was ok with
him being treated with Atorvastatin 80mg daily. In addition,
tacrolimus was continued with levels checked daily. Rifampin
and bactrim prophylaxis were also continued. His liver tests
were monitored and were elevated on admission to ALT/AST of
104/74 and were 62/144 prior to discharge. He is scheduled to
f/u in [**Name (NI) 1326**] [**Hospital 3585**] clinic.
#)HTN: His BP remained stable during this admission. He was
continued on metoprolol 50 mg [**Hospital1 **] and valsartan 320 mg daily.
His home medications of Terazosin and Cilostazol were also
continued as mentioned above.
#)Dyslipidemia: switch from Simvastatin to Atorvastatin 80 in
setting of acute MI. Zetia was discontinued on this admission.
On this admission, his total cholesterol was 92, HDL 15, LDL 62.
#)DM type 2: Insulin dependent. Historically A1c's have been
well controlled and was 6.8% on this admission. Glargine was
continued during this admission and he was placed on a sliding
scale for meal coverage.
#)Pruritus: Believed secondary to biliary strictures in
transplanted liver. Is on plasmapheresis twice weekly for
symptom relief. Dr. [**Last Name (STitle) **] was updated and he agreed that homoe
ursodiol and naltrexone be continued while inpatient.
#)PAD: home cilostazol 100 mg [**Hospital1 **] was continued and aspirin 325
mg daily was also given.
#)PROPHYLAXIS: He was treated prophylactically with Heparin SQ
and a Senna/Colace bowel regimen.
CODE: Full (confirmed w/ pt)
TRANSITIONAL:
- [**Last Name (un) **] follow up for better blood sugar control
- Mildly dilated ascending aorta on Echo, recommend f/u echo in
[**1-18**] years
- Start ACEI/[**Last Name (un) **] once renal function improved (was on Valsartan
320mg QD prior to admission)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. cilostazol *NF* 100 mg Oral [**Hospital1 **]
2. Ezetimibe 10 mg PO DAILY
3. Felodipine 10 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Lantus *NF* (insulin glargine) 32 Units Subcutaneous QHS
6. insulin lispro *NF* 15 Units Subcutaneous QID
Titrate to meal time FS
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
10. Rifampin 300 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 7 mg PO Q12H
14. Terazosin 10 mg PO HS
15. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
16. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
17. Ursodiol 600 mg PO QAM
18. Valsartan 320 mg PO DAILY
19. Vitamin D [**2169**] UNIT PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. naltrexone *NF* 50 mg Oral DAILY
Discharge Medications:
1. cilostazol *NF* 100 mg Oral [**Hospital1 **] Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
2. Multivitamins 1 TAB PO DAILY
3. naltrexone *NF* 50 mg Oral DAILY
4. Omeprazole 20 mg PO DAILY
5. Rifampin 300 mg PO Q12H
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Terazosin 10 mg PO HS
8. Ursodiol 900 mg PO QAM
9. Ursodiol 600 mg PO QPM
10. Vitamin D [**2169**] UNIT PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN chest pain or SOB
RX *nitroglycerin 0.4 mg 1 Tablet sublingually as needed for
chest pain Disp #*50 Tablet Refills:*0
12. Prasugrel 10 mg PO DAILY
start in AM on [**2182-8-26**]
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
14. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Finasteride 5 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
hold for sbp<110, hr<60
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
18. Tacrolimus 7 mg PO Q12H
19. Ciprofloxacin HCl 500 mg PO Q24H Duration: 14 Days
last day [**9-10**]
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
20. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Acute ST Elevated Myocardial Infarction (Heart Attack)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Mobile with walker.
Discharge Instructions:
Dear Mr. [**Known lastname 4541**],
You were admitted to [**Hospital1 69**] after
presenting with complaints of tremors and chest pain. You were
diagnosed with a heart attack and we urgently performed a
procedure to open the blocked artery by placing a stent in the
artery to keep it open. You were started on a new medication
called Prasugrel which is similar to a "super aspirin" and helps
to keep the artery open after having a stent placed. It is very
important that you take this new medication daily until
instructed to stop by your cardiologist. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]
or stop taking prasugrel unless Dr. [**Last Name (STitle) 171**] tells you it is OK.
You developed an infection of your blood stream from the line
used for Pheresis (done for your itching). This line was removed
and you will need to take an antibiotic, Ciprofloxacin 500mg for
until [**2182-9-10**]. Please call Dr [**Last Name (STitle) 171**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) 26187**] notice any fevers, chills, rashes or any other concerning
symptoms.
Your kidney function worsened after receiving IV contrast, used
to help open the blocked artery in your heart. Your kidney
function improved with IV fluids and with time. You should have
labs checked to assess kidney function two days after discharge.
Results will be sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
The following changes were made to your medications:
START:
Prasugrel 10mg / day
Ciprofloxacin 500mg once/day until [**2182-9-10**]
Atorvastatin 80 mg once daily
Aspirin 325mg once daily
Nitroglycerin 0.4mg SL
STOP:
Simvastatin 10mg daily
Ezetimibe 10mg daily
Felodipine 10mg daily
Triamterene/Hydrocholorothiazide
Valsartan
INCREASE:
Glargine from 32 units at bedtime to 40 units at bedtime
DECREASE:
Metoprolol 50mg twice daily to Metoprolol 25mg twice daily
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-9-4**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: THURSDAY [**2182-9-5**] at 10:15 AM
With: [**Name6 (MD) 1037**] [**Name8 (MD) 5647**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2182-9-4**] at 11:15 AM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Wednesday [**2182-9-4**] 1:30pm
**You did have an eye exam scheduled at [**Last Name (un) **] at this time. We
tried hard to get you to see both around the same time but it
wasnt possibl. We rescheduled the eye exam for [**2182-9-5**] at
9:00am. If you have any questions or concerns please call [**Last Name (un) **]
at the above number.
|
[
"999.32",
"038.9",
"272.4",
"276.1",
"585.9",
"V42.7",
"V58.67",
"698.8",
"995.91",
"403.90",
"038.40",
"414.01",
"E879.8",
"584.5",
"250.40",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"37.22",
"00.66",
"88.56",
"36.06",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
14120, 14171
|
7129, 11441
|
323, 348
|
14269, 14269
|
4954, 4954
|
16413, 17936
|
2774, 2885
|
12476, 14097
|
14192, 14248
|
11467, 12453
|
14441, 16390
|
6762, 7106
|
2900, 3952
|
3968, 4935
|
264, 285
|
376, 2032
|
4970, 6745
|
14284, 14417
|
2054, 2575
|
2591, 2758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,795
| 105,192
|
11716
|
Discharge summary
|
report
|
Admission Date: [**2163-9-15**] Discharge Date: [**2163-10-2**]
Date of Birth: [**2109-3-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
H/A, N/V x3days
Major Surgical or Invasive Procedure:
Transpenoidal pituitary rsxn([**9-21**])
History of Present Illness:
54F c/o H/A in frontal region of head since Tuesday morning
unrelieved with NSAIDS. She began vomiting Tuesday afternoon and
reports nausea and vomiting since. She denies falls or head
trauma. Denies difficulty walking, dizziness.
Past Medical History:
1. Rheumatic heart disease; status post mitral valve replacement
and tricuspid valve replacement in [**2156**] complicated by
postoperative heart block and now status post pacemaker.
2. Dilated cardiomyopathy with an ejection fraction of 40% to
45%.
3. Paroxysmal atrial fibrillation; status post cardioversion.
4. Status post atrial septal defect in [**2133**].
5. Hypertension.
6. Hypothyroidism.
7. Anemia.
Social History:
She is a homemaker and lives with husband and children in
[**Name (NI) 1468**]. Quit smoking 3 years ago, 4pack per year history. No
IVDU, No EtOH
Family History:
Heart disease
Physical Exam:
On Admisson:
Gen: Comfortable, NAD.
HEENT:Atraumatic, Normocephalic Pupils: PERRL EOMs full
Neck: Supple.
Neuro:
Mental status: Awake and alert x3, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-18**] throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: Heel to shin
Exam on Discharge:
AOx3, full strength and power throughout all extremities.
Pertinent Results:
Labs on Admission:
[**2163-9-15**] 10:00AM BLOOD WBC-11.0# RBC-4.15* Hgb-12.1 Hct-35.1*
MCV-85 MCH-29.1 MCHC-34.5 RDW-15.7* Plt Ct-303
[**2163-9-15**] 10:00AM BLOOD Neuts-80.0* Lymphs-15.5* Monos-3.2
Eos-0.9 Baso-0.3
[**2163-9-15**] 10:00AM BLOOD PT-43.3* PTT-33.2 INR(PT)-4.8*
[**2163-9-15**] 10:00AM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-142
K-3.0* Cl-100 HCO3-35* AnGap-10
[**2163-9-16**] 04:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
[**2163-9-15**] 08:04PM BLOOD LH-4.1 Prolact-13 TSH-2.2
[**2163-9-15**] 08:04PM BLOOD T4-7.9 Free T4-1.1
[**2163-9-15**] 08:04PM BLOOD Cortsol-30.2*
[**2163-9-15**] 10:00AM BLOOD Digoxin-0.4*
Labs on Discharge:
[**2163-9-29**] 10:55AM BLOOD WBC-18.3* RBC-4.17* Hgb-12.4 Hct-35.9*
MCV-86 MCH-29.7 MCHC-34.5 RDW-16.1* Plt Ct-458*
[**2163-9-30**] 09:10AM BLOOD PT-23.3* PTT-45.7* INR(PT)-2.3*
[**2163-9-29**] 10:55AM BLOOD Glucose-141* UreaN-14 Creat-0.8 Na-144
K-3.3 Cl-102 HCO3-32 AnGap-13
[**2163-9-29**] 10:55AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.3
Imaging:
Head CT ([**9-15**]):
IMPRESSION: Hyperdense sellar mass extending to suprasellar
region, most
likely a pituitary macroadenoma. MRI of sella would be helpful
for further
evaluation.
Head CTA([**9-15**])
IMPRESSION:
1. Sellar mass with suprasellar extension and potential mass
effect upon the optic chiasm. MRI is recommended if possible to
further evaluate these
structures. Diagnostic possibilities include macroadenoma, with
or without
hemorrhage, and less likely a Rathke's cleft cyst.
2. No evidence of intracranial hemorrhage. However, the density
of hte lesion itself may reflect prior bleeding. Pituitary
apoplexy cannot be excluded on CT imaging. Normal CTA circle of
[**Location (un) 431**].
Cards ECHO([**9-16**])
IMPRESSION: Normal global and regional left ventricular systolic
function. Mild global right ventricular systolic dysfunction.
Mechanical mitral valve prosthesis with borderline-high
gradients. Normally-functioning tricuspid annuloplasty ring.
Mild pulmonary hypetension.
CXR [**9-20**]:
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Unchanged cardiomegaly.
3. Subsegmental atelectasis left lung base.
Head CT [**9-21**]:
NOTE ADDED IN ATTENDING REVIEW:
1) No short-interval change in hyperattenuating, round primarily
intrasellar mass with suprasellar extension, remodeling the
dorsum sellae; dDx includes macroadenoma, perhaps with
hemorrhage, as well as intrasellar
craniopharyngioma or Rathke cyst.
2) Possibly low-lying cerebellar tonsils (unrelated), which
should be
clarified at time of MRI.
Head CT [**9-28**]:
IMPRESSION:
1. No acute intracranial abnormality.
2. Posteroperative chcanges of trans-sphenoidal resection of
pituitary mass, with decreased volume of mass within the sella
turcica.
Brief Hospital Course:
Patient was admitted on [**9-15**] via ED with complaint of Nausea and
vomiting for three days. Head ct was performed and a pituitary
mass identified.
Dx:Non-hem. pituitary lesion. After adequate work up and
consults with opthomology for visual field testing and
endocrinology, transpenoidal pituitary resection was conducted
on [**9-21**]. Post operatively her neuro exam was completely intact,
but there was question as to her pacemaker working appropriated.
It was interrogated, and deemed appropriate. Diuretic therapy
was withheld for several days post operatively to ensure the
absence of DI symptoms. She was restarted on Lasix on [**9-28**] at
60mg twice daily, as she appeared to be adequately diuresed
after surgery. Serum sodium and osm, as well as urine sodium,
osm, and specific gravity remained stable during
hospitalization, only requiring one dose of vasopressin on
POD#3. On POD#5, systemic heparin drip was started for her
mechanical valve. Coumadin was restarted on [**2163-9-27**]. She
received the following doses, 10mg, 10mg, 15mg, and 5mg during
her hospitalization. On [**10-2**] she was discharge to home without
the need of services with a INR of 2.5 and direction to follow
up with PCP on [**Name9 (PRE) 766**] AM for blood drawing to ensure adequate
INR level.
Medications on Admission:
Levothyroxine 75mcg', Digoxin 125mcg', Lopressor 50mg", Cartia
XT 120mg', Lisinopril 20mg', Lasix 120mg',Coumadin 5mg', Lipitor
10mg'.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1)
Injection once a day: Inject into the muscle daily on days that
you feel ill and/or unable to take your oral steroid medication.
Disp:*QS 4 doses* Refills:*0*
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
*Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You may continue to take your oral anticoagulation as
prescribed before hospitalization. Please be sure to follow up
with your PCP in the next couple days for blood drawing to
ensure an appropriate blood level
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
If on any day you do not feel well enought to take your oral
steriods; be sure to take the injection version as prescribed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
You also have the following appointments scheduled:
Endocrine:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37077**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2163-10-14**] 4:00
|
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icd9cm
|
[
[
[]
]
] |
[
"07.62"
] |
icd9pcs
|
[
[
[]
]
] |
8246, 8252
|
5200, 6494
|
336, 379
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8311, 8335
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2439, 2444
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9669, 10118
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1257, 1272
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8273, 8290
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6520, 6657
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8359, 9646
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1287, 1404
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280, 298
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3087, 5177
|
407, 640
|
1659, 2341
|
2360, 2420
|
2458, 3068
|
1419, 1643
|
662, 1074
|
1090, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,708
| 128,275
|
38276
|
Discharge summary
|
report
|
Admission Date: [**2132-7-9**] Discharge Date: [**2132-8-8**]
Date of Birth: [**2075-10-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain and LE pain
Major Surgical or Invasive Procedure:
[**2132-7-8**] EXPLORATORY LAPAROTOMY, EVACUATION OF HEMATOMA, REPAIR
OF BLADDER LACERATION, APPLICATION OF OPEN ABDOMINAL DRESSING
[**Doctor Last Name **]
[**2132-7-11**] ABDOMINAL EXPLORATION AND CLOSURE; REPOSITIONING OF
PELVIC DRAIN; ORIF RIGHT TIBIAL PLATEAU FRACTURE; ORIF LEFT
PELVIC FRACTURE WITH PERCUTANEOUS SCREW [**Doctor Last Name 1005**]
[**2132-7-16**] IVC FILTER FEMORAL PERCUTANEOUS ATTEMPTED AND ABORTED,
BRONCHOSCOPY WITH BRONCHOALVEOLAR LAVAGE
History of Present Illness:
56 year old female who reprtedly jumped ~15-20 feet in a
possible suicide attempt. Initially she complains lower
extremity pain abdominal pain.
Past Medical History:
Schizophrenia, DM, hyperlipedemia, COPD
Past Surgical History: total hysterectomy
Social History:
lives independently, funded by Advocates Supported Housing
agency, 1-2 visits to psych per month
Family History:
Noncontributory
Physical Exam:
ON ADMISSION
HR:108 BP:110/58 O(2)Sat:98 normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, tender abdomen no rebound no guarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema\nbilateral ankle
pain with diffuse tenderness d Dp 2+
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2132-7-8**] 09:35PM BLOOD WBC-12.8* RBC-4.29 Hgb-13.0 Hct-38.3
MCV-89 MCH-30.3 MCHC-33.9 RDW-14.5 Plt Ct-328
[**2132-7-8**] 09:35PM BLOOD Neuts-77.4* Lymphs-17.7* Monos-3.7
Eos-0.7 Baso-0.6
[**2132-7-8**] 09:35PM BLOOD PT-13.2 PTT-21.9* INR(PT)-1.1
[**2132-7-8**] 09:35PM BLOOD Glucose-200* UreaN-33* Creat-2.9* Na-138
K-5.5* Cl-105 HCO3-21* AnGap-18
[**2132-7-9**] 03:06PM BLOOD ALT-24 AST-57* LD(LDH)-391* CK(CPK)-970*
AlkPhos-23* TotBili-1.7* DirBili-0.9* IndBili-0.8
[**7-12**] CT head:
1. ? tiny SAH L frontal lobe w/o mass effect or shift.
Subcortical white matter hypodensity b/l nonspecific,
?demyleniting process
or chronic microvascular ischemic disease. unclear if
hyperdensity L inf frontal lobe is artifact. subtle meningeal
thickening or artifact in L frontal region. ? R temple hematoma.
unclear if hyperdensity L inf frontal lobe is artifact. subtle
meningeal thickening or artifact in L frontal region.
[**7-8**] Imaging:
CT Cspine: No acute cervical fracture or malalignment. Large
C5-C6 posterior osteophyte with moderate central canal narrowing
CT abd:
bladder rupture, + active extrav.
L sacral fx to the neural foramen. B/L sup/inf pubic rami fxs.
Fx L5 L transverse process Subcu air adj to the R lat 9th rib, ?
non-displaced fx, though no definite fracture seen.
Congenital partial duplex left kidney with mild hydronephrosis
in the upper pole moiety. Tiny pneumomediastinum, of uncertain
clinical significance. L adrenal nodule which can be further
characterized by dedicated MR [**First Name (Titles) **] [**Last Name (Titles) **] adrenal protocol. Two small
hepatic hemangiomas.
Bilateral thyroid nodules. Correlate clinically with thyroid
function tests and an ultrasound can be obtained for further
evaluation on a non-urgent basis.
MR [**Name13 (STitle) 430**] [**2132-7-14**]
IMPRESSION:
Moderate white matter changes which could represent small vessel
ischemic
disease in the setting of underlying hypertension or diabetes.
Appearance is nonspecific, however, and differential would
include demyelinating disease, vasculitis, Lyme disease or
sarcoid.
Mild sulcal hyperintensity which could represent a small amount
of
subarachnoid hemorrhage.
No evidence for hypoxic ischemic injury.
CT Cystogram
IMPRESSION:
1. No evidence of bladder leak, at the site of prior rupture,
with note made of suboptimal evaluation of anterior bladder
wall. Anterolateral mural irregularity on the left likely
reflects post-surgical change.
2. Slight left sided vesical-ureteral reflux.
Brief Hospital Course:
Presented to ED, initially hemodynamically stable, with obvious
deformity to left lower extremity. She had a positive FAST exam
and became hypotensive requiring large amounts of blood products
as well as crystalloid resuscitation. She received 10 units
pRBCs in the ED, 3 units of FFP, 2 units of platelets, and
approximately 10 liters of normal saline. In the ED, she had
remarkably bloody UOP and became hypotensive into the 50s. A
Cordis line was placed. CT scan of the torso [**7-8**] demonstrated:
bladder rupture, + active extrav. L sacral fx to the neural
foramen. B/L sup/inf pubic rami fxs. Fx L5 L transverse process
Subcu air adj to the R lat 9th rib, ? non-displaced fracture,
though no definite fracture seen. Congenital partial duplex left
kidney with mild hydronephrosis in the upper pole moiety. Tiny
pneumomediastinum, of uncertain clinical significance. On her
imaging and trauma evaluation she was noted to have the
following injuries:
-Bladder rupture
-Left LC1/2 with bilateral upper and lower pubic rami fx, ?
extends into acetabulum
-Left sacral zone III fx
-Left lumbar TP fx
-Bilateral calcaneal fx
-Left lateral malleolus fx
-Left [**3-14**] MT head fx
-Right Schatzker II tibial plateau
The patient went to interventional radiology for her multiple
pelvic fractures and bladder rupture and had an aortogram to
evaluate for extravasation however the study was negative and no
intervention was performed.
On [**7-9**] she was taken to the OR for ex-lap, evacuation of
hematoma, repair of bladder rupture, abdomen open for delayed
closure. She tolerated the procedure well and remained on neo
most of the day, with adequate UO. She was taken back to the OR
on [**7-11**] for left pelvis pinning, repair of right tibial plateau,
and abdominal closure. She was returned to the Trauma ICU.
For ~ a week she was persistently febrile up to 102 F and on CXR
was found to have a left retrocardiac opacity; she was started
on Vancomycin and Zosyn. Her sedation was weaned and she was
slow to awaken; Neurology was called who recommended a repeat
Head CT which did not show any significant findings. An MRI of
the head was then performed which did not demonstrate any
obvious deficits.
On [**7-15**] she was extubated, but failed requiring re-intubation. An
IVC filter was placed and the patient was kept intubated, a
bronchial lavage was performed for continued fevers. She was
eventually extubated and did well, she was continued on her tube
feeds in the ICU as she was unable to adequately swallow on her
own. Her home medications were started after the patient was
identified and medical history were confirmed.
Given her continued fevers and cultures demonstrating yeast in
the urine and sputum her antibiotics were restarted. She was on
vanc/zosyn. Fluconazole was started on [**7-18**]. On [**7-18**] she was
transferred out of the ICU to the floor.
On [**7-20**] she had respiratory distress, a code was called
requiring rapid intubation and was returned to the ICU. On
[**7-21**] her antibiotics were discontinued and she was successfully
extubated. She later was transferred to the floor again. ENT
was consulted for hoarseness and concern for vocal cord injury.
it was felt he the hoarseness was due to multiple intubations
and no further interventions were recommended.
She was followed by Psychiatry and Social work for ongoing
assessment and counseling for concerns surrounding the nature of
her trauma. She initially required 1:1 sitters; there were no
observed or reported suicidal behaviors. She has not displayed
any behavioral problems and has consistently been cooperative
with her care. Her home psychiatric meds were continued.
Because of her orthopedic injuries she is non weight bearing on
both legs. Physical and Occupational have worked closely with
her teaching bed to chair transfers for which she is
independent. she will follow up in [**Hospital 1957**] clinic in 2 weeks to
determine if she will need further operations.
Medications on Admission:
- ativan 0.5 mg [**Hospital1 **]
- flonase 2 sprays qd
- Glyburide 7.5 mg [**Hospital1 **]
- gemfibrozil 600 mg [**Hospital1 **]
- metformin 1000 mg [**Hospital1 **]
- simvastatin 40 mg qpm
- cogentin 1mg [**Hospital1 **]
- zyprexa 20 mg qhs
- prolixin liquid 25mg/5ml (5mg/1ml)
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) MG
Subcutaneous Q12H (every 12 hours).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
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 wheezing/sob.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing/sob.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
9. Fluphenazine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall/jump from ~15-20 ft
Bladder rupture
Urinary retention
Bilateral inferior/superior rami fractures
Depressed right tibial fracture
Bilateral calcaneal fractures
Left lateral malleolus fracture
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 hospitalized following an injury sustained after a
reported fall/jump from a great height. You required several
operartons to repair your injuries and will likely require
furhter operations at a later date by orthopedics.
As a result of your bladder injury a foley catheter was
required, several attempts at having this removed have resulted
in failure to urinate s othat the foley catheter needed to be
replaced. You were put on a meication called Flomax to help with
urine flow and will needto follow up in [**Hospital 159**] clinic in [**2-13**]
weeks for further testing.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 85162**] trauma,
call [**Telephone/Fax (1) 1228**] for an appointmnent.
Follow up in 2 weeks with Urology, call [**Telephone/Fax (1) 164**] for an
appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2132-8-8**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
] |
10132, 10231
|
4327, 8317
|
338, 806
|
10475, 10475
|
1793, 2279
|
11261, 11667
|
1217, 1234
|
8647, 10109
|
10252, 10454
|
8343, 8624
|
10650, 11238
|
1066, 1087
|
1249, 1774
|
272, 300
|
834, 980
|
2288, 4304
|
10490, 10626
|
1002, 1043
|
1103, 1201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,981
| 122,270
|
30486
|
Discharge summary
|
report
|
Admission Date: [**2130-3-27**] Discharge Date: [**2130-4-13**]
Date of Birth: [**2074-12-21**] Sex: F
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Washout of L prosthetic hip
Washout of L knee x 2.
Debridement of epidural abscesses.
Transesophageal echocardiogram
Placement of R IJ central line
Placement of L antecubital PICC line.
History of Present Illness:
55 yo F s/p L hip replacement 3 years ago now transfered from
[**Hospital6 **] with MSSA bacteremia with evidence of
infection of L hip, possible L knee, lumbar spine, urine, blood,
and emboli to brain.
.
Pt states she was in her USOH until [**3-5**] when she drove her son
to college. States she began having left lower back pain
radiating to L leg. Per her husband she had not previously been
on narcotics, but was given several prescriptions after a few ED
visits, neurology visit, and PCP visit in the past few weeks for
this pain. She states that leading up to [**3-22**] she had noticed
some chills and nausea. She also had a severe headache and some
neck stiffness. Her family states she was not eating or drinking
much at all. She denies bowel or bladder incontinence but states
sometimes she would have to cough to get her urine stream to
start. States over the 3 weeks she felt her legs getting weaker
L>R. On [**2130-3-22**] pt drove to [**Hospital3 **] for a bone scan
that had been ordered by her neurologist. Her WBC count had been
elevated and there was concern for myeloma vs. infection.
However, she only finished the 1st half of the scan and then
drove home. She was found on the front step of her house by her
neighbor struggling to get in the front door with altered mental
status. It was not known how long she had been sitting there.
She complained of bilateral leg weakness with pain in her left
lower back that radiated down her L leg. EMS reports her BP was
low at 90/68 and initially improved with NS but then decreased
again. At [**Hospital3 **] she was found to have rhabdomyolysis with
a CK of 3738 and a WBC of 16. Na was 119 and Cl was 87. Cr was
elevated at 3.8 (baseline 1.1) and UTI was diagnosed. CXR showed
bilateral infiltrates. Ddimer was positive but V/Q scan was low
prob for PE. She was started on levofloxacin and vancomycin as
well as hydrocortisone for the hypotension. Head CT showed
embolic disease. She began spiking fevers and blood cultures and
urine culture grew out MSSA. She complained of back and L hip
pain and a fluid collection was seen in the hip and aspiration
showed 66,000 WBC's and grew out MSSA as well. Lumbar MRI
possible epidural abscess L2-4. Troponin was initially 0.04 but
then became elevated and peaked at 17.19 on [**3-24**]. This was felt
to be an NSTEMI in the setting of demand from septic shock. She
was started on aspirin and beta-blocker. Renal failure resolved
with fluids.
.
On admission to MICU pt c/o severe lower back pain radiating
down L leg. States L knee is very painful and she cannot move
the L leg much [**2-10**] pain. Pt states her MS was initially poor but
has since cleared and she is now at baseline with regards to
mental functioning.
Past Medical History:
-HTN
-sciatica (was diagnosed 6-7 years ago, but pt states she has
not had any back pain since then until [**3-5**].)
-s/p left hip replacement 3 years ago.
-h/o cervical cancer s/p XRT 4 years ago.
-h/o Barrett's esophagus in the distant past.
Social History:
Lives in [**Hospital1 3597**] with husband and daughter. Denies smoking, ETOH,
or drugs.
Family History:
Father died at 61 with heart disease. Mother is in a nursing
home
Physical Exam:
Admission exam:
PE: 100.2, 131/71, 105, 20, 96% on RA
GEN: slightly somnolent but arouses to voice.
HEENT: PERRLA, EOMI. Mouth extremely dry with cracked lips and
dried blood on tongue.
Neck: supple, no LAD. Excoriation under chin (pt states was from
C-collar that was initially placed by EMS)
CV: tachy, regular, no m/r/g
Abd: obese, s/nt/nd, +bs
Ext: well healed scar on lateral aspect of L hip. Legs are puffy
bilaterally but no edema.
Neuro: A&Ox3. CN 2-12 in tact. Strength 5/5 in UE's bilaterally.
4+/5 in R leg, 2+/5 in hip flexors, 2+/5 in hamstrings and quads
(exam limited by pain). Pt has extreme pain on passive bending
of L knee. Ankle dorsi- and plantar-flexion [**5-13**] bilaterally.
Sensation in tact to LT throughout except on ball of L foot
which pt states is decreased. Toes upgoing bilaterally.
Rectal: good tone. Guaiac positive brown stool.
Pertinent Results:
Studies from Caritas [**Hospital6 5016**]:
.
CXR [**2130-3-22**]: diffuse infiltrates suspected for pneumonia.
.
Pelvis AP view [**2130-3-22**]: multiple surgical clips noted. Possible
LN dissection. Prosthetic L hip and acetabulum.
.
2 views of L shoulder [**2130-3-23**]: normal.
.
V/Q scan: low prob for PE.
.
Renal ultrasound [**2130-3-24**]: normal.
.
CT chest without contrast [**2130-3-24**]: patchy streaky densities in
the lung bases posteriorly on both sides probably small zones of
atelectasis or scarring. Some minimal thickening of the pleura
posteriorly especially at the R lung base. No pleural effusions
or confluent consolidations.
.
TTE [**2130-3-24**]: LVEF 60%, mild hypokinesis of RV infervior wall. 1+
TR, borderline pulm HTN. No vegetations seen.
.
MRI head [**2130-3-24**]: Wet read: multiple old [**Male First Name (un) 4746**] infarcts. R temp and
occipital cortical infarcts - acute. No enhancement.
.
MRI lumbar spine: DJD L2-3, [**3-12**], [**4-13**]. Marked stenosis of L3-4.
Large cyst in R hemipelvis - ?R ovarian cyst. s/p hysterectomy.
.
CXR [**2130-3-25**]: Streaky bilateral basilar atelectasis.
.
MRI c/t/l spine [**2130-3-26**]: Wet read: C-spine - unremarkable.
T-spine: enhancing lesion (intraderual, extramedullary) upper to
lower thoracic spine with anterior displacement of the spinal
cord, suspicious for tumor vs. infection vs. vascular
malformation. L-spine: extension of the enhancing lesion in the
dura to the upper lumbar spine. Multilevel DJD most prominent at
L3-4 with central canal stenosis.
.
CT abdomen/pelvis without contrast and CT guided aspiration of L
hip joint [**2130-3-25**]: Mild to moderate ileus - no acute
intra-abdominal abnormalities. CT guided biopsy performed.
.
MRI TLS spine [**4-3**]: T spine limited by movement, 1.
Spondylodiscitis at the L2/L3 through the L5/S1 levels with
large epidural
abscesses extending from the L2 to the S1 levels causing mild
canal stenosis at the L1 and L2 levels and moderate-to-severe
canal stenosis at the L4 and L5 levels. This appears not
significantly changed since [**2130-3-24**].
2. Extensive right psoas muscle and left erector spinae muscle
abscesses which are worsened since [**2130-3-24**].
3. Leptomeningeal enhancement of the conus and well as the
pachymeningeal enhancement of the thecal sac, as before,
concerning for subarachnoid vs subdural abscesses.
Labs from [**3-27**] before transfer:
WBC 12.5 (93.7% polys, 4.7% lymphs), Hct 28.5, Plt 316, Na 130,
K 3.7, Cl 99, CO2 27, BUN 19, Cr 1.0, Ca 7.3, t.bili 2.1, dir
bili 0.6, alk phos 87, ALT 36, AST 46, Alb 1.1, t.prot 5.9, trop
4.41 (trend 0.04 on admission -> 11.54 on [**3-23**] -> 17.19 on [**3-24**]
-> 6.35 on [**3-26**] -> 4.41 on [**3-27**]). INR 1.2.
BNP 379. LDL 98.
.
Culture data from OSH:
.
aspiration [**2130-3-25**]: gm stain negative, fluid culture: moderate
growth of Staph aureus, resistant to penicillin but sensitive to
oxacillin and all others.
.
Blood cultures:
[**3-22**]: Staph aureus (grew in <24 hours) in [**4-12**] bottles. R to
penicillin but [**Last Name (un) 36**] to all others inc oxacillin.
[**3-27**]: MSSA
.
U/A on admission [**2130-3-22**]: large blood, 100 protein, large LE,
innumberable RBC's and WBC. [**2-13**] epithelial cells, many bacteria.
.
Urine culture:
[**3-22**]: Staph aureus >100,000 CFU/ml. R to penicillin but [**Last Name (un) 36**] to
all others inc oxacillin.
.
[**3-28**]: Knee and hip fluid: MSSA.
.
ECG [**2130-3-27**]: sinus tach at 115, RBBB. Downsloping ST depressions
in I, avL. Q in III, AVF. T wave inversions with downsloping ST
segments in V1-V5.
.
Studies at [**Hospital1 18**]:
.
TEE [**2130-3-29**]: Mobile, linear echodensity as described above on
the aortic valve as described above. Though atypical in
appearance and location, this abnormality is consistent with a
vegetation.
.
TTE [**2130-3-30**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. mild symmetric LVH. LVEF 60-70%. RV size
and free wall motion nml. No AR. Trivial MR. 2+ TR.
Trivial/physiologic pericardial effusion.
.
Bilateral LENI's [**2130-3-29**] and [**2130-3-31**]: no evidence of DVTs.
.
MRI C-spine [**2130-3-31**]: No evidence of epidural abscess or abnormal
pathologic enhancement within the cervical spine.
.
MRI T and L-spine [**2130-4-2**]: Spondylodiscitis at the L2/L3 through
the L5/S1 levels with large epidural abscesses extending from
the L2 to the S1 levels causing mild canal stenosis at the L1
and L2 levels and moderate-to-severe canal stenosis at the L4
and L5 levels. This appears not significantly changed since
[**2130-3-24**].
2. Extensive right psoas muscle and left erector spinae muscle
abscesses which are worsened since [**2130-3-24**]. Leptomeningeal
enhancement of the conus and well as the pachymeningeal
enhancement of the thecal sac, as before, concerning for
subarachnoid vs subdural abscesses.
.
MRI T and L-spine [**2130-4-8**]: Status post laminectomies from L2 to
S1 level with decrease in epidural abscess. Some residual
epidural fluid collection is seen at L2 and L4 level as
described above. Area of low signal at the laminectomy site
within the surgical cavity, which compresses the thecal sac from
posterior aspect could be due to blood within the surgical
cavity or postoperative fluid collection. A drain is identified
within this cavity. Leptomeningeal and pachymeningeal
enhancement is seen in the lumbar thecal sac. Right psoas
abscess is again identified and is unchanged.
.
[**2130-4-10**] 6:34 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed 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.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
A/P: 55 yo F with h/o L hip replacement and DJD of lumbar spine
now with MSSA bacteremia with infection of urine, L hip, L knee,
intradural/epidural abscesses, aortic valve, psoas and erector
spinus muscle abscess, and emboli to brain:
.
# MSSA bacteremia: unclear etiology - could have started with
skin infection that seeded hip and then to other areas
afterwards. Use of steroids in setting of infection likely
allowed for further spread. Pt will need to be treated with
nafcillin 2g IV q4 indefinitely given extensive spread of
infection. She will follow up with Dr. [**Last Name (STitle) 9404**] in ID and needs
to have weekly labs sent to him (see page one). Kidney function
especially needs to be watched given Cr is rising, however, ID
has stated that they would only consider changing nafcillin if
kidneys severely worsened given that it is such a superior [**Doctor Last Name 360**]
would prefer not to change unless absolutely necessary. At [**Hospital1 18**]
all blood cultures were NGTD since [**3-28**]. No longer checking
surveillance cultures since would not change management. Picc
placed [**4-3**] for long-term nafcillin.
.
# L hip infection and L knee infection: MSSA grew out of hip and
knee. Ortho consulted - washed out knee and hip on [**3-28**].
Returned to OR for washout of knee only given purulent drainage
and persistent pain on [**4-1**]. Last procedure on L knee was [**4-1**]
so is now POD #12 on [**4-13**]. As for the hip, last procedure was
[**3-28**] so she is now POD #16 on [**4-13**]. Both L hip and knee staples
need to be removed on [**2130-4-14**]. Of note the hip has still be
having some serosanguinous fluid drainage which needs to be
watched and if it is accumulating rapidly Dr.[**Name (NI) 8091**] office
needs to be notified at [**Telephone/Fax (1) 72428**]. Dry sterile dressings
should be placed over this wound, while the knee can be kept
open to air. Follow up with Dr. [**Last Name (STitle) **] is arranged for [**4-27**].
.
# Epidural/Intradural abscess: Neurosurg and ortho spine had a
combined conference to discuss and felt that INTRAdural abscess
spanned T3-L3 and that debridement would be too morbid and pt
would not tolerate. However epidural abscess in L3-S1 was able
to be drained so ortho spine (Dr. [**Last Name (STitle) 1352**]) took to the OR on
[**4-5**] and drained abscess. C-spine negative for abscess. Given
weakness, per neuro recs who discussed with ID started steroids
dexamethasone 10 mg IV x1 and the 4 mg Q6H. Given pt responded
with likely steroid induced psychosis on second day, cut dose in
half and cut in half again - has been doing well since.
Currently on steroid taper - on prednisone 20mg to be tapered
quickly per page one. Dry sterile dressings should be placed on
the wounds and the staples should be removed on [**2130-4-17**]. If the
wound is worsening or problems arise, please contact Dr. [**Last Name (STitle) 1352**]
at [**Telephone/Fax (1) 72428**]. Pt has followup with Dr. [**Last Name (STitle) 1352**] on [**4-27**].
.
# psoas/erector spinae abscesses: First detected on MRI done
[**4-2**] (was not present on films from OSH). Not drainable by IR
(felt that there were too many little abscesses and putting a
drain in one or two would not help). Consulted surgery but they
also felt no intervention would be helpful. Ortho spine and ID
agreed need to reimage with possible CT in 2 weeks to determine
if abscesses are enlarging and would be amenable to drainage. Pt
had a very difficult time tolerating MRI's so it was hoped that
a CT with contrast could be used, however, now that her Cr is
worsening this may not be an option and an MRI might need to be
used. This scan needs to be completed before the patient sees
Dr. [**Last Name (STitle) 9404**] in ID on [**5-2**].
.
# Anasarca: pt was given over 30 L of fluid and blood and now
has anasarca with impressive edema in bilateral legs and arms.
It is likely that the edema is making movement more difficult.
On [**4-12**] she was given a dose of 20mg IV lasix with albumin, and
had some urine output, but Cr subsequently increased from 1.3 to
1.5. The plan is now to place TEDS/ACE bandages on her lower
extremities to try to squeeze some of the fluid into her
vasculature to help diuresis. Once her Cr improves or becomes
more stable trials of lasix may be done again.
.
# Pain management: initially was placed on dilaudid PCA with
boluses but after surgery in knee, hip, and epidural abscesses
pain seemed to improve. Pain has improved and she has been
transitioned to a fentanyl patch with oxycodone for breakthrough
pain (needs be used before turning and moving as this is when
pain is worst). This should be titrated as needed.
.
#Emboli in brain: OSH films were shown to radiology at [**Hospital1 18**] who
agreed was concerning for embolic strokes. Has evidence of
vegetation on aortic valve. Concern for abscess in brain by
neuro but neuro exam has improved and not worsened so feel that
repeat MRI would not change management currently. Dr. [**Last Name (STitle) **]
with neurology needs to see patient in followup - please call to
arrange this (Dr.[**Name (NI) 11858**] office was unavaiable on pt's d/c
to rehab).
.
# Diarrhea: was concerning for c.diff and pt was empirically
started on flagyl for a few days but stool samples returned
negative x 3 so flagyl was stopped.
.
# hyponatremia: Na was initially 116 at OSH, has improved to
135. Likely was from volume depletion since pt and family state
she has not been eating or drinking for last few weeks. She was
bolused with NS aggressively and hyponatremia corrected.
.
# ARF/urinary tract infection: bump in Cr from 1.1 to 1.3 to
1.5. urine eos were rare positive on repeat again rare positive
eos. UA showed 50WBC and grew out [**Last Name (LF) 23087**], [**First Name3 (LF) **] foley changed and
resent - again >50wbc. ID initially suspected not UTI but rather
AIN causing white cells in urine given culture grew only [**First Name3 (LF) 23087**].
Concern for prerenal versus AIN versus to ACE inhibitor - d/c'd
lisinopril. Given clear superioroity of nafcillin to vanco will
try to keep nafcillin as long as possible. Cr was improving s/p
d/c of lisinopril and improvement of fluid status (s/p many
boluses of fluid and blood after OR) but then in the last 2 days
has worsened (1.3 to 1.5). This was in the setting of trying to
diurese with lasix. This needs to be followed very carefully
with possible need for renal consult in the near future. Current
plan is to hold off on lasix and see if Cr stabilizes. Since Ua
was positive and urine culture grew out citrobacter, ID
recommended treating with ciprofloxacin for 7 days (day 1 [**4-13**]).
Another isolate was also seen on this urine culture and
identification is still pending and needs to be followed up on.
.
# Anemia: pt was persistently guiaic positive on exam. Possible
stress ulcer in setting of severe illness. Hemolysis labs
negative. Was given 2 units pRBC's on [**3-28**] and bumped from 24 to
33, but then trended back down to 24 on [**3-30**] and was given 1
more unit pRBC's. given 2uprbc on [**4-3**]. Given one further unit
before discharge on [**4-13**]. She was started on protonix 40mg IV
bid, switched to PO lansoprazole [**Hospital1 **]. Consulted GI to consider
scope, but they wanted to hold off for now given Hct has been
relatively stable and still in peri-MI setting. Hct should be
checked at least every other day for now, especially while
guaiacs are positive.
.
# h/o NSTEMI at OSH: was attributed to demand in setting of
hypotension and tachycardia. trop peaked at 17. ECG at [**Hospital1 18**]
shows downsloping ST segments with T wave inversions. tte
showeed no focal WMA. TEE showed vegetation only. Cardiology
consulted and [**Hospital 72429**] medical managment for now given overall
illness. She was started ASA 325mg po daily on [**3-30**]. BB and high
dose statin started per cardiology. Initially started ACEi but
then d/c'd given ARF. Daily ECG's were relatively unchanged.
.
# Dry mouth/dried blood on tongue and lips: likely from
dehydration with poor po intake. INR slightly elevated at 1.3 -
likely from nutritional deficiency. placed dobhoff with TF for
nutritional improvement. Mouth swabs to keep mouth moist. Needs
aggressive mouth care. Viscous lidocaine was initially used to
help with pain and sore throat but this has improved and
lidocaine has not been needed. Gave 5mg po vitamin K x 3 days on
arrival - INR corrected.
.
# Anxiety/depression: all of these events were very stressing to
the patient and she became very anxious. She was started on
paroxetine to help with this and also was given ativan prn. The
ativan was felt to be helpful and on the day of discharge this
was changed to clonazepam tid.
.
# Access: very poor peripheral access. IV was not able to place
peripheral. Central line placed [**2130-3-27**] to allow for blood draws
and antibiotics - was d/c'd [**4-11**]. Picc placed [**4-3**].
.
# FEN: given low albumin and very poor intake placed dobhoff
tube and started tubefeeds per nutrition recs.
.
# PPx: checked q3d lenis x 2 which were negative, heparin sq and
pnaboots. ppi, bowel regimen.
.
# Comm: with patient and family (husband and 2 daughters). Pt
states her eldest daughter is HCP. [**Name (NI) **] below.
.
# SW consult for pt/family coping given very grim prognosis and
inability to discuss this with patient given she becomes very
upset and emotional at beginning of any conversation which
involves likely poor outcome. Her coping improved throughout the
hospitalization, and it was explained that her condition carries
a very large mortality.
.
# Full Code.
Medications on Admission:
*per patient and family before the back pain started 3 weeks ago
she was only on:
-lisinopril unknown dose
-prilosec daily
*in the last few weeks she had been prescribed the following by
various physicians:
-gabapentin 300mg po tid
-diazepam 5mg po q8
-prednisone on a tapering dose at 50mg, finishing the last dose
on [**3-22**]
-diclofenac 75mg po bid
-hydrocodone 1-2 tabs po q4
-oxycodone 1 tab po q6
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Simvastatin 40 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: 5,000 units
Injection TID (3 times a day).
5. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
6. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Year (2) **]: One (1) Appl Topical
QID (4 times a day) as needed.
7. Paroxetine HCl 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
8. Quetiapine 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
10. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a
day).
11. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
12. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
14. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 2 days: last dose 4/6. .
15. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 2 days: [**Date range (1) 72430**]. .
16. Prednisone 5 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily)
for 2 days: [**Date range (1) 52620**]. .
17. Clonazepam 0.5 mg Tablet [**Date range (1) **]: One (1) Tablet PO TID (3 times
a day): hold for somnolence or RR<12.
18. Nafcillin 2 gm IV Q4H
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Date range (1) **]: Two
(2) ML Intravenous daily prn as needed: 10 ml NS followed by 2
ml of 100 Units/ml heparin (200 units heparin) each lumen Daily
and PRN. Inspect site every shift. .
20. Prochlorperazine Edisylate 5 mg/mL Solution [**Date range (1) **]: 5-10 mg
Injection Q6H (every 6 hours) as needed.
21. Cipro Oral
22. Ciprofloxacin 500 mg Tablet [**Date range (1) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
MSSA bacteremia with bacterial infections of:
L knee s/p washout
L prosthetic hip s/p washout
epidural/intradural abscess
psoas and erector spinae abscess
aortic valve vegetation
emboli to brain
urinary tract infection.
Infections above complicated by:
anemia - likely [**2-10**] GI bleed
NSTEMI
ARF
hyponatremia (resolved)
diarrhea
anasarca
Discharge Condition:
stable.
Discharge Instructions:
Renal function has been changing and will require daily
monitoring. Please see d/c summary for more details.
Followup Instructions:
Please keep the following follow up appointments - they are very
important. All of these appointments are at [**Hospital1 18**].
1) Ortho spine - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] - Thursday [**4-27**] at 8:35
a.m. [**Telephone/Fax (1) 72428**] on the [**Location (un) **] in the [**Hospital Ward Name 23**] building.
2) Ortho knee/hip - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - Thursday [**4-27**] at
10:00 a.m. [**Telephone/Fax (1) 72428**] on the [**Location (un) **] in the [**Hospital Ward Name 23**] building
(same suite as the appointment with Dr. [**Last Name (STitle) 1352**]).
3) Infectious disease - [**5-2**] at 11:00 a.m. with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 9404**], MD
[**Telephone/Fax (1) 457**] in the [**Hospital Unit Name **]. Weekly labs CBC with diff,
BUN and Cr, LFT's, need to be faxed to Dr. [**Last Name (STitle) 9404**] at
[**Telephone/Fax (1) 1419**]. Before this visit, the patient needs to have
repeat imaging of her Psoas abscess - a CT with contrast vs. MRI
- need to consider renal function before deciding which test
should be done. Be aware that pt needs to be heavily sedated
before MRI's.
4) Neurology - Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] - please call [**Telephone/Fax (1) 541**]
and ask for [**Doctor First Name 6480**] to schedule the appointment (will be in
approx 6 weeks but please call soon as appointments fill up
quickly).
|
[
"038.11",
"720.9",
"724.3",
"996.67",
"410.71",
"567.31",
"292.81",
"E932.0",
"349.82",
"428.0",
"324.0",
"711.06",
"527.7",
"V15.3",
"V10.05",
"276.51",
"584.9",
"599.0",
"280.0",
"324.1",
"434.11",
"E878.1",
"995.92",
"421.0",
"401.9",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"03.09",
"96.6",
"80.76",
"80.16",
"99.04",
"80.15"
] |
icd9pcs
|
[
[
[]
]
] |
23963, 24010
|
11513, 21140
|
281, 469
|
24397, 24407
|
4586, 10107
|
24564, 26076
|
3619, 3686
|
21596, 23940
|
24031, 24376
|
21166, 21573
|
24431, 24541
|
3701, 4567
|
232, 243
|
10142, 11490
|
497, 3229
|
3251, 3497
|
3513, 3603
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,670
| 190,137
|
30984
|
Discharge summary
|
report
|
Admission Date: [**2186-5-28**] Discharge Date: [**2186-6-21**]
Service: CARDIOTHORACIC
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
acute onset chest pain radiating to back
Major Surgical or Invasive Procedure:
[**2186-5-28**] emergency replacement of ascending/hemi arch aorta/AVR
(21mm [**Company 1543**] Mosaic Porcine valve/ 26 mm Gelweave graft)
[**2186-6-8**] emergency mediastinal re-exploration for tamponade
[**2186-6-16**] trachestomy/PEG/flexible bronchoscopy
History of Present Illness:
83 yo female presented to [**Hospital1 1474**] ER with acute onset chest
pain radiating to her back. CT chest revealed ascending aortic
dissection to the arch and descending aorta. Maximum diameter
4.9 cm ascending level. Transferred to [**Hospital1 18**] for urgent surgery.
Past Medical History:
Rheumatoid arthritis
MI [**2184**]
CAD
AS
syncope
HTN
elev. chol.
anemia
prior PE/DVT
PSH: chole, removal neck mass, breast mass removal
Social History:
no alcohol use
no tobacco use
Family History:
unknown
Physical Exam:
neuro grossly intact
CTAB
RRR
abd softly distended
extrems warm, no edema
62" 80kg
Pertinent Results:
[**2186-6-20**] 02:45AM BLOOD WBC-13.5* RBC-3.04* Hgb-9.2* Hct-27.6*
MCV-91 MCH-30.3 MCHC-33.3 RDW-18.5* Plt Ct-75*
[**2186-6-20**] 02:45AM BLOOD Plt Ct-75*
[**2186-6-20**] 02:45AM BLOOD PT-12.4 PTT-27.9 INR(PT)-1.1
[**2186-6-20**] 02:45AM BLOOD UreaN-20 Creat-1.4* Na-133 Cl-100 HCO3-24
[**2186-6-19**] 03:18AM BLOOD ALT-151* AST-58* LD(LDH)-438*
AlkPhos-205* TotBili-2.0*
[**2186-6-18**] 02:05AM BLOOD Lipase-28
[**2186-6-20**] 02:45AM BLOOD Phos-1.6* Mg-2.1
Cardiology Report ECHO Study Date of [**2186-5-28**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for ascending aortic dissection
and AVR
Height: (in) 62
Weight (lb): 176
BSA (m2): 1.81 m2
BP (mm Hg): 134/78
HR (bpm): 67
Status: Inpatient
Date/Time: [**2186-5-28**] at 18:14
Test: TEE (Complete)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *4.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 48 mm Hg
Aortic Valve - Mean Gradient: 24 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Mildly dilated aortic arch. Normal descending aorta
diameter. Focal
calcifications in descending aorta. Ascending aortic intimal
flap/dissection..
Aortic arch intimal flap/dissection. Thickened aortic wall c/w
intramural
hematoma.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Severe
AS (AoVA
<0.8cm2). Moderate to severe (3+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: Moderate pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Emergency
study. Results
Conclusions:
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2. Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4. A mobile density is seen in the distal ascending aorta
consistent with an
intimal flap/aortic dissection. A mobile density is seen in the
aortic arch
consistent with an intimal flap/aortic dissection. The aortic
wall is
thickened consistent with an intramural hematoma.
5.The aortic valve leaflets (3) are mildly thickened. There is
severe aortic
valve stenosis (area <0.8cm2). Moderate to severe (3+) aortic
regurgitation is
seen. T
6.The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral
regurgitation is seen.
7.There is a moderate sized pericardial effusion. No evidence of
tamponade.
Post bypass
Pt is being AV paced and receiving an infusion of epinephrine
and vasopressin.
1. RV systolic function was initially mildly depressed and
improved
subsequently with epinephrine.
2. Bioprosthetic valve seen in the aortic position. Leaflets
appear to move
well and the valve appears well seated. Trace aortic
insufficiency.
3. Graft material seen in the ascending aorta.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2186-5-29**] 10:55.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 73230**])
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2186-6-16**] 7:03 PM
CHEST (PORTABLE AP)
Reason: tube placement
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman s/p dissection with repl. asc./hemiarch
aorta/AVR now s/p trach/peg [**6-16**]
REASON FOR THIS EXAMINATION:
tube placement
INDICATION: 82-year-old woman with recent tracheostomy. Please
assess for the tube placement.
The tracheostomy tube is projecting 5.2 cm above the carina and
is in satisfactory position. The introducer sheath remains in
the right brachiocephalic vein. Tip of the temporary pacing wire
is unchanged with its tips noted at the level of the right
ventricle. NG tube extends into the body of the stomach with
distal end not included in the film. Mild blunting of both
costophrenic angles is unchanged compared to the prior study.
Mild mediastinal widening is also unchanged compared to the
prior study and is not an uncommon finding after recent CABG.
Small bilateral pleural effusions. There is no pneumothorax.
IMPRESSION:
1. Appropriate position of the tracheostomy tube with its tip
projecting 5.2 cm above the carina.
2. The remainder of the lines and tubes are in satisfactory
position.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: SAT [**2186-6-17**] 12:33 AM
Brief Hospital Course:
Admitted [**5-28**] and went directly from ER to OR with Dr. [**Last Name (STitle) 1290**]
for surgery. Transferred to the CSRU in stable condition on
epinephrine, propofol and nitroglycerin drips. Epinephrine tuned
off shortly after arrival to CSRU, but multiple drips then
titrated for tight BP management.Chest tubes and Swan removed on
POD #2. All narcotics stopped for eval.as she appeared to not
move left arm appropriately. Tube feeds started on POD #3 and
beta blockade titrated. Very brief period of asystole on [**6-1**]
that responded immediately to pacing, and then went into Afib.
Seen by EP service for AV block. She went in and out of Afib and
was cardioverted over the next 2 days. Procainamide started per
EP recs.
Extubated the afternoon of [**6-3**] but required emergency
reintubation that evening for respiratory failure. Over the next
few days her WBC rose to 26K and she wqas pancultured with
empiric triple abx started. Heparin was started for Afib and the
next day she decompensated with a drop in Hct. CT scan showed
cardiac tamponade and she returned to the OR on [**6-8**] for
re-exploration, but this continued to delay a pacer implantation
planned by EP. Temporary transvenous pacer placed later that
day. Lactate, LFTs and creatinine continued to rise with melena.
General surgery consult done Epinephrine drip continued for
support, and pitressin restarted on [**6-10**]. Renal consult done
and CVVHD started on [**6-10**]. Epi weaned on [**6-11**], and Afib
continued despite amiodarone therapy. Steroid therapy also
continued to be weaned. Diarrhea and continued elev. WBC
prompted evaluation for C. diff.
Thoracic surgery initially evaluated pt. for trach and PEG on
[**6-12**].Social work also continued to meet with the family
regarding prognosis, need for dialysis, and the patient's
wishes. Family meeting held with surgeon on [**6-15**] with initial
plan to allow dialysis as needed,continue care, and hopefully
transfer to nursing home for further recovery when ready.
However, on [**6-16**] the family was reconsidering and team notified.
Trach/PEG/flex. bronch done on [**6-16**] also. She continued to have
significant melena, was transfused and was again seen by
transplant surgery. Renal service recommended continuing
dialysis, but requested tunneled long-term access.
On [**6-20**], the family decided not to continue long-term dialysis
and she did not follow commands. Hospice care and comfort
measures only discussed with the family and the medical ethics
consult done given the disagreement about possible prognosis.
Final decision was to transfer care to the MICU attending on
[**6-20**]. Patient was made CMO, pacer and vent were discontinued per
family wishes. She expired on [**6-21**].
Medications on Admission:
prednisone 5 mg daily
omeprazole
atenolol
lisinopril
folic acid
ASA
fosamax
methotrexate
lasix
ambien
darvocet
Discharge Disposition:
Expired
Discharge Diagnosis:
thoracic aortic dissection
Afib
rheumatoid arthritis
Acute renal failure
MI [**2184**]
coronary atrery disease
aortic stenosis
syncope
HTN
elev. chol.
prior PE/ DVT
anemia
Discharge Condition:
expired
Completed by:[**2186-9-13**]
|
[
"998.11",
"427.5",
"459.2",
"997.1",
"276.2",
"518.5",
"403.91",
"584.5",
"348.1",
"441.01",
"412",
"V58.65",
"714.0",
"570",
"423.0",
"112.0",
"427.31",
"578.9",
"424.1",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.05",
"89.64",
"99.62",
"35.21",
"34.03",
"31.1",
"99.07",
"39.95",
"38.95",
"38.45",
"43.11",
"37.78",
"39.61",
"99.04",
"88.72",
"96.72",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
9499, 9508
|
6592, 9338
|
265, 528
|
9723, 9761
|
1184, 1702
|
1056, 1065
|
5311, 5408
|
9529, 9702
|
9364, 9476
|
1728, 5089
|
1080, 1165
|
185, 227
|
5437, 6569
|
556, 833
|
5124, 5274
|
855, 993
|
1009, 1040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,325
| 109,146
|
25003
|
Discharge summary
|
report
|
Admission Date: [**2115-10-5**] Discharge Date: [**2115-10-9**]
Date of Birth: [**2066-9-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Loss of Consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 49 yo M w/ h/o DVT x2 and hypertension who was
transferred from [**Hospital3 1280**] for bilateral PE with hemodynamic
instability.
.
Patient was walking upstair on AM of admission when he suddenly
syncopized. He was witnessed to fall to the ground after walking
up a flight of stairs and was unconscious and unresponsive for
approximately 2 to 3 minutes. He did not have any seizure
activity. He then woke up confused and diaphoretic. He denies
chest pain/SOB at that time. He was sent to [**Hospital1 **]. He was
hypoxic at 91% on RA and has BP of 80 over palp. Blood pressure
had been fluid responsive. CT chest revealed multiple large
bilateral PE (large proximal right mainstem thrombus and distal
left main thrombus, paucity of vessels R>L). Heparin was then
started. EKG showed S1Q3T3. HE also became hypotensive and was
transferred to [**Hospital1 18**] for possible thrombolysis. His initial VS
were T 96.3 P 79 BP 133/102 93% on RA.
.
According to him, he had right DVT 2 years ago in the setting of
multiple baseball injury to the same place. He could not recall
what medication he was on or how long he was on it. He again
have another DVT, this time on the left side discovered on
[**2115-9-7**] on the day that he was suppose to go for Archilles
tendon surgery. He went for the surgery and was on lovenox for 2
weeks after that (qd dosed). Reports a brother who "is
anticoagulated because he clots." Female members of his family
has no history of spontaneous abortion.
.
Patient has no h/o spontaneous bleeding. He was guiaic negative
in the ED. He claims that he did not hit his head when he fell.
.
Currently he has no chest pain or shortness of breath.
Past Medical History:
HTN
DVT
Achilles tendon repair [**2115-9-3**]
Social History:
patient denies smoking or alcohol. Married with children, plays
baseball
Family History:
+ brother with ? of hypercoag. d/o
Physical Exam:
Gen- [**Last Name (un) **] with family at bedside; breathing comfortable on
RA. NAD
HEENT- PERRLA, EOMI
CV- RR, no r/m/g, Hyperdynamic with PMI at sternal boarder. no
overt sternal heave.
resp- CTA B
abdomen- NT/ND, NABS. Guaiac "already 2 times". Neg per Med
Record
ext- no c/c/e. slight calf tenderness in his right LE, with
surgical scar, c/d/i. 2+ DP/PT
Pertinent Results:
Admission Labs:
.
[**2115-10-5**] 07:00PM CK(CPK)-219*
[**2115-10-5**] 11:00AM CK(CPK)-242*
[**2115-10-5**] 04:35AM CK(CPK)-48
[**2115-10-5**] 02:30AM CK(CPK)-204*
.
[**2115-10-5**] 07:00PM CK-MB-3 cTropnT-0.05*
[**2115-10-5**] 11:00AM CK-MB-4 cTropnT-0.10*
[**2115-10-5**] 04:35AM CK-MB-NotDone cTropnT-0.14*
[**2115-10-5**] 02:30AM CK-MB-3 cTropnT-0.14*
.
[**2115-10-5**] 02:30AM WBC-8.9 RBC-4.78 HGB-14.0 HCT-41.3 MCV-86
MCH-29.4 MCHC-34.0 RDW-13.3
[**2115-10-5**] 02:30AM NEUTS-83.3* LYMPHS-13.0* MONOS-2.3 EOS-1.2
BASOS-0.1
[**2115-10-5**] 02:30AM PLT COUNT-176
[**2115-10-5**] 02:30AM GLUCOSE-139* UREA N-20 CREAT-1.2 SODIUM-142
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2115-10-5**] 04:35AM PT-13.3 PTT-88.1* INR(PT)-1.2
[**2115-10-5**] 04:35AM CALCIUM-7.0* PHOSPHATE-2.7 MAGNESIUM-1.7
Discharge Labs:
[**2115-10-9**] 05:22AM BLOOD WBC-5.2 RBC-5.10 Hgb-15.1 Hct-42.8 MCV-84
MCH-29.6 MCHC-35.4* RDW-13.2 Plt Ct-206
[**2115-10-9**] 12:50PM BLOOD PT-17.6* PTT-47.5* INR(PT)-2.0
[**2115-10-9**] 05:22AM BLOOD Glucose-96 UreaN-17 Creat-1.3* Na-140
K-4.2 Cl-104 HCO3-24 AnGap-16
[**2115-10-9**] 05:22AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.0
Imaging:
ECHO [**2115-10-7**]:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. Trace aortic regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Trivial
mitral
regurgitation present.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
Brief Hospital Course:
Impression and plan:
49yo man with a history of 2 previous DVTs presented with
hemodynamically unstable bilateral pulmonary embolism,
transfered to [**Hospital1 18**] for possible tPA.
.
1.) Bilateral PE: Pt was initially tranferred to [**Hospital3 **]
Hospital for ?tPA administration as was hemodynamically unstable
at previous hospital. On presentation, the patient was volume
rescusitated and never became hemodynamically unstable -
therefore tPA was not administered. Pt was started on heparin
drip to achieve therapeutic PTT of 60-100. Throughout hospital
course, the heparin drip ranged from 1000-1300units/hr. Patient
was also started on Coumadin at 5mg PO qhs to goal INR [**3-14**].
Patient was discharge with INR = 2.0 with plans to continue
current Coumadin dose (5mg qhs) and will get 1 dose Lovenox 80mg
SC tonight, with plans to follow up in his [**Hospital 6435**] clinic on [**10-11**]
to recheck INR and adjust Coumadin dose as needed. It is likely
that he will need anticoagulation for at least 1 year given that
this episode was in setting of trauma (clot was present prior to
OR for achilles repair; likely [**3-13**] trauma from the baseball), if
not life-long anticoagulation given that patient developed DVT
under the circumstances. Our final recommendation to him was
for life long anticoagulation. He will follow up with hematology
(Dr. [**Last Name (STitle) **] for re-check of hypercoaguable labs in a couple
months, again given the fact that the patient developed this
clot and ?family history of a brother with some clotting
disorder.
.
2.) Hypertension: Hypertension meds held during hospitalization
as presented with ?hemodynamic instability. Pt advised to
restart all outpatient medications on discharge. .
Medications on Admission:
Wiaspan 500
Doxazosin 2mg
Ficardura
Ecotrin
Foltx
Discharge Medications:
1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
2 x 2mg tablets with 1 x 1mg tablets every night (dose may
change after blood levels drawn on friday [**10-10**] - will be
instructed at that time).
Disp:*30 Tablet(s)* Refills:*2*
2. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Take
2 x 2mg tablets with 1 x 1mg tablets every night (dose may
change after blood levels drawn on friday [**10-10**] - will be
instructed at that time).
Disp:*60 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please draw coags (PT, PTT, INR) on [**10-10**].
Adjust Coumadin as needed for goal INR of [**3-14**].
Follow up coag lab draws as needed after [**10-10**].
4. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once tonight ([**10-9**]) for 1 doses.
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Pulmonary Embolism
2.) Deep vein thrombosis in gastrocnemus vein
Discharge Condition:
Good
Discharge Instructions:
1.) Please contact physician if experience shortness of breath,
chest pain or pressure, increased swelling in leg, fainting,
fever > 100.4, any other questions/concerns
2.) Please follow up with appointments as directed below
3.) Please take medications as directed. [**Month (only) 116**] restart all
outpatient medications.
4.) Please follow diet as directed (eat consistent amounts of
green, leafy vegetables as described - do not have to avoid
them)
Followup Instructions:
1.) Please follow up at Dr.[**Name (NI) 62797**] clinic on Friday [**2115-10-11**] for
lab draws (may show up to clinic anytime friday morning). At
that time, dose of coumadin may be adjusted and will need to
follow up in clinic as directed.
2.) Please make an appointment with Dr. [**Last Name (STitle) **] (hematologist) in
a couple months time in order to re-check the hypercoaguable
work up that was checked previously. This will help with future
management in terms of if need to be on life-long coumadin or if
only need to be on coumadin for approximately 1 year.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"593.9",
"415.19",
"458.9",
"401.9",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7199, 7205
|
4549, 6298
|
337, 343
|
7318, 7325
|
2660, 2660
|
7828, 8495
|
2229, 2265
|
6399, 7176
|
7226, 7297
|
6324, 6376
|
7349, 7805
|
3513, 4526
|
2280, 2641
|
276, 299
|
371, 2054
|
2676, 3497
|
2076, 2123
|
2139, 2213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,101
| 142,063
|
15991
|
Discharge summary
|
report
|
Admission Date: [**2202-4-23**] Discharge Date: [**2202-5-4**]
Date of Birth: [**2122-10-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
Fevers and chills
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
The patient is a 79 yo M with a h/o of multiple myeloma along
with multiple other medical problems including diabetes and
severe cardiac disease including coronary artery disease and
chronic ischemic heart disease with an ejection fraction of less
than 25% along with chronic renal insufficiency p/w 1 week h/o
"not feeling well" and 1 day h/o fevers/chills and cough. The
patient was found at rehab to have a temp to 104.3/BP 82/45 and
decreased UOP. He was brought to [**Hospital1 18**] ER. The patient denies
abdominal pain, urinary symptoms, or chest pain. He reports some
difficulty breathing over the last week and has gotten SOB with
any activity. He has had decreased PO intake over the last few
days. On [**2202-4-20**] patient received day #1 of MM treatment with
Velcade at 1.3 mg/m2 (to be given on day 1,4,8,11) and Decadron
10 mg on these days as well.
ROS: sleeps with 3 pillows at baseline over last 1.5 years;
usually able to walk all around rehab without SOB, now can't
walk at all without SOB.
In the ER, the patient wasd febrile to 104 with SBP in the 70's.
He was started on the sepsis protocol. His lactate was 4.1
with WBC 6.1 with 6% bands. He was given a dose of cefepime. A
UA was negative and a CXR was clear. He was given a total of 3L
NS in the ED.
Past Medical History:
DM
HTN
CAD- s/p CABG x 2 (LIMA-Diag, SVG-ramus then jump to OM,
SVG-acute
marginal then jump to rPDA)
CHF- EF 20%
s/p A flutter ablation
s/p pacemaker (attempted BiV but only 1 lead placed)
NSVT- s/p ICD [**9-28**]
Multiple myeloma diagnosed by bone marrow biopsy in [**Month (only) 956**]
[**2198**] with treatments including: Thalidomide, Methylprednisone,
Melphalan. Now on Procrit and pulse dose decadron- last pulse
in [**Month (only) 216**].
CRI (recent Cr 2.6)
Prostate cancer, status post radiation therapy.
Bladder cancer, status post BCG instillation.
Oncology History:
Diagnosed with MM in [**12-29**] when he was noted to be mildly anemic
with a hematocrit of 36. Further workup with serum protein
electrophoresis revealed a suppressed IgA and IgM with an
elevated IgG of over 4 g consisting of monoclonal band. Given
his other medical issues, Mr. [**Known lastname 45794**] was initially treated with
melphalan and prednisone, but this was complicated by low counts
and poor tolerance. He also took thalidomide for a period of
time but he had increased dizziness and did not tolerate this
well. He, at times, would have pulses of Decadron twice in
[**7-/2200**] and then 1 pulse in [**1-/2201**] but these often led to
exacerbation of his congestive heart failure requiring
hospitalization. Because of his other medical issues, which
were often exacerbated with treatment for his myeloma, he often
was monitored by laboratory values and treated symptomatically
for his myeloma. He has been receiving Procrit for chronic
anemia with periodic transfusions in order to maintain his
hematocrit 28-30% due to his cardiac history. In [**8-/2201**], Mr.
[**Known lastname 45794**] was admitted due to worsening shortness of breath and
exacerbation of his congestive heart failure with also
increasing pain in the left hip area with more difficulty
walking. During the admission, he was found to have new lytic
lesions in the hip and back and was treated with radiation
therapy to the hip and back area along with a pulse of
Decadron. His last treatment (until this week) for his myeloma
was with a 3-day pulse of melphalan at 10 mg daily starting on
[**2201-10-12**].
Social History:
The patient was living at home until a recent extended admission
to [**Hospital1 18**] ([**Date range (1) 45797**]) after which he was discharged to rehab. Mr
[**Known lastname **] is married x 58 yrs and lives in [**Location 22361**] Mass. He has
3 adult sons, one of whom is a research administrator at [**Hospital1 18**].
Mr [**Known lastname 45798**] wife who had undergone bilateral knee replacements
last year, fell recently and shattered her femur. She is
currently in the [**Hospital **] Rehab in [**Location (un) 3915**]. He is a former
business executive. Has three sons. [**Name (NI) 4084**] smoked. Occasional
ETOH.
Family History:
Father laryngeal cancer, depression and history
of gynecologic cancer in two or more relatives,
mother MI at 72y/o
Physical Exam:
VS - T 103 (rectally), HR 74 BP 113/47 O2 93% 4L
General - thin male, NAD
HEENT - PERRL, dry mucous membranes
Neck - supple, RIJ in place
Chest - RRR +pacer device in place
Lungs - bilateral crackles at bases
Abdomen - soft, NT/ND
Ext - [**1-29**]+ pitting edema b/l
Pertinent Results:
REPORTS:
.
[**2202-4-23**] CXR - Single portable AP chest radiograph is compared to
[**2202-4-6**] and demonstrates no significant difference.
Again demonstrated are healing right-sided rib fractures and a
mottled appearance to the right clavicle. The cardiac
silhouette is stable, and the mediastinal contours are stable.
Pacemaker leads and sternotomy wires identified. No free air
under the diaphragms. No evidence for pulmonary opacification.
.
HAND (AP, LAT & OBLIQUE) LEFT PORT [**2202-4-24**] 1:31 PM
There are no radiographic findings to suggest osteomyelitis in
the left hand. If clinical suspicion is high, bone scan or MRI
may be considered. Diffuse vascular calcifications are present.
.
UNILAT LOWER EXT VEINS RIGHT [**2202-4-26**] 11:01 AM
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis.
.
TTE [**2202-4-29**]:
Conclusions:
The left atrium is dilated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (ejection
fraction 20-30 percent) secondary to akinesis and fibrosis of
the inferior and posterior walls, with at least mild hypokinesis
of the rest of the left ventricle. Tissue velocity imaging E/e'
is elevated (>15) suggesting increased left ventricular filling
pressure (PCWP>18mmHg). Tissue velocity imaging demonstrates an
e' of <0.08m/s c/w an elevated left ventricular filling pressure
(>12mmHg). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated. Right ventricular systolic function is borderline
normal. There are focal calcifications in the aortic arch. 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. There is no mitral valve
prolapse. No mass or
vegetation is seen on the mitral valve. Moderate to severe (3+)
mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is
seen. There is severe pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2202-2-4**], no major change is evident.
.
TEE [**2202-5-4**]:
Negative for vegetation (prelim)
.
LABS:
.
[**2202-4-30**] 12:00AM BLOOD WBC-4.2 RBC-2.60* Hgb-7.9* Hct-26.1*
MCV-100* MCH-30.4 MCHC-30.3* RDW-17.2* Plt Ct-108*
[**2202-4-29**] 12:00AM BLOOD WBC-6.0 RBC-2.54* Hgb-8.3* Hct-25.1*
MCV-99* MCH-32.5* MCHC-32.9 RDW-17.5* Plt Ct-110*
[**2202-4-28**] 12:05AM BLOOD WBC-4.1 RBC-2.48* Hgb-8.0* Hct-24.5*
MCV-99* MCH-32.5* MCHC-32.8 RDW-17.5* Plt Ct-92*
[**2202-4-27**] 12:00AM BLOOD WBC-3.8* RBC-2.59* Hgb-8.5* Hct-25.9*
MCV-100* MCH-32.8* MCHC-32.8 RDW-17.5* Plt Ct-88*
[**2202-4-26**] 09:49PM BLOOD WBC-3.9* RBC-2.65* Hgb-8.2* Hct-26.2*
MCV-99* MCH-31.1 MCHC-31.4 RDW-17.5* Plt Ct-85*
[**2202-4-26**] 12:00AM BLOOD WBC-3.7* RBC-2.62* Hgb-8.5* Hct-26.2*
MCV-100* MCH-32.4* MCHC-32.4 RDW-17.4* Plt Ct-72*
[**2202-4-25**] 01:49PM BLOOD WBC-4.4 RBC-2.52* Hgb-8.1* Hct-25.3*
MCV-101* MCH-32.3* MCHC-32.1 RDW-17.7* Plt Ct-73*
[**2202-4-24**] 04:07AM BLOOD WBC-5.4 RBC-2.60* Hgb-8.1* Hct-25.9*
MCV-100* MCH-31.0 MCHC-31.1 RDW-17.7* Plt Ct-52*
[**2202-4-23**] 09:43PM BLOOD WBC-5.8 RBC-2.85* Hgb-8.8* Hct-28.3*
MCV-99* MCH-31.0 MCHC-31.3 RDW-17.8* Plt Ct-57*
[**2202-4-23**] 03:10PM BLOOD WBC-6.1# RBC-3.12* Hgb-10.0* Hct-31.4*
MCV-101* MCH-32.2* MCHC-32.0 RDW-17.9* Plt Ct-69*
[**2202-4-23**] 09:43PM BLOOD Neuts-87* Bands-6* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2202-4-23**] 03:10PM BLOOD Neuts-90* Bands-6* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2202-4-30**] 12:00AM BLOOD Plt Ct-108*
[**2202-4-29**] 12:00AM BLOOD Plt Ct-110*
[**2202-4-29**] 12:00AM BLOOD PT-13.7* PTT-34.5 INR(PT)-1.2*
[**2202-4-28**] 12:05AM BLOOD Plt Ct-92*
[**2202-4-27**] 12:00AM BLOOD Plt Ct-88*
[**2202-4-27**] 12:00AM BLOOD PT-12.7 PTT-33.1 INR(PT)-1.1
[**2202-4-26**] 12:00AM BLOOD Plt Ct-72*
[**2202-4-26**] 12:00AM BLOOD PT-13.2* PTT-33.7 INR(PT)-1.2*
[**2202-4-25**] 01:49PM BLOOD Plt Ct-73*
[**2202-4-25**] 01:49PM BLOOD PT-13.4* PTT-33.2 INR(PT)-1.2*
[**2202-4-24**] 04:07AM BLOOD PT-16.2* PTT-51.7* INR(PT)-1.5*
[**2202-4-23**] 09:43PM BLOOD Plt Smr-VERY LOW Plt Ct-57* LPlt-2+
[**2202-4-23**] 03:10PM BLOOD Plt Ct-69*
[**2202-4-23**] 03:10PM BLOOD PT-14.8* PTT-35.6* INR(PT)-1.3*
[**2202-4-26**] 12:00AM BLOOD ESR-86*
[**2202-4-30**] 12:00AM BLOOD Glucose-104 UreaN-40* Creat-1.8* Na-141
K-3.9 Cl-106 HCO3-27 AnGap-12
[**2202-4-29**] 12:00AM BLOOD Glucose-151* UreaN-44* Creat-2.1* Na-138
K-3.9 Cl-105 HCO3-26 AnGap-11
[**2202-4-28**] 09:05PM BLOOD Glucose-169* UreaN-45* Creat-2.1* Na-139
K-3.9 Cl-105 HCO3-26 AnGap-12
[**2202-4-28**] 12:05AM BLOOD Glucose-113* UreaN-50* Creat-2.1* Na-137
K-4.4 Cl-104 HCO3-26 AnGap-11
[**2202-4-27**] 12:00AM BLOOD Glucose-141* UreaN-58* Creat-2.4* Na-138
K-4.5 Cl-105 HCO3-25 AnGap-13
[**2202-4-26**] 09:49PM BLOOD Glucose-150* UreaN-59* Creat-2.5* Na-136
K-4.6 Cl-105 HCO3-25 AnGap-11
[**2202-4-26**] 12:00AM BLOOD Glucose-115* UreaN-64* Creat-2.9* Na-133
K-4.4 Cl-102 HCO3-25 AnGap-10
[**2202-4-25**] 01:49PM BLOOD Glucose-167* UreaN-67* Creat-3.0* Na-135
K-4.4 Cl-103 HCO3-23 AnGap-13
[**2202-4-24**] 04:07AM BLOOD Glucose-137* UreaN-64* Creat-3.5* Na-135
K-5.0 Cl-101 HCO3-24 AnGap-15
[**2202-4-23**] 09:43PM BLOOD Glucose-174* UreaN-60* Creat-3.4* Na-136
K-5.0 Cl-102 HCO3-23 AnGap-16
[**2202-4-23**] 03:10PM BLOOD Creat-3.5*#
[**2202-4-23**] 03:10PM BLOOD Glucose-125* UreaN-61* Creat-3.4* Na-136
K-4.8 Cl-98 HCO3-24 AnGap-19
[**2202-4-27**] 12:00AM BLOOD CK(CPK)-12*
[**2202-4-23**] 03:10PM BLOOD ALT-27 AST-33 AlkPhos-183* Amylase-39
TotBili-0.5
[**2202-4-23**] 03:10PM BLOOD Lipase-15
[**2202-4-27**] 12:00AM BLOOD CK-MB-2 cTropnT-0.10*
[**2202-4-30**] 12:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
[**2202-4-29**] 12:00AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0
[**2202-4-28**] 09:05PM BLOOD Calcium-8.0* Phos-2.7 Mg-2.1
[**2202-4-28**] 12:05AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.9
[**2202-4-27**] 12:00AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.0
[**2202-4-26**] 09:49PM BLOOD Calcium-7.9* Phos-2.3* Mg-1.9
[**2202-4-26**] 12:00AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0
[**2202-4-25**] 01:49PM BLOOD Calcium-7.3* Phos-3.0 Mg-2.1
[**2202-4-24**] 04:07AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.6
[**2202-4-23**] 09:43PM BLOOD Calcium-7.5* Phos-3.2 Mg-1.5*
[**2202-4-23**] 03:10PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.3 Mg-1.7
[**2202-4-24**] 01:12AM BLOOD Cortsol-57.1*
[**2202-4-24**] 12:42AM BLOOD Cortsol-56.3*
[**2202-4-23**] 03:10PM BLOOD Cortsol-40.8*
[**2202-4-29**] 12:00AM BLOOD Vanco-15.9*
[**2202-4-26**] 07:30AM BLOOD Vanco-14.3*
[**2202-4-25**] 01:49PM BLOOD Vanco-7.4*
[**2202-4-24**] 04:07AM BLOOD Digoxin-0.9
[**2202-4-23**] 09:56PM BLOOD Type-[**Last Name (un) **] Temp-36.3 pO2-39* pCO2-40
pH-7.47* calHCO3-30 Base XS-4
[**2202-4-24**] 04:21AM BLOOD Lactate-1.7
[**2202-4-24**] 12:09AM BLOOD Lactate-2.3*
[**2202-4-23**] 09:56PM BLOOD Lactate-2.2*
[**2202-4-23**] 08:10PM BLOOD Lactate-1.8
[**2202-4-23**] 06:55PM BLOOD Lactate-1.4
[**2202-4-23**] 06:00PM BLOOD Lactate-1.5
[**2202-4-23**] 03:39PM BLOOD Lactate-4.1*
[**2202-4-23**] 06:00PM BLOOD O2 Sat-69
[**2202-4-23**] 06:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2202-4-23**] 06:10PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2202-4-23**] 06:10PM URINE RBC-0 WBC-[**2-28**] Bacteri-MANY Yeast-NONE
Epi-0
.
MICRO:
.
[**2202-4-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +, VIRIDANS
STREPTOCOCCI} EMERGENCY [**Hospital1 **]
[**2202-4-23**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {STAPH
AUREUS COAG +, VIRIDANS STREPTOCOCCI}; ANAEROBIC BOTTLE-FINAL
{STAPH AUREUS COAG +, VIRIDANS STREPTOCOCCI}
.
[**2202-4-23**] 3:20 pm BLOOD CULTURE FROM L VENIP # 2.
AEROBIC BOTTLE (Preliminary):
[**2202-4-24**] REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45799**] AT 6:45 AM.
STAPH AUREUS COAG +.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2502**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
BACTRIM (=SEPTRA=SULFA X TRIMETH) REQUESTED BY DR. [**Last Name (STitle) **].
[**Known lastname **]
[**2202-4-30**]. BACTRIM (=SEPTRA=SULFA X TRIMETH) PENDING.
VIRIDANS STREPTOCOCCI.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| VIRIDANS STREPTOCOCCI
| |
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2202-4-28**]):
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
VIRIDANS STREPTOCOCCI.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
Brief Hospital Course:
The patient is a 79y/o with h/o CAD, CHF20%, AD, CHF EF 20%, s/p
CABG x2, DM,
HTN, afib, multiple myeloma who recently started on
velcade/decadron tx on [**2202-4-20**], and also was noted to have
phlebitis at that time, now p/w sepsis. Growing [**3-30**] G+ cocci in
blood.
.
Sepsis: The patient was febrile to 104 on admission with SBP in
the 70's. A lactate was 4.1, 6% band, and requiring levophed
for hypotension. A CXR and U/A were unremarkable. He did have
a small plebitis on his left hand but this was unlikely the
source of his infection. He was initally started on cefepime
but was switched to ceftriaxone/vanco/azithromycin on admission
to the ICU. Hand X-rays were ordered to look for osteo
(negative) and repeat urine and CXR were obtained (were
negative). The day after admission the patient's blood gre [**3-30**]
bottle gram positive cocci, later shown to be MRSA. Pt was
continued on vanc, and ceftriaxone/azithro were d/c'd. ID was
consulted, given AICD present in setting of MRSA sepsis. A PICC
was placed for long-term Abx therapy. A TTE did not show
vegetation, and TEE also did not show vegetation (prelim read).
Pt was discharged on IV vanc, to complete [**4-1**] wk course (to be
determined at f/u in [**Hospital **] clinic)
.
Hypotension: The patient's hypotension was not responding to
fluids in the ER so he was started on levophed. This was
quickly weaned off a few hours after admission, cortstim test
(56-->57) was unclear and difficult to interpret. He was not
started on stress dose steroids. Pt was restared on valsartan
40mg and Toprol XL 25mg (lower dose than at home) prior to
discharge.
.
SOB: The patient has a h/o CHF with EF20% and 4+MR with multiple
recent admissions to [**Hospital1 18**] for CHF exacerbatons. He recieved
fluid during his ICU stay, and was then diuresed on the floor.
40mg IV Lasix was given initially, BP remained stable, however
pt was only slightly negative. Dose increased to 80 IV Lasix
PRN, without improvement in UOP. Lasix 180mg IV was then given
with good UOP. Restarted home [**Last Name (un) **] for afterload reduction, once
BP stabilized. Repeat echo showed EF 20-30%, 3+ TR, 3+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]n seen. Pt was discharged on Lasix 80mg PO bid, with
f/u planned for [**Hospital 1902**] clinic.
.
Multiple Myeloma: recently started on velcoade and decadron.
The patient's chemotherapy/steroids were held because of the
patients poor clinical status.
.
CV: V paced, continued on amiodarone and digoxin 0.0625 QOD. Pt
had episode of AICD firing this admission. Interrogation of
AICD revealed appropriate shock for Vtach This is the first time
pt had felt a shock from his ICD. EP was consulted, and Vtach
was thought possibly secondary to lack of BB (pt had not yet
been restarted on Toprol) or possibly due to CHF. Pt was
restarted on Toprol and placed on tele after the AICD firing,
with no further events. Pt was scheduled for f/u in device
clinic. Pt was continued on home statin and aspirin.
.
DM: continued lantus, covered with humolog SS.
.
CRI: baseline 2.2-2.6; up to 3.5 here, then down to 1.8 -->
likely had some element of acute on chronic renal failure in the
setting of fluid overload and poor forward flow. Cr improved to
1.8 with diuresis. Vanc was renally dosed initially, then
changed to 1g q24h as Cr improved.
.
Code: DNR/DNI
.
Dispo: to rehab
Medications on Admission:
On discharge ([**2202-4-14**]):
- Amiodarone 200 mg QD
- Valsartan 40 mg QD
- Bisacodyl 10mg QD
- Senna 8.6 mg QD
- Atorvastatin 80mg QD
- Psyllium 1.7 g Wafer QD
- Metoprolol Succinate 50 mg SR QD
- Epoetin Alfa 10,000 unit/mL M-W-F
- Lidocaine 5 %(700 mg/patch) Adhesive Patch, apply for 12 hours
a day
- Colace 100mg [**Hospital1 **]
- Digoxin 62.5 mcg QOD
- Home O2 Nasal canula 2 L
- Lasix 40 mg QPM
- Lasix 20 mg QAM
- Percocet 1 tab q4-6 PRN
- Prochlorperazine 10 mg Tablet TID PRN
- Lantus 10 Units QPM
- ISS
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Injection Q8H (every 8 hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: 0.0625 mg PO EVERY OTHER DAY
(Every Other Day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical QD ().
9. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours).
14. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Primary diagnoses:
MRSA sepsis
CHF (systolic, EF 20%)
Secondary diagnoses:
CAD
AICD firing secondary to Vtach
CRI
Discharge Condition:
Stable. Afebrile.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Please seek medical attention immediately if you feel a shock,
experience chest pain, shortness of breath, fevers, chills,
nausea, vomiting, or dizziness.
Please take all medications as prescribed. You will need to be
on IV vancomycin for at least 4-6 weeks (exact duration to be
determined during your clinic appointment with Infectious
Disease on [**2202-6-7**]). Continue IV vancomycin until this
appointment.
Please attend all follow-up appointments.
Please have your CBC, BUN, Cr, K, Mag, and vanc trough checked
every week.
You should have the CBC, BUN, Cr, and vanc trough results faxed
every week to [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] in [**Hospital **] clinic (fax # [**Telephone/Fax (1) 1419**]).
Followup Instructions:
Please have your CBC, BUN, Cr, and vanc trough checked every
week and have the results faxed to [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] Infectious
Disease clinic (fax # [**Telephone/Fax (1) 1419**]). You also had some bloody
stools during this admission, and you should talke with your PCP
about having [**Name Initial (PRE) **] colonoscopy as an outpatient.
You have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2202-5-18**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2202-5-20**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2202-6-7**] 11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2202-7-7**]
2:00
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
Completed by:[**2202-5-4**]
|
[
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"584.9",
"397.0",
"428.22",
"203.00",
"401.9",
"428.0",
"V45.02",
"038.11",
"V45.81",
"414.8",
"V09.0",
"427.1",
"451.82",
"424.0",
"785.52",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
20060, 20108
|
14722, 18125
|
289, 294
|
20267, 20287
|
4905, 14699
|
21212, 22348
|
4485, 4602
|
18693, 20037
|
20129, 20184
|
18151, 18670
|
20311, 21189
|
4617, 4886
|
20205, 20246
|
232, 251
|
322, 1614
|
1636, 3821
|
3837, 4469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,026
| 160,001
|
52655
|
Discharge summary
|
report
|
Admission Date: [**2151-2-2**] Discharge Date: [**2151-2-9**]
Date of Birth: [**2104-5-26**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Multidrug overdose
Major Surgical or Invasive Procedure:
Arterial line insertion
PICC line insertion
History of Present Illness:
46M h/o depression, narcotics abuse, multiple hospitalizations
for drug overdoses [**2-27**] suicide attempts (last in [**1-2**]), and
hepatitis C, presented to [**Hospital3 26615**] Hospital late night [**2151-2-1**]
- early morning [**2151-2-2**] after having been found down by his wife
on [**2151-2-1**] at 2100 with a empty bottle of ibuprofen next to him.
Initial ABG at AJH was pH 7.06/43/249/13. Earlier, pt had
declared to wife that he was "going to kill himself" if his wife
divorced him; wife ultimately reiterated her intention to leave
him.
.
At the time of presentation to OSH, pt received naloxone, was
intubated and started on bicarb gtt. Notable laboratories at
OSH included acetaminophen level at 672, AST 322, ALT 240, INR
1.4. Pt was then given N-acetylcysteine 9000 mg at 0130am on
[**2151-2-2**] and was then transferred to [**Hospital1 18**] for further management.
.
At [**Hospital1 18**], repeat ABG pH 7.33/pCO2 29/pO2 575/HCO3 16. Pt was
hemodynamically stable in ED except for brief rise of BP to
200/100, for which he was transiently on labetalol drip.
Arterial line was placed. Repeat labs showed acetaminophen 390,
AST 525, ALT 314, INR 2.9. Pt did not receive N-acetylcysteine
in the ED but was given an additional load of 8400 mg nAc and
activated charcoal upon transfer to the MICU.
.
ROS: Unable to assess given intubated, sedated.
Past Medical History:
# Polysubstance abuse
# Depression
# s/p past suicide attempts
# Hepatitis C: Genotype 1a, liver biopsy was performed in
[**2144-11-26**] indicating grade 2 inflammation, stage 0-I
fibrosis
# Hyperlipidemia
# Psoriasis
# Left ankle surgery x 4
# Right knee surgery
# s/p L BKA
Social History:
# Personal: Married, but heard wife was going to leave him
yesterday.
# Substance use: Polysubstance abuse; unknown tobacco use.
# GI note [**2149**]: "The patient is not currently working at this
time. He lives with his wife. [**Name (NI) **] has a history of alcohol
abuse and states at this time he drinks only approximately 2
drinks per year. He also has a history of cocaine use and
states that this last use of intravenous cocaine was
approximately 1 year ago. He notes today that he has been
taking Vicoden PRN and seems concerned about the quantity with
which he has been taking. He states that he has been using this
for pain but has also noted some dependency."
Family History:
Noncontributory
Physical Exam:
VS: Temp 99.4, BP 142/84, HR 106 sinus tachycardia, RR 28, O2sat
98% on AC 500/14, PEEP 5, FiO2 0.50
GEN: Intubated, sedated but opens eyes to name and command,
follows simple commands including squeezing hand, opening eyes,
wiggling right toes
HEENT: Pupils dilated, equal and minimally reactive to light,
sclerae anicteric
NECK: No supraclavicular or cervical lymphadenopathy, no JVD, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Clear anteriorly and laterally
CV: RRR, 3/6 systolic murmur heard best at LLSB
ABD: ND, BS+, soft, NT, no masses or hepatosplenomegaly
appreciated
EXT: s/p BKA on left, right without c/c/e, warm, good pulses
SKIN: No jaundice, large abrasion right posterior calf without
significant induration, no purulent drainage, track marks on
right foot
NEURO: As above, sedated however arousable and following simple
commands. Moving all 4s.
Pertinent Results:
[**2151-2-2**] 04:19AM WBC-8.4 RBC-3.54* HGB-11.1*# HCT-33.3*#
MCV-94 MCH-31.3 MCHC-33.3 RDW-15.6*
[**2151-2-2**] 04:19AM NEUTS-70.4* LYMPHS-24.9 MONOS-4.3 EOS-0.2
BASOS-0.2
[**2151-2-2**] 04:16AM TYPE-ART PO2-575* PCO2-29* PH-7.33* TOTAL
CO2-16* BASE XS--9
[**2151-2-2**] 04:19AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
[**2151-2-2**] 04:19AM ASA-NEG ETHANOL-NEG ACETMNPHN-390*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2151-2-2**] 04:19AM GLUCOSE-307* UREA N-9 CREAT-1.0 SODIUM-137
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-15* ANION GAP-18
[**2151-2-2**] 04:19AM CALCIUM-6.7* PHOSPHATE-2.3* MAGNESIUM-1.6
[**2151-2-2**] 04:19AM ALT(SGPT)-325* AST(SGOT)-413* ALK PHOS-58
AMYLASE-61 TOT BILI-1.1
[**2151-2-2**] 08:10AM PT-31.2* PTT-37.4* INR(PT)-3.2*
[**2151-2-2**] 05:26PM LACTATE-3.9*
[**2151-2-2**] 04:52PM ACETMNPHN-117.9*
[**2151-2-2**] 09:18PM PT-54.8* PTT-49.8* INR(PT)-6.4*
[**2151-2-2**] 09:18PM ALT(SGPT)-2055* AST(SGOT)-3421* LD(LDH)-2860*
ALK PHOS-70 TOT BILI-4.1*
.
Imaging:
.
[**2151-2-2**] CT head from OSH: No acute intracranial pathology.
.
[**2151-2-2**] CXR: Endotracheal tube is well positioned. A nasogastric
tube is detected coursing through the mediastinum with tip out
of view and side port in the expected region of the gastric
fundus. The lungs are clear. The cardiomediastinal silhouette
is normal. No effusion or pneumothorax.
.
[**2151-2-2**] CT C-spine
1. No acute fracture or abnormal alignment.
2. Multilevel degenerative changes.
.
[**2151-2-4**] CT head w/o contrast: Normal study.
.
[**2151-2-5**] CT head w/o contrast: Slight effacement of sulci since
the study of [**2151-2-4**]. This may indicate global swelling.
Brief Hospital Course:
46M h/o polysubstance abuse, hepatitis C, depression, and
multiple past suicide attempts, presented from OSH with suicide
attempt via polysubstance ingestion, most notably acetaminophen
with APAP level in the ?600s (390 here), intubated for airway
protection, admitted to the ICU s/p ingestion and intubation.
Admission was complicated by fulminant hepatic failure and
resulting cerebral edema, CNS-related fevers, coagulopathy, and
respiratory failure.
.
# Cerebral edema [**2-27**] fulminant hepatic failure: Pt presented
with altered mental status [**2-27**] multidrug ingestion, but serial
neurological tests as well as increasing ammonia levels
indicated the likely development of hepatic encephalopathy,
raising the concern for cerebral edema. Repeat CT head
demonstrated progressive sulci effacement concerning for global
swelling. [**2-5**] EEG was non-eleptiform but demonstrated low
voltage. One dose of mannitol was initially used to attempt to
reduce cerebral edema, but given pt's elevated serum osmoles,
this was not repeated. Deeper sedation with midazolam was
attempted to control respiratory status and reduce seizure risk,
but pt was nevertheless noted to seize on [**2-7**], with R arm
twitching and R head deviation, not controlled with high-dose
propofol drip. After discussions among neurology, pharmacy,
hepatology, and MICU team, pt was placed on pentobarbitol gtt to
control intracranial pressure, with continuous EEG monitoring to
assess seizure activity. Cooling blankets were also used to
further reduce core temperature to goal of 35-36 in an attempt
to control cerebral edema. Pentobarbitol gtt was discontinued
on [**2151-2-9**] in order to better assess pt's neurological status.
After pt was made [**Date Range 3225**], no further neurological monitoring was
undertaken.
.
# Fulminant hepatic failure [**2-27**] acetaminophen overdose: Pt was
loaded with NAC at 1am on [**2151-2-2**] at OSH but did not receive NAC
x 7-8 hrs after first dose. Upon arrival to [**Hospital1 18**], pt was
reloaded with NAC and then transitioned to NAC infusion per
hepatology recommendations until LFTs <1000 or INR < 2. Pt was
not considered a transplant candidate given his polysubstance
abuse and psychiatric history. NAC infusion was discontinued
after AST and ALT fell below 1000. Although liver function
tests began to normalize, cerebral edema [**2-27**] fulminant hepatic
failure complicated the [**Hospital **] hospital course, leading to the
decision to make the pt [**Name (NI) 3225**].
.
# Respiratory failure: Pt was intubated for airway protection at
OSH ED given his multidrug overdose. Pt initially tolerated
pressure support, but was later noted to be persistently
overbreathing the ventilator, raising the concern for
intracranial pathology. Sedation was titrated to control
tachypnea with limited success. Given concern for diffuse
alveolar hemorrhage, as well as GI bleeding with elevated INR,
pt was continued on the ventilator until the decision was made
for pt to receive comfort measures only. After pt was converted
to [**Name (NI) 3225**] status, pt was extubated and ceased spontaneous breathing
within minutes.
.
# Fever: Pt spiked repetitive fevers during his admission.
Pancultures were negative, and fevers were considered likely a
central neurologic problem instead of related to infection. Pt
was nevertheless started on broad-spectrum antibiotics with
prophylactic caspofungin. Cooling blankets were used to control
central core temperature.
.
# Multidrug overdose: Pt's toxicology screen was positive for
opiates, benzodiazepines, and acetaminophen; pt had also been
found next to an empty bottle of ibuprofen. Long QTc was found
on admission EKG, likely [**2-27**] quetiapine and venlafaxine
ingestion. Salicylates and EtOH toxicology screens were
negative. Activated charcoal was repeated upon admission, and
toxicology consult was obtained. Pt was initially followed with
serial EKGs to monitor for QT prolongation, but did not evince
subsequent pathologic changes.
.
# Coagulopathy: Pt demonstrated coagulopathy [**2-27**] fulminant
hepatic failure, and received FFP to reverse his INR in order to
reduce bleeding with intravenous line placements procedures.
.
# Code status: Pt was DNR, which was confirmed with family given
his poor prognosis. After extensive discussions about the
extremely limited likelihood that pt would be able to return to
his pre-admission baseline mental status, the family decided to
make pt [**Name (NI) 3225**] on [**2151-2-9**]. Pt died from respiratory failure
minutes after extubation.
Medications on Admission:
Venlafaxine dose unknown
Seroquel 100 mg QHS
Atenolol 50 daily
Trazodone 150 mg QHS
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant hepatic failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2151-2-9**]
|
[
"V66.7",
"286.9",
"305.90",
"458.9",
"965.00",
"311",
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"518.81",
"070.44",
"969.4",
"570",
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"276.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"96.72",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
10184, 10193
|
5423, 10021
|
286, 331
|
10263, 10273
|
3676, 5400
|
10329, 10367
|
2745, 2762
|
10155, 10161
|
10214, 10242
|
10047, 10132
|
10297, 10306
|
2777, 3657
|
228, 248
|
359, 1735
|
1757, 2035
|
2051, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,401
| 125,807
|
21645
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 56958**]
Admission Date: [**2128-3-16**]
Discharge Date: [**2128-4-14**]
Date of Birth:
Sex:
Service:
HOSPITAL COURSE: [**First Name4 (NamePattern1) 1022**] [**Known lastname 21020**] is a 35-year-old female with a
history of metastatic breast cancer and depression who was
admitted to the medical service on [**2128-3-16**] with
abdominal pain. The patient was noted to have significant,
upon evaluation, was noted to have markedly elevated liver
function tests consistent with acute alcoholic hepatitis. She
was admitted to the medical service with a presumptive
diagnosis of acute alcoholic hepatitis.
She was markedly icteric and encephalopathic on admission and
was treated on the medical service for approximately 3 weeks
with supportive care including lactulose, and nutritional
support, and IV fluids. During this time, she was being
considered for workup of liver transplantation.
On [**4-3**], she developed worsening abdominal pain.
Underwent a CT scan of the abdomen, which demonstrated severe
pneumatosis of the small bowel and colon.
On [**4-4**], shortly after the CT scan was done, a surgical
consultation was obtained and based upon the CT findings and
the patient's deteriorating clinical status including
ventilatory requirement as well as pressor requirement, she
was taken to the operating room for exploration.
Intraoperatively, the liver was noted to be frankly cirrhotic
and with significant retroperitoneal varices as well as hilar
varices. The small bowel was grossly unremarkable. The colon
was markedly distended with what appeared to be some
sloughing of the mucosa, but no evidence of transmural
infarction. The colon was markedly distended, and we made a
small colotomy by removing the appendix and advanced a sucker
into the colon to decompress the colon. With the colon
decompressed, it had a normal appearance, again without any
evidence of transmural ischemia.
The colotomy was closed, and we elected not to perform any
resections. The patient was taken back to the recovery room,
and over the course of the next several weeks, she had
initially made a marked improvement with weaning off her
pressors and having somewhat improved liver function, but
gradually this deteriorated. After formal discussion with her
parents regarding further management, at this time because of
her history of malignancy and significant mental illness, we
did not believe that she was a realistic liver transplant
candidate and that in the absence of any transplanted liver,
she would not likely survive the acute alcoholic hepatitic
episode.
The family had requested that no further surgical
intervention be performed and over the course of the next
several weeks, she gradually deteriorated and expired on
[**2128-4-14**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2128-7-19**] 08:04:32
T: [**2128-7-19**] 08:20:47
Job#: [**Job Number 56959**]
|
[
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"599.0",
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"263.9",
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icd9cm
|
[
[
[]
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[
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"96.6",
"39.95",
"54.91",
"33.24",
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icd9pcs
|
[
[
[]
]
] |
154, 3030
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,196
| 142,045
|
36962
|
Discharge summary
|
report
|
Admission Date: [**2146-5-23**] Discharge Date: [**2146-5-28**]
Date of Birth: [**2095-12-21**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 21193**]
Chief Complaint:
bifrontal headache x 2wks, nausea and vomiting
Major Surgical or Invasive Procedure:
Stereotactic brain biopsy
History of Present Illness:
50 yo F with h/o hypothyroidism presents with 2 wk h/o headache
and 1 week h/o vomiting, transferred from OSH due to multiple
intracerebral lesions with vasogenic edema.
2 wk h/o maxillary and frontal sinus pain, last 1 week more
midfrontal pain up to [**10-8**]. Seen in OSH 1 wk ago, started on
azythromycin. First 3 days of taking the medicine vomiting
30min-1hr after taking the medicine. Saw PMD, changed to
bactrim. At that time, PMD noted R facial droop, thought to be
Bell's palsy. Subsequently last 5 days she has been vomiting
every time she tries to eat anything or stands up. Family took
her to the ED again today for headaches and vomiting.
1-2 weeks ago had 2 falls, each on standing from seated position
with falling to the L. She reports feeling lightheded. OVerall
her gait has been a little unsteady.
Weight loss 9 lbs last 2 week due to nausea. Overall
generalized
weakness and fatigue x2-3 weeks. Slight cough.
At the OSH, CT head showed multiple bilateral parenchymal
lesions
with significant vasogenic edema (L frontal, L basoganglia, R
temporal, R frontoparietal, R occipito-temporal). 5mm midline
shift R to L. She was given decadron 10mg and loaded with
dilantin 1000mg (maybe 1250, unclear from documentation).
Neurosurgery consulted in ED here, said no surgical intervention
at this time.
Denies fevers, night sweats, chest pain, shortness of breath,
abdominal pain, diarrhea, blood in stools, rashes, joint pains.
No recent travel. No HIV risk factors.
Denies focal weakness, numbness/tingling, changes in vision,
syncope, seizures, changes in speech, confusion, difficulty
coming up with words.
Past Medical History:
Hypothyroidism
Social History:
Lives with husband and 16 [**Name2 (NI) **] child. 18 yo child home from
college for the summer. 29 yo daughter lives near by, here with
family today. Runs a day care in her home. Smokes 1ppd, [**12-31**]
ETOH beverages every 1-2 weeks, denies drugs. Married >30
years.
Family History:
non-contributory
Physical Exam:
VS: T 98.1 HR 78 RR 12-18 BP 119/70 Sat 98% on RA
General: Awake and alert, interactive and cooperative, NAD
HEENT AT/NC, mucous membranes moist and pink, no lesions
Neck Supple, no thyromegaly or thyroid lesions, no
lymphadenopathy
Chest Clear bilaterally, good aeration
CVS Normal S1 and S2, no m/r/g
ABD Soft, nondistended, nontender, normoactive bowel sounds
EXT no C/C/E, distal pulses full, warm and well perfused, brisk
capillary refill, no rashes or petechiae
Neuro
MS: alert. Oriented to person, hospital in [**Location (un) 86**], Ma, able to
pick name of hospital from a list, says month/day correctly.
Initially reports year at [**2126**] but able to say [**2145**] when given
choices. Fluent speech. Repetition slightly impaired (repeats
"no ifs, ands or buts" as "no ands, ifs or buts" on several
attemps, able to repeat the phrase "if I come, then she will
go"). Naming intact except needs first letter to name hammock.
Difficulty with [**Doctor Last Name 1841**] backwards but able to say DOW backwards.
Can
do simple addition, had difficulty with simple subtraction. No
apraxia (mimics brushing teeth). No L/R confusion.
CN: I--not tested; II,III--PERRLA4-->2, VFF by confrontation,
III,IV,VI--EOMI w/o nystagmus, no ptosis; V--sensation intact to
LT/PP; VII--mild flattening of R nasolabial fold but activates
well with spontaneous and voluntary smile; VIII--hears finger
rub
bilaterally; IX,X--voice normal, palate elevates symmetrically,
gag intact; [**Doctor First Name 81**]--trapezii [**5-3**]; XII--tongue protrudes midline.
Motor: Normal bulk and tone, no tremor, rigidity or
bradykinesia.
With arms out mild pronation bilat arms, no clearly assymetric
pronator drift.
Strength: Required more coaching for full strength in LLE
compared to R but full in LEs as reported below.
|ShFl|ElFl|ElEx|WrFl|WrEx|FgEx|FgFl|HpFl|KnEx|KnFl|Dors|Plan|
L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
R | 5 | 5 | 5 | 5 | 5- | 5- | 5 | 5 | 5 | 5 | 5 | 5 |
Coord: Rapid alternating and point-to-point (FNF, HTS, TTF)
movements intact.
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2+ | 2+ | 2+ | 3 | 1 | up |
R | 2+ | 2+ | 2+ | 2+ | 1 | up |
[**Last Name (un) **]: LT, PP, temperature, vibration and joint position
intact.
Gait: Hesitant small steps but able to walk without assistance.
+rhomberg. Difficulty with tandem gait.
Addendum: On admission mild pupillary assymetry noted. R 6-->4
and L 5-->2. Both briskly reactive. Exam otherwise unchanged.
No bradycardia or hyptertension. Sats dropped to 89% on RA,
back
up to 94% on RA.
Brief Hospital Course:
50 yo F with hypothyroidism, smoker presents with HA and
vomiting, multiple intracerebral nodules with surrounding
vasogenic edema, 5mm midline shift and early uncal herniation.
Mild MS changes (attention, repetition, naming), flattening R
nasolabial fold, 5-/5 R WE and FE, +rhomberg and small hesitant
steps. Most likely metastatic lesions. Primary is most likley
lung given CXR finding. DDx includes infection or primary brain
malignancy.
CT head on admission due to noted assymetry of pupils was
unchanged.
She was continued on decadron 4mg Q6hrs to decrease swelling,
and keppra 500mg po bid for seizure prophylaxis throughout
admission. She did not have any seizures.
Neurologic exam was notable for mental status changes (poor
attention, [**Last Name (un) **] indifference, mild word finding and repetition
difficulties), assymetry of pupils (R larger than L),
papilledema, mild R hemiparesis. No worsening of neurologic
status during admission.
CXR suspicious for lung mass. CT torso done to eval for primary
malignancy. Results as follows.
1. Right upper lobe lung mass likely represents primary lung
neoplasm such as
nonsmall cell or adenocarcinoma, although metastasis is also
possible. Biopsy
can be obtained for further evaluation.
2. Metastatsis to the mediastinum and right adrenal gland.
It was thought that lung primary is the most likely possiblity.
Especially as there is a spiculated appearance of brain lesions
on CT.
Primary care office contact. They do not have a record of any
recent mammograms or pap smears.
[**5-25**] She was transferred to the ICU for closer monitoring due to
her mild uncal herniation. She had no acute events overnight.
Came back to the floor on [**5-26**].
Neuro-oncolgy consulted and involved during admission. CEA 23
(elevated). LDH 163 (normal).
HIV negative.
Stereotactic biopsy of intracranial lesion, L frontal, done on
[**5-26**]. No complications.
MRI initially not tolerated. CT head with and without contrast
done instead, showing multiple complex rim-enhancing masses at
the [**Doctor Last Name 352**]-white matter
junction with associated vasogenic edema, consistent with
metastases. The
superficial right temporal lobe lesion appears to transgress the
pial
compartment, to involve the overlying dura, consistent with
leptomeningeal
spread of tumor. Brief MRI in planning for biopsy showed the
following: Redemonstration of four parenchymal complex enhancing
lesions at
the [**Doctor Last Name 352**]-white matter junction, consistent with metastases.
Right temporal
metastasis at the right tentorium demonstrates associated dural
thickening and
enhancement.
Preliminary pathology is metastatic carcinoma. Final pathology
pending on discharge.
Radiation oncology consulted, recommended palliative whole brain
radiation which is being arranged as an outpatient.
Medical oncology follow-up also to be arranged as an outpatient.
Continued home dose levothyroxine. Insulin SS and PPI while on
steroids.
Medications on Admission:
Synthroid 200 micrograms po qday
Tylenol prn
Pseudaphedrine prn
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
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:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
A right upper lobe lung lesion - most probably a neoplasm, with
intracerebral metastasis
Discharge Condition:
Most of the neurological deficits had improved, she remained
with a slight right sided ptosis
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Keppra (Levetiracetam) for
anti-seizure medicine, take it as prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Have your sutures out on [**6-3**] you can call [**Telephone/Fax (1) 1669**] for
an appointment with [**Doctor Last Name **] at the Neurosurgery office to remove
staples
You will be contact[**Name (NI) **] by [**Name (NI) **], Radiation Oncology and
Oncology for your outpatient appointments.
[**Name6 (MD) 3523**] [**Name8 (MD) 3524**] MD [**MD Number(2) 21196**]
|
[
"305.1",
"244.9",
"197.1",
"198.3",
"198.7",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"01.13",
"87.03"
] |
icd9pcs
|
[
[
[]
]
] |
8841, 8847
|
5124, 8114
|
322, 350
|
8980, 9076
|
10766, 11164
|
2371, 2389
|
8229, 8818
|
8868, 8959
|
8140, 8206
|
9100, 10743
|
2404, 5101
|
236, 284
|
378, 2025
|
2047, 2063
|
2079, 2355
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,258
| 122,371
|
40549
|
Discharge summary
|
report
|
Admission Date: [**2131-9-7**] Discharge Date: [**2131-9-16**]
Date of Birth: [**2052-9-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2131-9-7**] Coronary artery bypass grafting x
4(LIMA-LAD,SVG-OM1,SVG-OM2,SVG-PDA)
History of Present Illness:
78 year old male with stage III chronic kidney disease and a
creatinine level of 2.1 had a cardiac catheterization in [**6-/2118**]
with OM rotational atherectomy and 3.0 x 18mm (quantum ranger
GFX) stent placement. He had been doing well from a cardiac
standpoint until about 3 months ago when he started to
experience exertional dyspnea and left sided chest and arm
discomfort which occurs while climbing [**Location (un) 2030**], walking on
the treadmill or walking through the airport. His symptoms
resolve with rest or SL nitroglycerin. He recognizes these
symptoms as similar to before his previous stent. Initially the
plan was to medically manage him given his renal disease,
however the patient has had continued exertional symptoms so is
now referred for cardiac catheterization. He is now being
referred to cardiac surgery for evaluation for
revascularization.
Past Medical History:
Coronary artery disease s/p stent [**6-/2118**]
Hypetension
Gastric ulcer with GI bleed (3 years ago)
Stage III kidney disease (baseline 2.1)
BPH
Hematuria (trace at times)
Anemia
Hemorrhoids
Fibular fracture 01
Gout
Renal cyst
s/p mastoid surgery at age 3
s/p tonsillectomy
Social History:
Race:Caucasian
Last Dental Exam:2 weeks ago
Lives with:Wife
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 88779**] or cell # [**Telephone/Fax (1) 88780**]
Occupation: Architect/partner in a firm
Cigarettes: smoked cigars in the past infrequently
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-19**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- father had an MI in his 60's
Physical Exam:
Pulse:63 Resp:18 O2 sat:99/RA
B/P Right:126/64 Left:126/56
Height:5'[**31**]" Weight:215 lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] +1
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
Admission Labs:
[**2131-9-7**] 07:37AM HGB-11.5* calcHCT-35
[**2131-9-7**] 07:37AM GLUCOSE-110* LACTATE-1.8 NA+-138 K+-4.4
CL--106
[**2131-9-7**] 11:38AM FIBRINOGE-284
[**2131-9-7**] 11:38AM PT-13.2 PTT-24.2 INR(PT)-1.1
[**2131-9-7**] 11:38AM PLT COUNT-161
[**2131-9-7**] 11:38AM WBC-12.1*# RBC-2.81*# HGB-8.5*# HCT-25.4*#
MCV-91 MCH-30.2 MCHC-33.4 RDW-14.1
[**2131-9-7**] 12:58PM UREA N-35* CREAT-1.7* SODIUM-141
POTASSIUM-4.4 CHLORIDE-115* TOTAL CO2-23 ANION GAP-7*
Discahrge Labs:
[**2131-9-7**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-14**]+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results at time of surgery.
POST-BYPASS: The patient is AV paced. Biventricular function is
unchanged. Mitral regurgitation remains mild to moderate ([**1-14**]+).
The aorta is intact post decannulation.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2131-9-13**]
10:22 AM
Final Report:
Supine and upright abdominal radiographs were obtained. Multiple
dilated loops of small bowel are noted reaching a diameter of 5
cm in some
segments. Gas is observed in the transverse colon and splenic
flexure with a loop of colon interposed between the right
hemidiaphragm and the liver. Air fluid levels are present in
upright view. No evidence of free air or abnormal
calcifications. Sternotomy wires are intact and surgical clips
are noted in the mediastinum. Bibasilar discoid atelectasis is
also observed.
IMPRESSION: Ileus. No significant interval change.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-9-12**] 9:21
PM
Final Report:
There has been interval placement of an esophageal catheter with
tip coiled within the stomach. The lungs appear unchanged with
low lung
volumes and bibasilar atelectasis. A trace left-sided effusion
may be
present. No pneumothorax or pulmonary edema is seen. Median
sternotomy wires and mediastinal clips appear unchanged.
IMPRESSION: Interval placement of esophageal catheter with tip
in the
stomach.
[**2131-9-14**] 06:30AM BLOOD WBC-10.4 RBC-3.11* Hgb-9.5* Hct-27.9*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-282
[**2131-9-14**] 06:30AM BLOOD Glucose-105* UreaN-60* Creat-2.0* Na-137
K-4.3 Cl-100 HCO3-23 AnGap-18
[**2131-9-16**] 05:00AM BLOOD WBC-10.9 RBC-3.14* Hgb-9.4* Hct-28.4*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.2 Plt Ct-377
[**2131-9-16**] 05:00AM BLOOD UreaN-45* Creat-1.8* Na-139 K-3.8 Cl-105
Brief Hospital Course:
Mr. [**Known lastname 88781**] was a same day admit and on [**9-7**] he was brought to
the operating room where he underwent coronary artery bypass
grafting. Please see operative report for surgical details. In
summary he had:coronary artery bypass grafting x4 with- left
internal mammary artery to left anterior descending artery,
reverse saphenous vein graft to obtuse marginal one, reverse
saphenous vein graft to obtuse marginal two, reverse saphenous
vein graft to posterior diagonal artery. He tolerated the
operation well and following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and was extubated. On post-op day one he was started on
beta-blockers and diuretics. Later on POD1 he was transferred to
the step-down floor for further recovery. Chest tubes and
epicardial pacing wires were removed per cardiac suregry
protocol.
Once on the floor he was noted to have an illeus and an
nasogastric tube was placed.General surgery was consulted. His
bowel regime was modified and his ileus resolved. He worked with
physical therapy to increase his mobility and endurance. He
continued to progress and on POD# 9 he was discharged to home.
All follow up appointments were advised.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth twice a day
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 2
Tablet(s) by mouth daily in the am
OLMESARTAN [BENICAR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth as needed for PRN
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth daily
Medications - OTC
ACETYLCYSTEINE [NAC] - (Prescribed by Other Provider) - 600 mg
Capsule - 1 Capsule(s) by mouth [**Hospital1 **] pre and post procedure as
per Dr. [**Last Name (STitle) **]
ASPIRIN [ECOTRIN] - (Prescribed by Other Provider) - 325 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth daily
FERROUS SULFATE [IRON] - (Prescribed by Other Provider) - 325
mg (65 mg iron) Capsule, Extended Release - 1 Capsule(s) by
mouth daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*qs ML(s)* Refills:*0*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day).
Disp:*120 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft
x4(LIMA-LAD,SVG-OM1,SVG-OM2,SVG-PDA)
Past medical history:
Hypetension
Gastric ulcer with GI bleed (3 years ago)
Stage III kidney disease (baseline 2.1)
Benign Prostatic Hypertrophy
Hematuria (trace at times)
Anemia
Hemorrhoids
Fibular fracture '[**21**]
Gout
Renal cyst
s/p stent [**6-/2118**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg - Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] on [**2131-10-17**] at 1PM- [**Hospital Unit Name **] [**Hospital Unit Name **]
Wound check with office nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] 2A on [**9-25**] @ 10:30 am
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2131-10-5**] at 10:00am
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6680**] in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2131-9-16**]
|
[
"403.90",
"560.1",
"787.3",
"411.1",
"585.3",
"414.01",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9556, 9614
|
5958, 7256
|
329, 416
|
10009, 10231
|
2780, 2780
|
11070, 11822
|
2027, 2092
|
8473, 9533
|
9635, 9729
|
7282, 8450
|
10255, 11047
|
2107, 2761
|
270, 291
|
444, 1317
|
2796, 5935
|
9751, 9988
|
1631, 2011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,157
| 173,000
|
24170
|
Discharge summary
|
report
|
Admission Date: [**2106-10-16**] Discharge Date: [**2106-10-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
GI bleed s/p spincterotomy
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] and sphincterotomy [**2106-10-16**]
[**Month/Day/Year **] and epinephrine hemostasis [**2106-10-18**]
History of Present Illness:
This is a [**Age over 90 **] year-old male with a history of chronic kidney
failure and BPH who presented on [**2106-10-16**] with fever, sharp
abdominal pain and nausea. He was found to have CBD dilation,
fever, pain and elevated LFTs. Patient was admitted to the
surgical service and taken for [**Date Range **] on [**2106-10-16**] when a
sphincterotomy was performed, stent placed, and CBD stones
removed. Patient was placed on cipro/flagyl. The evening of
hospital day 2, patient developed acute onset abdominal pain,
nausea, and hematemesis. On hospital day 3, patient was noted to
have hematocrit drop from 36-->31 and he returned to the [**Date Range **]
suite where he was found to be visibily bleeding from the
sphincterotomy site. The vessel was injected with epinephrine
and cauterized and hemostatis acheived. A new double pig tail
biliary stent was placed. Patient was transferred to the [**Hospital Unit Name 153**]
for hemodynamic monitoring in the setting of GI bleed at
sphincterotomy site.
ROS: Patient has mild intermittent right upper quadrant pain. He
denies any fevers, chills, weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
Chronic renal failure, baseline Cr 1.5
BPH
s/p Cholecystectomy at age 60
Social History:
Lives in senior living center for the past 25 years. Daughter
very involved in his care. No past or present ETOH, remote
tobacco from age 16-60 yrs (34 pky smoking history).
Family History:
NC
Physical Exam:
Vitals: T:97.5 BP:107/70 HR:75 RR: 12 O2Sat: 92% on RA
GEN: Well-appearing, well-nourished, no acute distress, looking
younger than stated age
HEENT: EOMI, PERRL, mild scleral icterous, 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, mild RUQ tenderness, ND, +BS, no HSM, no masses, no
rebound or guarding
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.
SKIN: No cyanosis or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2106-10-16**] 12:16AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2106-10-16**] 12:16AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2106-10-16**] 12:30AM PLT COUNT-107*
[**2106-10-16**] 12:30AM NEUTS-90.4* LYMPHS-5.8* MONOS-3.2 EOS-0.5
BASOS-0.1
[**2106-10-16**] 12:30AM WBC-5.6 RBC-5.73 HGB-13.2* HCT-42.5 MCV-74*
MCH-23.0* MCHC-31.0 RDW-15.3
[**2106-10-16**] 12:30AM ALBUMIN-4.1 CALCIUM-9.1 PHOSPHATE-2.2*
MAGNESIUM-2.2
[**2106-10-16**] 12:30AM LIPASE-18
[**2106-10-16**] 12:30AM ALT(SGPT)-297* AST(SGOT)-166* ALK PHOS-233*
TOT BILI-2.5*
[**2106-10-16**] 12:30AM GLUCOSE-142* UREA N-24* CREAT-1.6* SODIUM-141
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
[**2106-10-16**] 12:32AM LACTATE-2.6*
[**2106-10-16**] 09:55AM PLT SMR-LOW PLT COUNT-94*
[**2106-10-16**] 09:55AM WBC-8.9# RBC-4.69 HGB-10.6* HCT-33.3* MCV-71*
MCH-22.7* MCHC-31.9 RDW-16.5*
[**2106-10-16**] 09:55AM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-4.0#
MAGNESIUM-1.8
[**2106-10-16**] 09:55AM LIPASE-13
[**2106-10-16**] 09:55AM ALT(SGPT)-209* AST(SGOT)-113* ALK PHOS-176*
AMYLASE-26 TOT BILI-2.8*
[**2106-10-16**] 09:55AM GLUCOSE-103 UREA N-20 CREAT-1.5* SODIUM-140
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
[**2106-10-16**] 11:57AM PT-14.4* PTT-41.2* INR(PT)-1.3*
[**2106-10-22**] 05:20AM BLOOD WBC-5.8 RBC-4.09* Hgb-9.4* Hct-29.9*
MCV-73* MCH-23.1* MCHC-31.5 RDW-18.1* Plt Ct-222
[**2106-10-22**] 05:20AM BLOOD Glucose-103 UreaN-14 Creat-1.4* Na-138
K-4.0 Cl-107 HCO3-24 AnGap-11
[**2106-10-22**] 05:20AM BLOOD ALT-54* AST-35 AlkPhos-126* TotBili-1.6*
[**2106-10-22**] 05:20AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0
Brief Hospital Course:
# Choledocholithiasis s/p [**Month/Day/Year **] complicated by sphincterotomy
bleed: Patient found to have hct drop from 36-->31 and visible
bleeding vessel on repeat [**Month/Day/Year **] at sphincterotomy site. Per [**Month/Day/Year **]
team, hemostasis was acheived and stent patent.
He was transfused on [**10-19**] and hct has remained stable at ~30.
Broad spectrum antibiotics were started in the setting of repeat
instrumentation with cipro/flagyl for 5 days total. He has
remained afebrile and LFT's have trended downward appropriately.
He c/o occassional abdominal discomfort and has had 2 episodes
of diarrhea on [**10-22**]. A stool for C. diff has been ordered. He
has been tolerating a regular diet. He is scheduled for a
repeat [**Month/Year (2) **]/ stent removal in six weeks.
# Chronic Kidney Failure stage III: At baseline of 1.5.
# Thrombocytopenia: Has low baseline dating back to [**2103**] in low
130s.
# Anemia, [**3-6**] acute blood loss: Baseline of HCT 42.
# BPH: Continue on outpatient regimen of finasteride, doxazosin
# Code: full code, was DNR in unit.
# Comm: [**Name (NI) **] [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 46291**]
Medications on Admission:
doxazosin 2mg daily
finasteride 5mg daily
vit. B12
bisacodyl
metamucil
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-3**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 61406**] Home Health, [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
choledocholithiasis with biliary obstruction
s/p [**Location (un) **] with stone removal and stent placement, complicated by
sphincterotomy bleed
Secondary Diagnoses:
#. Chronic Kidney Disease Stage 3
#. BPH
#. Cholelithiasis
Discharge Condition:
Stable, starting to eat regular diet, c/o occassional abdominal
discomfort. Has had 2 episodes of diarrhea on [**10-22**]. Ambulating
well.
Discharge Instructions:
Please do not take Aspirin until Tuesday [**10-26**].
Return to the Emergency Department if you have nausea, vomiting,
fever, chills, abdominal pain, jaundice, black stools, bleeding,
dizziness, weakness or any other concerning symptoms.
Followup Instructions:
Stent removal in six weeks.Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS
Date/Time:[**2106-12-2**] 9:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2106-12-2**] 9:00
Completed by:[**2106-10-23**]
|
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"574.20",
"600.00",
"585.3",
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icd9cm
|
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"51.87",
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"39.98",
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icd9pcs
|
[
[
[]
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6609, 6696
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4651, 5836
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292, 420
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6986, 7128
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2909, 4628
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225, 254
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1867, 1941
|
1957, 2132
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,176
| 164,872
|
31229
|
Discharge summary
|
report
|
Admission Date: [**2162-10-13**] Discharge Date: [**2162-11-12**]
Date of Birth: [**2094-2-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
wound erythema, chest pain
Major Surgical or Invasive Procedure:
68F s/p sternal wound debridement & VAC [**10-15**],
debridement/closure [**10-18**], trach/J-tube [**10-29**]
History of Present Illness:
68 yo F s/p CABG [**2162-9-6**] and superficial sharp debridement of
distal sternal wound, presented with increasing erythema of
superior mid sternal incision.
Past Medical History:
CABG X 4(LIMA->LAD, SVG->Diag, SVG->OM, SVG->PDA) [**9-6**]
PMH:
-Coronary Artery Disease
-Chronic Obstructive Pulmonary Disease
-Hypertension
-Peripheral Vascular Disease - prior stenting Left Lower
Extremity
-Abdominal Aortic Aneurysm
-Hysterectomy
Social History:
Heavy smoker, over 2 packs per day for 50 years, quit
approximately 3 months prior to admission. She denies ETOH. She
is retired and lives with her daughter.
Family History:
Brother with MI at age 72
Physical Exam:
NAD
CV RRR
Lungs CTAB x crackles at left base
Abdomen Obese, benign
Extrem without edema
MSI with ~6 inches of erythema & warmth at prox end, fluctuent.
No active drainage. Distal incision open ~1cm in diameter base
beefy red, healthy without erythema or drainage.
Discharge
Vitals 98.1, 91 SR 137/63 14 99% on 35% Trach collar
Neuro Alert oriented x3 nonfocal using passy muir valve with
encouragement
Cardiac RRR no m/r/g
Resp clear bilat except decreased bilat bases - on trach collar
Abd soft, NT, ND with jtube in lmq
Ext warm trace edema
Incision - sternal healing there is small amout fibrinous tissue
middle line edges no fully approximated - wearing bra (keep on
at all times)
Pertinent Results:
[**2162-11-12**] 03:51AM BLOOD WBC-7.0 RBC-3.25* Hgb-9.7* Hct-29.9*
MCV-92 MCH-30.0 MCHC-32.6 RDW-16.6* Plt Ct-304
[**2162-10-13**] 04:15PM BLOOD WBC-11.2* RBC-3.81* Hgb-10.9* Hct-33.1*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.4 Plt Ct-531*
[**2162-11-9**] 02:38AM BLOOD Neuts-81.0* Lymphs-12.4* Monos-4.7
Eos-1.7 Baso-0.2
[**2162-11-12**] 03:51AM BLOOD Plt Ct-304
[**2162-11-3**] 03:18AM BLOOD PT-11.7 PTT-24.5 INR(PT)-1.0
[**2162-10-15**] 12:13PM BLOOD PT-13.4* PTT-27.9 INR(PT)-1.2*
[**2162-10-13**] 04:15PM BLOOD Plt Ct-531*
[**2162-11-3**] 03:18AM BLOOD Fibrino-604*#
[**2162-11-12**] 03:51AM BLOOD Glucose-105 UreaN-17 Creat-0.7 Na-139
K-4.5 Cl-99 HCO3-38* AnGap-7*
[**2162-10-13**] 04:15PM BLOOD Glucose-145* UreaN-24* Creat-1.2* Na-139
K-4.2 Cl-100 HCO3-26 AnGap-17
[**2162-10-25**] 06:03PM BLOOD ALT-39 AST-22 LD(LDH)-284* AlkPhos-154*
Amylase-55 TotBili-0.5
[**2162-10-25**] 03:52PM BLOOD ALT-45* AST-23 AlkPhos-176* Amylase-65
TotBili-0.5
[**2162-10-25**] 06:03PM BLOOD Lipase-36
[**2162-10-25**] 03:52PM BLOOD Lipase-41
[**2162-11-12**] 03:51AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.2
[**2162-10-27**] 03:02AM BLOOD TSH-1.3
[**2162-10-27**] 03:02AM BLOOD T4-3.9* T3-55*
[**2162-11-12**] 03:51AM BLOOD Vanco-14.0
[**2162-11-1**] 02:21AM BLOOD Type-ART Temp-36.7 pO2-135* pCO2-42
pH-7.40 calTCO2-27 Base XS-1
[**2162-11-4**] 4:00 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2162-11-5**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2162-11-5**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative
[**2162-11-3**] 8:29 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2162-11-5**]**
GRAM STAIN (Final [**2162-11-3**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2162-11-5**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2162-11-8**] 1:32 PM
CHEST (PORTABLE AP)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman s/p CABG, superficial sternal wound infection
REASON FOR THIS EXAMINATION:
r/o inf, eff
INDICATION: Status post CABG with superficial sternal wound
infection.
Portable AP chest dated [**2162-11-8**] is compared to the prior from
[**2162-11-3**]. The patient has been extubated and a tracheostomy tube
has been placed, which is positioned in the mid-trachea at the
thoracic inlet. A nasogastric tube terminates in the stomach. A
right subclavian central venous catheter terminates in the
region of the cavoatrial junction; however, the tip is not well
seen. The heart size and mediastinal contours are stable. The
lungs are clear. There is no pleural effusion or pneumothorax.
IMPRESSION: Status post tracheostomy. No acute cardiopulmonary
abnormality
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: WED [**2162-11-10**] 8:06 AM
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2162-11-4**] 8:52 AM
PORTABLE ABDOMEN
Reason: evaluate for contrast passage
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with s/p sternal wound and trach/j tube
placement
REASON FOR THIS EXAMINATION:
evaluate for contrast passage
HISTORY: 68-year-old female status post sternal wound,
tracheostomy and J- tube placement. Here to evaluate for
contrast passage.
COMPARISON: Abdominal radiograph of [**2162-11-3**].
FINDINGS: A single portable semi-erect radiographed view of the
abdomen reveals a small amount of contrast remaining within the
colon. The bowel gas pattern is unremarkable. An NG tube is seen
with its tip in the stomach. No jejunal tube is seen. A vertical
abdominal staple line is seen. Surgical clips are seen in the
thorax. Degenerative changes are seen in the thoracolumbar
spine.
IMPRESSION: Small amount of contrast remains within the colon
only. No evidence of obstruction. A jejunal tube is not seen,
however, a nasogastric tube is seen with its tip in the stomach.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: SAT [**2162-11-6**] 8:10 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73691**]TTE (Complete)
Done [**2162-10-26**] at 1:35:02 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2094-2-3**]
Age (years): 68 F Hgt (in): 61
BP (mm Hg): 90/40 Wgt (lb): 167
HR (bpm): 90 BSA (m2): 1.75 m2
Indication: Hypotension.
ICD-9 Codes: 424.0, 440.0
Test Information
Date/Time: [**2162-10-26**] at 01:35 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2007W039-0:00 Machine: Vivid [**7-24**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 70% >= 55%
Findings
LEFT ATRIUM: LA not well visualized.
RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. A
catheter or pacing wire is seen in the RA and extending into the
RV. Normal/small IVC diameter (<=1.5cm) with respiratory
collapse (estimated RAP 0-5mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Hyperdynamic LVEF >75%. No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Cannot
assess regional RV systolic function.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - body habitus. Suboptimal
image quality - ventilator. Emergency study performed by the
cardiology fellow on call.
Conclusions
The estimated right atrial pressure is 0-5mmHg. There is mild
symmetric left ventricular hypertrophy. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is probably normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened and there is no aortic stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Valvular regurgitation could not be fully
assessed but there is probably no significant mitral
regurgitation. There is a trivial/physiologic pericardial
effusion.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician
Date: [**2162-11-11**]
Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP on [**2162-11-11**] Affiliation:
[**Hospital1 18**]
PASSY-MUIR VALVE EVALUATION / DISPENSE
HISTORY:
Thank you for reconsulting on this 68 y/o female who underwent a
4 vessel CABG (left internal mammary artery grafted to the left
anterior descending, reverse saphenous vein graft to the PDA,
second marginal branch, diagonal branch) on [**2162-9-6**] by Dr.
[**Last Name (STitle) **] for CAD with worsening angina. Her hospital course was
notable for some distal sternum/sternal wound separation which
was locally debrided and treated with antibiotics. She was
discharged on [**2162-9-21**] on oral levofloxacin and followed
closely.
On [**2162-10-12**] it was noted that the superior portion of the
sternal
wound had erythema and she was started on oral clindamycin. She
presented on [**2162-10-13**] with worsening symptoms and subsequently
had the superficial portion of that wound opened and then was
taken to the OR for formal exploration and debridement. The
chest
was left open. On [**2162-10-18**], she had a chest closure procedure
with a pectoral flap. Her course was c/b VAP. S/p multiple
extubations. S/P trach and PEG on [**2162-10-29**] w/jejunostomy
placement.
PMHx/PSHx:
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Hypertension
Peripheral Vascular Disease - prior stenting Left Lower
Extremity
Abdominal Aortic Aneurysm
Hysterectomy
Pt has been seen twice for a PMV evaluation on [**11-5**] and [**11-9**],
but did not tolerate as noted by immediate SOB, high tracheal
pressures and audible rush of air when the valve was removed.
The
pt was downsized to a Portex #7 yesterday and we returned to
repeat the evaluation. Pt also had her NG tube removed.
TRACH TYPE: Portex #7, cuffed, disposable inner cannula
SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION:
Pt has had minimal secretions and did not require suctioning
prior to cuff deflation. O2 SATs were at 100% with RR ~18 prior
to deflation and remained stable after deflation. She did not
require suctioning after deflation.
PMV TOLERANCE / VOCAL QUALITY / O2 SATS:
The valve was placed for ~15 minutes while on trach collar.
tracheal pressures were lower than on previous evaluations and
were between +/- 10 cm/H2O. Pt reported breathing was
comfortable
and O2 SATs and RR remained stable. The valve was removed
without
any audible rush of air. She was able to produce clear voicing
with adequate volume, although slightly reduced.
SUMMARY:
Ms. [**Known lastname 31394**] is now able to tolerate placement of the valve
following trach downsize and NG tube removal. She was able to
wear the valve for ~15 minutes and it was left on following the
evaluation. She was able to produce clear voicing and is
expected
to tolerate the valve for extended periods of time.
The pt is also judged to be ready for a swallow evaluation, but
it was deferred today [**2-19**] anxiety and I told the pt we will
return tomorrow to complete a swallow evaluation.
RECOMMENDATIONS:
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
2. Monitor O2 Sats / respiration while valve is in place.
3. Do not allow the patient to sleep with the valve in place.
4. PMV wear schedule is up to the discretion of the
nurse and/or respiratory therapist.
These recommendations were shared with the patient, nurse and
medical team.
_______________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP
Pager #[**Numeric Identifier 2622**]
Face time: 1:00-1:25
Total time: 50 minutes
Brief Hospital Course:
She was admitted and started on IV antibiotics. A small area at
the proximal incision was opened and packed at the bedside. She
was started on IV antibiotics. The fluctuence worsened and she
was taken to the operating room on [**10-15**] where she underwent a
sternal wound debridement and vac dressing application. She was
transferred to the ICU and paralyzed and sedated. She was seen
by plastic surgery and was taken to the operating room on [**10-18**]
where she underwent left pac advancement and right pec turnover
flap, bilateral mammary advancement flap closure. She was
extubated the next day but required reintubation for respiratory
distress the same day. She was started on tube feeds. She was
extubated again on [**10-21**] and started on IV steroids for COPD. She
was seen by infectious diseases and continues on a course of
vancomycin for 6 weeks. She was reintubated again on [**10-22**] for
respiratory distress. She was started on a 10 day course of
zosyn for presumed pneumonia. She developed coffee ground OGT
output and falling hct, and was seen by GI. She was again
extubated on [**10-27**] and was reintubated for respiratory distress.
She ws seen by thoracic surgery for consideration of trach and
PEG. On [**10-29**] she underwent tracheostomy, PEG and jejunostomy
placement. He tube feeds were increased to goal. NG tube
remained to suction due to high output but was placed to gravity
on [**11-8**], and was dc'd on [**11-10**] without vomiting. Her trach was
downsized on [**11-10**] and began to use passy-muir valve on [**11-11**].
She was ready for discharge to rehab [**11-11**].
Medications on Admission:
plavix
zocor
paxil
colace
ASA
fluticasone salmeterol
xanax
tiotropium
zantac
lopressor
albuterol
lasix
kcl
glipizide
clindamycin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2
times a day).
3. Polyvinyl Alcohol 1.4 % Drops [**Month/Year (2) **]: 1-2 Drops Ophthalmic PRN
(as needed).
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
5. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
DAILY (Daily).
6. Simvastatin 40 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 6-10 Puffs Inhalation
Q2H (every 2 hours) as needed.
10. [**Doctor First Name **]-Med Suppository [**Doctor First Name **]: One (1) Suppository Rectal QID
PRN ().
11. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor First Name **]: One (1)
Injection [**Hospital1 **] (2 times a day).
12. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
15. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day).
16. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Inhalation once a day.
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Inhalation twice a day.
19. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
once a day: completes [**11-27**] .
20. Paxil 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
21. PICC line
PICC line per protocol
22. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: Ten (10) units
Subcutaneous once a day.
23. Insulin Sliding scale
please see page 2
24. Glyburide 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
sternal wound infection s/p debridement and closure
respiratory failure s/p trach
CAD s/p CABG X 4 [**9-6**]
PMH: COPD, HTN, PVD (s/p PCI>LLE)
Discharge Condition:
good
Discharge Instructions:
Please wash up 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 Please
keep incision covered with DSD while still healing and has trach
No lifting more than 10 pounds for 2 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] please call to schedule 2 weeks [**Telephone/Fax (1) 170**]
Dr [**First Name (STitle) **] [**Street Address(2) **]. [**Apartment Address(1) **], [**Location (un) **], [**Numeric Identifier 1415**] ([**Telephone/Fax (1) 14596**] Thrusday [**11-18**] at 230 pm
Dr [**Last Name (STitle) 7443**] Phone:[**Telephone/Fax (1) 457**] Monday [**2162-11-22**] at 9am
Weekly vancomycin levels (thrusdays) results to [**Hospital **] clinic Fax #
[**Telephone/Fax (1) 1419**] attn Dr [**Last Name (STitle) 7443**]
Completed by:[**2162-11-12**]
|
[
"998.59",
"998.6",
"458.29",
"414.00",
"518.81",
"278.01",
"E878.8",
"441.4",
"491.21",
"E849.7",
"E849.8",
"999.9",
"440.20",
"998.32",
"486",
"562.10",
"E878.2",
"263.9",
"250.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.72",
"89.64",
"96.04",
"83.82",
"46.39",
"38.93",
"99.15",
"93.59",
"33.24",
"96.07",
"31.1",
"77.61",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
17861, 17931
|
13613, 15228
|
349, 462
|
18118, 18125
|
1868, 3993
|
18670, 19234
|
1118, 1145
|
15407, 17838
|
5386, 5454
|
17952, 18097
|
15254, 15384
|
18149, 18647
|
1160, 1849
|
283, 311
|
5483, 13590
|
490, 651
|
673, 926
|
942, 1102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,187
| 119,361
|
10477
|
Discharge summary
|
report
|
Admission Date: [**2126-5-7**] Discharge Date: [**2126-5-13**]
Date of Birth: [**2078-3-8**] Sex: F
Service: SURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic Cyst
Major Surgical or Invasive Procedure:
Distal Pancreatectomy with Splenectomy
History of Present Illness:
Mrs. [**Known lastname 24913**] is a delightful woman her late 40s who has been
identified on axial CT abdominal imaging to have a cystic mass
in the body and tail of her pancreas (CEA 5279, amylase 7310).
It is consistent with a mucinous neoplasm and I believe warrants
resection which was advised she undertake.
Past Medical History:
s/p EUS in [**2-/2126**] for cyst aspiration (CEA 5279, amylase 7310),
s/p tubal ligation [**2104**], history of seizure disorder, s/p
laparascopic ovarian cyst removal X 2, fibromyalgia, s/p
coiling/stent of cerebral aneurysm [**2122**]
Social History:
She is not a heavy alcohol user. She lives in [**Location **], is married
with 3 children.
Family History:
Father had lung cancer due to asbestos.
Physical Exam:
On discharge:
T: 98.3/97.6 HR: 74 BP: 104/62 RR: 20 O2: 94%RA
Gen: AAOx3, NAD
Heart: RRR
Lungs: CTAB
Abd: +BS, soft, appropriately tender, ND, incision C/D/I,
staples intact
Extr: + blisters on R knee and L medial thigh - most likely from
TEDS, bacitracin and telfa applied, otherwise no edema, no
tenderness
Pertinent Results:
[**2126-5-7**] 11:05AM BLOOD Hct-32.2*
[**2126-5-8**] 04:17AM BLOOD WBC-15.0*# RBC-3.19*# Hgb-10.8*#
Hct-31.7* MCV-99* MCH-33.9* MCHC-34.2 RDW-13.3 Plt Ct-349
[**2126-5-11**] 06:50AM BLOOD WBC-8.6 RBC-2.72* Hgb-9.4* Hct-26.2*
MCV-96 MCH-34.7* MCHC-36.0* RDW-13.2 Plt Ct-453*
[**2126-5-11**] 01:02PM BLOOD Hct-27.9*
[**2126-5-11**] 06:50AM BLOOD Glucose-110* UreaN-5* Creat-0.5 Na-140
K-4.1 Cl-101 HCO3-30 AnGap-13
[**2126-5-11**] 06:50AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2126-5-12**] 04:22PM Peritoneal Amylase-125
[**2126-5-12**] 09:29PM Peritoneal Amylase-219 (after fulls, no
increase in volume of output)
.
Pathology Examination
SPECIMEN SUBMITTED: SPLEEN & DISTAL PANCREAS.
Procedure date Tissue received Report Date Diagnosed
by
[**2126-5-7**] [**2126-5-7**] [**2126-5-13**] DR. [**Last Name (STitle) **]. BROWN/lfb
Previous biopsies: [**-1/2573**] SKIN, LEFT UPPER THIRD
TOE/sl/agn.
[**-1/2548**] CONSULT SLIDES REFERRED TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
DIAGNOSIS:
1. Spleen: No diagnostic abnormalities.
2. Pancreas, distal:
A. Mucinous cystic neoplasm with low grade to moderate
dysplasia. No invasive carcinoma seen, entire cyst examined. The
cyst has ovarian type stroma.
Much of the cyst lining has been destroyed and replaced by
fibrous tissue with hemosiderin, giant cells and cholesterol.
B. Focal chronic pancreatitis and pancreatic intraepithelial
neoplasia 1.
C. Accessory spleen.
D. 5 lymph nodes with no tumor seen.
Clinical: Pancreatic cyst.
Brief Hospital Course:
Patient was admitted and underwent distal pancreatectomy with
splenectomy (with mobilization of splenic flexure of colon) on
[**2126-5-7**]. She tolerated the procedure well without complications
(please refer to operative note for further details).
Post-operatively, she did well.
Neuro: She had an epidural placed pre-op by APS but had low
BP's while in the PACu. She remained in the PACU overnight to
monitor her BP's and the epidural was adjusted by APS but low
BP's persisted. It was capped and a PCA was started. Her
pressures improved and she was transferred to the floor. The
PCA provided some pain control temporarily but the epidural had
to be restarted with just bupivicaine 0.05% solution and the PCA
was continued in order to control her pain. She did well on
this combination. She was restarted on her depakote via NGT
immediately post-op for seizure prophylaxis. Her epidural was
discontinued on [**2126-5-12**] by APS along with her PCA and her pain
was controlled with PO dilaudid.
CV: Her blood pressures were lowered in the presence of her
epidural but she stabilized after it was changed to only
bupivicaine and there were no issues after it was removed. She
was restarted on her home lipitor on [**5-11**].
Resp: She was stable respiratory wise. Her oxygenation on room
air was normal and she was ambulating well without incident.
GI: She was initially NPO immediately post-op with an NGT. The
NGT was removed on [**5-8**] and she was started on sips on [**5-9**].
She tolerated PO's and was advanced as tolerated. On [**5-12**] she
was on full liquids and her JP amylase 125 and 219 (the latter
was after full liquids). There was no change in the volume or
quality of the JP output and it was subsequently removed on [**5-13**]
(POD#6). She was tolerating a regular diet by POD#6. Her
incision was C/D/I and her staples are to be removed in clinic.
GU: She had a Foley that was removed on [**5-11**] hours after the
epidural was capped. She voided without incident afterwards.
ID: She received her meningococcal, pneumococcal and haemophilus
vaccines on POD#3.
Of note, she developed blisters on her R knee and L medial thigh
from presumably the [**Male First Name (un) **] stockings. They did not appear infected
and bacitracin ointment with Telfa were applied. She was
instructed to keep areas clean, dry and covered with antibiotic
ointment and TELFA.
Medications on Admission:
lipitor 10', depakote 500', asa 81', prozac 10', mvi, ca, vit c
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Cyst
Discharge Condition:
Good
Tolerating Diet
Pain well controlled
Incision C,D,I
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please resume all regular home medications and take any new meds
as ordered.
.
Continue to ambulate several times per day.
.
You may wash and shower. Keep your incision clean and dry. Pat
dry after your shower.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] to remove your staples in
approximately 1-2 weeks. Please call ([**Telephone/Fax (1) 14347**] to schedule
an appointment.
|
[
"577.2",
"215.5",
"272.4",
"577.1",
"780.39",
"458.9",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"52.52",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
6017, 6023
|
2990, 5396
|
285, 326
|
6083, 6142
|
1445, 2967
|
7322, 7503
|
1056, 1097
|
5510, 5994
|
6044, 6062
|
5422, 5487
|
6166, 7299
|
1112, 1112
|
1126, 1426
|
230, 247
|
354, 669
|
691, 930
|
946, 1040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,355
| 187,154
|
34148
|
Discharge summary
|
report
|
Admission Date: [**2111-12-28**] Discharge Date: [**2112-1-5**]
Date of Birth: [**2074-4-21**] Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 year old man with pmh of DM type 1 diagnosed 17 years ago
complicated with severe gastroparesis, neuropathy, and h/o CAD
s/p MIs and stent placement who presented to the ED in DKA. The
patient was last seen at [**Hospital1 **] on [**10/2111**] for evaluation for
pancreas transplant. Over the past several months he's had
multiple admissions for severe gastroparesis with sx of n/v,
inability to hold down food, and generalized weakness.
.
He originally presented today to [**Hospital 189**] hospital's ED and was
transferred to [**Hospital1 **]. On arrival to the ED vital signs were 98.1
111 169/54 16 100% RA. His initial glucose was 481 on arrival
with a bicarb of 11 and a gap of 28. + ketones in the urine. His
white count was 9.4 with 94.2% neutrophils. His urine was
negative for infection. A glc at 16:45 was 497. His insulin gtt
was initially started at 8 units/hr. His repeat glucose was 496
and his insulin gtt was increased to 12 units per hr. He
received 2L of IVF. At the time of transfer NS with 40meg of
potassium was hung. He vomited coffee ground emesis in the ED
and received zofran 8mg. He also reported abdominal pain and
received morphine 4mg IV x1. He was tachycardic in the ED to the
120s-130s. EKG was sinus tach without any ischemic changes.
Vitals prior to transfer were temp T95.2 HR120 BP157/71 RR17
100% RA.
.
On arrival to the floor, vitals were 97.5 HR 121 BP 151/78 RR22
100% on room air. Lactate on arrival to the floor was 3.8. The
patient reports he's been hospitalized >20 times in the last 4
months for gastroparesis flares. He has not been hospitalized in
DKA for yrs. He was last discharged from [**Hospital 189**] hospital a few
days ago. He was taking his regular home dosing of lantus and
ISS. He states his home blood sugars have been running 100s to
mid 200s. He last took his blood sugar yesterday am and it was
165. He generally takes his blood sugars twice a day. He took
his home lantus yesterday am and this am but did not take
yesterday evening's dose. He began to have emesis yesterday am
and it continued overnight and into today. He also developed
severe abdominal pain. He reports severe diffuse abdominal pain
and nausea. He has chills currently but denied chills while at
home. He denies chest pain, sob, cough, diarrhea, or skin
ulcers.
.
(-)Denies headache, congestion, ear pain, throat pain, cough,
shortness of breath. Denies chest pain, chest pressure. Denies
constipation. Denies dysuria, frequency, or urgency. Unable to
obtain further history secondray to patient discomfort.
Past Medical History:
T1DM - w/ recurrent DKA and diagnosed 17 yrs ago, being
evaluated for pancreas transplant
Multiple recent hospitalizations for severe gastroparesis
Multiple MIs
CAD s/p multiple stents and multiple MIS (secondary to cocaine
abuse)
Depression
HTN
Diabetic nephropathy
Hyperthyroidism
Hyperlipiedemia
GERD
hiatal hernia
erosive esophagitis
Social History:
Lives with his wife and children. Denies h/o smoking or etoh
use. No current use of illicits. h/o cocaine use none since
[**2101**]. On disability
Family History:
one cousin with history of diabetes
Physical Exam:
VS: 95.2 HR 129 BP 151/78 RR21 100%
GEN: rigors, emesis, and appears uncomfortable
HEENT: very dry mucus membranes
RESP: CTA b/l with good air movement throughout
CV: tachycardic, no m/r/g
ABD: diffuse abdominal tenderness with no rebound or guarding
EXT: no c/c/e, radial pulses +2, pt declined taking off socks to
feel DP pulses
SKIN: no rashes
NEURO: AAOx3. Moving all extremities
Pertinent Results:
Admission labs:
[**2111-12-28**] 03:00PM WBC-9.4 RBC-4.69 HGB-13.6* HCT-39.8* MCV-85
MCH-29.0 MCHC-34.2 RDW-14.3
[**2111-12-28**] 03:00PM NEUTS-92.4* LYMPHS-5.9* MONOS-1.3* EOS-0.2
BASOS-0.1
[**2111-12-28**] 03:00PM ALT(SGPT)-18 AST(SGOT)-18 ALK PHOS-111 TOT
BILI-0.5
[**2111-12-28**] 03:00PM BLOOD Glucose-481* UreaN-16 Creat-1.0 Na-137
K-4.2 Cl-98 HCO3-11* AnGap-32*
[**2111-12-28**] 08:34PM BLOOD Calcium-9.5 Phos-2.2*# Mg-1.8
Imaging:
CXR: Normal CXR with suboptimal images (left lung portion
excluded)
ABD film: Normal gas pattern.
[**2111-12-28**] 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-12-28**] 11:58AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2111-12-28**] 11:05PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2111-12-30**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-12-30**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-12-28**] BLOOD CULTURE Blood Culture,
Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic
Bottle Gram Stain-FINAL INPATIENT
Brief Hospital Course:
DKA: The patient presented to an OSH with malaise, abdominal
pain, nausea and emesis. He at the OSH had a sugar of 481 with a
bicarbonate of 11, an anion gap of 28 and ketones in his urine.
Pt was admitted to the MICU for management of diabetic
ketoacidosis. Pt was aggressively hydrated and started on
insuling gtt. [**Last Name (un) **] endocrinologist were consulted and assisted
in the management of his DKA/glucose. His anion gap closed and
he was transferred out of the ICU on standing lantus and sliding
scale with a normal blood glucose and normalized potassium.
While on the floor, pt had ongoing issues related to his
gastroparesis and was kept on maintenance fluids and sc insulin.
The standing lantus was titrated to maintain his FSBS between
100-200.
.
Gastroparesis: The patient presented with severe nausea, emesis
and abdominal pain. It is unclear whether the gastroparesis
exacerbation precipitated DKA or his gastroparesis was worsened
by the DKA. Pt had some reported blood in the emesis though
his hematocrit remained stable and this seemed to resolve after
admission. It was thought most likely due to [**Doctor First Name 329**] [**Doctor Last Name **]
tear. His nausea was treated with reglan, zofran and ativan
PRN. His abdominal pain was poorly controlled with morphine and
he was transitioned to dilaudid which did acheive better pain
control. Pt was initially advanced to a regular DM diet and
developped recurrent emesis. The patient was started on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
diet which he tolerated for 3 meals. He was then advanced to a
low fat, lactose free diet which he tolerated for 3 meals. He
was discharged being able to take a regular DM diet and his
abdominal pain controlled with PO dilaudid.
.
Diabetic neuropathy: The patient's neuropathic medication
regimen was restarted once the patient was tolerating po meds.
.
Tachycardia: This is likely secondary to severe dehydration and
abdominal pain. EKG was unremarkable. This resolved after
rehydration and better pain control.
.
CAD: Has h/o MIs (in setting of cocaine) and stenting. He was
ruled out for MI with negative troponins and an unremarkable
EKG. Statin and beta blocker were held while not taking PO,
however were restarted once the patient was taking POs. Pt will
need to discuss restarting Aspirin after he is seen by his PCP,
[**Name10 (NameIs) **] was not given in house due to the possible [**Doctor First Name 329**] [**Doctor Last Name **] tear
and intermittent emesis.
.
Depression: The patient's depression medication regimen was
restarted once the patient was taking PO medication.
.
HTN: The patient's hypertensive regimen was restarted once the
patient was taking PO medication. Blood pressure controlled when
pain was controlled.
.
Hyperlipidemia: The patient's hyperlipidemia regimen was
restarted once the patient was taking PO medication.
.
Medications on Admission:
DOXEPIN 100 mg daily
DULOXETINE 30 mg daily
GABAPENTIN 300 mg po daily
INSULIN ASPART per sliding scale
INSULIN GLARGINE 23 units every am & pm
LISINOPRIL 2.5 mg po daily
METOCLOPRAMIDE 10 mg po QID
METOPROLOL TARTRATE 50 mg po daily
MIRTAZAPINE 30 mg qhs
OLANZAPINE 2.5 mg daily
OMEPRAZOLE 20 mg daily
ONDANSETRON HCL 4 mg every eight hours prn
SIMVASTATIN 20 mg po daily
ZOLPIDEM 5 mg qhs
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea.
Disp:*12 Tablet(s)* Refills:*0*
2. doxepin 25 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. olanzapine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO once
a day.
11. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*8 Tablet, Rapid Dissolve(s)* Refills:*0*
12. insulin lispro 100 unit/mL Solution Sig: One (1) Please use
as specified by your previous sliding scale Subcutaneous four
times a day.
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*8 Tablet(s)* Refills:*0*
14. insulin glargine 100 unit/mL Solution Sig: One (1) 25 units
Subcutaneous qAM, qPM.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Senna Lax 8.6 mg Tablet Sig: 1-2 Tablets PO qHS PRN.
18. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Diabetic Ketoacidosis
Diabetic Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Abdominal Pain/Emesis/Diabetic Gastroparesis
Your abdominal pain appears to be caused by a your diabetic
gastroparesis, at this time. It resolved after receiving reglan,
zofran, ativan, and erythromycin. Somtimes other symptoms can
develop later. Therefore it is very important to carefully
monitor your condition at home and go to the Emergency
Department immediately if you have any of the warning signs
listed below.
Warning Signs:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Diabetic Ketoacidosis/Hyperglycemia
During your stay in the hospital, you were found to have an
elevated blood sugar (glucose). This is known as hyperglycemia.
This can cause a condition called Diabetic Ketoacidosis which
you were found to have.
The most common cause of hyperglycemia is diabetes, which you
have. You should keep your sugars under control. If your sugars
are too high, you can become very ill from dehydration and
shock.
Mild elevations in blood sugar may not cause any symptoms, but
over time, elevated blood sugar levels can lead to an increased
risk of infection as well as damage your kidneys, nervous
system, eyes, heart and blood vessels.
You are already started on treatment for elevated blood sugar,
it is important to watch for signs of low blood sugar. This is
known as hypoglycemia. Low blood sugar can make you
lightheaded, dizzy, weak, or confused. Sweets (sugar candy or
juice) can help raise blood sugar levels. If your symptoms are
due to low blood sugar, sweets should immediately cause your
symptoms to go away.
You should go to the Emergency Department immediately if you
have any of the warning signs listed below.
Warning Signs:
* You are not getting better in 24 hours, or you are getting
worse in any way.
* Dizziness, lightheadedness, sweating, confusion, siezure
activity or change in behavior.
* Increased urination, increased thirst or increased hunger.
* You experience new chest pain, pressure, squeezing or
tightness.
* You have shaking chills, or a fever greater than 102 degrees
(F)
* New or worsening cough or wheezing.
* Abdominal (belly) pain, vomiting, severe headache.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Department: TRANSPLANT CENTER
When: MONDAY [**2112-2-1**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: NAHRA,RAJAA H.
Address: [**Location (un) 78712**], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**0-0-**]
Appt: [**1-7**] at 10am
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2112-1-13**] at 9:20 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2112-1-5**]
|
[
"250.43",
"530.81",
"242.90",
"401.9",
"412",
"357.2",
"414.01",
"250.63",
"272.4",
"V45.82",
"536.3",
"287.5",
"276.51",
"553.3",
"250.13",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10038, 10099
|
5040, 7947
|
274, 280
|
10188, 10188
|
3854, 3854
|
13261, 14091
|
3397, 3434
|
8389, 10015
|
10120, 10167
|
7973, 8366
|
10339, 13238
|
3449, 3835
|
231, 236
|
308, 2855
|
3871, 5017
|
10203, 10315
|
2877, 3217
|
3233, 3381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,218
| 153,570
|
10211
|
Discharge summary
|
report
|
Admission Date: [**2114-6-1**] Discharge Date: [**2114-6-18**]
Date of Birth: [**2045-1-18**] Sex: F
Service: SURGERY
Allergies:
adhesive / Pravastatin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Cold left foot
Major Surgical or Invasive Procedure:
[**2114-6-1**] Left groin exploration
History of Present Illness:
HPI: 69F with a longstanding history of PVD who in [**2103**]
underwent
left fem to above knee popliteal bypass and has subsequently had
multiple vascular interventions. She was recently diagnosed with
stenosis of the left CFA with blunted graft velocities.
Endarterectomy with graft revision with Dr. [**Last Name (STitle) **] was planned
after resolution of her groin infections.
She returns today with approximately ten days of worsening LLE
pain. She states that she still has motor function but does not
have sensation in the foot. She denies fevers or chills at this
time.
ROS: (+) per HPI
(-) syncope, AAA, venous stasis changes, headache, numbness,
tingling, fevers, chills, fatigue, malaise, significant weight
loss, weight gain, changes in hearing or vision, chest pain,
shortness of breath, DOE, hemoptysis, cough, wheeze,
palpitations, abdominal pain, nausea, vomiting, diarrhea,
constipation, denies dysuria, rash, pruritis, joint pain, heat
intolerance, cold intolerance, easy bruising, bleeding, mood
changes
Vascular Risk Factors: Diabetes, Hypercholesterol, Hypertension,
Obesity, Smoking History, Genetics.
Past Medical History:
HTN / CVA x2 ([**2096**]) / DM / depression / PVD / eczema /
L fem-[**Doctor Last Name **] ([**2103**])/ L CEA [**2097**] / bilateral carotid stents / L
TKR / choly / Left Lower Extremity Angiography w/ iliac stent
placement / left common femoral artery angioplasty ([**2111**])
Social History:
Smoker.
Family History:
unknown
Physical Exam:
T98.6 HR80 BP106/56 RR16 Sat98% on 2L NC
Gen: AOx3 intermittently but does have audiovisual
hallucinations
CV: RRR s1s2
Resp: decreased breath sounds throughout, no focal
abnormalities, no w/r/r
abd: soft, non-tender, non-distended
extremities: LLE with extensive dry gangrene on the foot
beginning to extend up close to the lower leg and spreading in
the foot. RLE with patchy areas of necrosis but no overt
gangrene. She has no detectable pulses or signals below her
left femoral artery.
Pulses: Fem [**Doctor Last Name **] dp pt
R P P d d
L d - - -
Pertinent Results:
[**2114-6-1**] CTA ABD:CT OF THE PELVIS AND EXTREMITIES WITH IV
CONTRAST:
The bladder is mildly distended. The uterus is normal. No
adnexal masses are detected. There is no intrapelvic free fluid
or lymphadenopathy. Included views of the intrapelvic small and
large bowel are normal.
There are no bony lesions concerning for malignancy or
infection. No acute fracture is detected. The patient is post
bilateral total knee
arthroplasties, with no evidence of hardware loosening or
failure.
Moderate soft tissue edema extends throughout the subcutaneous
tissues of both lower extremities. No focal fluid collections
are identified.
CT ANGIOGRAM:
Severe atherosclerotic calcifications are again seen throughout
the abdominal aorta and iliac branches.
LEFT VESSELS:
Compared to the [**2114-2-18**] examination, there is now new
occlusion of the left common iliac artery (3A:30) and left
external iliac artery. Severe
atherosclerotic calcifications of the left CFA limits evaluation
for patency, but no internal flow is seen.
A femoropopliteal (above-knee) bypass is again seen, with
unchanged moderate narrowing at the common femoral takeoff
(3A:91), but demonstrating wide patency otherwise. Branches of
the femoral profunda are patent. The native superficial femoral
artery is heavily calcified and no internal flow is detected.
Extensive calcifications are seen throughout the popliteal
artery, with the lower segment not visualized due to extensive
streak artifacts from the left knee prosthesis. Three-vessel
runoff is demonstrated (3A:293), however, there is marked
attenuation of the left anterior tibial artery in comparison to
the prior CT examination (3A:345), and diminutive flow is seen
at the dorsalis pedis. In comparison to the [**2-23**]
examination, there appears to be overall diminished flow of the
peroneal and posterior tibial arteries, however, patency remains
preserved.
RIGHT VESSELS:
Severe atherosclerotic calcifications and stenosis of the right
iliac artery, particularly at the distal portion and external
segment, appears minimally changed since [**2114-2-18**]. Patency of
the right profundus femoral is demonstrated. However, there is
again complete occlusion of the right superficial femoral
artery. Evaluation for the right popliteal artery is impossible
due to the degree of extensive calcifications and streak
artifacts from the right knee prosthesis.
A three-vessel runoff is demonstrated at the right calf, with
irregular
attenuation throughout the right posterior tibial artery, all
unchanged since [**2114-2-23**].
IMPRESSION:
1. Occlusion of the left common iliac, external iliac, and
common femoral
artery is new since [**2114-2-23**].
2. Unchanged moderate stenosis at the takeoff of the left
femoropopliteal
bypass (above-knee). Patent flow and caliber is demonstrated
through the
remainder of the course of the graft.
3. Three-vessel runoff demonstrated at the left calf, however,
there is
overall decreased vascular flow, in particular the left anterior
tibial
artery, in comparison to the [**2114-2-23**] examination, likely
from poor iliac and femoral inflow.
4. Unchanged occlusion of the right superficial femoral artery.
Right
three-vessel runoff is again seen, with mild irregular
attenuation of the
posterior tibial artery.
[**2114-6-4**] ECHO
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 34061**]Portable TTE
(Complete) Done [**2114-6-4**] at 3:36:05 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - [**Hospital Ward Name 517**]
[**Hospital Unit Name 22682**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-1-18**]
Age (years): 69 F Hgt (in):
BP (mm Hg): 98/69 Wgt (lb): 193
HR (bpm): 106 BSA (m2):
Indication: Left ventricular function. Low oxygen saturation.
ICD-9 Codes: 424.1, 424.2
Test Information
Date/Time: [**2114-6-4**] at 15:36 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2012W000-0:00 Machine: E9-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.0 cm
Left Ventricle - Fractional Shortening: 0.49 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *21 < 15
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 18 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Mitral Valve - E Wave: 1.5 m/sec
Mitral Valve - E Wave deceleration time: 146 ms 140-250 ms
TR Gradient (+ RA = PASP): *32 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by
TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is trivial mitral regurgitation. There
is mild 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 preserved global biventricular
systolic function. Mild aortic valve stenosis. Pulmonary artery
hypertension.
CLINICAL IMPLICATIONS:
Based on [**2108**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**2114-6-6**] CXR
PORTABLE AP CHEST X-RAY
INDICATION: Evaluation for infiltrate or effusion. The patient
with
intubation.
COMPARISON: [**2114-6-5**] at 9:16 a.m.
FINDINGS:
Moderate pulmonary edema is slightly improved. The endotracheal
tube ends 4.8 cm above the carina. Right-sided jugular line
ends in the mid SVC. The NG tube is in adequate position. The
mediastinal contour is normal. Cardiac contour is slightly
enlarged and unchanged.
CONCLUSION:
There is a slight improvement of moderate pulmonary edema.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
The pt was admitted through the emergency room after 10 days of
worsening LLE pain. Her foot was cool to touch with pallor
distal to ankle, delayed cap refill, diminished sensation
throughout but she had preserved motor function. She was placed
on a heparin gtt and brought to the Endovascular Hybrid room for
left groin cut down and possible intervention. A meeting was had
with her husband in the midst of the case and he asked that we
try to do what we could. Her vessels were heavily calcified and
intervening was thought to be unsafe and so the case was
aborted. The wound was closed loosely as to not compress the
graft and a VAC dressing was placed. She was extubated
immediately. She was later transferred to the floor with the
heparin drip continued.
While on the floor a palliative care consult was obtained. On
the 15th she went into Afib with RVR to the 150's. Shw was
given 20 of IV lasix as well as transfused 2 Units PRBC's for a
Hct of 22.8. Ultimately she received an additional 3 units of
packed cells. We offered the pt amputation as an option for her
dry gangrene, she refused. She refused most care and
intervention and a psych consult was obtained for competancy. A
meeting was held with the pt and her husband and it was
determined that she was able to make appropriate decisions for
her own care.
Discharge planning to hospice was initiated and she was
discharged to hospice once a bed was available.
Medications on Admission:
accupril 40', ASA 325, foltx 1-2.5-25, lasix 20', metformin
500'', metoprolol 100', norvasc 10', oxybutynin 5'''', plavix
75', pravachol 80', salsalate 1500'', zoloft 25'
Discharge Medications:
1. Sertraline 25 mg PO DAILY
2. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
3. Gabapentin 600 mg PO TID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Baclofen 2.5 mg PO BID
6. Fentanyl Patch 12 mcg/hr TP Q72H
RX *fentanyl 12 mcg/hour One patch Q72Hrs Disp #*10 Transdermal
Patch Refills:*0
7. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever
8. Baclofen 5 mg PO QHS
9. Miconazole Powder 2% 1 Appl TP QID:PRN to groin
10. OLANZapine (Disintegrating Tablet) 5 mg PO QHS agitation
11. OxycoDONE Liquid 2.5-5 mg PO Q2H:PRN pain
RX *oxycodone 20 mg/mL 2.5-5 mg by mouth Q2hrs Disp #*1 Bottle
Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) **]
Discharge Diagnosis:
Left lower extremity ischemia / dry gangrene
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were seen at [**Hospital1 18**] because you have problems with arterial
blood supply to your left leg. Because of the damage to the
blood vessels you are unable to have any bypass or stenting to
improve the blood flow. It was recommended that you have both
the left leg as well as the right leg amputated below the knees.
You did not wish to have this procedure. You were advised that
the infection/gangrene in your foot will likely spread and that
it is very likely that you will die. You are being discharged
to hospice care
Please use caution with fentanyl patch in the setting of fever
Please do not hesitate to contact the hospital if you change
your mind or with any other questions.
Followup Instructions:
None. Call the hospital or surgery department at [**Telephone/Fax (1) 2756**]
if you have any further questions.
Completed by:[**2114-6-18**]
|
[
"518.51",
"440.4",
"486",
"440.24",
"V66.7",
"276.3",
"V64.1",
"305.1",
"V43.65",
"V46.3",
"433.10",
"438.20",
"285.9",
"530.81",
"444.81",
"427.31",
"250.00",
"682.7",
"424.1",
"440.31",
"276.61",
"278.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09",
"33.24",
"39.32",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13323, 13401
|
11015, 12456
|
296, 336
|
13490, 13490
|
2485, 10137
|
14351, 14496
|
1840, 1849
|
12678, 13300
|
13422, 13469
|
12482, 12655
|
13626, 14328
|
1864, 2466
|
10160, 10992
|
242, 258
|
364, 1495
|
13505, 13602
|
1517, 1798
|
1814, 1824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,664
| 144,516
|
51174
|
Discharge summary
|
report
|
Admission Date: [**2200-2-2**] Discharge Date: [**2200-2-27**]
Date of Birth: [**2132-5-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Acute worsening of shortness of breath this AM.
Major Surgical or Invasive Procedure:
Bronchoscopy x2
central line placement
tracheostomy
G-J tube placement
PRBC transfusion
echocardiogram
History of Present Illness:
Mr. [**Known lastname 106212**] is a 67 year-old gentleman with a history of HIV
(last CD4 273, VL<50), as well as a history of DM type 2, CAD
status post CABG and RCA stent, PVD, CRI, GERD, CHF, TIA and
history of large cell lymphoma s/p chemotherapy in [**2189**], who now
presents with worsening SOB and low-grade temperature. Mr.
[**Known lastname 106212**] was last admitted electively for the work-up of cognitive
decline on [**2199-11-8**]. Work-up revealed no change in brain MRI,
CSF with HIV viral load improved from prior but still high. The
working diagnosis was HIV encephalopathy. He was last seen in
clinic on [**2200-12-30**], at which time crixivan was increased and
Nevirapine was added for increased CSF penetration.
According to his wife, Mr. [**Known lastname 106212**] has had mild shortness of
breath for a number of weeks, with acute worsening this AM. No
history of cough, rhinorrea, or sore throat. + orthopnea with
stable use of 3 pillows over the past week, no peripheral edema.
Marginal improvement in SOB with escalating doses of Lasix to 40
mg PO BID. By the patient account, he had some left arm pain
yesterday, which was relieved with NTG X 1. This AM, he had some
dull aching left-sided chest pain, but did not take NTG. Per the
wife, he frequently complains of chest pain at home, without
recent acceleration of symptoms. + nausea over the past week, no
vomiting. No GI or GU complaints. He developed a low-grade fever
100.8 at home this AM, and they were advised by Dr. [**Last Name (STitle) **] (ID)
to present to the ED for furter evaluation.
In the ED, vitals T 101.2, HR 95, regular, BP 167/67, RR 40, Sat
80% on room air. He was placed on 100%NRB, with saturation
98-100%. He received Lasix 40 mg IV x 1 as well as CTX 1 gm IV +
Vancomycin 1 gm IV X 1.
Past Medical History:
1. HIV, diagnosed in [**2185**]. Last CD4 273, VL<50 on [**2200-12-30**].
Patient has history of KS, CMV esophagitis. Source of
transmission unknown.
2. CAD, s/p 2-vessel CABG in [**2194**] and RCA stent in 10/[**2198**].
Patent stents on last cath in 10/[**2198**].
3. Diastolic CHF
4. History of large cell lymphoma (liver and periaortic Lymph
nodes) s/p 6 rounds of chemotherapy in [**2189**]
5. Peripheral vascular disease.
6. DM type 2
7. Hypertension
8. GERD
9. CRI with history of hyperkalemia. Baseline creatinine
variable. Last 0.8 in 11/[**2199**].
10. History of TIA [**4-/2199**] with left hemiplegia that resolved.
11. Status post anterior disc excision and fusion C7-Ti in [**2189**].
12. h/o resp failure requiring intubation [**7-7**] (x7 days) with
"double PNA" and resp failure in [**State 33977**] in [**5-7**]
13. Probable HIV encephalopathy
Social History:
He lives with his wife in [**Name (NI) 1562**].
He is a lifelong non-smoker.
No EtOH consumption and no history of illicit drug use.
+ flu shot this year.
Family History:
Sister died of CAD and CVA
Brother has h/o CAD
Mother has h/o CAD
Physical Exam:
PHYSICAL EXAMINATION:
VITALS: T 101.2, HR 95, BP 140s/80s, RR 22, Sat 100% on NRB
GEN: Emaciated man, hard of hearing, in NAD. No respiratory
distress.
HEENT: Anicteric, MMM.
NECK: JVP elevated around 6 cm ASA, no carotid bruit. Neck
supple.
RESP: Fair air entry bilaterally. Bibasilar crackles L>R, no
clear bronchial breathing appreciated.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS normoactive. Abdomen soft, mild tenderness to palpation,
chronic per patient. No HSM.
EXT: No pedal edema. Pedal pulses not palpable.
INTEGUMENT: No skin rash.
Pertinent Results:
Relevant laboratory data on admission:
CBC: WBC 14.8, Hb 12.7, Hct 35.4 (was 42 on [**2199-12-30**]), Plt
205. Differential N80%.
Chemistry:
Na 132, K 6.7 (hemolysed, repeat 3.8), Cl 97, HCO3 25, BUN 30,
Creat 2.2 (was 0.8 in [**11/2199**]), Glucose 115, Ca 9.5, Mg 2.2,
Phos 3.4.
AST 99, ALT 30, ALP 84, LDH 1114, Amylase 60, lipase 37, T bili
0.6
CK 408, MB 7
CD4 273, VL <50 on [**2199-12-30**]
Blood culture pending.
Cryptococcal antigen pending.
EKG: NSR, rate 78 bpm. Left axis deviation, normal intervals.
LVH by voltage criteria. Elevated J point V2-3 (not new), <1mm
ST depression I, II, aVL, V5-6, not new.
SINGLE VIEW CHEST, AP: There has been interval development of
bilateral patchy alveolar opacities and increased interstitial
opacities. Scarring within the left lung is unchanged. The
patient is status-post median sternotomy with cervical hardware
identified.
IMPRESSION: Interval development of diffuse, bilateral
interstitial alveolar opacities. These findings are consistent
with left ventricular heart failure and/or multifocal pneumonia.
Brief Hospital Course:
Complex patient with HIV, CAD s/p CABG and PTCA, diastolic CHF,
DM type 2, presenting with worsening SOB, low-grade temperature
and nausea.
1. Respiratory failure: multifactorial with CAP +/- aspiration
PNA and diastolic CHF contributing to presentation.
-- Pt was intubated on [**2200-2-3**] and extubated on [**2200-2-7**] then
reintubated on [**2200-2-8**] due to respiratory distress. CXR at that
time demonstrated diffuse bilateral infiltrates with thick
consolidation of RUL consistent with either aspiration or
worsening lobar PNA. CXR done 2 days later showed significant
clearing of infiltrates with persistent RUL consolidation, so it
was felt pt had aspiration pneumonitis. complicating the issue,
he also had signs of volume overload and initially responded to
diuresis. pulmonary hemorrhage basically excluded by CT chest
on [**2200-2-6**] NOT revealing pulmonary hemorrhage and anti-GBM and
ANCA were negative.
-- Patient was treated with 14 day course of levofloxacin for
presumed CAP. He was also treated with 10 day course of
vancomycin and zosyn for presumed nosocomial/vent-assoc PNA
given diffuse b/l infiltrates found during hosp course after
intubation.
-- Multiple sputum Cx's and BAL x 2 never yielded a pathogen
[PCP (-) x 2, influenza (-)x2, [**Date Range **] (-), AFB (-), viral cultures
(-)x2]. Bronchoscopy x 2 revealed minimal secretions. BCx
negative x12 sets (including fungal isolates).
-- LENIs were done x2 and no DVT found; bedside TTE on [**2200-2-8**]
showed no evidence of RV failure in setting of acute
decompensation
-- A PA catheter was placed on [**2-12**] to better evaluate volume
status given ? diastolic dysfnx. PCWP was measured as 18-20,
with normal cardiac output and normal SVR. The patient was felt
to be volume overloaded and attempts were made at diuresis,
initially with nesiritide but unsuccessful and low dose lasix
was administered on an as needed basis with good effect.
-- Tracheostomy performed at bedside on [**2-13**] due to failure to
wean.
-- He was weaned down to PSV 10/5 and was using Passy Muir valve
by time of discharge with periods of trach collar without
difficulty. This can continued to be weaned at Rehab.
-- He continued to have thick tan secretions but no abx
indicated as pt afebrile. Cultures remained negative and pt did
have intermitent low grade temps spikes attributed to
intermitent aspiration.
*
*
2. Renal Failure: likely ATN as pt was hypotensive for >20mins
on admission and muddy brown casts. however, labs were also c/w
pre-renal etiology.
-- as he had +urine eos and crystals, his HAART (indinavir) was
held x3 days, but no significant change occured and his ARF was
not felt to be secondary to med side effects
-- creatine improved and patient was able to have good post-ATN
diuresis with assistance of lasix.
-- prior to hospitalization, baseline creat was 1.1. Despite
resolution of ATN, it appears that his new baseline is around
1.5 which he has been in the past.
*
3. Shock: hypotensive on admission, responded to dopamine and
weaned off within 24 hrs. The etiology was likely septic +/-
cardiogenic as described above.
*
4. Anemia: etiology not completely clear. throughout his MICU
stay, he episodically dropped his hct but responded to
transfusions. this presentation was consistent with blood loss
anemia, however, no source was discovered. he had similar drops
in his hct during last admission in [**2199-7-4**] without etiology
either.
-- his stool was guaiac negative x4 initially and CT abd x 2 w/o
source of bleed. CT Chest w/o evidence of alveolar hemorrhage.
he was later found to have guaiac positive stools after he had
continuous diarrhea and a rectal tube was inserted
-- hemolysis labs(-) x 3. retic 3.4% and 1.7%. iron studies
with low iron and TIBC, but elevtaed ferritin after
transfusiuons- like anemia secondary to iron deficiency and
chronic disease and HAART medications. This can continued to be
followed as an outpatient and consider EGD or colonoscopy in
future once acute issues resolved.
-- Mr [**Known lastname 106212**] has prevously had EGD and C-scope in [**2198**] and [**2194**]
which showed gastritis but otherwise WNL. He did have a
questionable hx of IBD, but this was ruled out on prior
biopsies.
-- repeat EGD was discussed with patient and he declined. as
his drop in hct was not critical, it is reasonable to follow up
with outpatient EGD if it continues to be an issue
-- ID did not feel his HAART medications were contributing to
his anemia
*
5. PNA- bilat opacities. Intubated after trial of BiPAP
secondary to hypercarbia.
- Unlikely PCP given good compliance with bactrim, no recent
steroids, CD4>250, negative PCP x 2 from BAL
- likely has bacterial involvement (pneumococcal, staph,
klebsiella, legionella) +/- volume overload
- BAL x2 done neg for PCP, [**Name10 (NameIs) **], Cx. legionella negative
- last temp spike [**2200-2-24**], but thought secondary to aspirations
as cultures remained negative and CXR improved.
*
6. CHF: TTE was performed [**2200-2-4**] which showed EF >55% with E/A
of 2.4, which was felt [**2-5**] to diastolic dysfunction. His blood
pressure was monitored and he was maintained on metoprolol,
amlodopine, hydralazine and isordil with as needed doses of
lasix.
*
7. CAD: CAD s/p CABG s/p stent [**10-6**]
- no active signs of ischemia and EKG unchanged
- Ruled out for MI with 3 neg CE's twice
- increased trop likely secondary to ARF
- FLP checked and LDL 60
- continued on asprin and [**Year (2 digits) 4532**]
*
8. Diarrhea: significant loose stools requiring placement of
rectal tube. C. Dif negative x6. microsporidia, cyclospora,
cryptosporidium all neg. the source of this is unknown but may
be related to his TFs. It was the source of his non-AG
acidosis. By time of discharge this had resolved and he was
stable.
*
9. DMII- insulin drip initially and transitioned to sliding
scale insulin with [**Hospital1 **] NPH with reasonable glucose control.
*
10. FEN: there is concern for gastroparesis given that he became
very distended each time TFs were given through NG tube. post
pyloric feeding tube attempted x2 by IR, but unsuccessful.
-- PEJ tube placed [**2200-2-19**] and TFs restarted.
-- he was fitted with a Passy-Muir valve which he started using
on [**2200-2-21**].
-- eval by speech and swallow at bedside inconclusive as
aspirated on thin liquids, but able to tolerate thich custard
without difficulty. They reccommended video swallow which can
be obtained at rehab as well.
-- reglan has been used in past with success and should be
attempted if problems develop
-- continue lansoprazole for reflux
*
11. Code: Full
*
12. Prophylaxis: continue subcutaneous heparin until ambulating
regularly
*
13. Dispo: discharge to rehab for further trach care and
weaning, further assessment of swallow and physical therapy.
Medications on Admission:
Lasix 40 mg PO BID
Crixivan 333mg 3 tabs PO TID
Aspirin 325 mg PO QD
Epivir 150 mg PO BID
Clonopin 0.25 mg PO QHS
Lopressor 50 mg Po BID
Paxil 20 mg Po QD
Vitamin E 400 IU PO QD
Bactrim SS i tab PO QOD
Ziagen 300 mg PO BID
Zantac 150 mg PO TID
Zyprexa 5 mg Po QD
Norvasc 10 mg PO QD
[**Date Range **] 75 mg PO QD
Nevirapine 200 mg PO BID (started 2 weeks ago, increased to [**Hospital1 **]
on Thursday)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Community acquired Pneumonia
respiratory distress
shock
diastolic dysfunction
acute renal failure secondary to ATN and pre-renal
Anemia
HIV
Diabetes type 2
Discharge Condition:
Stable on trach collar from 2-7 hrs daily, with pressure supprt
[**5-8**] rest of times, off antibiotics
Discharge Instructions:
Please call PCP or return for increased shortness of breath,
fevers or pain. Please continue all medications and try to wean
of ventilator and continue to assess swallow.
Followup Instructions:
Please follow up with your PCP and Dr [**Last Name (STitle) **] within 1-2 weeks.
|
[
"518.81",
"507.0",
"486",
"560.1",
"V10.79",
"414.00",
"263.9",
"995.92",
"276.2",
"250.00",
"280.0",
"276.5",
"428.0",
"584.5",
"042",
"428.30",
"785.52",
"536.3",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"96.72",
"38.91",
"31.1",
"96.6",
"96.04",
"89.64",
"44.38",
"99.04",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12414, 12475
|
5120, 11961
|
361, 466
|
12675, 12781
|
4031, 4056
|
13001, 13086
|
3365, 3432
|
12496, 12654
|
11987, 12391
|
12805, 12978
|
3447, 3447
|
3469, 4012
|
274, 323
|
494, 2291
|
4070, 5097
|
2313, 3177
|
3193, 3349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,448
| 181,789
|
48392
|
Discharge summary
|
report
|
Admission Date: [**2125-10-25**] Discharge Date: [**2125-10-30**]
Date of Birth: [**2075-5-24**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old
woman with end stage renal disease on dialysis three days a
week since [**2119**]. End stage renal disease was thought to be
secondary to glomerulonephritis. She is admitted for
recipient of a cadaveric kidney transplant. On admission she
denies any chest pain, nausea, vomiting, fevers or chills.
She reports a mild dyspnea on exertion, which is her
baseline.
PAST MEDICAL HISTORY: Significant for coronary artery
disease for which she is status post stent of the left
anterior descending coronary artery. Hypercholesterolemia.
Myocardial infarction in the year [**2123**], neuropathy and
history of endocarditis.
PAST SURGICAL HISTORY: Significant for right hernia repair,
PD catheter insertion and left AV graft in [**2125-2-8**], which
as undergone two revisions for thrombosis.
MEDICATIONS ON ADMISSION: Lopressor 25 mg po b.i.d.,
Coumadin 6 mg po q.d., Renagel 3200 mg with meals, Vistaril
prn, Hydroxizine prn, Diazepam 10 mg q.h.s., Epogen after
dialysis, Lipitor 10 mg po q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with her husband. She
denies any alcohol or drug use.
PHYSICAL EXAMINATION: On admission the patient is afebrile
with a temperature of 96. Heart rate 91. Blood pressure
114/55. Respiratory rate 12. 100% on room air.
LABORATORIES ON ADMISSION: White count of 3.8, hematocrit
32.2, platelets 162, PT 16.4, PTT 31.8, INR 1.9, sodium 144,
potassium 4.2, chloride 102, bicarbonate of 32, BUN 17,
creatinine of 4.7, glucose of 90.
Persantine MIBI test done on [**2125-7-4**] revealed a fixed
severe defect in the anterior wall and apex, moderate
reversible defects of the lateral and inferior wall, ejection
fraction is 23% with diffuse hypokinesis and akinesis at the
apex.
Catheterization on [**7-11**] significant for three vessel disease.
HOSPITAL COURSE: On the day of admission the patient was
taken to the Operating Room where she underwent a cadaveric
renal transplant. She tolerated the procedure well and was
transferred to the PACU in stable condition. The estimated
blood loss was 200 and the patient was given 3 liters of LR
intraoperatively. There was note that due to the patient's
cardiac status kidney profusion became optimal after twenty
minutes of the revascularization of the kidney. The patient
was brought to the PACU and was then taken and transferred to
the Surgical Intensive Care Unit for close monitoring of
cardiac status and urine output from the kidney. Early the
patient's kidney was producing up to 100 cc of urine per
hour, but then early on postoperative day number one the
patient's urine output had dropped down to 20 to 50 cc units
per hour. This was correlated with dips in the patient's
blood pressure from 120 down to approximately 100 down to
even 90. With this correlation of hypertension and drop in
urine output, the patient was placed on Dopamine drip and
titrated to have a pressure above 120. With this titration
the patient's urine output did increase slightly and by the
second postoperative day the patient's urine output had
increased to between 50 and 100 cc per hour.
During this time she was also found to have a hematocrit of
28 and was transfused 2 units of packed red blood cells,
which one was CMV negative and one was leuko reduced through
filter. She remained hemodynamically stable though despite
the fact of a lower blood pressure, she was tolerating a
regular diet and ambulating and otherwise felt well. On the
third postoperative day with her pressure stable between 115
and 120 systolic, the patient's urine output up to 2.8 liters
over 24 hours. The patient was transferred to the floor for
the remainder of her recovery. Her creatinine during this
time had remained elevated going from 4.8 directly
postoperatively to 6.4 on postoperative day number three. We
continued to hydrate her and her urine output continued to be
adequate and the patient remained stable.
On postoperative day number five the creatinine had come down
to 5.6. The patient's urine output had risen to 100 to 120
cc per hour. The patient otherwise was doing well on oral
pain medications and on a regular diet. The patient's JP
drain was found to be having very little output and the
patient's JP was discontinued prior to discharge. The
patient's Foley was discontinued and the patient was able to
void and the patient is being discharged in stable condition.
The patient's immunosuppressive regimen began with a
Solu-Medrol taper beginning at 200 cc dropping by 40 per day
to a final dose of Prednisone of 20 mg po q.d. the patient
was also started on CellCept 1 gram b.i.d., but Cyclosporin
was held secondary to her delayed graft function. She was
given five doses of Thymoglobulin three doses of full
strength on the first three postoperative days and two doses
of half strength on the fourth and fifth postoperative day.
On the third postoperative day she was started on Prograf 2
mg po b.i.d. and Prograf levels will be checked on an
outpatient basis.
In addition to her immunosuppressants she was started on
Bactrim single strength po q.d. She received Pamidronate one
dose and Nystatin swish and swallow. Coumadin had been
started to keep the graft patent and it was decided to
discontinue the patient's Coumadin during this admission.
The patient is stable and now ready for discharge.
DISCHARGE DIAGNOSES:
1. End stage renal disease dialysis three days a week.
2. Status post cadaveric renal transplant with delayed graft
function.
3. Coronary artery disease with an EF of 23%.
4. Hypercholesterolemia.
5. Myocardial infarction [**10/2124**].
6. History of endocarditis.
7. Neuropathy.
MEDICATIONS ON DISCHARGE: 1. Prograf 2 mg po b.i.d. 2.
Prednisone 20 mg po q.d. 3. CellCept [**Pager number **] mg po b.i.d. 4.
Bactrim single strength one po q.d. 5. Nystatin swish and
swallow q.i.d. 6. Zantac 150 mg po b.i.d. 7. EC ASA 325
mg po q.d. 8. Lopressor 12.5 mg po b.i.d. 9. Colace 100
mg po b.i.d.
FOLLOW UP: The patient will follow up in the [**Hospital 1326**]
Clinic as arranged. The patient should have Prograf levels
checked.
CONDITION ON DISCHARGE: Stable.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2125-11-2**] 17:26
T: [**2125-11-6**] 15:42
JOB#: [**Job Number 101914**]
|
[
"412",
"414.01",
"V45.82",
"582.9",
"585",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5565, 5853
|
5880, 6181
|
1006, 1238
|
2040, 5544
|
833, 979
|
6193, 6317
|
1352, 1510
|
158, 552
|
1525, 2022
|
575, 809
|
1255, 1329
|
6342, 6628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,328
| 116,896
|
29115
|
Discharge summary
|
report
|
Admission Date: [**2153-12-18**] Discharge Date: [**2154-1-1**]
Date of Birth: [**2082-7-24**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Elective nephrectomy for metastatic renal cell carcinoma
Major Surgical or Invasive Procedure:
Left radical nephrectomy
History of Present Illness:
This is a 71 year-old woman with metastatic renal cell
carcinoma diagnosed in [**3-22**] and COPD being transferred to the
[**Hospital Unit Name 153**] s/p left radical nephrectomy for respiratory monitoring.
Patient was hypoxic to the 80's prior to intubation and
therefore aneasthesia and surgery preferred monitoring in ICU
with likely extubation tomorrow AM. History obtained largely
from providers and their notes, patient intubated, sedated.
As per anaesthesia and surgery, surgery was uneventful, no
complications.
On arrival, patient easily arousable, denies pain.
Past Medical History:
Metastatic renal cell carcinoma
COPD, FEV1 2.17-67%predicted
Cholecystectomy.
Status post surgical repair of uterine prolapse, TAH/BSO
Obesity
Heavy Smoker
H/o DVT s/p IVC filter implantation
Social History:
The patient lives with her daughter in [**Name (NI) 8391**]. She
formally worked in a factory, however, denies any chemical or
radiation or asbestos exposure to her knowledge. She also
worked at stop-and-shop briefly. She reports a 80-pack-year
history of tobacco. She quit approximately 9 years ago. She
reports occasional alcohol use, however, none currently
Family History:
Her mother died in her 50s from a postoperative pulmonary
embolus. Father died in his 70s from congestive heart failure.
She reports having 5 siblings. Her brother with esophageal
cancer and there is a prominent family history of type
2 diabetes. She is of Irish descent. She has 6 children all of
whom are in good health. There is no family history of breast,
GYN, colonic, or renal cell cancer in the family.
Physical Exam:
VS: Temp: 98.1 BP:124 /66 HR:75 RR:12 99% O2sat
I/O: 2750/540--last 24 hours/Weight 106.7
Vent setting: AC 12x700 (no spont breaths) FiO2 of 60% PEEP:5
ABG:7.34/51/233
general: intubated, sedated, easily arousable
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, distant heart sounds, no murmurs, rubs
or gallops appreciated
abdomen: obese, large ventral hernia, +b/s, soft, nt,
left flank: large dressing in place, NT, without signficant
bleeding
extremities: no edema, pneumoboots
skin/nails: no rashes/no jaundice
neuro: sedated, easily arousable, responsive to commands, moves
all four extremities, wiggles toes and squeezes fingers to
command
Brief Hospital Course:
ICU and hospital course:
Mrs. [**Known lastname **] is a 71 yo F with a PMH of metastatic renal cell
carcinoma, COPD, chronic kidney disease, h/o DVT who presented
to the ICU after a nephrectomy. Prior to the nephrectomy, she
was mildly hypoxic, and it was felt that she would not be easy
to extubate.
## Respiratory failure: The pt arrived to the ICU intubated and
sedated. Her sedation was slowly weaned and she was extubated
successfully on the day after admission. She continued to
require oxygen by nasal canula to maintain O2 sats in the 90s.
Her hypoxia was likley secondary to chronic insufficiecny in the
context of atelectasis and volume overload. She was continued on
her fluticasone/salmeterol 500/50 and albuterol and ipatropium
nebulizer treatments prn. She will need supplemental O2 on
discharge. On discharge she was sating at 95% on 2L (pre-op
88-92% on RA).
## s/p nephrectomy: pt tolerated the procedure well. She
initially had pain at the surgical site which slowly resolved.
Her wound was C/D/I at discharge after staples were removed. Her
final pathology revealed conventional (clear cell) renal cell
carcinoma pT3a: tumor directly invades adrenal gland or
perirenal and/or renal sinus fat but not beyond Gerota's fascia;
spoke with Dr. [**Last Name (STitle) **] regarding her follow-up and the results of
the lung biopsy, which after review are consistent with
metastatic disease obviating the need for a lung biopsy. She
will follow-up with Dr. [**Last Name (STitle) **] in the next week in clinic and is
instructed to call to confirm this appt; in addition she is
scheduled for CT Chest [**1-2**].
## ileus/SBO: patient stopped passing flatus and had worsening
abdominal distention. She then had bilious emesis x 2 for a
total of 600 cc. An NG tube was placed which returned 200 cc of
bilious, nonbloody fluid. Abdominal imaging showed evidence of
small bowel dilation consistent with ileus vs. obstruction. As
patient's operation was not within the peritoneal cavity but
retroperitoneal, it was believed to be more likely ileus in the
setting of increased pain med requirements. Indeed her prolonged
hospital course was secondary to a prostracted ileaus that was
initially managed with NGT/decompression however by POD [**11-28**]
the NG was remvoed, her diet was advanced and she tolerated it
well. Of note, she consistently passed flatus and had BMs
throughout the ileus. Also, C Diff was sent which was negative.
Interval KUBs would show dilated small loops with AFLs, no free
air that would resolve thorughout her course. She was placed on
RTC Reglan toward the end of her course to expedite resolution;
GI was curbsided and beleived she has a protracted ileus that
was responded to conservative measures. In addition surgery was
consulted and recommended similar conservative measures. By the
end of her hospital course she was tolerating a regular diet and
having regular bowel movements.
## CKD: Baseline Cr 1.2-1.4. Normal increase in Cr after
nephrectomy is approximately 30-40%. Her creatinine was 1.6 on
discharge from the ICU. This had settled at 1.3 at time of
discharge. Her lytes were otherwise stable throughout; her
potassim was optimized.
## Hyperglycemia: Likely in setting of stress from surgery and
mild underlying insulin resistance. Was no longer requiring
insulin at time of discharge from the ICU.
## h/o DVT: Should likely be on life-long anticoagulation given
she had a malignancy-associated DVT. Was maintained on heparin
SC TID while in house. Will need to restart warfarin 1-2 weeks
post-op.
## Dispo: PT worked throughout her course and she successfully
ambulated with assistance. She will need to continue aggressive
PT at rehab.
Medications on Admission:
see H&P
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**12-18**] Disk with Devices Inhalation [**Hospital1 **] ().
3. Acetaminophen 650 mg Suppository Sig: [**12-18**] Suppositorys Rectal
Q6H (every 6 hours) as needed for fever, pain.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Discharge Condition:
Good
Discharge Instructions:
Please see the nephrectomy discharge instructions
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 3748**] in [**1-20**] weeks. Call ([**Telephone/Fax (1) 39050**] to make an appointment.
Please follow up with Hematology Oncology, Dr. [**Last Name (STitle) **] at
[**0-0-**]. You have an appt. for next week. This was
confirmed with Dr. [**Last Name (STitle) **]. She is scheduled for CT Chest [**1-2**]
coordinated with Heme-Oncology.
Completed by:[**2154-1-1**]
|
[
"197.0",
"189.0",
"585.9",
"799.02",
"V58.61",
"518.0",
"560.1",
"997.4",
"E878.6",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
7247, 7317
|
2900, 2908
|
372, 399
|
7393, 7400
|
7736, 8151
|
1621, 2038
|
6661, 7224
|
7338, 7372
|
6629, 6638
|
2926, 6603
|
7424, 7713
|
2053, 2877
|
276, 334
|
427, 1006
|
1028, 1222
|
1238, 1605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,821
| 189,348
|
48614
|
Discharge summary
|
report
|
Admission Date: [**2137-4-11**] Discharge Date: [**2137-5-3**]
Service: MEDICINE
Allergies:
Neurontin / Bactrim / Penicillins / Macrodantin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
nausea/vomiting/abdominal pain
Major Surgical or Invasive Procedure:
Nasogastric tube placement
History of Present Illness:
Pt is [**Age over 90 **] yo female with lung CA (presumed), Afib, CHF, NIDDM,
who p/w 3 days of N/V and abd pain. Initially, the pain was
crampy in nature ([**4-6**]) but has worsened to [**7-7**]. She was
vomiting fecal-like material. No F/C or dysuria. No bowel
movements or flatus for 3 days. Pt has chronic CP/SOB, but did
not have any CP/SOB in ED. NG was placed, 1 L of feculent emesis
was suctioned. CT showed small bowel obstruction. She received
levo/flagyl, protonix, [**Month/Year (2) **], morphine, and 5L NS. She was also
found to be guaiac positive in ED (guaiac neg by [**Doctor First Name **] consult).
.
In the ED she was found to be hypotensive to the 60's, and EKG
showed ST depressions in the lateral leads. Surgery was
consulted, and diagnosed likely bowel obstruction causing
ischemia, however the family decided on non-operative
management. Pt was admitted to the MICU for further management
Past Medical History:
1. Atrial fibrillation s/p pacemaker placement. Previously on
Coumadin, discontinued [**3-1**] hemorrhagic CVA.
2. LV systolic dysfunction per echo [**3-/2131**], with EF 30-35%, 2+
MR and 2+ TR.
3. DM type 2, last hemoglobin A1c 7.3 on [**1-1**]
4. Hypertension
5. Hypercholesterolemia
6. Chronic renal insufficiency
7. Mild dementia
8. Peptic ulcer disease
9. History of CVA X 3
10. Negative colonoscopy [**1-/2132**], negative EGD [**2-/2134**]
11. Multiple pulmonary nodules found on chest CT, under
investigation. Planned for bronchoscopy with BAL on [**10-16**].
Differential includes vasculitis, malignancy or infection.
Family has decided on no work up.
Social History:
She currently lives with her daughter, and goes to day care 5
days a week. No tobacco, no EtOH. She ambulates with a walker at
baseline.
Daughter [**Name (NI) 102271**] that patient should not go to a nursing home.
Has many services at home and takes excellent care of mother.
Family History:
noncontributory
Physical Exam:
Vitals: T 95.7 BP 117/63 HR 78 RR 22 O2sat 100% on 100%NRB
Gen: frail, sleepy, occasionally moaning
HEENT: PERRL
Neck: Supple. JVD difficult to appreciate.
Cardio: RRR, nl S1S2, no m/r/g
Resp: bibasilar crackles
Abd: soft, diffusely tender to mild palpation, no rebound or
guarding
Ext: no c/c/e
Neuro: A&Ox0, occasionally follows simple commands, otherwise
eyes closed and moaning
Pertinent Results:
[**2137-4-12**] 03:25AM BLOOD WBC-7.0 RBC-3.44* Hgb-9.7* Hct-29.7*
MCV-86 MCH-28.0 MCHC-32.5 RDW-16.9* Plt Ct-163
[**2137-4-11**] 03:13AM BLOOD Neuts-77* Bands-1 Lymphs-15* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2137-4-12**] 03:25AM BLOOD Glucose-73 UreaN-18 Creat-0.9 Na-146*
K-3.8 Cl-118* HCO3-22 AnGap-10
[**2137-4-10**] 06:45PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2137-4-11**] 03:13AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2137-4-11**] 10:44AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2137-4-11**] 03:34AM BLOOD Type-[**Last Name (un) **] pO2-29* pCO2-68* pH-7.26*
calTCO2-32* Base XS-0 Intubat-NOT INTUBA
[**2137-4-10**] 06:52PM BLOOD Lactate-3.1*
[**2137-4-11**] 03:34AM BLOOD Lactate-1.3
.
CT abd/pelvis (prelim): Abnormally dilated loops of small bowel
with decompressed distal bowel consistent with small bowel
obstruction. Large cavitary lung mass in right lower lobe, large
mass in left lower lobe.
.
Abd XR: Numerous small air-fluid levels and several loops of
dilated bowel are concerning for obstruction. Lung masses at the
lung bases are better evaluated on previously performed chest
x-ray. Multilevel degenerative changes of the lumbar spine
including multiple lumbar spine vertebral body compression
fractures.
.
CXR: Interval increase in size in right lower lobe cavitary
lesion, and probable increase in right hilar adenopathy. Left
lower lobe nodule is unchanged. No evidence of focal
consolidation to suggest pneumonia. No pneumoperitoneum.
.
Last EGD [**2134**]
Esophagus:
Mucosa: A salmon colored mucosa suggestive of short segment
Barrett's Esophagus was seen.
Stomach: Normal stomach
Duodenum: Flat Lesions A single small angioectasia that was not
bleeding was seen in the second part of the duodenum. [**Hospital1 **]-CAP
Electrocautery was applied for hemostasis successfully.
Impressions: Short segment Barrett's esophagus
Angioectasia in the second part of the duodenum (thermal
therapy)
Otherwise normal EGD to third part of the duodenum
.
Last Colonoscopy [**2132**]
Findings: Protruding Lesions Non-bleeding grade 1 internal
hemorrhoids
were noted.
Impression: Grade 1 internal hemorrhoids
Otherwise normal Colonoscopy to cecum
.
EKG: NSR @ 86, LAD, STD in I, II, III, aVL, V4-V6, TWI in I, II,
aVL (STD laterally are new)
Brief Hospital Course:
[**Age over 90 **] yo f with presumed lung CA, CHF, DM, here with small bowel
obstruction.
Initial management in the MICU. Family declined surgery but
wanted to continue aggressive medical management of her
condition. The patient was maintained on IVF and her abdominal
exam improved. The NGT was removed and the patient was
transferred to the floor after starting po intake. The morning
after transfer, she again became distended, developed pain and
began vomiting. The NGT was replaced with 850 cc immediate
output. She was kept NPO/NGT/IVF for several days with no
improvement in her symptoms. Extensive discussions were had
with the family regarding her unresolving SBO and the daughter
wanted to continue aggressive care. She became volume overloaded
while on IVF, so the fluid was d/c'ed as it was no longer
medically indicated. Output from her NGT stopped, so her NGT was
d/c'ed. She was kept comfortable and passed away.
Medications on Admission:
amiodarone 200mg qday
Protonix 40mg qday
iron 325mg qday
Senna
timolol
Xalatan
[**Age over 90 **] 20mg qday
albuterol qid
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
SBO
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"584.9",
"403.90",
"428.22",
"427.31",
"424.0",
"599.0",
"250.02",
"560.9",
"V45.01",
"162.8",
"038.9",
"272.0",
"263.0",
"276.7",
"585.9",
"397.0",
"276.51",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6118, 6127
|
4978, 5913
|
285, 313
|
6174, 6183
|
2692, 4955
|
6239, 6249
|
2257, 2274
|
6086, 6095
|
6148, 6153
|
5939, 6063
|
6207, 6216
|
2289, 2673
|
215, 247
|
341, 1259
|
1281, 1945
|
1961, 2241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,112
| 174,188
|
50602+50603+50604
|
Discharge summary
|
report+report+report
|
Admission Date: [**2170-5-2**] Discharge Date: [**2170-5-17**]
Date of Birth: [**2093-12-30**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 76-year-old gentleman
with a history of diabetes type 2 with last hemoglobin A1C in
[**7-/2169**] of 11 percent who was in his usual state of health
until the morning of admission when he noticed that his blood
glucoses were abnormally high in the 500 to 550 range and
that he felt nauseated. Patient vomited times two. The
emesis was non-bloody and non-bilious. He denied any chest
pain, shortness of breath, palpitations. No dyspnea on
exertion but states that he did have limited exercise
tolerance secondary to gait imbalance. Patient had stable
two-pillow orthopnea, no postnasal drip, positive lower
extremity edema in the past controlled with a "water pill."
Patient states that he has never had a stress test echo or
other cardiac workup. Patient's CAD risk factors include
diabetes type 2, hypertension, his age, gender, obesity,
sedentary lifestyle. The patient went to an outside hospital
secondary to his high blood sugars and nausea and vomiting.
At the outside hospital he continued to have dry heaves and
CK was 13.13, MB was pending, AST 174, ALT 174. The
patient's EKG at the outside hospital revealed an isolated Q
wave in Lead III and ST elevations in V1 through V3. He was
transferred to the [**Hospital3 **] for further management. CK at
the [**Hospital3 **] initially was 2200 with an MB of 200 and
troponin 6.1.
EKG was unchanged from prior at the outside hospital.
Cardiology was consulted and patient was started on Heparin
and renally dosed 2b3 inhibitor.
PAST MEDICAL HISTORY: Type 2 diabetes; most recent
hemoglobin A1C in [**7-/2169**] was 11. His diabetes is
complicated by peripheral neuropathy and question of
Parkinson's disease, history of lacunar infarct, history of
depression, history of left-sided Bell's palsy, status post
cholecystectomy, status post appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lantus 36 units q. h.s.
2. Regular insulin sliding scale.
3. Paxil.
4. [**Doctor First Name **].
5. Lasix.
6. Blood pressure medicines that are unknown at time of
admission.
SOCIAL HISTORY: Patient is married with children. He is a
former car salesman. No tobacco. Rare ETOH.
FAMILY HISTORY: Father drowned. Mother has diabetes
mellitus and sister has coronary artery disease.
LABORATORY DATA ON ADMISSION: White count 13.7, hematocrit
36.4, platelet count 196, neutrophils 92, 5 lymphs, 1.6
monos, 0.4 eos. Coags: 13.8 for PT, PTT 22.1, INR is 1.3,
CK 2289, MB 200, index 8.7, troponin 6.17. Lytes: 136 for
sodium, potassium 6.5, chloride 96, bicarbonate 30, BUN 51,
creatinine 2.2, glucose 150.
EKG: Sinus rhythm, 88, normal axis, normal intervals, [**Street Address(2) 28585**] elevation V1 through V3, 0.[**Street Address(2) 1755**] depressions V5 and V6,
Q waves in Lead III, evidence of left ventricular hypertrophy
and left atrial abnormally.
Chest x-ray is consistent with congestive heart failure.
PHYSICAL EXAMINATION: Patient's vitals are as follows:
Temperature is 98.2, blood pressure is 130/70, respiratory
rate is 12, patient is satting at 96 percent on 3 liters.
Generally, the patient is a well developed male in no acute
distress, alert and oriented times three. HEENT: Jugular
venous distention is 12 cm, no lymphadenopathy, otherwise
extraocular movements intact. Oropharynx is clear with moist
mucous membranes. Heart is regular rate and rhythm, a normal
S1, normal S2, and positive for S3, pulmonary bibasilar
crackles, right greater than left; no rales. Abdomen is
obese, soft, nontender, nondistended with no
hepatosplenomegaly. Extremities: No clubbing, cyanosis, or
edema.
HOSPITAL COURSE BY SYSTEM: Patient was taken to the
Catheterization Lab. He had a right heart coronary
angiography, rotablator, and drug-eluting stent of proximal
mid left anterior descending. Patient's cardiac output was
4.6, index 2.16. His pulmonary capillary wedge was 10, PA
pressure 27/12, mean was 19, and the results of the
catheterization were as follows: Left anterior descending 90
percent proximal long, 70 percent mid, diffuse disease
distally up to 80 percent first diagonal, 70 percent
proximal, 90 percent distal of the left circumflex, and 99
percent PDA bifurcating obtuse marginal 1 with 80 percent
upper branch and 70 percent lower branch, right coronary
artery 100 percent origin, probably nondominant.
Patient also had an intraprocedure echo performed which
revealed a depressed ejection fraction at approximately 20
percent with a relative preservation on inferolateral wall.
Post myocardial infarction patient was maintained on an intra-
aortic balloon pump. The patient had three TAXUS stents
placed to his left anterior descending. Post procedure
patient was brought to the Cardiac Care Unit. Patient's
hematocrit dropped to 32.9, had been 36.4. Though he was
hemodynamically stable he later developed respiratory
distress, was intubated, two pressors were started for
hypotension. Chest x-ray was performed which revealed no
congestive heart failure with patchy infiltrates. The
patient was started on Levophed as well as Dopamine. There
was concern that patient may have down stents. He was taken
to the Catheterization Lab for a re-look which revealed that
all stents were patent, and at that time he was placed on an
intra-aortic balloon pump. Patient returned to the CCU on
Levophed and Dopamine as well as a balloon pump.
His status overnight worsened and patient's hematocrit
dropped to 23.7. He received four units of packed red blood
cells, four units of fresh frozen plasma, one bag of
platelets, 10 units of vitamin K. Had a CT which was
positive for right-sided intrapleural hematoma as well as an
extra pleural hematoma. On further view of the CT films it
became evident that the patient had a cracked rib. On
discussing the case with the Cardiac Medicine team that
initially had the patient overnight, it became evident that
patient had a ventricular fibrillation arrest in the
Emergency Room and did received chest compressions for a
short period of time. In total, patient received a total of
12 units of packed red blood cells, 12 units of platelets,
four bags of fresh frozen plasma, and vitamin K.
Post myocardial infarction patient was weaned off of his
intra-aortic balloon pump. His cardiac status was stabilized
on Lopressor, Hydralazine, as well as Isordil. Captopril was
held off given the patient did have chronic renal
insufficiency. Patient's cardiac status remained stable
throughout his hospitalization. His blood pressures remained
mildly hypertensive to normotensive.
Pump: Patient was initially maintained on p.r.n. Lasix and
later changed to Natrecor along with p.r.n. Lasix boluses.
Patient's creatinine bumped to 3.6 on the Natrecor along with
p.r.n. boluses were discontinued. Patient also had a Swan
placed as line status and his numbers were as follows: RV
30, number 12 at 30 cm, pH 139/21 at 42 cm, pulmonary
capillary wedge 15 at 53, cardiac output 9.1, index 4.2, and
SVR 413. These findings were felt to be consistent with a
sepsis. Patient was placed on broad spectrum antibiotics
including Levofloxacin, Vancomycin, and Flagyl. His Natrecor
was stopped. The cortisol was checked, which was within
normal limits. Patient's cardiac output and index continue
to improve on antibiotics and by date of transfer his cardiac
output was 6.2, index 2.89, SVR 890. Patient was replaced on
Lasix GTT and diuresed well. His creatinine remained stable.
Rhythm: Throughout his hospitalization patient remained in
normal sinus rhythm but did have evidence of an
supraventricular tachycardia with three-beat run to the max.
Electrophysiology was consulted and felt that patient would
likely need an ICD once extubated and medically stable. The
patient's electrolytes were kept off.
Pulmonary: For patient's right-sided hemothorax patient had
chest tubes placed by Cardiothoracic Surgery. Patient
initially had aggressive output, but then output fell. A
video-assisted thoracic surgery was performed with drainage
of bloody fluid. Post VATS right-sided chest tubes were
placed. Patient had minimal drainage at these chest tubes
and in the setting of a mild decrease in hematocrit, a
noncontrast CT was obtained. Per the radiologist there was
evidence that there may be some new areas of oozing. The
case was discussed with Cardiothoracic Surgery who felt that
patient did not have evidence of active bleeding.
Patient's chest tubes were pulled. Patient's hematocrit
remained stable. Extubation, however, was very difficult.
The patient was very difficult to wean from AC mode of
ventilation. Changing him to pressure support was attempted. The
patient would become extremely tachypneic and would drop his
tidal volumes. Eventually a trach was placed on [**2170-5-16**].
Again, weaning from the ventilation was attempted, but
patient's rhythm consistently remained above 100 and he would
become tachycardiac as well as drop his tidal volumes on
attempt to try a spontaneous breathing trial. This failure
was felt secondary to fluid overload and due to persistence
of intrapulmonary infiltrate secondary to the hemothorax.
Renal failure: Patient's renal failure was improving on
Lasix at time of discharge from the Cardiac Care Unit. His
creatinine bumped to a high of 3.6 felt likely secondary to
overdiuresis as well as sepsis.
Diabetes: Patient was maintained on an insulin GTT. He had
very good glycemic control throughout his hospitalization.
Patient was initially maintained on tube feeds later changed
to Nepro with ProMod. He had a PEG placed on [**2170-5-17**].
Lines: Patient's lines at time of transfer to the Medical
Intensive Care Unit included a right art line, right-sided
Swan, and a left IJ. Patient is a Full Code. The
communication was with the family throughout his
hospitalization.
Infectious Diseases: Patient, in the setting of hypotension
and elevated cardiac output, as well as decreased SVR
and sepsis, blood cultures were sent off which, by time of
transfer, were no growth to date. Patient also had a urine sent
off which was no growth. A sputum culture was consistent with
oropharyngeal flora. Clostridium difficile was sent times one;
was to follow up to be performed still. Other sources of
infection were felt to include patient's hemothorax as well as
chest tube insertion sites as those areas had some mild purulent
discharge which was managed by wound care. The patient was
maintained on Levofloxacin, Vancomycin, and Flagyl and then later
changed to Levofloxacin and Vancomycin by time of transfer to the
Medical Intensive Care Unit.
Patient also had a stage 2 decubitus ulcer on his coccyx
which were managed with DuoDerm as well as air mattress.
MEDICATIONS ON TRANSFER TO MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Acetaminophen liquid 650 q. 4 to 6 hours.
2. Aspirin p.r.n. 325 one p.o. q.d.
3. Isosorbide dinitrate 40 mg one p.o. t.i.d.
4. Lansoprazole 30 mg one p.o. q.d.
5. Levofloxacin 250 mg one IV q. 48 hours.
6. Metoprolol 50 mg one p.o. t.i.d.
7. Atorvastatin 40 mg one p.o. q.d.
8. Calci-Mix 1334 one p.o. t.i.d. with tube feeds.
9. Plavix 750 mg one p.o. q.d.
10. Docusate 100 mg one p.o. b.i.d.
11. Fentanyl citrate IV.
12. Versed IV.
13. Furosemide GGT 10 mg per hour.
14. ______ 50 mg one p.o. q. 6 hours.
15. Insulin GTT.
16. Miconazole powder.
17. Paxil 20 mg one p.o. q.d.
18. Senna one p.o. b.i.d.
19. Vancomycin 1000 units one IV q. 24 hours.
The remainder of [**Hospital 228**] hospital course, as well as
patient's discharge status, will be dictated by patient's
acute team.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2170-5-17**] 13:07:35
T: [**2170-5-17**] 14:45:42
Job#: [**Job Number **]
Unit No: [**Numeric Identifier 105330**]
Admission Date: [**2170-5-17**]
Discharge Date: [**2170-5-25**]
Date of Birth:
Sex:
Service:
This dictation will cover [**Hospital 228**] hospital course from [**2170-5-17**], until [**2170-5-25**]. The remainder of the [**Hospital 228**]
hospital course will be dictated by the physician who takes
over patient's care. Please refer to previous discharge
summary done by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D., for details of previous
hospital course.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular:
A. Coronary artery disease: Given patient's recent ST
elevation myocardial infarction, the patient continued
on his cardiac medications, to include a beta blocker,
aspirin, Plavix and statin.
B. Congestive heart failure: The patient's recent
echocardiogram disclosed an ejection fraction of 20 percent.
Given patient's renal failure, he could not be started on an
ACE inhibitor. He continued on hydralazine, nitrates and
beta blocker. Doses were increased as blood pressure
tolerated. The patient was initially diuresed with a Lasix
drip yet Lasix was eventually discontinued given concern for
overdiuresis and worsening renal function. At the time of
this dictation, however, it is clear that patient is grossly
volume overloaded and will benefit from further diureses. As
of [**5-25**], Lasix 80 IV b.i.d. has been re-initiated.
Patient continues to make good response to this dose of
Lasix.
C. Rhythm: The patient has had episodes of non-sustained
ventricular tachycardia noted on telemetry. Given patient's
recent ST elevation myocardial infarction and ejection
fraction less than 30 percent, patient would likely benefit
from EP study and automatic implantable cardioverter-
defibrillator when medically stable.
1. Pulmonary: Upon transfer to Medical Intensive Care Unit
patient's ventilator settings were adjusted with the goal
to wean patient from ventilator. He was initially changed
to pressure support ventilation. Patient has been weaned
off of the pressure support and currently tolerates trach
collar. The patient currently off all sedation. Patient
continues to ventilate and oxygenate well on the trach
collar.
1. Renal: The patient has history of chronic renal
insufficiency. The Renal service was consulted regarding
patient's acute renal failure. Acute renal failure is
thought to be secondary to multiple insults, to include
cardiogenic shock, contrast administration, over-diuresis,
and possible infection. Review of urinary sediments
disclosed granular casts consistent with tubular injury.
Renal ultrasound was negative for hydronephrosis or
stones. On [**2170-5-23**], a 24 hour urine test was
performed. The patient's creatinine clearance was
estimated to be 10 cc/minute. On [**2170-5-25**], a
hemodialysis catheter was placed by Interventional
Radiology. The patient will undergo hemodialysis given
persistently elevated BUN and creatinine. Patient
continues to make good urine output and may not require
long term hemodialysis.
1. Neurologic: As patient was weaned off his sedating
medications, there was concern for altered mental status
given patient's ventricular fibrillation arrest on
presentation in the Emergency Department. CT of the head
was performed. CT disclosed global white matter disease
consistent with vascular dementia. There was no evidence
for an acute bleed. An EEG disclosed diffuse slowing.
MRI showed no evidence of cortical infarct. The Neurology
Service was consulted given concern for patient's altered
mental status. The Neurology Service was concerned about
the possibility of toxic metabolic insults, to include
sedating medications in the setting of renal failure, and
possibly uremia contributing to patient's altered mental
status. Since [**5-22**], patient's mental status has
improved daily. He has undergone placement of
______________ valve to determine if he is able to speak.
He continues to undergo these trials daily.
1. Diabetes mellitus: The patient was initially maintained
on an insulin drip. He has now been switched to long-
acting Glargine at night with a regular insulin sliding
scale.
1. Infectious Disease: Upon transfer to the Medical
Intensive Care Unit, all of patient's antibiotics were
discontinued. He has remained afebrile during this
hospitalization. His head CT did disclose evidence for
sinusitis. The patient was treated with ceftriaxone for
three days. The patient remains afebrile and white blood
cell count is not elevated.
1. Nutrition: Patient continues on Nepro tube feeds per
percutaneous endoscopic gastrostomy tube.
1. Prophylaxis: The patient has been maintained on a proton
pump inhibitor, subcu heparin
__________________________________________________________
____________________. The right internal jugular central
line was discontinued upon transfer to the Medical
Intensive Care Unit. The patient's left internal jugular
central line was discontinued on [**5-25**]. A PICC line
has been placed on [**5-25**] by Interventional Radiology.
The remainder of this dictation will be completed by the
resident who assumes patient's care on [**2170-5-26**].
INCOMPLETE DICTATION
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 48404**]
Dictated By:[**Doctor Last Name 22663**]
MEDQUIST36
D: [**2170-5-25**] 22:48:59
T: [**2170-5-26**] 05:45:51
Job#: [**Job Number 48209**]
Admission Date: [**2170-5-2**] Discharge Date: [**2170-6-5**]
Date of Birth: [**2093-12-30**] Sex: M
Service: MED
HOSPITAL COURSE: Respiratory failure: The patient was again
status post trach on [**5-16**] secondary to failure to extubate.
Of note during this hospitalization, events including a VATS
evacuation of the right hemothorax and on [**5-9**]. The right
hemothorax was thought to be secondary to a complication of
chest compressions.
On follow-up x-ray upon discharge, the patient had a
persistent right loculated pleural effusion. CT Surgery was
reconsulted before discharge, and they recommended no further
treatment at this time given no acute worsening of
respiratory status.
The patient remained trach dependent throughout this
hospitalization and required 50 percent trach mask throughout
his hospitalization. The patient was continued on frequent
suctioning, as well as oxygen therapy after discharge from
the intra-coronary.
Acute renal failure: Of note, during this hospitalization on
past discharge summary, the patient is thought to have acute
renal failure secondary to ATN, which is secondary to
cardiogenic shock, in addition to intravenous contrast given
during his cardiac catheterization, over diuresis, and
questionable during the Intensive Care Unit stay.
Of note also, the patient was initiated on hemodialysis after
a catheter was placed by Interventional Radiology on [**2170-5-25**]. After the second day of hemodialysis, the patient was
transferred to the floor with a creatinine of 3.0; however,
the patient was becoming oliguric. The patient was started
on Lasix 80 mg IV b.i.d.. The patient's BUN and creatinine
remained the same after 3-4 days of Lasix at this dose;
however, the patient's urine output increased remarkably up
to 2 L a day.
The Renal Team felt that the patient has no acute indications
to continue dialysis; however, upon discharge, his tunneled
IJ catheter will remain in place given the patient's 10-year
status and may need further hemodialysis in the near future.
The patient has anemia secondary to his renal disease and is
on Epogen. The patient will need follow-up iron studies in
one month as iron studies here remained normal. The patient
is on Calcitriol secondary to increased PTH.
Additionally in terms of volume status and dialysis, the
patient is to have daily weights checked and is to continue
intravenous Lasix at the outside hospital. If the patient
has a weight gain of over 3 lbs and/or urine output is
decreasing, the patient may need hemodialysis per the Renal
Team. Ideally his blood pressure should remain above
systolic of 100 to maintain renal perfusion.
Cardiovascular: Of note during his MICU stay, the patient
had an urgent cardiac catheterization showing severe jugular
venous distension, including lesions in his left anterior
descending coronary artery which were severe diffuse disease
up to 80 percent in the distal left anterior descending
coronary artery. This was intervened on with three stents
placed; however, his left circumflex continues to have a 70
percent lesion, a distal 90 percent lesion, and a 99 percent
stenosis in the left posterior descending coronary artery.
This additionally bifurcated on one branch with an 80 percent
stenosis of the lower branch and a 70 percent stenosis. Of
note, right coronary artery was known to be totally occluded.
Once transferred to the floor, the patient had a hemodialysis
session at which the patient complained of chest pain and had
dynamic ST changes in lead V4 and V5 with ST depressions.
Cardiology was reconsulted, and combined efforts of
Cardiology and Renal stated that the patient is candidate for
cardiac catheterization in the future, however, would like to
hold off on cardiac catheterization until his renal function
returns to near normal.
Therefore, the patient will continue on his CAD medications
including his Aspirin, statin, Plavix, beta-blocker, and
additionally is on Nitroglycerin, and Hydralazine. Of note,
the patient has multiple wall motion abnormalities on
echocardiogram including an akinetic apex. The patient
should be considered to start Coumadin in the future given
his akinetic apex.
Congestive heart failure: The patient has an ejection
fraction of 20 percent. Of note, attempts were made to
diurese him in the Medical Intensive Care Unit with
Nesiritide and a Lasix drip. These efforts were discontinued
given his worsening renal function; however on the floor, the
patient was restarted on Lasix 80 IV b.i.d. with good
response. The patient is to continue diuresis upon discharge
with a goal of negative 500 to negative 1 L I&Os. The
patient is to continue his Hydralazine and Isordil.
Nonsustained ventricular tachycardia: The patient was seen
by Electrophysiology in the Medical Intensive Care Unit.
Based upon discharge to the floor, the patient had no runs of
nonsustained ventricular tachycardia. The patient is a
likely candidate for EPF in the future and possible AICD
placement. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 284**] upon discharge and after renal function resolves.
Impaired mental status: Of note, the patient became more
interactive once transferred to the floor. The patient in
the Medical Intensive Care Unit had a negative MRI and
negative head CT. Additionally, EEG showed diffuse changes
consistent with a broad differential. The patient was
started on hemodialysis initially with thoughts that his
uremia was causing these mental status changes; however, with
dialysis, the patient's uremia improved; however, his mental
status did not improve drastically. Most likely the patient
has a component of noxious brain injury given his episode of
ventricular fibrillation arrest.
FEN: The patient had a PEG tube placed on [**5-17**] in the
Medical Intensive Care Unit. Speech and Swallow evaluation
was done on the floor which the patient passed and is to be
maintained on a pureed diet.
The patient was additionally on tube feeds which can be
slowly be weaned as his p.o. diet is increased. This again
needs to be followed up at his acute rehabilitation.
Access: The patient has a PICC line placed by IR on [**5-25**].
Code status: The patient was maintained full code throughout
this admission.
DISCHARGE MEDICATIONS:
1. Paroxetine 20 mg p.o. q.d.
2. Plavix 75 p.o. q.d.
3. Senna 1 tab b.i.d. p.r.n.
4. Docusate 2 tab b.i.d.
5. Tylenol p.r.n.
6. Aspirin 325 p.o. q.d.
7. Miconazole Nitrate powder applied t.i.d. p.r.n.
8. Lansoprazole 30 mg p.o. q.d.
9. Heparin 5000 U subcue t.i.d. which should be continued at
rehabilitation.
10. Albuterol 2-4 puffs q.6 hours p.r.n.
11. Lipitor 80 mg p.o. q.d.
12. Hydralazine 25 mg p.o. q.6 hours
13. Isosorbide Dinitrate 20 mg p.o. t.i.d.
14. Epogen 10,000 U two times a week, Monday and
Thursday.
15. Metoprolol 100 mg p.o. t.i.d.
16. Calcitriol 0.25 mcg p.o. q.d.
17. Lasix 80 mg IV b.i.d.
18. Glargine 30 U q.h.s. and regular Insulin sliding
scale, of note, this will need to be titrated as tube
feeds are decreased.
DISCHARGE INSTRUCTIONS: Anemia: Again the patient needs to
have iron studies done in one month, as he is on Epogen.
Dialysis: The patient is to have his dialysis catheter
flushed twice a week and flushed with heparin afterwards.
The patient additionally is to have daily weights check with
a goal of another 500 cc negative 1 L initially. If his
weight increases more than 3 lbs, the patient's Lasix dose
may need to be increased.
DISCHARGE DIAGNOSIS: Coronary artery disease status post ST
elevation myocardial infarction with ventricular fibrillation
arrest.
Acute renal failure secondary to presumed ATN.
Resolving delirium.
????
Congestive heart failure with systolic dysfunction.
Status post right hemothorax, status post VATs.
Status post PEG tube.
Failure to wean status post trach.
FOLLOW UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 105331**], his primary care physician. [**Name10 (NameIs) **] patient is also to
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] after acute renal
failure resolves.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5617**]
Dictated By:[**Doctor Last Name 11001**]
MEDQUIST36
D: [**2170-6-5**] 18:03:10
T: [**2170-6-5**] 18:46:12
Job#: [**Job Number 105332**]
|
[
"584.5",
"428.0",
"785.51",
"511.8",
"428.20",
"998.11",
"410.71",
"427.1",
"427.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"99.20",
"89.64",
"31.1",
"37.23",
"43.11",
"96.72",
"36.07",
"34.04",
"88.56",
"96.04",
"37.61",
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] |
icd9pcs
|
[
[
[]
]
] |
2354, 2457
|
24117, 24916
|
25375, 25721
|
17916, 22954
|
24941, 25353
|
12669, 17898
|
25733, 26301
|
3103, 3781
|
165, 1671
|
2472, 3080
|
22970, 24094
|
1694, 2230
|
2247, 2337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,194
| 158,328
|
35694
|
Discharge summary
|
report
|
Admission Date: [**2105-1-2**] Discharge Date: [**2105-1-10**]
Date of Birth: [**2041-9-7**] Sex: M
Service: SURGERY
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
bloody urine
Major Surgical or Invasive Procedure:
1. Sigmoid colectomy
2. Mobilization of splenic flexure.
3. Takedown of colovesical fistula.
4. Partial cystectomy
Cystoscopy, bilateral ureteral stent placement.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 63-year-old male
with known diverticulitis, colovesicular fistula, and recent
myocardial infarction and atypical chest pain. He has gotten
this atypical chest pain worked up recently with a cardiac
catheterization. See findings below. He has gotten cardiac
clearance from his cardiologist for a sigmoid resection.
Past Medical History:
PAST MEDICAL HISTORY:
# CAD: MI in [**2075**] and [**2078**]
-- Four vessel CABG at [**Hospital1 2025**] in [**2092**]
-- POBA of LCx on [**2103-2-2**]
-- DES to LCx on [**2103-3-29**]
# Hypertension
# Hyperlipidemia
# DM-type II (borderline)
# Sleep apnea -- on CPAP
# Arthritis -- mostly fingers
# Hernia repair as an infant
# Arthroscopy of the left knee
CARDIAC RISK FACTORS:
+Diabetes, +Dyslipidemia, +Hypertension
CARDIAC HISTORY:
# CABG: Four vessel in [**2092**] at [**Hospital1 2025**] (patent LIMA-LAD and SVG-OM1,
subsequently occluded SVG-OM2 and SVG-RPDA)
# PERCUTANEOUS CORONARY INTERVENTIONS:
-- In [**2103-2-2**], he underwent PCI (POBA only due to difficulty
delivering stent) of the origin LCX with 30-40% residual
stenosis and stable mild dissection performed after recurrent
angina and an abnormal nuclear stress.
-- In [**2103-3-29**], he had a repeat cath for progressive repeated
angina. He underwent DES to ostial proximal LCx after showing
80-90% disease. He also had diffuse (60-70%) proximal LCX
disease and reported 3VD.
.
.
2D-ECHOCARDIOGRAM AT OSH:
EF 50-55%, LVH, septal hypokinesis, trace MR.
.
OSH IMAGING:
Abdominal CT - colovesicular fistula likely secondary to sigmoid
divericuli.
.
ETT ([**2103-1-23**]):
He underwent a nuclear stress test on [**2103-1-23**] where he was able
to exercise 6 minutes 35 seconds to a maximum heart rate of 113
bpm. Nuclear imaging revealed an inferior wall MI, mild
ischemia in the in the mid to basal septum, inferior and septal
hypokinesis, LV systolic dysfunction and an EF of 45%.
.
Echocardiogram ([**2103-1-2**]):
Echocardiogram from [**2103-1-2**] revealed a slightly enlarged LA and
aortic root, normal systolic function of both ventricles, and
LVEF of 75%.
.
CARDIAC CATH ([**1-/2103**]):
PTCA COMMENTS:
Initial angiography showed recurrent severe (80-90%) ostial LCX
stenosis followed by diffuse (60-70%) proximal LCX disease. We
planned to treat this with PTCA and stenting. Bivalirudin was
commenced prophylactically. The patient also receieved ASA and
Plavix (chronically on 75 mg daily and was reloaded post
procedure with additional 600 mg). A 4.0 XB guide provided
excellent support and a Choice PT Extra Support wire crossed the
lesion without difficulty. We performed serial inflations
staring with 1.5x15 Maverick balloon (at 10-12 ATM), 2.5x15 mm
Voyager at 8-12 ATM) and 3.0x15 mm Voyager (at 7-14 ATM). We
then delivered a 3.0x15 mm Endeavor DES at 18 ATM, post-dilated
with 3.0x15 mm Quantum Maverick at 20 ATM and 3.5x8 mm Quantum
Maverick at 10 ATM. Final angiography showed 0% residual
stenosis with TIMI 3 flow and no dissection or distal emboli.
The patient left the cath lab in stable condition and free from
angina.
COMMENTS:
1- Successful PTCA and stenting of the ostial-proximal LCX with
a 3.0x15 mm Endeavor DES, post-dilated to 3.5. Final angiography
showed 0% residual stenosis with TIMI 3 flow and no dissection
or distal emboli.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stening of the ostial-proximal LCX with
an Endeavor Drug-Elluting Stent.
.
Social History:
He is married with two grown children. He works as a general
salesman for an elevator company.
Smoking: Quit ~20 years ago, previously smoked 2 PPD for 15
years
Alcohol: Occasional, social
Drugs: None
Family History:
Father died of a MI at age 32.
Otherwise noncontributory.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: His temperature is 97.3, heart rate 63, blood
pressure 160/80, respirations 14, and oxygen saturation 96%.
GENERAL: He is a well-appearing male in no apparent distress.
LUNGS: Clear to auscultation bilaterally.
HEART: Normal S1, S2; regular rate and rhythm.
ABDOMEN: Soft, obese, nondistended, and nontender. He has a
ventral hernia.
EXTREMITIES: Full range of motion.
Pertinent Results:
[**2105-1-9**] 06:10AM BLOOD WBC-4.0 RBC-2.75* Hgb-9.1* Hct-26.2*
MCV-95 MCH-33.2* MCHC-34.8 RDW-14.9 Plt Ct-218
[**2105-1-8**] 05:50AM BLOOD WBC-4.0 RBC-2.57* Hgb-8.8* Hct-24.7*
MCV-96 MCH-34.2* MCHC-35.6* RDW-14.8 Plt Ct-157
[**2105-1-7**] 06:10AM BLOOD WBC-3.5* RBC-2.55* Hgb-8.6* Hct-24.6*
MCV-97 MCH-33.6* MCHC-34.8 RDW-15.0 Plt Ct-145*
[**2105-1-7**] 12:40AM BLOOD WBC-3.9* RBC-2.50* Hgb-8.5* Hct-23.9*
MCV-96 MCH-33.8* MCHC-35.4* RDW-14.9 Plt Ct-146*
[**2105-1-9**] 06:10AM BLOOD Plt Ct-218
[**2105-1-8**] 05:50AM BLOOD Plt Ct-157
[**2105-1-7**] 06:10AM BLOOD Plt Ct-145*
[**2105-1-7**] 12:40AM BLOOD Plt Ct-146*
[**2105-1-9**] 06:10AM BLOOD Glucose-109* UreaN-14 Creat-1.0 Na-142
K-3.4 Cl-104 HCO3-27 AnGap-14
[**2105-1-8**] 05:50AM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-142
K-3.1* Cl-106 HCO3-28 AnGap-11
[**2105-1-7**] 06:10AM BLOOD Glucose-120* UreaN-14 Creat-1.0 Na-144
K-3.5 Cl-106 HCO3-25 AnGap-17
[**2105-1-7**] 12:40AM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-144
K-3.6 Cl-108 HCO3-25 AnGap-15
[**2105-1-7**] 04:00PM BLOOD CK(CPK)-75
[**2105-1-7**] 06:10AM BLOOD CK(CPK)-106
[**2105-1-6**] 06:25AM BLOOD CK(CPK)-279
[**2105-1-9**] 06:10AM BLOOD cTropnT-0.03*
[**2105-1-7**] 04:00PM BLOOD CK-MB-1 cTropnT-0.03*
[**2105-1-7**] 06:10AM BLOOD CK-MB-2 cTropnT-0.03*
[**2105-1-6**] 06:25AM BLOOD CK-MB-1 cTropnT-0.02*
[**2105-1-9**] 06:10AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
[**2105-1-8**] 05:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
[**2105-1-2**] 05:12PM BLOOD Hgb-12.0* calcHCT-36
[**2105-1-2**] 05:12PM BLOOD freeCa-1.08*
[**2105-1-2**]: EKG:
Sinus rhythm. Prior inferior myocardial infarction. Compared to
the previous tracing of [**2104-12-29**] there is variation in precordial
lead placement. The rate has increased. Otherwise, no diagnostic
interim change.
[**2105-1-3**]: chest x-ray:
Lungs are low in volume, and there is opacification at both lung
bases which could be atelectasis or alternatively pneumonia or
even aspiration. The upper lungs are clear. The heart is normal
size. NG tube passes into the stomach and out of view.
[**2105-1-5**]: chest x-ray:
FINDINGS: In comparison with the study of [**1-3**], the nasogastric
tube has been removed. Continued low lung volumes with
enlargement of the cardiac
silhouette without vascular congestion. There has been some
clearing of the atelectatic changes at the bases.
[**2105-1-6**]: EKG:
Sinus rhythm. There is a non-specific intraventricular
conduction delay. There are Q waves in the inferior leads
consistent with prior inferior myocardial infarction. Compared
to the previous tracing of [**2105-1-2**] the QRS duration is longer
[**2105-1-7**]: chest x-ray:
There are persistent low lung volumes. Cardiomegaly and widened
mediastinum are stable. Patient is status post CABG. Bibasilar
atelectases are unchanged. There are no new lung abnormalities,
pneumothorax, or pleural effusion. Sternal wires are aligned.
[**2105-1-9**]: voiding cystogram:
No bladder leak after colovesicular fistula repair.
Brief Hospital Course:
63 year old gentleman who presents to the Acute Care service
for elective repair of [**Last Name (un) **]-vesicular fistula and colectomy.
He was taken to the operating room on [**1-2**] where he had a
cystectomy and bilateral ureteral stent placements. This
procedure was done prior to his sigmoid colectomy, partial
cystectomy, and repair of colovesical fistula. During his
operative course, he had a 400cc blood loss. He did have an
epidural catheter placed for pain control. His foley needed to
be replaced after it was removed with the ureteral stents and
did have hematuria and clots after it was replaced. He was
extubated in the operating room and monitored in the intensive
care unit for respiratory insufficiency. He did require a blood
transfusion for a decreased hematocrit.
On POD #3, he was transferred to the floor. His epidural
catheter was discontinued on [**1-6**]. He was started on sips
without complaints of nausea. He did have an episode of
hypertension which was controlled with hydralazine and
metoprolol. During this same time, he developed confusion and
decreased oxygen saturation. Because of his history of recent
myocardial infarct, cardiac enzymes were sent and he ruled out.
Over the next day, his confusion resolved. His abdominal wound
had nylon sutures added for partial closure and dry dressing
changes. He underwent a cystogram on [**1-9**] to determine bladder
leakage. No bladder leakage was reported and the foley catheter
was discontinued on [**1-9**]. There was some difficulty in removing
the catheter and it resulted in some bleeding. He is due to void
this afternoon.
His vital signs are stable and he is tolerating a regular
diet. He has been out of bed and has ambulated without
assistance. His hematocrit is 26.2.
He has been evaluated by physical therapy and recommendations
made for his discharge to home with VNA assistance for the
dressing changes and monitoring of his blood pressure.
It is recommended that he follow up with his Cardiologist in
[**1-16**] days and return to the Acute Care clinic 1 week.
Medications on Admission:
[**Last Name (un) 1724**]: Metoprolol 200'', Nitroglycerin 0.4 SL prn, Crestor
40', ASA 325', Prinivil 10', MVI', Fishoil capsule'
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
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. Crestor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day: hold for blood pressure <110, hr>100.
6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO twice a day: hold
for blood pressure <100, hr <60.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
diverticulitis
colovesicle fistula
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 to have a portion of your
colon resected becuase of diverticulitis and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-vesical
fistula. Prior to this procedure, you had a visualzation of your
bladder and placement of bilateral ureteral stents to aid in the
colon resection. You did have sigmoid colectomy and a partial
cystectomy. You are now preparing for discharge home with the
following instructions.
Followup Instructions:
Please folow up with the Acute Care service in 1 week. You can
schedule this appointment by callling #[**Telephone/Fax (1) 600**]
Please follow up with your cardiologist in [**1-16**] days, Dr. [**Last Name (STitle) 81206**],
to review your medications.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
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"250.00",
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icd9cm
|
[
[
[]
]
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[
"57.83",
"57.6",
"87.77",
"45.76",
"03.90",
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] |
icd9pcs
|
[
[
[]
]
] |
10970, 11029
|
7740, 9825
|
280, 446
|
11108, 11108
|
4715, 7715
|
11739, 12105
|
4208, 4268
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10007, 10947
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11050, 11087
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9851, 9984
|
3831, 3972
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11259, 11716
|
4283, 4283
|
4305, 4696
|
228, 242
|
503, 853
|
11123, 11235
|
897, 3814
|
3988, 4192
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,551
| 196,315
|
30839
|
Discharge summary
|
report
|
Admission Date: [**2106-4-24**] Discharge Date: [**2106-4-30**]
Date of Birth: [**2052-5-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Nausea, lightheadedness, dizziness
Major Surgical or Invasive Procedure:
[**2106-4-24**] Cardiac Catheterization
[**2106-4-26**] Three Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary to left anterior descending, vein grafts
to obtuse marginal and posterior descending artery
History of Present Illness:
This is a 53 year old male who reported that several hours after
biking ~25 miles he was getting into bed, felt lightheaded &
nauseous while supine, rose quickly from a seated position and
realized he was going to pass out, thus lowered himself to the
floor and had his wife call EMS. The patient denies any
associated LOC, CP, SOB, or palpitations.Of note, the patient
reports that he had his first episode with similar symptoms in
[**2105-6-27**] after a bicycle crash. He had a syncopal event after
exertion without associated CP, SOB, palpitations. Since then
the patient has had several episodes of lightheaded and nausea
subsequent to exertion or a valsalva manuver. After calling EMS,
the patient was taking to [**Location (un) **], found to have Q's and TWI in
III and aVF (new). HR 40s, sbp initially 70's, then up to
100s/50s after IVF. Trop I borderline. Got Aspirin, Plavix,
started on Heparin gtt and transferred to [**Hospital1 18**] for further
management.
Past Medical History:
Hypertension
Hyperlipidemia
Chronic Renal Insufficiency
History of collar bone surgery 1 month ago
Prothrombin Gene Mutation and Factor V Leiden
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse
Family History:
Cousin with MI at age 37. Paternal grand father with MI in 70s.
Physical Exam:
VS: T:99 BP:112/71 HR:50 RR:12 O2:99
Gen: WDWN middle aged male lying comfortably, diaphoretic.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MMM, No
xanthalesma.
Neck: Supple with flat JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
Regular bradycardia, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NT, mild suprapubic distension. 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.
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:
[**2106-4-24**] 04:30AM BLOOD WBC-12.4* RBC-4.16* Hgb-12.1* Hct-36.8*
MCV-88 MCH-29.2 MCHC-33.0 RDW-13.6 Plt Ct-166
[**2106-4-24**] 09:55AM BLOOD WBC-9.4 RBC-4.06* Hgb-11.3* Hct-35.5*
MCV-88 MCH-27.9 MCHC-31.8 RDW-13.8 Plt Ct-164
[**2106-4-24**] 04:30AM BLOOD Neuts-89.5* Bands-0 Lymphs-7.5* Monos-2.5
Eos-0.1 Baso-0.3
[**2106-4-24**] 09:55AM BLOOD Neuts-78.7* Lymphs-15.4* Monos-4.7
Eos-0.2 Baso-0.9
[**2106-4-24**] 04:30AM BLOOD PT-14.4* PTT-150* INR(PT)-1.3*
[**2106-4-24**] 04:30AM BLOOD Glucose-118* UreaN-22* Creat-1.8* Na-138
K-4.6 Cl-104 HCO3-29 AnGap-10
[**2106-4-24**] 04:30AM BLOOD CK(CPK)-445*
[**2106-4-24**] 09:55AM BLOOD ALT-53* AST-81* AlkPhos-70 TotBili-0.5
[**2106-4-24**] 04:30AM BLOOD CK-MB-46* MB Indx-10.3*
[**2106-4-24**] 04:30AM BLOOD cTropnT-0.45*
[**2106-4-24**] 04:04PM BLOOD CK-MB-105* MB Indx-10.7* cTropnT-1.65*
[**2106-4-24**] 11:40PM BLOOD CK-MB-70* MB Indx-7.6* cTropnT-1.98*
[**2106-4-25**] 06:12AM BLOOD CK-MB-53* MB Indx-6.2* cTropnT-2.70*
[**2106-4-24**] 04:30AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.2 Cholest-116
[**2106-4-24**] 04:30AM BLOOD Triglyc-27 HDL-37 CHOL/HD-3.1 LDLcalc-74
[**2106-4-24**] CARDIAC CATHERIZATION: Coronary angiography in this
right dominant system demonstrated a totally occluded proximal
RCA; the distal vessel filled from LAD collaterals via an acute
marginal branch. The LMCA was normal, the proximal LAD had a
tubular 80% stenosis beginning at its origin; there were serial
70% and 50% LAD lesions at the levels of D1 and D2 respectively.
The LCX system was notable for a 50% lesion in OM1 but otherwise
was without significant epicardial disease. Limited resting
hemodynamics revealed normal systemic arterial pressures of
102/64 mmHg.
[**2106-4-24**] TTE: The left atrium is normal in size. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with inferior akinesis. Overall
left ventricular systolic function is mildly depressed. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2106-4-26**] Groin Ultrasound: No significant hematoma in the area of
concern. No evidence of pseudoaneurysm or AV fistula.
[**2106-4-30**] 06:35AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.4* Hct-28.3*
MCV-88 MCH-29.4 MCHC-33.3 RDW-13.9 Plt Ct-208
[**2106-4-29**] 06:20AM BLOOD WBC-7.9 RBC-2.99* Hgb-8.7* Hct-26.2*
MCV-88 MCH-29.3 MCHC-33.3 RDW-14.0 Plt Ct-177
[**2106-4-28**] 06:25AM BLOOD WBC-12.3* RBC-3.15* Hgb-9.4* Hct-27.8*
MCV-88 MCH-29.9 MCHC-33.9 RDW-13.9 Plt Ct-186
[**2106-4-27**] 11:43AM BLOOD WBC-13.7* RBC-3.21* Hgb-9.3* Hct-27.9*
MCV-87 MCH-29.0 MCHC-33.5 RDW-14.0 Plt Ct-162
[**2106-4-27**] 02:09AM BLOOD WBC-12.1*# RBC-3.03* Hgb-9.0* Hct-25.9*
MCV-86 MCH-29.7 MCHC-34.7 RDW-13.9 Plt Ct-167
[**2106-4-30**] 06:35AM BLOOD Glucose-106* UreaN-21* Creat-1.7* Na-140
K-4.5 Cl-95* HCO3-36* AnGap-14
[**2106-4-29**] 06:20AM BLOOD Glucose-126* UreaN-18 Creat-1.8* Na-140
K-4.4 Cl-98 HCO3-36* AnGap-10
[**2106-4-28**] 06:25AM BLOOD Glucose-110* UreaN-16 Creat-1.7* Na-138
K-4.4 Cl-99 HCO3-31 AnGap-12
[**2106-4-27**] 02:09AM BLOOD UreaN-12 Creat-1.4* Na-139 Cl-111*
HCO3-23
[**2106-4-28**] 06:25AM BLOOD Calcium-8.3* Phos-3.8# Mg-1.7
[**2106-4-25**] 06:12AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND
[**2106-4-25**] 06:12AM BLOOD FACTOR V LEIDEN-PND
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent urgent cardiac
catheterization. This revealed a right dominant system with
severe disease of the left anterior descending and right
coronary arteries. The circumflex had a 50% lesion in the first
obtuse marginal. Given that his coronary disease was poorly
suitable for PCI, the cardiac surgical service was consulted and
further evaluation performed. An echocardiogram showed mild
depressed left ventricular function(LVEF 50%) with only mild
mitral regurgitation. Given the need for surgical intervention,
Plavix was not continued. He remained pain free on medical
therapy and was eventually cleared for surgery. On [**4-26**],
Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery.
For surgical details, please see seperate dictated operative
note. Following the operation, he was brought to the CSRU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. His CSRU course was
uneventful and he transferred to the SDU on postoperative day
one. He remained in a normal sinus rhythm as beta blockade was
advanced as tolerated. Chest tubes and wires were removed
without complication. Over several days, he continued to make
clinical improvements with diuresis. His renal function remained
stable, creatinine remaining between 1.5 - 1.8. He was
eventually cleared for discharge to home on postoperative day
four. At discharge, his oxygen saturations were 97% room air and
all surgical wounds were clean, dry and intact. Discharge chest
x-ray showed clear lungs with only small bilateral effusions.
Medications on Admission:
Lisinopril 40mg daily
HCTZ 25 mg daily
Lipitor recently changed to simvastatin
ASA 81 mg daily.
Cialis 5 mg once a week
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: Please take with KCl.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days: Take
with Lasix.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Acute MI, Hypertension,
Hypercholesterolemia, Chronic Renal Insufficiency, Prothrombin
Gene Mutation and Factor V Leiden
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-1**] weeks, call for appt
Dr. [**Last Name (STitle) **] or local cardiologist in [**1-30**] weeks, call for appt
Local PCP, [**Name10 (NameIs) **] call for appt
Completed by:[**2106-4-30**]
|
[
"414.01",
"V17.3",
"410.71",
"585.9",
"458.9",
"511.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.56",
"36.15",
"88.53",
"39.61",
"37.22",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9431, 9498
|
6463, 8092
|
311, 538
|
9699, 9706
|
2857, 6440
|
10025, 10255
|
1850, 1915
|
8263, 9408
|
9519, 9678
|
8118, 8240
|
9730, 10002
|
1930, 2838
|
237, 273
|
566, 1540
|
1562, 1710
|
1726, 1834
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,349
| 119,516
|
35397
|
Discharge summary
|
report
|
Admission Date: [**2120-2-6**] Discharge Date: [**2120-2-15**]
Date of Birth: [**2054-8-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zosyn / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
migrated stent with complex tracheal stenosis
Major Surgical or Invasive Procedure:
[**2120-2-14**]: Flexible bronchoscopy with trach sutured to secure
airway.
[**2120-2-13**]: Hemodialysis line replacement by IR.
[**2120-2-9**]: Rigid bronchoscopy, flexible bronchoscopy,
Tumor destruction (granulation tissue), therapeutic aspiration
of
secretions, percutaneous tracheostomy tube placement Portex
Per-Fit #7.
[**2120-2-9**] Rigid bronchoscopy, flexible bronchoscopy,
foreign body removal (tubular stent [**24**] x 40 mm) and
therapeutic aspiration of secretions.
[**2120-2-6**] Flexible Bronchoscopy.
History of Present Illness:
64 y/o female with h/o chronic respiratory failure s/p
endotracheal intubation and tracheostomy tube placement
complicated by post-tracheostomy complex tracheal stenosis
(location: 1 cm from cricoid /length 2cm / narrowing with
associated TM). Underwent rigid bronch and silicone stent
placement(40 mm x 15mm) with external fixation on [**4-5**] and
revised on [**11-5**]. Since then she reports to be doing well with
no
dyspnea nor stridor. She does report some cough and small
amounts
of clear mucus drainage at the suture site. She denies local
pain, erythema or fever.
Past Medical History:
Trachael stenosis hospitalized [**7-4**] prolongued vent had trach
placed removed [**12-4**]
atrial fibrillation on warfarin
?OSA on CPAP no formal sleep study
ESRD on HD MWF has tunneled cath
multinodular goiter s/p biopsy
Morbid obesity
HTN
C difficile colitis
cellulitis with "fat necrosis" requiring skin grafting, c/b
sepsis
peripheral neuropathy ?GBS following birth of 2nd child
left leg weakness
tracheomalatia
Chronic leg ulcers
Recurrent UTI
urinary stress incontinence
iron deficiency anemia
nephrolithiasis
Social History:
Lives at home with husband and daughter. [**Name (NI) 4906**] is
dermatologist. Denies drinking or smoking.
Family History:
noncontributory
Physical Exam:
VS: T 98.9, HR 68 irreg afib, BP 110/66, RR 18, O2 sats on 40%
TM 97%
Physical Exam:
Gen: pleasant in NAD
Neck trach secured.
Resp: lungs clear after cough t/o
CV: irreg rate and rhythm
Abd: soft, NT, ND
Ext: warm, no edema. Left subclavian hemodialysis line intact.
Pertinent Results:
[**2120-2-12**] 02:25AM BLOOD WBC-11.3* RBC-3.67* Hgb-11.4* Hct-34.5*
MCV-94 MCH-31.0 MCHC-33.0 RDW-16.8* Plt Ct-342
[**2120-2-13**] 06:40AM BLOOD PT-14.6* PTT-27.8 INR(PT)-1.3*
[**2120-2-13**] 06:40AM BLOOD Glucose-86 UreaN-28* Creat-4.7*# Na-136
K-4.2 Cl-94* HCO3-30 AnGap-16
[**2120-2-13**] 06:40AM BLOOD Calcium-9.0 Phos-4.7*# Mg-2.3
CXR: [**2120-2-12**]
In comparison with the study of [**2-11**], there is little overall
change. Tracheostomy tube remains in place. Continued bilateral
opacifications consistent with atelectasis and effusion. The
possibility of supervening pneumonia cannot be excluded.
Coumadin 5mg T,R and 7.5 M,W,F,Sa,Sun.
[**2120-2-13**] 06:40AM BLOOD PT-14.6* PTT-27.8 INR(PT)-1.3*
[**2120-2-14**] 08:15AM BLOOD PT-16.9* PTT-30.8 INR(PT)-1.5*
[**2120-2-15**] 07:50AM BLOOD PT-19.7* INR(PT)-1.8*
Brief Hospital Course:
Mrs. [**Known lastname 24630**] was admitted to the IP service after she was found
to have a migrated stent during bronchoscopy on [**2120-2-6**]. The
patient had her coumadin for atrial fibrillation held and
vitamin K for 2 days given for supratherapeutic INR of 4.6,
prior to undergoing planned rigid bronch with stent removal. The
patient meanwhile continued her M.W.F HD, and noted was brown
discharge around her HD catheter. This was sent for culture
which was staph aureus + sensitive to gentamicin, which was
started on [**2120-2-11**] given after HD. Vanco had been started on
[**2120-2-8**] awaiting culture results. On [**2120-2-8**] the patient was
noted to have right neck erythema and swelling, with smelly
discharge near the external tracheal button. CT neck was done
which did not show any fluid collections or areas of concern
surrounding the HD catheter site. The patient proceeded with
stent removal, but due to central airway obstruction secondary
to complex tracheal stenosis and malacia a #7 Per Fit
tracheostomy was placed.
The patient had bursts of atrial fibrillation with rates in
150's which she had in the past, and was hemodynamically stable.
Per hospital policy, the patient was transfered to the ICU for
afib control; rate control acheived by prn metoprolol IV and po
uptitration of the diltiazem, and diltiazem drip.
She was transfered to the floor [**2120-2-12**] and has been stable. PT
evaluated the patient and recommend PT 3x a week for
strengthening. She had passy muir evaluation with speech and
swallow; which she did not pass due strained-strangled vocal
quality and subjective discomfort with the valve in place.
Speech commented that this may not improve until the patient
undergoes further intervention for her tracheal stenosis.
IR changed the HD catheter from the right SC to the left SC on
[**2120-2-13**]. Coumadin was started [**2120-2-11**] for her atrial
fibrillation; resuming home dosing. On the evening of [**2120-2-13**]
the patient was suctioning under her trach and it popped out,
with a couple minutes of desaturations to the 70's until the
trach was replaced. The patient underwent [**2120-2-14**] bronch which
showed stable airway and her trach was secured with sutures.
Secretions have been minimal but due to the high level of care
the patient needs which the family is unable to provide, and to
watch her airway it was recommended the patient transfer to
pulmonary rehab for a short stay for strengthening, airway
management, and education with the daughter. It is noted that
the patient has not required IV metoprolol for her afib rate
control since she has been on the floor [**2120-2-12**]. The patient
completed her antibiotic course as discussed above, on [**2120-2-14**].
The patient was accepted at [**Hospital 5503**] rehab today and cleared
for discharge by Dr. [**Last Name (STitle) **].
Medications on Admission:
Cardizem 60mg PO TID (30mg) in am M/W/F before dialysis
Calcium Acetate 667mgs PO TID with meals
Nephrocaps PO Daily
Coumadin 5mg PO daily
Protonix 40mg PO BID
Discharge Medications:
1. Air Comprssor
for 40% Trach with humidification
2. Suction Machine
14 French suction catheters
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
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).
7. Xopenex 1.25 mg/3 mL Solution for Nebulization Sig: Three (3)
mL Inhalation every 4-6 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. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every eight (8) hours:
give only with mucomyst for this secretions.
12. Warfarin 5 mg Tablet Sig: 1-2 Tablets PO at bedtime: 5mg Tu,
Thurs, and 7.5mg M,W,F,Sa, Sun. dose depends on INR. goal [**1-31**]:
check with HD.
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml
Miscellaneous every eight (8) hours: must be given with
albuterol to prevent broncospasm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital 80686**] hospital
Discharge Diagnosis:
Complex tracheal stenosis, with stent migration, retrieval and
tracheostomy
Atrial fibrillation on warfarin
ESRD on HD MWF has tunneled cath
multinodular goiter
Morbid obesity
HTN
C difficile colitis
peripheral neuropathy
left leg weakness
tracheobronchomalacia
Chronic leg ulcers
Recurrent UTI
urinary stress incontinence
iron deficiency anemia
nephrolithiasis
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:
Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, or sputum production
-Difficulty with your trach or managing secretions.
Continue humidified oxygen with trach.
Follow up with PCP regarding INR checks and coumadin management.
Followup Instructions:
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Tuesday Date/Time:[**2120-4-2**] 11:30 in the [**Hospital Ward Name 121**]
Building Chest Disease Center [**Hospital1 **] I
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2120-4-2**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2120-4-2**]
12:30
NOTHING TO EAT OR DRINK AFTER MIDNIGHT [**2120-4-2**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2120-2-15**]
|
[
"519.19",
"V58.61",
"V45.11",
"285.21",
"E915",
"996.59",
"V58.83",
"E879.1",
"996.62",
"327.23",
"E878.1",
"996.73",
"519.8",
"427.31",
"518.84",
"585.6",
"041.11",
"933.1",
"278.01",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"98.15",
"33.21",
"32.01",
"33.23",
"96.04",
"39.95",
"38.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7841, 7917
|
3339, 6203
|
363, 884
|
8323, 8323
|
2491, 3316
|
8841, 9519
|
2172, 2189
|
6416, 7818
|
7938, 8302
|
6229, 6391
|
8500, 8818
|
2289, 2472
|
278, 325
|
912, 1488
|
8337, 8476
|
1510, 2031
|
2047, 2156
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,481
| 159,620
|
24460
|
Discharge summary
|
report
|
Admission Date: [**2113-4-12**] Discharge Date: [**2113-4-17**]
Date of Birth: [**2038-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Coffee Ground Emesis
Major Surgical or Invasive Procedure:
EGD [**2113-4-13**]
History of Present Illness:
75 y/o M with h/o remote traumatic brain injury, HTN, and h/o
Barrett's esophagous presents from nursing home after witnessed
coffee ground emesis X 1. He was found the morning of admission
with coffee grinds on pillow. When the nursing home staff got
him up for the day he had one episode of emesis that was noted
to be dark black and a large dark brown bowel movement without
any bright red blood and he was transferred to [**Hospital1 18**] ED.
.
In the emergency department, VS were T 97.6 HR 83 BP 179/89 RR
20 POx 100 on RA. His exam was remarkable for pale appearing,
benign abdomenal exam, and guiac negative stool. He received 1L
NS and was typed and cross with plan 2 units. Two 18g PIVs were
placed. He received 40mg IV pantoprazole and IV zofran. An NG
levage was attempted with induction for emesis with return of
coffee grounds and NG tube was placed to suction. GI was
consulted with plan for EGD in the MICU.
Prior to transfer to the [**Hospital Unit Name 153**], HR 120, w/ frequent
PVCs/bigeminy, and SBP 130s.
.
History was obtained from care givers and medical record due to
patient's baseline mental status.
.
On arrival to the [**Hospital Unit Name 153**], patient reported no nausea, abdominal
pain, chest pain, difficulty breathing. He states he has a
long-standing cough unchanged from baseline.
Past Medical History:
- Complex regional pain syndrome
- Traumatic brain injury s/p remote MVC, slurred speech at
baseline
- Prostate ca ([**9-/2109**]--operated by dr. [**Last Name (STitle) **])
- CRI (baseline Cr 2-2.2)
- h/o GI bleed admitted [**2-/2111**] --EGD with esophagitis
- Iron deficiency anemia
- Thrombocytopenia
- HTN
- Incontinence.
Social History:
Tob x 15 yrs (stopped 40 yrs ago), no ETOH recently (though may
have had Etoh hx), no IVDU, Lives at [**Location (un) **], has home
health aides on the weekend. Per hha, was in MVA in 50's and had
brain injuries. Sister is [**Name (NI) **]: [**Name (NI) 16883**] [**Telephone/Fax (1) 61863**]
Family History:
none per pt
Physical Exam:
GENERAL: Pleasant, well appearing elderly male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM w/ some coffee ground remains.
OP clear. NG tube in place draining coffee grounds. Neck Supple,
No LAD, No thyromegaly.
CARDIAC: Regular rhythm with occasional premature beats, normal
rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: wet cough, rhoncorus throughout, good air movement
biaterally, no wheezing.
ABDOMEN: Distended, NABS. Soft, NT. No HSM appreciated
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Right wrist contraction. Right ankle surgical
scar.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. Slurred speech. CN 2-12 grossly
intact. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2113-4-12**] 10:32PM HCT-38.5*
[**2113-4-12**] 12:09PM COMMENTS-GREEN TOP
[**2113-4-12**] 12:09PM HGB-13.9* calcHCT-42
[**2113-4-12**] 12:05PM GLUCOSE-178* UREA N-43* CREAT-1.6* SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2113-4-12**] 12:05PM estGFR-Using this
[**2113-4-12**] 12:05PM ALT(SGPT)-23 AST(SGOT)-16 CK(CPK)-91 ALK
PHOS-78 TOT BILI-0.4
[**2113-4-12**] 12:05PM LIPASE-13
[**2113-4-12**] 12:05PM cTropnT-0.04*
[**2113-4-12**] 12:05PM CK-MB-NotDone
[**2113-4-12**] 12:05PM WBC-12.4*# RBC-4.49* HGB-13.5* HCT-40.4
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.3
[**2113-4-12**] 12:05PM NEUTS-95.1* LYMPHS-2.5* MONOS-2.1 EOS-0.1
BASOS-0.2
[**2113-4-12**] 12:05PM PLT COUNT-192
[**2113-4-12**] 12:05PM PT-13.8* PTT-24.0 INR(PT)-1.2*.
H Pylori serology negative
.
EGD [**2113-4-13**]:
Segmental erythema and erosion of the mucosa were noted in the
antrum. These findings are compatible with erosive gastritis.
Duodenum: Normal duodenum.
Impression: Ulcers in the lower third of the esophagus
Medium hiatal hernia
Erythema and erosion in the antrum compatible with erosive
gastritis
Mucosa suggestive of Barrett's esophagus
Otherwise normal EGD to second part of the duodenum
Recommendations: [**Hospital1 **] PPI
check h-pylori serology and treat if positive.
schedule a f/u appt with Dr. [**Last Name (STitle) **] in 6 weeks to aarange for
a repeat EGD and biopsy of esophagus. clinic# [**Telephone/Fax (1) 463**]
Avoid ASA and NSAIDs.
.
CXR [**2113-4-13**]:
FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is
unchanged. Mild indistinctness of the pulmonary vessels and
perihilar haziness is consistent with a mild degree of
interstitial edema. There is no focal consolidation,pneumothorax
or pleural effusion.
IMPRESSION: Mild interstitial edema.
.
TTE [**2113-4-14**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with inferolateral hypokinesis
and basal inferior hypokinesis. 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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Suboptimal study.
.
CXR [**2113-4-14**]:
PA AND LATERAL CHEST, [**2113-4-14**]
HISTORY: Mild wheezing. History of asthma, suspect CHF.
IMPRESSION: PA and lateral chest compared to [**2113-4-13**]:
Lungs are fully expanded and clear. Heart size is normal and
there is no
pleural effusion. Previous vascular congestion has cleared since
[**4-13**].
There is no pulmonary edema.
Brief Hospital Course:
This is a 75 yo M with remote traumatic brain injury who
presented with hematemesis.
.
#. Upper GI bleed: Pt presented with complaints of coffee ground
emesis and dark stools. He received 2 U PRBC on arrival to the
ED and was admitted to the ICU for further monitoring. He had no
further episodes of bleeding s/p EGD on [**4-13**] which revealed
esophageal ulcers, gastritis, and [**Last Name (un) 865**] esophagus. His hct
remained stable at 38. He was treated with a PPI [**Hospital1 **]. H pylori
serology was negative. He has required no further transfusions
and hct has remained stable. He should remain off any aspirin or
ibuprofen/motrin etc. until follow up with GI in 6 weeks.
.
# Leukocytosis: WBC on admission was 12.5, possibly secondary to
stress response. He had no fever and no infiltrate on CXR to
suggest pneumonia. Leukocytosis resolved.
.
#. HTN: On admission pts lisinopril was initially held. He was
restarted on it, but his SBP remained elevated up to 170-180.
His lisinopril was increased to 20 mg daily and he was started
on Toprol XL 12.5 mg daily (as TTE noted changes consistent with
CAD so he would benefit from being on a beta blocker). SBP the
following day was only 100 and creatinine rose from 1.3 to 1.7,
so his lisinopril was decreased back down to 5 mg daily. With
the addition of the Toprol, BP was well controlled in the low
100s.
.
# Acute systolic CHF: Pt had noted mild interstitial edema on
admission CXR. On transfer from the ICU to the floor, the pt was
noted to have wheezing and was satting 93% RA at rest. BNP was
elevated at 1527. He did not appear to be in any respiratory
distress. TTE showed pt has an EF of 45% with mild regional
left ventricular systolic dysfunction with inferolateral
hypokinesis and basal inferior hypokinesis (consistent with
CAD). The patient was given Lasix 10 mg IV x1 on [**2113-4-13**] and
again on [**2113-4-14**]. Toprol XL 12.5 mg daily was started. Repeat
CXR on [**2113-4-14**] showed no further pulmonary edema. Will not send
pt out on lasix at this time as pt likely had acute failure due
to IVF and PRBC he received while here.
.
# CAD: Not noted history of this on admission, but TTE is
consistent with CAD. ASA is being held in setting of recent GI
bleed and pts PCP will need to determine appropriate timing to
reinitiate. Continued lisinopril, Started Toprol XL for both CAD
and systolic CHF. Pt is already on a statin.
.
# Hypernatremia: Na noted to be 146 on [**4-14**]. Given D5W and Na
normalized.
.
# Deconditioning: The pt was seen by PT on [**4-15**] and felt that pt
needed either 24 hour care with home PT vs. [**Hospital1 1501**] placement.
Family and pt were agreeable to [**Hospital1 1501**] placement.
.
# H/o Iron deficiency anemia: Continued ferrous sulfate
.
#. s/p traumatic brain injury: Baseline slurred speech and poor
historian, has guardian in place
.
# Chronic Pain Syndrome: Continued home lyrica, QAM tylenol
.
#. Chronic kidney failure: Pts baseline creatinine is 1.5. His
creatinine varied from 1.3-1.7 while here. Creatinine was 1.5 on
day of discharge.
.
# h/o BPH: Continued flomax
.
# Dispo: Pt discharged to rehab in stable condition.
Medications on Admission:
ASA 81mg daily
Iron
Lisinopril 5mg daily
Fortical nasal spray in alternate nostrils daily
[**Doctor First Name **]-gay ointment to right foot prn
Simvastatin 20mg QHS
Aspirin 81mg daily
Docusate 100mg [**Hospital1 **]
Ferrous sulfate one po daily
Prilosec 20mg daily
Vitamin D 800 units daily
Azo cranbery one tablet [**Hospital1 **]
Acetaminophen 1000mg Q7am
Folic Acid 1mg daily
Flomax 0.4mg QHS
Lyrica 50mg [**Hospital1 **]
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): This is iron supplements and can be
purchased over the counter.
2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. FORTICAL 200 unit/Actuation Aerosol, Spray Sig: One (1) spray
Nasal once a day: spray in alternate nostrils daily.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day: This can be purchased over the counter.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO once a
day.
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Hematemesis
Esophagitis/Gastritis
GI bleed
Acute systolic congestive heart failure
Hypertension
Discharge Condition:
stable, hematocrit stable
Discharge Instructions:
You were admitted with hematemesis (vomiting blood) and dark
stools. You were given 2 units of blood when you first arrived
and your were initially admitted to the intensive care unit. You
had an upper endoscopy which showed you have inflammation of you
stomach and esophagus, and you have ulcers in your esophagus.
.
You were on a medication called prilosec. This has been
increased to 40 mg twice a day to help protect your stomach.
.
Your blood pressure was noted to be high. You were started on
another blood pressure medication called Toprol XL.
.
You were noted to have acute congestive heart failure (mild).
You were given a medication called lasix to help you urinate off
the extra fluid in your lungs. You were also started on a
medication called Toprol XL (which is a blood pressure
medication) to help control your heart failure. You should weigh
yourself everyday. If you gain more than 3 lbs or note increased
wheezing, you need to call your doctor. You should try to
consume a low sodium diet (no more than [**2-7**] grams of sodium a
day).
.
You should not take your aspirin anymore until instructed to do
so by your doctors [**Name5 (PTitle) 61864**] it [**Name5 (PTitle) 61865**] to your ulcers/GI
bleeding.
.
Your primary care doctor should follow you at your nursing home
after discharge from rehab. You need to follow up with Dr.
[**Last Name (STitle) **] of GI as scheduled.
.
Call your doctor or return to the ER for any recurrent vomiting
with blood, bloody or black stools, abdominal pain, chest pain,
shortness of breath, worsening wheezing, fever, or any other
concerning symptom.
Followup Instructions:
GI FOLLOWUP: Provider: [**First Name8 (NamePattern2) 3722**] [**Name11 (NameIs) 3723**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2113-5-23**] 1:30
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2113-4-17**]
|
[
"530.21",
"403.90",
"428.23",
"280.9",
"585.9",
"535.50",
"530.85",
"428.0",
"276.0",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11369, 11459
|
6305, 9466
|
336, 357
|
11599, 11627
|
3298, 6282
|
13283, 13614
|
2384, 2397
|
9944, 11346
|
11480, 11578
|
9492, 9921
|
11651, 13260
|
2412, 3279
|
276, 298
|
385, 1708
|
1730, 2058
|
2074, 2368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,505
| 176,802
|
47820
|
Discharge summary
|
report
|
Admission Date: [**2109-6-14**] Discharge Date: [**2109-6-20**]
Date of Birth: [**2042-7-26**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Unable to void
Major Surgical or Invasive Procedure:
foley catheter changed
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old man with juvenile rheumatoid
arthritis and an indwelling foley catheter secondary to an
atonic bladder. He presented to the ED today with a one day
history of inability to void and abdominal pain. He states that
he uses a leg bag during the day and a larger bag at night,
which are emptied by his two PCAs (each comes for 2 hours a day,
morning and evening). He is not aware of any abnormal-appearing
urine recently and has not had dysuria. He also reports that to
his knowledge his leg ulcer is at baseline, not getting worse.
.
In the ED, initial vs were: 97.8 103 136/79 18 100%. His Foley
was exchanged and drained 1 L of purulent-looking urine. This
resolved his abdominal pain. He had very poor access, so labs
were not able to be obtained. He had an intraosseous line placed
in the right lower extremity and was given IL of IV fluids.
While in the ED, he was noted to be hypotensive to SBP
40s-50s/P; however, his small arms and body habitus made a good
[**Location (un) 1131**] difficult. BP in the leg was 90s/40s, and his mental
status was clear throughout. His left lateral ankle was also
noted to be malodorous. He received vancomycin (for leg
cellulitis) and zosyn for antibiotics.
.
On the floor, patient reported complete resolution of abdominal
pain. He reported discomfort at the IO site, as well as his
chronic hip and knee pain because he did not receive home pain
meds in ED.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- with chronic indwelling foley catheter
- Juveile rheumatoid arthritis (no steroids in decades, but
history of chronic steroids x 15 years)
- Osteoporosis
- GERD
- Left venous stasis ulcer, chronic
- Hemorroids
- Chronic pain of knee, back, shoulder, hip
- s/p C. difficile infection
- Cellulitis/osteomyelitis of his calf
- Multiple orthopedic surgeries (no hardware per patient) to
ankles, knees, neck, right elbow
Social History:
Former smoker, 10 pack years. Rare alcohol. Retired
neurohistologist (formerly worked at [**Hospital1 **]). Lives alone in
an apartment in [**Location (un) **], two PCAs help him in the morning and
evening. Uses an electric wheelchair to get around both at home
and outside his home.
Family History:
Brother died of colon cancer in his 40s. Mother with alcoholism,
cirrhosis, and heart attack. Sister alive and well. Father alive
with hypertension.
Physical Exam:
Physical Exam on Admission to [**Hospital Unit Name 153**]
Vitals: T: BP: 121/67 P: 91 R: 18 O2: 96% on RA
General: Alert, oriented, no acute distress. Small body habitus
with foreshortened extremities and small hands and feet.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given body habitus (large
jowls), no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: Small amount of purulent discharge at urethra, foley in
place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Superficial ulceration of left lower extremity with
copious yellow exudative discharge and minimal surrounding
erythema, slightly indurated.
Pertinent Results:
Labs on Admission: [**2109-6-14**] 04:20PM
WBC-15.5*# RBC-3.53* Hgb-6.9* Hct-23.4* MCV-66* Plt Ct-385
Neuts-83.8* Lymphs-11.6* Monos-3.8 Eos-0.5 Baso-0.3
PT-14.4* PTT-39.7* INR(PT)-1.2*
Glucose-112* UreaN-30* Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-26
AnGap-12
Calcium-7.7* Phos-2.8 Mg-1.9
URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
URINE RBC-30* WBC->182* Bacteri-MOD Yeast-NONE Epi-0
URINE WBC Clm-MANY Mucous-MANY
Labs on Discharge: [**2109-6-19**] 01:04PM
WBC-10.6 RBC-3.27* Hgb-6.4* Hct-22.9* MCV-70* Plt Ct-337
Glucose-113* UreaN-17 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-28
AnGap-11
Imaging:
[**2109-6-14**]
- Tib/Fib X -ray: Intraosseous catheter is seen with tip in the
proximal tibial metadiaphysis beyond the cortical margin. Bones
are diffusely osteopenic with ankylosis involving the hindfoot,
midfoot and ankle. Extensive degeneration and distortion
incompletely assessed at the knee. Extensive vascular
calcifications are also seen.
IMPRESSION: IO catheter in the proximal tibia.
Microbiology:
URINE CULTURE (Final [**2109-6-19**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORK UP PER DR [**Last Name (STitle) **].[**Doctor Last Name **] [**2109-6-15**].
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
AMPICILLIN AND Penicillin Sensitivity testing performed
by
Sensititre. Daptomycin Sensitivity testing per DR [**Last Name (STitle) **]
#[**Numeric Identifier 30694**].
Daptomycin Sensitivity testing performed by Sensititre.
SENSITIVE TO Daptomycin (MIC=1MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PROTEUS MIRABILIS
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ =>32 R 1 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I =>4 R
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S 4 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PENICILLIN G---------- 4 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 year old man with a history of JRA and
bladder atony with chronic indwelling Foley who presents with
one day of urinary retention and abdominal pain.
# Urinary tract infection. Most likely [**1-30**] urinary retention
from clogged/obstructed Foley catheter. Foley catheter was
changed on [**2109-6-14**]. Last documented catheter change prior was
in [**Month (only) 547**]. Upon admission to the ICU, hemodynamics were stable
with improvement of his abdominal discomfort. His outpatient
urologist was informed. Urine culture was significant for VRE
and Psuedomonas, and the patient was placed on Macrobid and
Meropenem initially, which was transitioned to Macrobid and
Piperacillin-Tazobactam at discharge. A PICC was placed in the
LUE for home antibiotics, and he will complete a total of 14
days of antibiotics. Safety labs to be sent on Wednesday, [**6-26**] and faxed to the ID division. Patient will susbsequently
follow-up with his outpatient ID physician [**Last Name (NamePattern4) **].[**Last Name (STitle) **]. Patient
remained afebrile, asymptomatic and hemodynamically stable
throughout his stay on the general medicine service.
# Urinary retention. [**1-30**] bladder atony with chronic indwelling
Foley. Since the change of Foley catheter on admit, his
abdominal discomfort improved, suggesting possible clogging in
the catheter. Patient will have continued follow-up with his
outpatient urologist. [**Month (only) 116**] need scheduled foley catheter changes,
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7986**] (NP) and Dr.[**Name (NI) 825**] note on [**2108-7-6**]
# Chronic leg ulcer, PVD: Baseline per patient. Patient has been
followed by Dr. [**Last Name (STitle) **] for his non-healing ulcer. Asa 162mg was
continued, and QOD Aquacel silver dressings were ordered. Blood
cultures remained negative. No antibiotics were given
specifically for the wound infection.
# Hypotension. Concerning for peri-sepsis initially, but
apparently hypotension in the ED and borderline in the ICU.
Unclear if this was due to poor cuff [**Location (un) 1131**] given his body
habitus and use of a large cuff in the ED or if it recovered
quickly after 1L of IVF. Using pediatric cuff, readings
remained mostly in the 110s.
# Microcytic Anemia: History of iron-deficient anemia. No
evidence of acute bleed. Pt was continued on his home iron
therapy. Iron studies were normal. HCT remained near his
baseline during his admission.
# Osteoporosis: Likely secondary to chronic steroid use. Has
chronic pain related to multiple surgeries. Continued home
Actonel (Mondays). Continued methadone and oxycodone for chronic
pain
Code Status: OK to intubate, defibrillate or cardiovert; no
chest compressions
Medications on Admission:
FAMOTIDINE 40 mg qPM
METHADONE 5 mg/5 mL Solution, 10 ml by mouth at 6pm
OXYCODONE 10 mg q4 hours
RISEDRONATE 35 mg every week
ASPIRIN 162 mg daily
FERROUS GLUCONATE 324 mg TID
MULTIVITAMIN
Discharge Medications:
1. famotidine 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. methadone 10 mg/mL Concentrate Sig: One (1) PO DAILY AT 6 ()
as needed.
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. risedronate 35 mg Tablet Sig: One (1) Tablet PO weekly on
Monday () as needed for osteoporosis.
5. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
6. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 17 doses.
Disp:*17 Capsule(s)* Refills:*0*
9. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
dose Intravenous every six (6) hours for 8 days.
Disp:*8 day's supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
hypotension
urinary tract infection-complicated
atonic bladder with chronic foley
L.leg chronic ulcer
juvenile rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were intially admitted with abdominal pain and inability of
your foley catheter to drain. For this, you had your foley
catheter replaced. You were given antibiotics for a urinary
tract infection. You will need to take Zosyn and Macrobid upon
discharge through [**6-28**].
Medication changes:
1. Take Zosyn and Macrobid through [**6-28**]
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]
When: Wednesday [**2109-6-26**] at 3:15 PM
Address: [**Street Address(2) 12840**],[**Apartment Address(1) 40744**], [**Location (un) 6017**],[**Numeric Identifier 12842**]
Phone: [**Telephone/Fax (1) 40745**]
Department: INFECTIOUS DISEASE
When: FRIDAY [**2109-7-5**] at 8:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2109-12-4**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10107**], NP [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"733.00",
"276.52",
"V15.82",
"041.7",
"459.81",
"V16.0",
"E879.6",
"599.0",
"714.30",
"596.4",
"788.29",
"682.6",
"707.12",
"458.9",
"707.22",
"443.9",
"707.03",
"041.04",
"996.31",
"285.9",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11043, 11101
|
7123, 9929
|
298, 323
|
11278, 11278
|
4021, 4026
|
11921, 12814
|
2949, 3099
|
10169, 11020
|
11122, 11257
|
9955, 10146
|
11460, 11737
|
3114, 4002
|
11757, 11898
|
244, 260
|
4577, 7100
|
1811, 2190
|
351, 1793
|
4040, 4558
|
11293, 11436
|
2212, 2631
|
2647, 2933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,753
| 169,859
|
12145
|
Discharge summary
|
report
|
Admission Date: [**2129-2-26**] Discharge Date: [**2129-3-3**]
Service:
CHIEF COMPLAINT: Status post cardiac catheterization
complicated by groin bleed.
HISTORY OF PRESENT ILLNESS: Patient is a [**Age over 90 **]-year-old female
with no prior cardiac history who presented to [**Hospital1 **]
Emergency Room on the AM of [**2129-2-26**] with vague symptoms of
dizziness and lightheadedness and found to have ischemic ST
changes inferiorly and in the precordium on
electrocardiogram. The patient was given aspirin and started
on Heparin drip as well as give a 2B3A inhibitor and
transferred to [**Hospital1 69**] for
cardiac catheterization. In addition at the outside hospital
the patient was noted to be mildly hypotensive with heart
rate in the 40's with a junctional rhythm. The patient
denied any chest pain, short of breath throughout.
Cardiac catheterization at [**Hospital1 188**] revealed diffuse left anterior descending disease with
40% proximal/mid-lesion, an 80% OM1 lesion, 30% OM2 lesion, a
proximal 90% right coronary artery lesion, diffuse proximal
and mid-RCA disease, and a 60% mid-RCA lesion. The patient
is status post percutaneous transluminal coronary angioplasty
and stenting to the right coronary artery.
Post catheterization course complicated by extensive groin
bleeding and the patient taken emergently to the operating
room by Vascular Surgery. During this time, although the
details were unclear, the patient had a PEA arrest requiring
chest compression and then spontaneously converted to a
functional rhythm. The patient noted to have a femoral
artery tear and underwent repair via vascular surgery. The
patient admitted to CCU, intubated/sedated with right groin
surgically dressed.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoarthritis.
ALLERGIES: Penicillin.
MEDICATIONS:
1. Atenolol 25 mg p.o. q day.
2. Dyazide 37.5/25 mg p.o. q day.
3. Aspirin 81 mg p.o. q day.
4. Advil p.r.n.
5. B-12 shot q month.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a resident of [**Doctor First Name **] Terrace
Facilitated Living.
PHYSICAL EXAMINATION: Vital signs temperature 96.6, blood
pressure 143/89, heart rate 72, respiratory rate 10, O2 sat
of 100% on an FIO2 of 100% In general the patient is an
obese, elderly white female lying in bed intubated and
sedated. Head, eyes, ears, nose and throat exam: Pupils are
equal, round, and reactive to light and accommodation. Neck
soft and supple. Heart was regular rate and rhythm.
Positive S1 and S2, no murmurs, rubs or gallops. Lungs were
clear to auscultation bilaterally. Abdomen was obese, soft,
nontender, nondistended, normal active bowel sounds.
Extremities were warm, dorsalis pedis pulses were 2+ on the
right lower extremity. No clubbing, cyanosis or edema.
LABORATORY DATA: From [**Hospital **] Hospital on the morning of
[**2129-2-26**] a white blood count of 12.4, hematocrit of 32.9,
platelets 216. Differential 72 neutrophils, 22 lymphocytes,
4 monocytes. 1% eosinophils. Sodium 141, potassium 4.2,
chloride 105, bicarbonate 20, BUN 35, creatinine 2.0, glucose
of 271, total protein 6.3, albumin 3.6. Alk phos of 70, CK
of 78, calcium 8.6. T-bili of 0.3 and LDH of 259. AST of
45. ALT of 30. Prothrombin time 12.4, PTT 29.8 and INR of
1.0.
LABS OBTAINED IN CCU on [**2129-2-26**] - in the PM white blood count
of 15.0, hematocrit 36.3, platelets 96, sodium 140, potassium
4.9, chloride 113, bicarbonate 17, BUN 34, creatinine 1.3,
glucose of 200, lactate 3.8, a CK of 565 with an MB of 82 and
an index of 1425. Calcium 7.7, phosphate 5.0, mag 1.5.
Arterial blood gases on assist control tidal volume of 650,
rate of 10, PEEP 5 and 100% FIO2 was pH 7.33, pCo2 32, and a
pO2 of 355.
ELECTROCARDIOGRAM: From outside hospital showed a junctional
rhythm at 55 beats per minute, ST elevations in 2, 3 and AVF,
V1 through V3. ST depressions in 1 and AVL. Q's in V1 and a
wide QRS complex.
Electrocardiogram at [**Hospital1 69**] was
in sinus rhythm in the 50's, normal axis. Poor R-wave
progression. Chest x-ray showed the tip of the endotracheal
tube to be approximately 3 cm above the carinii, tip of the
nasogastric tube was noted to be below the diaphragm, no
focal consolidations were noted. The cardiac silhouette was
mildly enlarged, pulmonary vascular markings were within
normal limits, and no pneumothorax or pleural effusions were
noted.
Cardiac catheterization from [**2-26**] showed one vessel and branch
vessel disease in the codominant system, left main coronary
artery normal, left anterior descending had a mild luminal
irregularity, the left circ had mild luminal irregularities
with 80% focal stenosis in the OM1 and 30% in the OM2, the
right coronary artery had a [**Last Name (LF) 38068**], [**First Name3 (LF) **] 90% lesion in the
proximal portion with a 60% mid-lesion. Severe elevation of
right sided filling pressures with mean right atrial pressure
of 22 mm of mercury, right ventricular systolic of 35 mm of
mercury and diastolic to 21 mm of mercury, moderately
increased left sided pressures with a wedge of 24 mm of
mercury and a left ventricular and diastolic pressure of 26,
moderately decreased cardiac output with a cardiac index of
2.3 and an EF noted to be 64% with mild costobasilar
hypokinesis.
IMPRESSION: [**Age over 90 **]-year-old female with no known coronary artery
disease, transferred from outside hospital after experiencing
lightheadedness and dizziness. Found to have ST changes
suggestive of an acute inferior myocardial infarction with
right ventricular involvement. Status post cardiac
catheterization at [**Hospital1 69**] and
identified two vessel disease with subsequent right coronary
artery stenting. Post catheterization course complicated by
right groin bleed and PEA arrest and patient taken to
operating room emergently for femoral artery repair.
HOSPITAL COURSE BY SYSTEM:
1. Cardiac:
A. Ischemia. As above, the patient is status post acute
inferior myocardial infarction which was managed successfully
by primary stenting of the proximal right coronary artery
with 0% residual stenosis. No dissection and normal flow.
In light of post catheterization complications, a decision
was made to not utilize 2B3A post catheterization as well as
to defer use of aspirin or Plavix until the morning of
[**2129-2-27**]. During the subsequent part of the [**Hospital 228**]
hospital stay the patient was maintained on a cardiac medical
regimen of aspirin, Plavix, Lopressor, Captopril and Lipitor.
The doses of the Lopressor and Captopril were titrated up,
blood pressure and heart rate tolerating. Discharge doses of
Zestril 20 mg p.o. q day and Toprol XL 150 mg p.o. q day.
B. Pump. As above patient had an EF of 64% with mildly
decreased cardiac output and mild posterior basilar
hypokinesis. The patient was not noted to be in failure by
radiographic evidence nor clinical findings and was not
diuresed during her hospital stay. Rhythm. The patient was
noted to have a junctional rhythm at outside hospital with
rates in the 40's. On admission to the CCU at [**Hospital1 346**] the patient was noted to be in sinus
bradycardia with rates in the 50's which subsequently
improved to the 70's and 80's allowing for titration of
beta-blocker for better rate control.
2. Hypertension. The patient's blood pressure noted to be
poorly controlled while at [**Hospital1 188**] and doses of beta-blocker and ACE inhibitor were
titrated up accordingly. In addition from the medical
records from outside hospital it was noted that the patient
was on a standing dose of a diuretic as an outpatient and
patient should be started on Hydrochlorothiazide at 25 mg
p.o. q day.
Lipid. Lipid panel was sent off and noted to be elevated
at a total cholesterol of 146 with an LDL 82 and a HDL of 42
which in light of recent coronary events was likely low and
decision was made to start the patient on Lipitor 10 mg p.o.
q day.
3. Vascular. As above. The patient a status post right
femoral artery tear with subsequent repair in the O.R. by
Vascular surgery.
As per Vascular surgery team, all anti-coagulation on
hospital day one to be held to ensure that patient was
hemodynamically stable with a stable hematocrit. The
patient's right groin was dressed on admission to the CCU and
vascular team continued to follow daily noting warm
extremities and good pulses distally with no expansion of the
groin hematoma.
At the time of discharge a resolving hematoma was noted and
decision for suture removal to occur approximately 10 to 12
days after placement on [**2129-2-26**] as per PCP as an outpatient.
4. Heme. Patient with anemia, status post transfusion at
outside hospital of two units of packed red blood cells. In
addition during the patient's surgical repair the patient was
transfused two units of packed red blood cells without
complications. The patient's hematocrit remained relatively
stable at [**Hospital1 69**] however on
[**2129-2-28**] the patient's hematocrit was noted to drop from 33.5
down to 24.7 and there was great concern for a
retroperitoneal or intra-thigh bleed. The patient was
transfused two units of packed red blood cells with an
appropriate rise in hematocrit. In addition, CT scan of the
abdomen, pelvis and thigh was undertaken and there was no
evidence of an intra-abdominal, pelvic or retroperitoneal
hematoma.
The patient was hemodynamically stable throughout this
episode and subsequent vascular surgery evaluation prompted
recommendations for continued clinical monitoring as well as
serial hematocrits.
After that episode the patient's hematocrit remained stable
ranging from 32 to 36 with a value of 36.2 at the time of
discharge.
5. Renal. Patient with a creatinine of 2.0 at outside
hospital which was thought to be likely pre-renal in nature
versus chronic renal insufficiency. The patient was hydrated
at [**Hospital1 69**] and subsequently the
patient creatinine decreased to a value of 1.0 at the time of
discharge.
6. Pulmonary. The patient was intubated and sedated at the
time of admission to the CCU. The patient was extubated the
following morning without complications and there were no
acute pulmonary issues while an inpatient at [**Hospital1 346**].
7. Physical therapy. The patient was evaluated by the
physical therapy team at [**Hospital1 69**]
and was able to walk 100 feet without complications and the
feeling of the Physical therapy team that patient was not in
need of any acute rehabilitation.
CONDITION ON DISCHARGE: Stable. The patient is to be
discharged to [**Doctor First Name **] Terrace Facilitated Living with VNA.
DISCHARGE DIAGNOSIS:
1. Acute inferior myocardial infarction with right
ventricular involvement. Status post percutaneous
transluminal coronary angioplasty and stenting of the
right coronary artery to right femoral artery tear,
Status post vascular surgery repair.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. Plavix 75 mg p.o. q day times 30 days.
3. Protonix.
4. Toprol XL 150 mg p.o. q day.
5. Zestril 20 mg p.o. q day.
6. Lipitor 10 mg p.o. q day.
7. Hydrochlorothiazide 25 mg q day.
Follow-up appointment with primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 22980**] in Naddick in two to three days for post cardiac
event care as well as referral to a cardiologist in the
Naddick area.
In addition the patient will need removal of right groin
sutures 10 to 12 days after initial placement on [**2129-2-26**]. As
per primary care physician.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36
D: [**2129-3-7**] 21:43
T: [**2129-3-7**] 22:04
JOB#: [**Job Number 38069**]
|
[
"997.1",
"593.9",
"442.3",
"410.41",
"998.12",
"427.5",
"E879.0",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"37.23",
"88.53",
"88.56",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
1992, 2010
|
11008, 11924
|
10677, 10985
|
5909, 10524
|
2133, 5882
|
101, 166
|
195, 1739
|
1761, 1975
|
2027, 2110
|
10549, 10656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,584
| 101,944
|
43910
|
Discharge summary
|
report
|
Admission Date: [**2174-7-22**] Discharge Date: [**2174-7-29**]
Date of Birth: [**2132-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 yo with DM II and HTN who presents with 2 days of abdominal
pain. THe patient reports that on Wednesday after eating a
[**Last Name (un) **] he developed abdominal pain, nausea, vomiting and
diarrhea. He states that the abdominal pain is located
predominantly in the LLQ, was mostly crampy and intermittently
sharp in character, non-radiating. Over the next two days the
pain got progressivley worsening abdominal pain. He was only
able to take minimal po intake. Nothing appeared to make the
pain worse or better. He does not recall any aspiration however
he noted his breathing started to became more laboured on
Thursday. He reports mild pleuritic chest pain associated with
deep breaths, non positional. He also noted a fever for the
first time on Friday as well as worsening respiratory
secretions. Because of the worsening respiratory status and his
abdominal pain he decided to go to the [**Location (un) 620**] [**Hospital1 **] on Friday.
There he was found to have an elevated WBC, Lipase and Amylase
and a CT abdomen was consisted with pancreatitis. The patient
was transfered to [**Hospital1 18**] for further care after receiving 2L NS,
levofloxacin and Flagyl.
.
ED course: On arrival to the [**Hospital1 18**] ED the patient was
tachycardic to 136, febrile to 101, normotensive to 129/79 with
a RR of 19 and O2sat of 80RA. THe patient was started on O2 by
nasal canula which was uptitrated over the next hours ultimately
requiring a NRB. The patient was given a total of 5L of NS as
fluid resuscitation. A CTA was done as well as a CT abdomen and
pelvis which was negative for PE, but comfirmed a b/l lower lobe
pneumonia and acute pancreatitis without necrosis. He was given
Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for
anxiety.
.
On admission to the ICU the patient complaint of LLQ pain, [**4-7**],
non-radiating. He confirmed respiratory distress but rated that
stable over the last several hours. He denied any nausea
currently and did not have any further diarrhea. Pt denies any
recent travel, excessive ETOH or yellow discoloration of skin.
pt reports recent food excess during attendance of a symposium.
.
ROS: negative for rash, dysuria, changes in the color of the
urine or stool.
Past Medical History:
Polycythemia
Impaired fasting glucose-on metformin
Obesity
Depression
Pre-hypertension
Social History:
ETOH: occ social, no recent binge drinking
Tobacco: none
Occupation: chemistry researcher working with Iridium
Living situation: lives with wife and 2 children, age 16 and 4
[**11-30**]
Family History:
Father with valve replacement at age 72
Physical Exam:
VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB
Gen: NAD, AAOx3, talking in full sentences
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in b/l bases, positive egophony,
no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank,
no rebound or guarding
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l
Pertinent Results:
EKG: SR, tachycardia, rate 120, NA, NI, no ST or TW changes
.
CTA/ CT abdomen: [**2174-7-22**]
1. No evidence of pulmonary embolism.
2. Bilateral lower lobe airspace consolidation, likely
pneumonia, with small bilateral pleural effusions.
3. Acute pancreatitis, without evidence of acute complication.
4. Fatty liver.
5. Bilateral renal hypodensities, likely small cysts
US liver - FINDINGS: The bedside ultrasound examination is
markedly limited by patient body habitus, and inability to
cooperate due to pain and respiratory distress. Limited images
of the liver demonstrate increased echogenicity, likely
representing fatty liver. Gallbladder was unable to be
identified.
IMPRESSION:
Markedly limited portable study. Nonvisualization of the
gallbladder. Echogenic liver.
[**2174-7-26**]
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: Evaluate for pseudocyst formation, abscess, or interval
[**Doctor Last Name **]
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with pancreatitis and rising WBC, and SOB with
tachycardia.
REASON FOR THIS EXAMINATION:
Evaluate for pseudocyst formation, abscess, or interval change
in pancreatitis. R/o PE for persistent tachycardia and SOB.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 30-year-old man with pancreatitis and shortness of
breath.
Comparison is made to the CTA of the chest performed on [**7-22**], [**2173**].
TECHNIQUE: Axial MDCT images were obtained from thoracic inlet
to pubic symphysis. The CTA of the chest was performed based on
pulmonary embolism protocol; nontheless, there is suboptimal
contrast timing for assessing pulmonary embolism. The CT of the
abdomen and pelvis portion is performed with CTE protocol. Two
separate injections of contrast were administered, with the
chest covered with both injections.
CT OF CHEST WITH AND WITHOUT IV CONTRAST: The heart and great
vessels appear unremarkable. No pathologically enlarged hilar,
mediastinal or axillary nodes are noted. Severe degree of
atelectatic changes is noted within the anterior [**Doctor First Name **] segment
of right lower lobe and base of the right middle lobe. Moderate
degree of atelectasis is also noted at the left lung base. Given
the presence of air bronchograms particularly at the left lower
lobe, there is likely superimposed consolidation. Trace
bilateral pleural effusion is seen, which is more prominent on
the left side.
Although the pulmonary artery contrast bolus appears suboptimal
(probably due to patient habitus and slower injection rate due
to IV size) on both scans of the chest, there is no evidence of
pulmonary embolus within the limits of the study.
CT OF THE ABDOMEN WITH IV CONTRAST: The pre-pancreatic
fluid/phlegmon in the anterior pararenal space appears slightly
larger, especially inferiorly-- there is increased fluid along
the left lateroconal fascia. A small amount of fluid now tracks
down the left anterior pararenal space to the pelvis. A trace of
fluid is also seen within the right anterior pararenal space.
The pancreas enhances homogeneously and there is no site of
necrosis. No definite fluid collection is shown in the pancreas.
No loculated pseudoaneurysm is visualized. No evidence of SMV or
portal vein thrombosis.
There is hepatic steatosis. A 1.8 cm hypodense structure is
again noted within the dome of the liver, with fluid density
likely representing a cyst. Small amount of ascitic fluid has
developed adjacent to the liver and spleen. The gallbladder and
intra- and extra- hepatic bile ducts are unremarkable. This
spleen, adrenal glands and kidneys have normal appearance. No
pathologically enlarged retroperitoneal or mesenteric node is
noted. No free air is noted within the abdomen.
CT OF THE PELVIS WITH IV CONTRAST: The rectum has a normal
appearance. The sigmoid colon contains multiple diverticula,
with no evidence of diverticulitis. The urinary bladder and
distal ureters appear unremarkable. No pathologically enlarged
pelvic or inguinal nodes are visualized. No free air is noted
within the pelvis. As noted above, a small amount of fluid
tracks into the pelvis.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Overall similar appearance of peripancreatic inflammation;
however, anterior pararenal fluid and phlegmon is minimally
increased. No pancreatic necrosis, pseudocyst, or abscess is
visualized.
2. No evidence of pulmonary embolism.
3. Atelectatic with superimposed consolidation at both lung
bases.
4. Small amount of ascites is noted within the abdomen and
pelvis.
5. Small hypodense lesion of the dome of the liver, which are
too small to characterize, likely a cyst.
CHEST (PORTABLE AP) [**2174-7-26**] 6:16 AM
CHEST (PORTABLE AP)
Reason: ? interval change
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with DM2 presents with acute pancreatitis and ?
aspiration pneumonia, please assess for interval change
REASON FOR THIS EXAMINATION:
? interval change
CHEST
HISTORY: Aspiration pneumonia.
COMPARISON: [**2174-7-24**].
The patient has taken a poor inspiratory effort. Compared to the
prior study there is increased pulmonary vascular
re-distribution. There is blunting of both costophrenic angles
left greater than right consistent with pleural effusions. There
is persistent retrocardiac opacity.
IMPRESSION: Bilateral pleural effusions and persistent left
retrocardiac opacity.
Increased pulmonary vascular re-distribution consistent with
mild CHF.
[**2174-7-28**] - CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The
visualized portion of the lung bases demonstrates small left
pleural effusion which is unchanged. Linear atelectatic
changes/pulmonic infiltrate of the left lower lobe and right
lower lobe appear unchanged. The heart and great vessels appear
unremarkable. A small axial hiatal hernia is unchanged.
The pancreas and peripancreatic inflammation are unchanged. No
definite fluid collection is noted. No area of pancreatic
necrosis is identified. No definite gas is noted within the
peripancreatic tissue.
The liver has faaty infiltration. The gallbladder, intra- and
extrahepatic bile ducts, spleen, and adrenal glands appear
unremarkable. The small hypodense lesion of the dome of the
liver appears unchanged. The right kidney contains a small
hypodense lesion which is too small to characterize and appears
relatively unchanged compared to the prior study. The stomach,
duodenum, and small bowel loops are unremarkable. There is ileus
of the transverse colon adjacent to the site of inflammation.
The remainder of the colon appear unremarkable. Small amount of
ascites is noted within the abdomen. No free air is identified.
No pathologically enlarged retroperitoneal or mesenteric nodes
are noted.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon,
urinary bladder, and distal ureters are unremarkable. Small
amount of ascites noted within the pelvis. No pathologically
enlarged pelvic or inguinal nodes are noted. No free air is
noted within the pelvis.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Similar appearance of peripancreatic inflammation with no
necrosis, pseudocyst or abscess formation. The anterior
pararenal fluid and the phlegmon are stable.
2. Transverse colon ileus is unchanged compared to the prior
study.
3. Unchanged appearance of small bilateral pleural effusion with
atelectatic changes. Small ascites unchanged.
4. Stable appearance of a small hypodense lesion of the dome of
the liver.
5. Fatty liver.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal (for BSA) biventricular cavity sizes with
preserved global
and regional biventricular systolic function.
[**2174-7-29**] 05:45AM BLOOD WBC-16.3* RBC-4.27* Hgb-13.2* Hct-37.9*
MCV-89 MCH-31.0 MCHC-35.0 RDW-14.1 Plt Ct-206
[**2174-7-28**] 06:00AM BLOOD WBC-17.1* RBC-4.48* Hgb-14.0 Hct-39.8*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.5 Plt Ct-237
[**2174-7-27**] 05:55AM BLOOD WBC-19.4* RBC-4.70 Hgb-14.3 Hct-42.3
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-212
[**2174-7-22**] 03:00PM BLOOD WBC-19.6*# RBC-5.21 Hgb-16.3 Hct-45.5
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.6 Plt Ct-188
[**2174-7-26**] 05:28AM BLOOD WBC-24.5* RBC-5.07 Hgb-15.7 Hct-45.2
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-235
[**2174-7-29**] 05:45AM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-3* Promyel-1*
[**2174-7-22**] 03:00PM BLOOD Neuts-87.8* Lymphs-8.0* Monos-3.7 Eos-0.4
Baso-0.2
[**2174-7-26**] 05:28AM BLOOD Neuts-84* Bands-2 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-1* Promyel-2*
[**2174-7-29**] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2174-7-26**] 05:28AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2174-7-23**] 04:42AM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2*
[**2174-7-29**] 05:45AM BLOOD UreaN-5* Creat-0.7 Na-134 K-3.9 Cl-95*
HCO3-32 AnGap-11
[**2174-7-22**] 03:00PM BLOOD Glucose-284* UreaN-12 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-27 AnGap-9
[**2174-7-28**] 06:00AM BLOOD ALT-15 AST-19 AlkPhos-59 TotBili-0.5
[**2174-7-22**] 03:00PM BLOOD ALT-42* AST-24 CK(CPK)-54 AlkPhos-59
Amylase-141* TotBili-1.0
[**2174-7-27**] 05:55AM BLOOD Lipase-47
[**2174-7-24**] 04:16AM BLOOD Lipase-78*
[**2174-7-23**] 04:42AM BLOOD Lipase-140*
[**2174-7-22**] 03:00PM BLOOD Lipase-220*
[**2174-7-22**] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-7-23**] 04:42AM BLOOD Albumin-2.7* Calcium-7.3* Phos-1.2*
Mg-1.8
[**2174-7-29**] 05:45AM BLOOD Mg-2.0
[**2174-7-28**] 06:00AM BLOOD Triglyc-318*
[**2174-7-22**] 03:00PM BLOOD Triglyc-832*
[**2174-7-27**] 05:55AM BLOOD Osmolal-287
[**2174-7-26**] 05:28AM BLOOD TSH-2.4
[**2174-7-24**] 01:51AM BLOOD Type-ART PEEP-8 FiO2-60 pO2-86 pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2174-7-22**] 03:14PM BLOOD Comment-GREEN TOP
[**2174-7-22**] 03:14PM BLOOD Lactate-1.4
[**2174-7-26**] 08:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2174-7-26**] 08:02PM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2174-7-26**] 03:34AM URINE AmorphX-MOD
[**2174-7-22**] 11:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035
[**2174-7-26**] 03:34AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2174-7-26**] 3:34 am URINE Site: CATHETER
**FINAL REPORT [**2174-7-27**]**
URINE CULTURE (Final [**2174-7-27**]): NO GROWTH.
[**2174-7-28**] 6:27 am STOOL CONSISTENCY: LOOSE Source: Stool.
**FINAL REPORT [**2174-7-28**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2174-7-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2174-7-25**] 4:03 am BLOOD CULTURE Site: ARM
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2174-7-22**] 7:20 pm BLOOD CULTURE Site: ARM
**FINAL REPORT [**2174-7-28**]**
AEROBIC BOTTLE (Final [**2174-7-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2174-7-28**]): NO GROWTH.
Brief Hospital Course:
Acute pancreatitis - likely from hyperlipidemia/
hypertriglyceridemia. Started on niacin (pre Rx with EcASA).
Pancreatitis treated with NPO, IVF, analgesics and bowel rest.
Improved remarkably and tolerating low fat diet well at
discharge.
For a few days prior to discharge reported 'bloating' CT abdomen
showed transverse colon ileus, likely from the pancreatitis in
the neighbouring area. No colitis noted. GI consulted and hey
did not recommend any neostigmine, decompression etc. Avoiding
narcotics. The patient did not have much discomfort or pain and
was eating well on the day of discharge. Advised to follow up
with PCP.
Hyperlipidemia - Niacin as above with EcASA. Dietary consulted
to educate on a low fat diet. Patient advised weight loss as
well as low fat diet. To get LFT, lipids checked next week with
PCP.
Bilateral pneumonia - treated initially with IV zosyn and
improved with decreasing WBC. Was weaned off oxygen.
Transitioned to levofloxacin and flagyl. To complete a 14 days
course (total). CT chest neg for PE. Patient has symptoms of
OSA. Again advised to follow up with PCP for arranging [**Name Initial (PRE) **]
pulmonary sleep study.
Transverse colon ileus - as above
Abnormal CBC differential - heme consulted and they saw toxic
granulations of smear. Advised to get another CBC with diff with
PCP after active infection issues resolve.
Liver lesion on CT (incidental finding) - Advised to get a
follow up US/CT in 6 months. I shall defer to PCP for arranging
this.
Abnormal UA - repeat testing should be done with PCP [**Last Name (NamePattern4) **] [**11-30**]
weeks and if blood persists, patient will need more testing and
work-up. Will defer to PCP.
Depression - meds continued.
DM type 2 - metformin stopped and to be restarted at home (day
after discharge)
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
9. Niacin 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: take 30-60
mins before niacin.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Bilateral pneumonia
Transverse colon ileus
Abnormal CBC differential
Liver lesion on CT (incidental finding)
Abnormal urinanalysis
Hyperlipidemia / hypertriglyceridemia
Hypertension
Depression
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you notice worsening abdominal pain,
nausea, vomiting, fevers, chills or any other symptoms of
concern to you.
Keep your appointments.
Take medicines as indicated.
Complete the course of antibiotics.
Avoid alcohol use; avoid use around niacin dose. Take the
aspirin 30 - 60 mins prior to the niacin dose.
See your doctor next week to check a blood tests.
Strictly adhere to a low fat diet.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**] on Friday [**2174-8-5**] at 1330 hours.
Please go there 15 mins prior to the appointment.
(Fax: 1-[**Telephone/Fax (1) 4776**])
Please follow up with your doctor for a repeat blood count (CBC,
renal function, liver tests as well as a lipid panel, UA)
|
[
"428.0",
"401.9",
"560.1",
"577.0",
"250.00",
"511.9",
"486",
"311",
"571.8",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18731, 18737
|
15584, 17385
|
329, 336
|
18993, 19002
|
3510, 4448
|
19471, 19803
|
2922, 2963
|
17468, 18708
|
8304, 8424
|
18758, 18972
|
17411, 17445
|
19026, 19448
|
2978, 3491
|
275, 291
|
8453, 15269
|
15299, 15299
|
15328, 15561
|
364, 2593
|
2615, 2703
|
2719, 2906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,535
| 192,933
|
31679
|
Discharge summary
|
report
|
Admission Date: [**2123-10-29**] Discharge Date: [**2123-11-10**]
Date of Birth: [**2044-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Allopurinol / Ace Inhibitors / Amiloride
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABG x3 (LIMA->LAD, SVG->RAMUS, SVG->PDA), MV repair (30mm ring)
[**11-1**]
History of Present Illness:
79 yo M admitted to [**Hospital **] hospital on 9.11 with chest pain and
troponin of 12.Cardiac cath on 9.14 showed 3vd. Transferred for
CABG.
Past Medical History:
[**Hospital **] AF, HTN, ^chol., prostate ca-rad rx, depression
Social History:
lives alone
20 pack year tob
[**2-16**] etoh/day
Family History:
NC
Physical Exam:
HR 53 RR 18 BP 100/72
Elderly male in NAD
Lungs CTAB
Cor [**Last Name (un) **]
Abdomen benign
No edema, no varicosities, no carotid bruits, 2+dp/pt pulses
Pertinent Results:
[**2123-11-9**] 06:00AM BLOOD WBC-9.9 RBC-3.17* Hgb-9.6* Hct-29.1*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.9 Plt Ct-228
[**2123-11-7**] 04:45AM BLOOD WBC-8.1 RBC-2.99* Hgb-9.5* Hct-27.8*
MCV-93 MCH-31.9 MCHC-34.4 RDW-14.6 Plt Ct-190
[**2123-11-9**] 06:00AM BLOOD PT-15.8* INR(PT)-1.4*
[**2123-11-9**] 06:00AM BLOOD Plt Ct-228
[**2123-11-8**] 06:18AM BLOOD PT-15.7* INR(PT)-1.4*
[**2123-11-7**] 04:45AM BLOOD PT-15.2* INR(PT)-1.4*
[**2123-11-6**] 05:35AM BLOOD PT-14.3* INR(PT)-1.3*
[**2123-11-9**] 06:00AM BLOOD UreaN-36* Creat-1.8* K-4.5
[**2123-11-7**] 04:45AM BLOOD Glucose-88 UreaN-48* Creat-2.1* Na-141
K-4.1 Cl-105 HCO3-29 AnGap-11
[**2123-11-6**] 05:35AM BLOOD Glucose-85 UreaN-48* Creat-2.1* Na-143
K-4.3 Cl-105 HCO3-31 AnGap-11
CHEST (PA & LAT) [**2123-11-8**] 10:50 AM
FINDINGS: Comparison with the study of [**11-3**], there has been the
development of extensive opacification at the bases, more marked
on the left, with a meniscus consistent with pleural effusions.
The lungs are essentially clear.
IMPRESSION: Developing bilateral pleural effusions, much more
prominent on the left.
[**2123-11-10**] 05:55AM BLOOD Hct-29.1*
[**2123-11-10**] 05:55AM BLOOD PT-15.8* INR(PT)-1.4*
[**2123-11-10**] 05:55AM BLOOD UreaN-33* Creat-1.7* K-4.7
Brief Hospital Course:
He was started on heparin gtt and surgery was planned for the
following Monday. On [**11-1**] he was taken to the operating room
where he underwent a CABG x 3 and MVRepair. He was transferred
to the ICU in critical but stable condition on epinephrine and
propofol. He was extubated on POD #1. He was restarted on
coumadin for [**Month/Year (2) **] afib. He was transferred to the floor on
POD #3. He was started on ibuprofen for a pericardial rub. He
initially had problems with hypotension but slowly improved and
was restarted on a beta blocker. He was ready for discharge to
rehab on POD # 7, he awaited a bed and was discharged to rehab
on POD #9.
Medications on Admission:
ASA 81', Dig 0.125', Diltiazem CD 240', Avapro 150', Lopressor
25", Zocor 10", Aldactone 25'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO ONCE (Once) for
1 doses.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD, MR
[**First Name (Titles) **] [**Last Name (Titles) **], HTN, ^chol., prostate ca-rad rx, depression
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No driving or lifting more than 10 pounds until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 39975**] 2 weeks
Completed by:[**2123-11-10**]
|
[
"424.0",
"V58.61",
"427.31",
"272.0",
"458.29",
"585.9",
"V10.46",
"414.01",
"403.90",
"397.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3678, 3708
|
2200, 2853
|
319, 397
|
3858, 3866
|
933, 2177
|
738, 742
|
2996, 3655
|
3729, 3837
|
2879, 2973
|
3890, 4142
|
4193, 4347
|
757, 914
|
269, 281
|
425, 569
|
591, 656
|
672, 722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,250
| 103,382
|
50077
|
Discharge summary
|
report
|
Admission Date: [**2158-6-5**] Discharge Date: [**2158-6-15**]
Date of Birth: [**2089-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Intermucosal adenocarcinoma of the
gastroesophageal junction.
Major Surgical or Invasive Procedure:
TransHiatal Esophagecty, jejunostomy, pyloroplasty
History of Present Illness:
The patient is a 68 year-old
gentleman with a 25 year history of GERD. He was recently
diagnosed with intermucosal adenocarcinoma of his
gastroesophageal junction, in the setting of a Barrett's
esophagus. The patient's preoperative work-up was negative
for any metastatic disease and therefore, he was deemed to be
suitable for a transhiatal esophagectomy.
Past Medical History:
GERD, recent dysphagia. Biopsy proven intramucosal AdenoCA and
[**Last Name (un) 865**] on EGD
PMH: HTN, Gout, SVT, BPH, basal cell CA
PSH: R ORIF, R IH, vasectomy
Family History:
non-contributory
Physical Exam:
general: well appearing male in NAD s/p esophagectomy and
feeding J-tube.
HEENT: left neck incision well approx, no redness, no drainage.
Staples d/c'd. JP Drain d/c'd.
Chest: CTA bilat
Cor: RRR S1, S2
Abd: soft, NT, +BS. J-tube site benign. Abd incision intact, no
redness, no drainage. Every other staple d/c'd.
extrem: no C/C/E
neuro: intact.
Pertinent Results:
CXR:
[**2158-6-9**]: In comparison with study of earlier in the day, there
has
apparently been thorcentesis with removal of pleural fluid and a
more sharp
appearance of the right costophrenic angle. No evidence of
pneumothorax. No
change in the appearance of the mediastinum or left chest.
Brief Hospital Course:
Pt was admitted and taken to the OR for
Esophagogastroduodenoscopy,Transhiatal esophagectomy with
bilateral plasty and placement of a feeding jejunostomy tube.
Or course was uneventful. An epidural was placed for pain
control. An NGT, JP and chest tube were placed at the time of
surgery. Pt was admitted to SICU post op intubated for vent
support and hemodynamic monitoring and volume resusitation. Pt
was extubated on POD#1.
POD#2 trophic tube feeds started.Left chest tube placed to water
seal. NGT d/c'd.
POD#3 developed afib- unsuccessful rate control w/ lopressor.
Responded to amiodarone bolus and drip.
POD#4 CXR w/ progressive right effusion- tapped for 900cc old
bloody fluid.
POD#5 PICC line for amiodarone until taking po's. Tube feeds
slowly increased to goal. Epidural d/c'd and pain well
controlled w/ roxicet. Bowel regimen effective.
POD#6 c/o right upper quad pain- w/u neg for biliary disease.
POD#7 given trial of grape juice orally and no evidence of juice
in anastomotic JP drain.
POD#8 Diet advanced to clears and [**Last Name (un) 1815**] well. Did c/o
intermittant fullness and cramping. Tube feeds held and given
laxative w/ good result and tube feeds were resumed.
POD#9 diet advancedto fulls. po meds were intiated and tube
feeds were advanced to goal.
POD#10 Pt abulating indep w/ RA sats 98%. d/c'd to home w/ vna
services for tube feed assistance.
d/c'd to home and will return for barium swallow before
advancing diet.
Medications on Admission:
atenolol, allopurinol, doxazocin, mvi, glucosamine, polaramine
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (un) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*420 ML(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (un) **]: One Hundred (100) mls
PO BID (2 times a day) as needed for constipation.
Disp:*420 mls* Refills:*2*
3. Lactulose 10 gram/15 mL Syrup [**Last Name (un) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*400 ML(s)* Refills:*1*
4. Doxazosin 1 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO HS (at bedtime).
5. Allopurinol 100 mg Tablet [**Last Name (un) **]: Three (3) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
8. tube feeding
replete with fiber continuous at 90cc/hr
flush w/ 50cc water every 8hrs and before and after feeds and
medication.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GERD, recent dysphagia. Biopsy proven intramucosal AdenoCA and
[**Last Name (un) 865**] on EGD
PMH: HTN, Gout, SVT, BPH, basal cell CA
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, nausea, vomiting, diarrhea, inability to
tolerate tube feeds or oral intake.
Continue on your tube feeds as directed and take full liquids by
mouth. No caffiene and no carbonation.
Flush your feeding tube with 50cc water before and after
medications and before and after feeding connect and disconnect.
if you feeding tube sutures break, tape your tube securely in
place and call the office [**Telephone/Fax (1) 170**] to have the sutures
replaced.
If you feeding tube falls out, save the tube and call the office
immediately. The tube needs to be replaced immediately because
the tract closes very quickly. You will need to come into the
office to have the feeding tube replaced. Bring your old tube
w/ you when you come in.
Followup Instructions:
You have a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP/ Dr.
[**Last Name (STitle) **] on wednesday [**6-21**] on the [**Hospital Ward Name **] [**Hospital Ward Name 121**] building
[**Hospital1 **] one in the chest disease center at 1:30pm.
You have a barium swallow on [**6-21**] at 11am on the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center [**Location (un) **] radiology. Stop your
tube feedings at midnight the night before.
Completed by:[**2158-6-15**]
|
[
"998.2",
"511.9",
"427.89",
"274.9",
"600.00",
"401.9",
"151.0",
"458.29",
"V45.89",
"530.85",
"E870.0",
"427.31",
"789.00",
"530.81",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"38.93",
"88.73",
"96.6",
"34.91",
"44.29",
"97.01",
"03.90",
"46.39",
"43.5",
"42.41",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4408, 4465
|
1742, 3195
|
382, 435
|
4644, 4651
|
1426, 1719
|
5547, 6087
|
1027, 1045
|
3308, 4385
|
4486, 4623
|
3221, 3285
|
4675, 5524
|
1060, 1407
|
280, 344
|
463, 823
|
845, 1011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,777
| 187,776
|
11893
|
Discharge summary
|
report
|
Admission Date: [**2153-2-27**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
female with a history of hypertension, atrial fibrillation
(not on Coumadin), apparently status post fall earlier on the
day of admission and subsequently became unresponsive. The
patient was brought to [**Hospital1 69**]
by EMS with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 5. The patient was
intubated in the Emergency Room for airway protection.
According to the patient's daughter, the patient had not been
feeling well for the last 48 hours. Main symptoms were
nausea, vomiting and diarrhea. The patient saw her PCP the
day prior to admission, and her symptoms were attributed
mainly to dehydration. The patient was actually feeling well
on the day of admission. The daughter had witnessed patient
fall in the kitchen. Daughter states that patient may have
had blood in her stools several days prior. In the Emergency
Room, trauma series films were negative (patient was found to
have CK of 1700, MB index negative, but troponin was greater
than 50). EKG in the Emergency Room showed 3-[**Street Address(2) 5366**]
elevations in leads 2, 3, AVF with reciprocal depression
anteriorly. The patient was taken to cardiac catheterization
emergently, reviewing LAD with 70% mid stenosis, subtotal
occlusion of RCA. Stent was placed in RCA. The patient was
not placed on Integrilin after a cardiac catheterization
secondary to concern for possible head trauma. An LV gram
was not performed secondary to elevated creatinine of 2.3.
PAST MEDICAL HISTORY: 1) Atrial fibrillation on Digoxin. 2)
Hypertension. 3) PVD.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Enalapril 20 mg po q d, Digoxin
.25 mg po q d, Toprol XL 100 mg po q d, Lasix 60 mg po q d,
potassium supplement 10 mEq po bid.
SOCIAL HISTORY: The patient did not use tobacco or alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission patient was afebrile,
blood pressure 134/40, pulse 77, respirations 20, intubated.
General, patient was unconscious and intubated and sedated.
Head and neck exam, pupils equal, round and reactive to
light. Sclera anicteric. Mucus membranes moist. C collar
in place. Chest clear to auscultation bilaterally.
Cardiovascular, regular rate and rhythm, normal S1 and S2,
[**3-21**] crescendo systolic ejection murmur originating at left
sternal border and radiating to apex. Abdomen soft,
nontender, non distended, good bowel sounds in all four
quadrants, no masses. Extremities, no clubbing, cyanosis or
edema, 2+ dorsalis pedis pulses bilaterally, small groin
hematoma. Neurologic exam, patient was not following
commands, moving all four extremities, withdrawing to pain,
toes downgoing bilaterally.
LABORATORY DATA: White blood cell count 20.1, hematocrit 32,
platelet count 171,000, INR 1.2, PTT 22.1, sodium 134,
potassium 4.7, chloride 98, CO2 23, BUN 67, creatinine 2.4,
glucose 138, amylase 338, fibrinogen 617, CK 1,714, MB 19
with MB index of 1.1, troponin greater than 50. Urinalysis
showed specific gravity 1.025, PH 5, white blood cells 0-2,
RBC 0-2. Arterial blood gases on admission as follows: PH
7.45, CO2 36, O2 463 on assist control. Ventilation settings
unknown on admission. CT of head showed no bleed, 1 cm soft
tissue density in the right retro-orbital space. Chest x-ray
clear, no effusions or pneumothorax, endotracheal tube in
place. X-ray of abdomen and pelvis negative for fractures.
C spine negative. EKG on admission, normal sinus rhythm at
66 beats per minute, leftward axis, normal intervals, LVH 3-4
mm ST segment elevation 2, 3, AVF with reciprocal 3 mm ST
segment depressions V2 through V4.
HOSPITAL COURSE: Impression was that this was an 89-year-old
female with a history of hypertension, atrial fibrillation,
who presented after a fall and after being found unresponsive
earlier in the day. The patient was found to have EKG
changes suggestive of an inferior wall myocardial infarction,
with cardiac catheterization showing likely RCA culprit
lesion, which was stented successfully.
1. Cardiovascular: A) Congestive heart failure: The
patient's systolic function was unknown, secondary to not
being able to perform an LV gram during cardiac
catheterization secondary to increased creatinine. However,
the patient's hemodynamic status was consistent with
decreased RV systolic function secondary to possible RV
infarct. The patient was persistently hypotensive through
cardiac catheterization with systolic blood pressures in 70's
to 80's, requiring aggressive IV fluid hydration for RV
slight ventricular support. According to PCP, [**Name Initial (NameIs) 228**]
baseline blood pressures were 180-200. Patient's blood
pressure increased with aggressive IV fluid hydration, and
ultimately patient remained hemodynamically stable off IV
fluid resuscitation. Preload reduction with nitrates was
avoided. An echocardiogram was later performed, showing a
left ventricular ejection fraction of 40%, mildly dilated
left atrium, mild left ventricular hypertrophy, mild left
ventricular systolic dysfunction with severe hypokinesis of
inferior wall, moderate global right ventricular free wall
hypokinesis, trace AR, mild MR, and trivial pericardial
effusion. Ultimately, patient remained hemodynamically
stable off IV fluid resuscitation and back on her oral
hypertensive regimen. B) Ischemia: The patient was
suspected to have had an MI in the preceding 48 hours prior
to admission, and her GI symptoms may have been a
manifestation of her inferior wall MI. A stent was
successfully placed in RCA. The patient was started on
Aspirin, Plavix, and heparin for usual post cath protocol.
Beta blocker and ACE inhibitor were added after patient was
more hemodynamically stable with the recovery of RV function.
Daily EKGs showed persistent ST elevations in the inferior
leads, which persisted but became less in intensity
throughout hospital stay. The patient denied any further
chest pain during hospital stay. C) Rhythm: The patient had
a history of atrial fibrillation, on Digoxin and Lopressor.
The patient remained in normal sinus rhythm throughout
hospital course. The patient was put back on Lopressor after
patient was more hemodynamically stable for rate control.
Digoxin was discontinued. On day #7 of hospital, the patient
had a 9 beat run of V tach. At that time, patient's vital
signs were stable, and patient was resting comfortably. As
this was an isolated run of V tach, and patient was
asymptomatic during episode, no further investigation was
pursued.
2. Renal: The patient's creatinine was elevated at 2.2 on
admission (baseline creatinine 1.4 to 1.6 according to PCP).
The patient's ACE inhibitor was held initially. With
aggressive IV fluid hydration, the patient's creatinine came
down to 1.1. The patient had good urine output throughout
hospital course. ACE inhibitor was restarted when patient
was more hemodynamically stable, with no change in creatinine
from baseline.
3. Pulmonary: The patient was initially intubated on
admission mainly for airway protection. The patient's chest
x-ray was clear on admission, and patient had been
oxygenating well while intubated. The patient was extubated
once mental status improved 48 hours after admission, with no
complications. On day #5 of hospital course, the patient had
an episode of shortness of breath and agitation. Chest x-ray
was obtained, showing mild pulmonary edema. This was
attributed possibly to aggressive IV fluid hydration for
right ventricular support. IV fluid hydration was stopped
and patient was diuresed with Lasix, with resolution of
shortness of breath. The patient was put on standing Lasix
20 mg po q d thereafter. The patient's oxygen saturation
remained stable thereafter.
4. Hematology: The patient was transfused a total of 3
units packed red blood cells for hematocrit less than 30.
The patient's daughter reported a history of questionable
bloody stools, however, the patient's stools were guaiac
negative on admission. The patient's hematocrit remained
stable after transfusion.
5. Neurologic: The patient remained lethargic and difficult
to arouse for first 48 hours of hospital stay. However,
patient later appeared to wake up and became more alert, but
her mental status, according to patient's family, was not
back to baseline. As patient could not communicate her
needs, the patient's C spine was cleared via MRI of C spine
to rule out ligamentous injury.
6. GI: The patient received NG tube feeds while intubated.
After extubation, patient was evaluated by speech and
swallow, and failed her test. The patient was thought to
have possibly failed her test secondary to sedation that she
had received for "agitation". Speech and swallow was
consulted to reevaluate patient once her mental status
improved.
DISCHARGE STATUS: The patient is going to rehab.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Plavix 75 mg
po q d, Toprol XL 100 mg po q d, Enalapril 20 mg po q d,
Lasix 20 mg po q d, Lipitor 10 mg po q d, Prevacid 30 mg po q
d, Senokot one tablet po bid.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2153-3-6**] 11:26
T: [**2153-3-6**] 11:46
JOB#: [**Job Number 37482**]
|
[
"410.41",
"401.9",
"414.01",
"396.3",
"427.1",
"782.1",
"E888.9",
"398.91",
"959.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"96.71",
"88.56",
"36.01",
"36.06",
"46.32",
"96.6",
"96.34",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1970, 1988
|
9009, 9458
|
3782, 8985
|
2011, 3764
|
96, 1610
|
1633, 1891
|
1908, 1953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,026
| 150,039
|
50112
|
Discharge summary
|
report
|
Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-13**]
Date of Birth: [**2122-8-20**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 74-year-old woman with
history of Alzheimer's disease and hypercholesterolemia who
has had two to three months of 25 pound weight loss, anorexia
and dysphagia. She also reports increased burping. This was
thought initially to be a side effect of Aricept, which was
started approximately six months ago, however, with
persistence of these symptoms, she reported to her primary
care physician's who initiated a malignancy work-up. She was
found to have pulmonary nodules on chest x-ray suspicious for
lung metastases, guaiac positive stools, anemia, increased
LFTs and also a bone scan positive for metastatic disease.
The primary site of cancer was unknown. She was scheduled
for a barium swallow on [**4-7**] and it is unclear whether
this was done or not. She had a negative mammogram in
[**2196-12-27**].
She was scheduled for a colonoscopy and
esophagogastroduodenoscopy as an outpatient on the morning of
admission, however, earlier that morning, she had an episode
of bright red blood, hematemesis/hemoptysis after taking her
pills. It was only approximately one ounce in quantity.
There were no clots and no sputum. She had no other
associated symptoms of nausea, vomiting, chest pain,
lightheadedness, melena, bright red blood per rectum or
abdominal pain. Her husband also reports she had transient
hematuria ten years ago. An intravenous pyelogram was done
with tomography with finding of widened bladder neck,
otherwise, normal.
The patient was sent from the Emergency Room where her vital
signs were stable to the Esophagogastroduodenoscopy Suite
where it was revealed an abnormal mucosa in the esophagus
from 30 cm to 22 cm distally with adherent clot and moderate
oozing. Colonoscopy was not performed at that time secondary
to active bleeding and she was transferred to the Medical
Intensive Care Unit for one night for observation.
PAST MEDICAL HISTORY:
1. Alzheimer's disease.
2. Weight loss, dysphagia, anorexia, pulmonary nodules on
chest x-ray guaiac positive stools, metastatic bone lesion on
bone scan, increased LFTs,
3. Hypercholesterolemia.
MEDICATIONS AT HOME: Aricept 5 mg po q.d., Lipitor 10 mg po
q.d., Prempro .625/2.5 mg q.d., Centrum multivitamin.
FAMILY HISTORY: No coronary artery disease. Father with
duodenal/stomach cancer. Mother with question of mass in
chest.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with her husband. One son, two
grandchildren. She smokes less than one pack per day times
35 years and has occasional alcohol use.
REVIEW OF SYSTEMS: No fevers, chills, nausea, vomiting,
shortness of breath or chest pain.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.1. Pulse
96. Blood pressure 113/54. Respiratory rate 14-18. O2
saturation 100% on two liters nasal cannula. In general in
no acute distress, pleasant woman. Neck: No
lymphadenopathy, no thyromegaly, no axillary lymphadenopathy.
Head, eyes, ears, nose and throat: Anicteric sclerae, dry
mucous membranes. Cardiovascular: Regular rate and rhythm,
no murmurs, rubs or gallops. Pulmonary: Clear to
auscultation bilaterally. Abdomen: Soft, nontender,
question of palpable liver edge 2 cm below diaphragm.
Extremities: No edema. Neurological: Cranial nerves
intact. Left lower extremity greater than right lower
extremity weakness, [**2-28**] on the left and [**4-30**] on the right.
LABORATORY DATA ON ADMISSION: White blood cell count 12.5,
hematocrit 26.8, platelets 361,000. Neutrophils 87%,
lymphocytes 8%, monocytes 5%, INR 1.1, PT 12.7, PTT 24.9.
Sodium 138, potassium 3.3, chloride 99, bicarbonate 26, BUN
23, creatinine .8, glucose 120.
WORK-UP PRIOR TO ADMISSION ON [**3-23**]: Sedimentation rate
68, ALT 33, AST 71, alkaline phosphatase 296, T bilirubin .8,
GGT 81, albumin 3.8, total protein 6.9, globulin 3.1, calcium
9.9, TSH 2.6, iron 3, total cholesterol 218, TIBC 280, B12
984, folate greater than 20, ferritin 245, TRF 215, HDL 65,
cholesterol to HDL ratio 3.4, SPEP abnormal band in gamma
region 2% of total protein, IgG 698, IgA 318, IGM 214, IFE
monoclonal IgM cap was seen. 24 hour urine: PH 5, protein
15, volume 380 cc, UPEP no Bence [**Doctor Last Name **] proteins, only
albumin. Urine culture on [**3-23**] negative.
CT of the head without contrast [**2196-6-26**]: Moderate atrophy
without significant abnormalities. Mammogram [**2196-12-27**]:
No evidence of malignancy. Chest PA and lateral [**2197-2-24**]:
Extensive pulmonary and right hilar metastases. Left hip
x-ray [**2197-3-28**]: Normal pelvis and left hip. Bone scan
[**2197-4-7**]: Positive for multiple foci of increased
activity, most likely secondary to metastatic disease,
particularly in the right iliac crest within parietal region
of calvaria.
Esophagogastroduodenoscopy [**2197-4-10**]: Normal stomach,
normal duodenum, esophagus with abnormal mucosa with bleeding
in esophagus from 30 cm where the TE junction is seen to 22
cm proximally, adherent clot, active bleeding and friability.
Lumen narrowed with ulceration and irregular mucosa. No
varices. Biopsy performed at lower [**12-29**] of esophagus and
middle [**12-29**] of esophagus.
IMPRESSION: This is a 74-year-old woman with metastatic
cancer of unclear etiology, although
esophagogastroduodenoscopy results reveal bleeding
ulcerations along the esophagus suggesting primary
adenocarcinoma of the esophagus.
SUMMARY OF HOSPITAL COURSE:
1. Bleeding eosphageal ulcerations: Likely eosphageal
cancer. Patient was in the Medical Intensive Care Unit for
one night and supported with intravenous fluids and
transfused two units. She remained hemodynamically stable
and hematocrit also bumped up appropriately to above 30 with
the transfusions and remained stable throughout her hospital
stay. Two large bore IVs were placed. Patient had no more
episodes of hematemesis or any other signs of active
bleeding. She was transferred to the floor after one night
in the Medical Intensive Care Unit and her diet was advanced
with good toleration. Patient was placed on a Protonix drip
in the unit and once she came to the floor was on Protonix 40
mg po b.i.d.
On the second day of admission, she was noted to have
increased coagulation factors. INR 1.5, PT 14.6, PTT 25.7.
She was started on Vitamin K subcutaneous injections times
three days and her coagulation laboratories normalized by the
time of discharge.
2. Hematology/Oncology: Patient was seen in the hospital by
Dr. [**Last Name (STitle) **] from Hematology/Oncology who had already seen
her once as an outpatient. The biopsy taken during
esophagogastroduodenoscopy was nondiagnostic as it was mainly
clot and necrotic tissue. However, a CT scan was done of her
torso showing mediastinal lymphadenopathy, right hilar
adenopathy, dilation of esophagus with air fluid level in the
distal esophagus and distal esophageal wall markedly
thickened beyond TE junction suspicious for malignancy.
Innumerable pulmonary metastatic lesions and metastatic liver
lesions, little normal liver tissue left, right adrenal mass
likely metastases, renal cyst bilaterally, no free fluid or
free air in the peritoneal cavity or pelvic cavity, no lytic
or blast lesions seen in the bone.
Of note, cavitary metastatic lesions in lungs suggestive of
squamous cell primary. Given this, result of her CT scan, as
well as what was done prior with definite metastatic disease,
the patient's husband was seen by the Home Hospice Service
and choose this as the next route management. Dr. [**Last Name (STitle) **]
and her oncologist also felt that were no aggressive
therapeutic measures to be done at this point, however, at a
later time, if she becomes more symptomatic in terms of her
swallowing or breathing, there may be room for palliative
radiation or stenting placement in her esophagus. The
patient will follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
She was discharged to Home Hospice.
3. Alzheimer's disease. Appears to be moderate. Patient's
family very supportive, making decisions for her. Aricept
was held given her esophageal ulcerations.
CONDITION OF DISCHARGE: Stable.
DISCHARGE STATUS: Home with home hospice.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po b.i.d.
2. Other medications the same except for her Aricept, which
was discontinued.
DISCHARGE DIAGNOSES:
1. Alzheimer's disease.
2. Hypercholesterolemia.
3. Metastatic cancer, possibly of eosphageal origin.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2197-4-14**] 00:01
T: [**2197-4-14**] 00:01
JOB#: [**Job Number 36353**]
|
[
"272.0",
"285.22",
"198.7",
"197.0",
"198.5",
"530.82",
"150.5",
"331.0",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
2388, 2533
|
8474, 8820
|
8344, 8453
|
2277, 2371
|
5563, 8321
|
2806, 3547
|
2710, 2783
|
163, 2033
|
3562, 5534
|
2055, 2255
|
2550, 2690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,837
| 180,988
|
8276
|
Discharge summary
|
report
|
Admission Date: [**2104-11-15**] Discharge Date: [**2104-11-23**]
Date of Birth: [**2029-5-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 75 year-old female with a history of COPD,
pulmonary fibrosis, atrial fibrillation, type 2 diabetes
mellitus and colonic adenocarcinoma who presented from [**Hospital **]
Rehab with shortness of breath and chest pain. The pt. herself
is a poor historian and the history is per the nursing notes
from rehab and the pt's. son and daughter. [**Name (NI) **] the nurse's note
from rehab, the pt. developed chest pain which radiated to her
left arm and desaturated to the low 80's early the morning of
admission while being changed. An EKG was performed at the time
which was significant for 3mm up-sloping ST elevations in V1-V3.
She was given an aspirin and metoprolol and was transferred to
the [**Hospital1 18**] ED for further evaluation.
Further discussion with the pt's son and daughter revealed that
the pt. had been experiencing fevers approximately 5 to 6 days
ago. She also had a cough productive of yellowish sputum.
Apparently she had a chest Xray at the time which was suggestive
of pneumonia and she was started on levofloxacin. She was also
started on ceftriaxone and vancomycin on the day PTA.
In the emergency department, the pt. reported that the chest
pain had resolved without intervention. Her first set of
cardiac enzymes were not elevated. An EKG was performed which
showed atrial fibrillation, ST elevations in V1-V3, TWI in V5
and V6 and LBBB. She was initially saturating at 77% on 5L O2
via nasal cannula and improved to 96-100% on 2L NC and 95% face
tent. Her chest Xray was remarkable for pulmonary edema. She
was given 40mg IV lasix and urinated 1L. She was also given
combivent nebs and one gram of each vancomycin and ceftriaxone.
She was admitted to the ICU for respiratory distress.
On presentation to the MICU, the pt. complained only of some
difficulty breathing. She stated that the reason she came to
the hospital was for a "panic attack." She is unclear on the
exact events that caused her to come to the hospital. She did
not complain of fevers, chills, diaphoresis, chest pain, arm
pain, nausea, vomiting, abdominal pain, dysuria, melena, BRBPR.
Past Medical History:
-atrial fibrillation
-type 2 diabetes mellitus
-colon cancer, h/o colonic perforation, s/p hemicolectomy [**9-15**]
-COPD, baseline SaO2 is 92-95% on 2-3L O2 via NC
-pulmonary fibrosis
-HTN
-mitral regurgitation
- CHF
Social History:
Pt. lives at [**Hospital **] Rehab.
Denied use of tobacco, alcohol, or illicit drugs.
Family History:
Non-contributory.
Physical Exam:
T: 97.8F P: 109 R: 30 BP: 137/88 SaO2: 95% on 2L NC and 95% face
tent
General: awake, alert, NAD
HEENT: PERRL, EOMI, MMM, no lesions in OP
Neck: supple, no JVD appreciated
Pulmonary: fine bibasilar rales about 1/2 up lung fields
Cardiac: tachycardic, irregularly irregular rhythm, II/VI SEM at
LSB to apex
Abdomen: well-healed surgical scar, soft, NT/ND, active bowel
sounds, no masses
Extremities: no c/c/e bilaterally, warm to touch, 2+DP and PT
pulses bilaterally
Neurologic: alert and oriented x 3, but was confused at times
and unable to clearly articulate her history. CN II-XII intact,
normal strength, bulk and tone throughout.
Skin: no rashes or lesions.
Rectal: guiaic negative.
Pertinent Results:
Labs on admission:
[**2104-11-15**] 03:11PM CK(CPK)-20*
[**2104-11-15**] 03:11PM CK-MB-3 cTropnT-<0.01
[**2104-11-15**] 11:03AM HGB-9.9* calcHCT-30
[**2104-11-15**] 09:43AM TYPE-ART TEMP-37.1 O2-75 PO2-59* PCO2-37
PH-7.49* TOTAL CO2-27 BASE XS-4 INTUBATED-NOT INTUBA
[**2104-11-15**] 09:35AM URINE HOURS-RANDOM
[**2104-11-15**] 09:35AM URINE GR HOLD-HOLD
[**2104-11-15**] 09:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2104-11-15**] 04:15AM GLUCOSE-98 UREA N-10 CREAT-0.5 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2104-11-15**] 04:15AM ALT(SGPT)-27 AST(SGOT)-40 LD(LDH)-283*
CK(CPK)-22* ALK PHOS-76 AMYLASE-69 TOT BILI-0.5
[**2104-11-15**] 04:15AM LIPASE-60
[**2104-11-15**] 04:15AM cTropnT-<0.01
[**2104-11-15**] 04:15AM CK-MB-NotDone
[**2104-11-15**] 04:15AM DIGOXIN-0.6*
[**2104-11-15**] 04:15AM NEUTS-85.9* BANDS-0 LYMPHS-8.3* MONOS-4.8
EOS-0.9 BASOS-0.1
[**2104-11-15**] 04:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2104-11-15**] 04:15AM PT-23.9* PTT-36.2* INR(PT)-3.6
[**2104-11-15**] 04:15AM RET AUT-4.0*
Brief Hospital Course:
1. Hypoxia: The pt. was admitted to the MICU for hypoxia. The
cause was felt to be multifactorial and secondary to underlying
pulmonary fibrosis, COPD, CHF and pneumonia. Initially, she was
thought to be in heart failure and was diuresed with some
improvement in her hypoxia on the first hospital day. Further
diuresis, however, proved unsatisfactory. A TTE was performed
which revealed preserved global biventricular systolic function,
moderate pulmonary artery systolic hypertension., moderate
mitral regurgitation, moderate tricuspid regurgitation, and mild
aortic regurgitation.
Initially, she was treated with vancomycin, and levofloxacin for
pneumonia. After a speech and swallow evaluation was performed
which revealed that the pt. was aspirating, metronidazole was
added for anaerobic coverage. She deteriorated clinically over
the course of the first three hospital days, however, with
increasing oxygen demands. On the fourth hospital day, IV
steroids were begun in attempt to treat her underlying pulmonary
fibrosis. This led to a marked improvement in her clinical
status as her respiratory distress was ameliorated. She was
eventually weaned down to 4L of O2 via nasal cannula prior to
transfer to the floor.
She continued to do well on the floor and was further weaned to
3L O2 by NC. Vancomycin was discontinued and the pt was
discharged on Levofloxacin and Flagyl to complete a total of 14
days. Her steroids were tapered starting the day of discharge
when she was switched from Solumedrol to prednisone 60 mg PO qd.
She will continue on a slow steroid taper after discharge.
2. Anemia: The pt. was noted to have a low hematocrit on
admission. Workup revealed studies consistent with anemia of
chronic inflammation. She was transfused a total of one unit of
packed red blood cells for a hematocrit below 27. Her hematocrit
was stable throughout her floor admission.
3. Diabetes mellitus: The pt. had well-contolled glucose levels
on a sliding scale of regular insulin until IV steroids were
begun at which time she required an insulin drip to maintain
adequate serum glucose levels. She was transitioned back to a
sliding scale of regular insulin prior to transfer to the floor.
She was restartedon Metformin at the time of discharge and may
required sliding scale insulin while on steroids.
4. Aspiration: The pt. had a speech and swallow evaluation on
the second hospital day which showed evidence of aspiration.
Accordingly, she was begun on tube feeds. A speech and swallow
exam was repeated on [**11-21**], which did not show any aspiration.
Her NG tube was discontinued and she was placed on pureed foods
and was taking pills.
5. Atrial fibrillation: On presentation the pt. was found to be
in atrial fibrillation with a rapid ventricular response. This
was successfully rate-controlled with the addition of metoprolol
and digoxin. She was maintained on warfarin with a therapeutic
INR for stroke prophylaxis.
6. ?Dementia: Pt may have been developing dementia over the last
months. She was intermittently delerious during her
hospitalization. At the time of discharge she is oriented to
place and person, but not time.
Medications on Admission:
-levofloxacin 250mg po daily x 5 days
-vancomycin 1g IV daily x 1 day
-ceftriaxone 2g IV daily x 2 days
-lasix 20mg po daily
-albuterol-ipratropium nebs q6h prn
-fluticasone 2 puffs ih [**Hospital1 **]
-warfarin, dose based on INR per rehab notes.
-digoxin 0.125mg po daily
-atenolol 50mg po daily
-metformin 500mg po daily
-lansoprazole 30mg po daily
-oxazepam 15mg po daily
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
12. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks.
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 weeks.
16. Haloperidol 3-5 mg IV HS:PRN anxiety
17. Methylprednisolone
80mg qd until [**11-23**], then 60mg qd x 1wk, then 40mg qd x 1wk,
then 20mg qd x 1wk, then 10mg qd x 1 wk, then off.
18. Regular Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
pneumonia
COPD
pulmonary fibrosis
atrial fibrillation
diabetes mellitus
Discharge Condition:
Stable on 2-3L O2 NC.
Discharge Instructions:
Continue taking your medications as prescribed. Call your
primary care physician or return to the emergency room if you
have increasing shortness of breath, cough, or fevers. Continue
taking your medications (antibiotics and prednisone) as
directed.
Followup Instructions:
Please call your primary care physician for [**Name Initial (PRE) **] follow up
appointment within 2 weeks of discharge from the hospital.
Patient was discharged to an extended care facility
|
[
"507.0",
"V10.05",
"285.9",
"250.00",
"427.31",
"424.0",
"294.8",
"428.0",
"428.22",
"496",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9990, 10069
|
4773, 7938
|
338, 345
|
10184, 10207
|
3590, 3595
|
10505, 10699
|
2847, 2866
|
8364, 9967
|
10090, 10163
|
7964, 8341
|
10231, 10482
|
2881, 3571
|
278, 300
|
373, 2487
|
3610, 4750
|
2509, 2728
|
2744, 2831
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,133
| 142,953
|
44465
|
Discharge summary
|
report
|
Admission Date: [**2197-5-26**] Discharge Date: [**2197-5-29**]
Date of Birth: [**2132-9-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher stents to proximal Ramus,
mid RCA
History of Present Illness:
Patient is a 64 yo M with CAD s/p MI in [**2176**], '[**83**], '[**88**] with
stenting to his RCA in '[**83**], '[**92**] and to his LAD in [**2188**], 2 vessel
CAD per cath in [**2192**], as well as well controlled DM2, HTN,
hyperlipidemia who presents with chest pain. Pt was in his USOH
until this AM doing yard work. The patient experienced [**8-30**]
SSCP with extreme diaphoresis and mild nausea, similar to his
previous heart attacks. The pain did not radiate. The pain was
initially unrelieved by SL nitro x4. The pain resolved by the
time the EMTs arrived, but returned in the ambulance.
.
In the ED, EKG demonstrated 2mm ST elevations in II, III, aVF as
well as in V3-V6. Pt was given ASA, Plavix, heparin gtt,
integrillin gtt, nitro/morphine and taken to the cath lab
urgently.
.
In the cath lab, the patient was found to have 40% mid LAD
stenosis, 90% ostial, 40% mid in-stent mild RCA stenosis. Cypher
stent was placed to ostial RCA requiring rotoblation with
satisfactory result. Patient was also found to have elevated PA,
PCWP and was given Lasix 20mg IV.
.
On arrival to the CCU, the patient did complain of [**12-31**] chest
pain, much improved from presentation. The patient otherwise
felt well and denied any complaints.
.
On further ROS, the patient had been otherwise well. His last
episode of chest pain was one month ago while at work, relieved
by SL nitro x2. He otherwise denied HA, lightheadedness, f/c,
SOB, PND, orthopnea, red/black stool, easy bruising, bleeding,
or sudden neurological changes.
.
Cardiac review of systems is notable for 2/10 chest pain, NO
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CAD, status post MI in [**2176**], [**2183**], and [**2188**]. Had a PTCA and
stenting of his RCA in [**2183**]. He had stenting of his distal,
middle, and proximal LAD in [**2189-1-19**]. Cathed in [**2192**] (see
below) s/p Cypher stents to prox Ramus, mid RCA. Exercise MIBI
in [**1-23**] demonstrated good exercise tolerance (9.5 min on [**Doctor First Name **])
w/o ischemic changes, and fixed inferior wall defect.
2. Dyslipidemia: [**3-27**] LDL 66, HDL 47, Chol 148
3. Hypertension.
4. Type 2 diabetes mellitus: [**3-27**] Hgb A1C 6.4%
5. Tinnitus.
6. Anxiety.
7. NASH (negative hepatitis A, B, and C; negative [**Doctor First Name **]).
.
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: CABG: N/A
.
Percutaneous coronary intervention, in [**2192**] anatomy as follows:
Right dominant system. 2 vessel CAD with the LMCA with mild
luminal irregularites. The LAD had mild luminal irregularities
with no flow limitation and a widely patent previously placed
stent. There was a large caliber ramus vessel with a focal 80%
stenosis. The LCx had mild luminal irregularities and no flow
limitations. The RCA had mild diffuse disease with a 40% ostial
stenosis followed by a 50% mid stenosis and a 70% distal lesion
just after the previously placed stent. EF 50% with mild
inferior hypokinesis.
.
Hemodynamic evaluation showed marked elevation of right and left
heart filling pressures with a RVEDP of 15mmHg and LVEDP of
26mmHg. There was evidence of pumonary HTN with a PAP of
60/22mmHg. The cardiac index was preserved (3.1lt/min/m2).
.
s/p Cypher stents to prox Ramus, mid RCA
Social History:
Patient lives at home with him wife. Is a mechanical engineer.
He has a 60 pack yr smoking history but quit over 25 yrs ago. He
drinks occatinally. He denies recreational drugs. He is very
active in his ADLs
Family History:
Positive for MI in his father. Mother with end stage renal
disease
Physical Exam:
VS: T 96.8, BP 130/42, HR 62, RR 11, O2 100% on 3L NC
Gen: Pleasant, well appearing caucasian male in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm. No bruits appreciated
CV: RR, normal S1, S2. No S4, no S3. no m/r/g
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Clear ant/lat with
faint bibasilar rales
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R groin with mild oozing but no masses or
tenderness. Ext otherwise warm
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG (in CCU): NSR at 60bpm, nl Axis, 1.5mm ST elevations in II,
III, aVF, TWI in aVL, and resolution of ST elevations in V3-V6
2D-ECHOCARDIOGRAM performed on [**2197-5-26**] demonstrated:
Mildly dilated left atrium. Normal Left ventricular wall
thicknesses and
cavity size. Mild regional left ventricular systolic dysfunction
with focal severe hypokinesis of the basal half of the inferior
wall, remaining LV segments contract normally. Normal RV chamber
size and free wall motion. Mildly thickened aortic valve
leaflets without aortic stenosis. No AR. Trivial mitral
regurgitation is seen. Anterior space most likely represents a
fat pad. Compared with [**2194-1-31**], the inferior wall motion
abnormality is more pronounced.
CARDIAC CATH performed on [**2197-5-26**] demonstrated:
Right dominant, 40% mid LAD stenosis. Patent ramus stent. 90%
ostial RCA stenosis also with 40% mid in-stent restenosis.
HEMODYNAMICS: PCWP mean 26mmHg, RA mean 15 mmHg, PAP 59/22/39
CXR [**2197-5-28**] No evidence of congestive heart failure. Right lower
lobe linear atelectasis most likely due to elevated right
hemidiaphragm.
[**2197-5-26**] 10:45AM BLOOD CK(CPK)-147 CK-MB-4 cTropnT-<0.01
[**2197-5-26**] 10:09PM BLOOD CK(CPK)-814* CK-MB-76* MB Indx-9.3
cTropnT-0.85*
[**2197-5-27**] 02:35AM BLOOD CK(CPK)-694* CK-MB-46* MB Indx-6.6*
[**2197-5-27**] 03:31AM BLOOD CK(CPK)-909* CK-MB-84* MB Indx-9.2*
cTropnT-1.03*
[**2197-5-27**] 03:31AM BLOOD ALT-50* AST-127* LD(LDH)-353* AlkPhos-62
TotBili-0.8
[**2197-5-26**] Glucose-276* UreaN-22* Creat-0.9 Na-143 K-4.1 Cl-109*
HCO3-20*
[**2197-5-29**] Glucose-152* UreaN-16 Creat-0.9 Na-137 K-4.8 Cl-102
HCO3-28
[**2197-5-28**] PT-12.2 PTT-23.6 INR(PT)-1.0
[**2197-5-26**] WBC-9.3# RBC-3.95* Hgb-12.6* Hct-36.1* MCV-91 MCH-32.0
MCHC-35.0 RDW-12.5 Plt Ct-246
[**2197-5-28**] WBC-8.9 RBC-4.02* Hgb-12.6* Hct-37.4* MCV-93 MCH-31.4
MCHC-33.8 RDW-12.9 Plt Ct-244
Brief Hospital Course:
64 yo M with CAD s/p multiple MIs, s/p multiple stents to RCA,
LAD, ramus, DM2, HTN, hyperlipidemia presents with chest pain
and STEMI, s/p cardiac cath and further stenting to ostial RCA.
STEMI: Pt with known CAD with multiple interventions in the
past. Pt found to have 40% mid LAD stenosis, and 90% ostial,
40% mid in-stent mild RCA stenosis. Ostial RCA required
rotoblation then Cypher stent was placed. The rest of his stents
were patent. Patient's chest pain resolved. Still with residual
STEs inferiorly. CEs peaked at CK = 909. He was treated
medically with ASA 325mg daily, plavix 75mg daily, beta blocker
and ACEI as tolerated, and high dose statin. He is to continue
plavix for at least one year and instructed on the importance of
this. He is not to stop this medication without first talking
to his cardiologist.
Pump: Echo done post-MI and EF currently depressed at 45% in
setting of STEMI. He had high PA pressures and PCWP in cath lab
and likely ventricular dysfunction. He was diuresed until
euvolemic. He was continued on ACEI.
Rhythm: Patient remained in normal sinus rhythm.
.
Type 2 Diabetes: Last A1C in [**3-27**] 6.4% and relatively controlled
blood glucose. Continued on aggressive HISS while in house.
Restarted glucotrol and Januvia on discharge.
HTN: Switched outpatient BB (carvedilol) to Lopressor and ACEI
(lisinopril) and increased doses as tolerated. Held Diltiazem.
Will discharge on metoprolol ER 150mg daily and lisinopril 2.5mg
daily. Would like to increase lisinopril as outpatient if blood
pressure can tolerate it.
Dyslipidemia: Per lipid panel in [**3-27**], was adequately controlled
on current regimen (TC 148 LDL 66 HDL 47). However, in setting
of acute MI, started high-dose crestor (40mg).
Anxiety: Currently stable. Contined on lexapro 10mg daily.
Patient was discharge home in stable condition without
complaints of SOB, CP, or palpitations. Vitals on discharge BP
102/56 HR 75 RR 18 Pox 97% on RA. Physical exam on discharge
revealed moist mucous membranes, heart regular rate and rhythm,
lungs clear and extremities warm, without edema. Right groin
site with minimal ecchymosis without bruit. He was instructed
to follow-up with his PCP and his outpatient cardiologist, Dr.
[**Last Name (STitle) **] within one month.
Medications on Admission:
Coreg 25 mg [**Hospital1 **]
Cartia 120 mg qday,
Lisinopril 2.5 mg qday
Aspirin 325 mg qday
Crestor 10 mg qday
Januvia 5mg daily
Glucotrol 2.5mg [**Hospital1 **]
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. 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*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. JANUVIA Oral
8. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Dyslipidemia
Hypertension
Diabetes
Discharge Condition:
ambulating, afebrile, comfortable on room air
Discharge Instructions:
You have been evaluated for your chest pain; you were found to
have a heart attack. You had a stent placed in one of the
arteries to your heart. You need to take your ASPIRIN and PLAVIX
EVERY DAY. You will be on aspirin therapy for life. You should
not discontinue your plavix without discussing with your
cardiologist first. You should take it easy for 1-2 weeks.
Please take your medications as prescribed. Please contact your
primary physician or return to the emergency room should you
develop any of the following symptoms: chest pain, difficulty
breathing, pain in your groin, numbness or tingling in either
leg, back pain, fever > 101, chills, dizziness or
lightheadedness or any other concerns.
Followup Instructions:
Please contact your primary care physician for an appointment
within 1-2 weeks. You can contact Dr. [**Last Name (STitle) 2903**] at [**Telephone/Fax (1) 2205**].
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], within
2-4 weeks. Dr.[**Name (NI) 20312**] office will contact you with an
appointment time. If you have not heard from them by the end of
the week, please call [**Telephone/Fax (1) 4022**] to make an appointment.
|
[
"414.01",
"416.0",
"518.0",
"V45.82",
"401.9",
"272.4",
"250.00",
"300.00",
"410.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"00.45",
"00.66",
"37.21",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
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] |
10129, 10135
|
6848, 9144
|
324, 396
|
10249, 10297
|
4923, 6825
|
11049, 11502
|
4014, 4082
|
9357, 10106
|
10156, 10228
|
9170, 9334
|
10321, 11026
|
4097, 4904
|
274, 286
|
424, 2127
|
2149, 3773
|
3789, 3998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,709
| 159,724
|
6884
|
Discharge summary
|
report
|
Admission Date: [**2183-2-12**] Discharge Date: [**2183-3-26**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Colon cancer
Major Surgical or Invasive Procedure:
Sigmoid colectomy and partial small bowel resection
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **]-year-old gentleman with a [**1-10**] month history
of not feeling well, associated with weight loss of an unknown
amount, and diarrhea. On workup, he was found to have a sigmoid
colon cancer at 25 cm and CT scan showed a possible adherent
matted loop of small bowel which may have a small bowel fistula.
He presents now for resection.
Past Medical History:
1st degree AV block
Social History:
Denies EtOH or tobacco
Family History:
NC
Physical Exam:
At time of discharge:
Alert, oriented X 1 (self only)
PERRL, EOMI
RRR
CTAB
Abdomen soft, NT/ND, +bs, no masses, well healing incision
Ext without C/C/E
Pertinent Results:
Pathology results from 3/8/6
Segmental resection of colon (sigmoid): Mucinous adenocarcinoma,
arising in a villous adenoma. The carcinoma extends through the
colonic wall and invades the full thickness of an adjacent
segment of small bowel, forming two fistula tracts
[**2183-3-3**]: WBC-5.7 RBC-3.24* Hgb-9.0* Hct-27.5* MCV-85 MCH-27.8
MCHC-32.7 RDW-17.5* Plt Ct-281
[**2183-3-5**]: Hct-36.1*#
[**2183-2-16**]: PT-12.1 PTT-29.3 INR(PT)-1.0
[**2183-3-5**]: Glucose-133* UreaN-65* Creat-2.1* Na-143 K-5.6* Cl-108
HCO3-26 AnGap-15
03/28/06Glucose-117* UreaN-54* Creat-1.4* Na-144 K-4.7 Cl-111*
HCO3-25 AnGap-13
[**2183-2-12**]: Glucose-123* UreaN-17 Creat-1.0 Na-143 K-3.8 Cl-116*
HCO3-18* AnGap-13
[**2183-2-14**]: ALT-10 AST-23 LD(LDH)-185 AlkPhos-84 Amylase-14
TotBili-0.3
Lipase-10
[**2183-2-18**]: proBNP-9278*
[**2183-2-17**]: proBNP-[**Numeric Identifier 25969**]*
[**2183-2-12**]: CK-MB-NotDone cTropnT-0.06*
[**2183-2-13**]: CK-MB-NotDone cTropnT-0.07*
[**2183-2-13**]: CK-MB-7 cTropnT-0.06*
[**2183-3-5**]: Calcium-9.8 Phos-4.3 Mg-1.9
[**2183-2-19**]: TSH-8.0*
Brief Hospital Course:
On [**2183-2-12**] Mr. [**Known lastname **] was admitted to the surgery service under
the care of Dr. [**Last Name (STitle) **]. He was taken to the OR for resection.
For details of the operation, please see Dr.[**Name (NI) 6218**] operative
report. Postoperatively he was admitted to the ICU and placed on
an amiodarone drip due to rapid atrial fibrillation. His pain
was well controlled with an epidural. Cardiology and EPS were
consulted POD1 for assistance in controlling Mr. [**Known lastname 1226**]
tachycardia. Once stable, Mr. [**Known lastname **] was transferred to the
floor on HD 3. His diet was slowly advanced. On the night of HD
4, he was found to be increasingly somnolent, difficult to
arouse, and unable to follow commands. His ABG was 7.27/51/66/24
and he was hypernatremic. He was transferred back to the ICU for
close monitoring. Due to increasing agitation Mr. [**Known lastname **] [**Last Name (Titles) 25970**]d to pull out his foley, Dobhoff that had been placed
for tube feeding, and his IV. Geriatrics was consulted for his
mental status changes and felt that his pain medication may have
contributed to his confusion. His pain was now well controlled
with tylenol only. He was transferred back to the floor on POD 8
with a 1:1 sitter. He gradually became slightly more alert and
oriented as his hypernatremia was corrected. His diet was
advanced to regular, however his po intake was poor. Supplements
and TPN were initiated. On HD 20, TPN, PICC and foley were
d/c'd. Pts PO intake remained poor. His BUN and creatinine
continued to rise. On HD 22, IVF were reinitiated. HD 23,
substantial increase of K to 6.5 with increase BUN to 80 and
creatinine 2.1. Urine lytes were ordered along with stat EKG.
Renal was consulted. Gerientology continued to follow pt and
provide recs. Notable decline in mental status and increase in
agitation. Pts state continued to decline with increased
creatinine and BUN. Multiple boluses were adminsitered. On HD
26, urine output noted to have decreased to less than 15/hr.
Oxygen level had diminshed to 88% on room air and was placed on
a fask mask with which he had sats of 93%. Pt transferred to the
unit. Continued decline in respiration and patient foudn to be
acidotic as per ABG. Pt intubated and NGT placed. Renal team
spoken with and dialysis begun. As the hospitalization
progressed, his overall status began to improve.
Neurologically, all hiss sedation was minimized. We were able
to wean all of his pressor support. In terms of the ventilator,
he was weaned to nasal cannula gradually. Tube feeds were
initiated via a g-tube(placed [**3-16**]) and advanced to goal rate
with good urine output. He finished a course of meropenum for
enterobacter in the blood. The patient was being screened for
rehab when on the morning of [**3-26**], he acutly went into
bradycardia, then cardiac arrest. Patient was intubated and
ACLS protocol was initiated. The attending surgeon was present
at that time and after a short period of time, the code was
called and the patient expired.
Medications on Admission:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Colon cancer
Discharge Condition:
expired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
|
[
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"427.31",
"427.5",
"401.9",
"276.51",
"428.0",
"244.9",
"569.81",
"599.0",
"197.4",
"293.0",
"153.3",
"276.0",
"790.7",
"996.62",
"584.5",
"518.81"
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icd9cm
|
[
[
[]
]
] |
[
"45.62",
"96.72",
"96.6",
"43.11",
"93.90",
"96.04",
"99.15",
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"38.95",
"39.95",
"38.93",
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icd9pcs
|
[
[
[]
]
] |
5244, 5317
|
2135, 5189
|
282, 336
|
5374, 5525
|
1041, 2112
|
849, 853
|
5338, 5353
|
5215, 5221
|
868, 1022
|
230, 244
|
364, 750
|
772, 793
|
809, 833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,027
| 119,352
|
35158
|
Discharge summary
|
report
|
Admission Date: [**2189-4-20**] Discharge Date: [**2189-4-23**]
Date of Birth: [**2121-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Ventricular Tachycardia
Major Surgical or Invasive Procedure:
EP study
History of Present Illness:
This patient is a 67 y/o with a history of nonischemic
cardiomyopathy s/p ICD for primary prevention (VT in past,
[**1-11**], VF- shocked appropriately). He has been on amiodarone
since since end of [**2187**], and developed thyroid dysfunction. He
wishes to come off the arrythmia and presented to Dr. [**Last Name (STitle) **]
[**12-13**] for EP study for the possibilty of ablation to terminate
the VT. He discontinued amiodarone 1 month ago.
The patient had EP study for VT/VF ablation, and was shocked
externally for VF. He LV and RV were mapped and there ws no scar
seen, normal voltage. Given that there was no scar to ablate and
he had VF in the lab, the plan is for dofetilide load. Of note,
he had an 8 french arterial sheeth and 3 venous sheeths on the
right.
On admission to the CCU, patient was complaining of pain in his
mid back. he denied chest pain, lightheadedness, palpatations,
shortness of nreath
On review of systems:
- he denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools.
- He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Nonischemic cardiomyopathy, LVEF 35%
s/p ICD implantation in [**2184**]
Ventricular Tachycardia
BPH
Resection of skin cancer
s/p resection of a lipoma from the back
CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension
CARDIAC HISTORY:
-CABG: no
-PERCUTANEOUS CORONARY INTERVENTIONS: none. per report had clean
cath [**2187**].
-PACING/ICD: [**2184**], primary prevention ICD for nonischemic
cardiomyopathy. Guidant VVI ICD
Social History:
Social History: He is married. He has two daughters who are
healthy one [**Doctor Last Name **] daughter who is also healthy. He denies any
tobacco use and has alcohol on rare occasions.
Family History:
Family History: His father is deceased. He died at 76 due to
congestive heart failure. His mother died of breast cancer. He
has one brother in the [**Hospital3 **] Systems who has multiple
medical problems, mostly due to chronic alcohol abuse. He has
two sisters who are healthy. There is no family history of
sudden cardiac death.
Physical Exam:
VS: T 96.2, 55, 122/62, 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pall
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly and laterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. left and right groin, minimal pain, no
hematoma, no bruits
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
ECG: sinus bradycardia, rate 56,
Pertinent Results:
Lab Data
[**2189-4-20**] 10:40AM BLOOD Glucose-92 UreaN-19 Creat-0.9 Na-141
K-4.5 Cl-105 HCO3-31 AnGap-10
[**2189-4-20**] 10:40AM BLOOD WBC-5.5 RBC-4.06* Hgb-12.9* Hct-37.0*
MCV-91 MCH-31.7 MCHC-34.7 RDW-13.6 Plt Ct-219
[**2189-4-23**] 05:35AM BLOOD WBC-6.3 RBC-3.70* Hgb-11.8* Hct-34.0*
MCV-92 MCH-32.0 MCHC-34.9 RDW-13.6 Plt Ct-200
[**2189-4-23**] 05:35AM BLOOD Glucose-101 UreaN-17 Creat-0.9 Na-142
K-4.9 Cl-107 HCO3-28 AnGap-12
No micro data
Imaging
ECGs
[**4-20**] Sinus bradycardia
Ventricular premature complex
Left axis deviation
Intraventricular conduction delay with left anterior fascicular
block
Lateral ST-T changes are nonspecific
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 184 122 472/472 62 -60 107
[**4-20**] Sinus rhythm with ventricular premature complexes
Left axis deviation
Intraventricular conduction delay with left anterior fascicular
block
Lateral ST-T changes are nonspecific
Since previous tracing of the same date, no significant change
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 160 124 458/473 61 -56 103
[**2189-4-21**] Sinus bradycardia
Left axis deviation
Intraventricular conduction delay with left anterior fascicular
block
Lateral ST-T changes
Since previous tracing of [**2189-4-20**], heart rate slower,
ventricular premature
complex not seen, and QTc interval longer
Intervals Axes
Rate PR QRS QT/QTc P QRS T
50 196 122 518/500 56 -60 124
Brief Hospital Course:
Ventricular Tachycardia/Fibrillation: Pt has h/o VT previously
on amiodarone which was discontinued secondary to thyroid
dysfunction. He had EP study where he had 1 episode of induced
VF requiring DCCV with no scar to ablate. He had normal LV
voltage map. He was loaded with dofetilide. He had mild QT
prolongation on dofetilide 500 mcg [**Hospital1 **] (QTc ~480) so dose was
reduced to 125 mcg [**Hospital1 **]. He received 6 doses in house and was
monitored on telemetry without event. He will have an event
monitor at discharge for 2 weeks and have his creatinine checked
every 3 months while on dofetilide. He should avoid taking
hydrochlorothiazide or verapamil while on dofetilide.
Urinary retention: Likely due to longstanding BPH. Patient
initially taking tamsulosin in house, although switched to his
home alfuzosin. Foley was d/c'd and he had residual bladder
volume of 750ml. His outpatient urologist was called; foley was
replaced and he'll follow up with urology the day following
discharge.
Medications on Admission:
Coreg 3.125mg twice a day
Levothyroxine 25mcg daily every morning
Pravastatin 20mg daily every evening
Uroxatral 10mg daily every evening
Aspirin 81mg daily every morning
Amiodarone discontinued one month ago
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
7. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO daily ().
8. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Tachycardia
Non-ischemic cardiomyopathy
Chronic Systolic Dysfunction EF 20%
Benign Prostatic Hypertrophy
Urinary Retension
Discharge Condition:
stable.
Discharge Instructions:
You had an ablation that was unsuccessful in finding an
inducable ventricular tachycardia. You had a ventricular
fibrillation arrythmia that required an external shock. You were
admitted for a dofetilide load (Tikosyn) and had frequent ECG's
to monitor your QT interval. Dr. [**Last Name (STitle) **] would like you to
have an event monitor at discharge for 2 weeks. You need to have
your creatinine checked every 3 months while you are taking
Tikosyn. Do not take any hydrochlorothiazide or Verapamil when
you are on Tikosyn. This was given to you in the hospital and
instructions regarding use were reveiwed with you.
Medication changes:
1. Dofetalide 125mg twice daily: to prevent ventricular
tachycardia instead of the amiodarone.
2. Lisinopril: to decrease the pressure that your heart pumps
against and help your heart pump better.
.
You had trouble urinating after we took out the foley catheter.
We talked to Dr. [**Last Name (STitle) 80249**] who asked that we replace the foley
and you will see him tomorrow for further treatment.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] if you have any trouble getting
the Tikosyn or if you have any questions about this discharge.
Followup Instructions:
Cardiology:
[**Doctor First Name **]-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] Phone: [**Telephone/Fax (1) 11254**] Date/time: Tuesday
[**5-5**] at 12:15pm.
.
Electrophysiology:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Friday [**7-31**] at 1:40pm.
.
Urology:
Dr. [**Last Name (STitle) 80249**] Phone: [**Telephone/Fax (1) 80250**] Friday [**4-24**] at 11:45am.
.
Completed by:[**2189-4-23**]
|
[
"429.9",
"600.00",
"V45.02",
"244.9",
"425.4",
"426.82",
"427.41",
"788.20",
"V10.83",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
6970, 6976
|
5030, 6038
|
340, 350
|
7155, 7165
|
3574, 5007
|
8571, 9057
|
2530, 2848
|
6298, 6947
|
6997, 7134
|
6064, 6275
|
7189, 7809
|
2863, 3555
|
1321, 1831
|
7829, 8548
|
277, 302
|
378, 1302
|
1853, 2293
|
2325, 2498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,130
| 149,384
|
40366
|
Discharge summary
|
report
|
Admission Date: [**2113-11-6**] Discharge Date: [**2113-12-5**]
Date of Birth: [**2092-2-11**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
trauma s/p fall
Major Surgical or Invasive Procedure:
[**2113-11-6**]
1. Right common femoral arterial access.
2. Aortogram.
3. Selective angiograms of right T9, T10 and T11 posterior
intercostal arteries with coil and Amplatzer plug and Gelfoam
embolization.
[**2113-11-13**]
1. Percutaneous tracheostomy with bronchoscopy.
2. Percutaneous endoscopic gastrostomy.
3. Scalp laceration debridement, washout and complex
layered closure, total length 13 cm.
[**2113-11-17**]
Right thoracentesis
[**2113-11-17**]
left thoracostomy tube placement
History of Present Illness:
20 year old male who complains of S/P
FALL. The patient was seen upon arrival. This is called as a
trauma stat. The patient reportedly fell 20 feet onto his
head. He is in obvious scalp laceration in the field. There
were attempts at intubation. His GCS was initially 3. He
then woke up and became more combative. The paramedics were
unable to take a blood pressure because he was combative.
Past Medical History:
PMH: schizophreniform d/o
PSH: none
[**Last Name (un) 1724**]: none
Social History:
lives with his mother, was attending BU on an
acting scholarship when he first developed psychoses. He has had
some legal issues, on probation for acting bizarrely and
resisting arrest.
Substance use history: mother reports heavy THC use in the past
and occasional alcohol abuse as well.
Family History:
NC
Physical Exam:
On Admit per ED note:
HR:120 BP:145
Constitutional: Collar and backboard, he has occipital
laceration that is bleeding.
HEENT: Pupils are midpoint there is right eye deviation the
right eye
collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Back was visualized and there was no obvious
trauma
Neuro: He is combative mildly. He appears to be moving all
extremities. We are unable to assess his mental status.
Pertinent Results:
MICRO:
[**11-7**] MRSA screen: negative
[**11-10**] UCx: negative
[**11-10**] BCx: NG
[**11-10**] sputum: NGTD
[**11-12**] BAL: GS- 2+PMNs, 1+sq epith cells, 2+GPCs pairs/clusters;
Cx- MORAXELLA CATARRHALIS. >100,000 ORGANISMS/ML..
[**11-12**] BCx: NG
[**11-12**] UCx: NG
[**11-17**]: UCx - no growth
[**11-17**]: Blood Cx - No growth
[**11-17**]: BAL - 3+ GNR, 3+ GPC - coag + staph - resistant only to
clinda and erythro
[**11-17**]: Pleural fluid: GS negative, Cx - No growth
[**11-21**]: UCx No growth
IMAGING:
[**11-6**] CXR: mediastinal double density(? paraspinal hematoma);
right sided rib fractures
[**11-6**] CT HEAD: WETREAD - Left SDH along left cerebral convexity
with 6mm rightward shift from midline. small right temporal
parenchymal contusion. bilateral occipital subgaleal hematomas.
occipital skull fracture. left occipital condyle fracture.
[**11-6**] CT C-SPINE: WETREAD - left occipital condyle fracture.
rest of C-spine intact. mediastinal hematoma better assessed on
CT Chest. Intubated.
[**11-6**] CT TORSO: WETREAD - Extensive posterior mediastinal
hematoma, likely from disruption of intercostal vessels, with
two small areas of active extravasation. Aorta and major blood
vessels intact without pseudoaneurysm. Multiple posterior right
rib fractures with anterior displacement of ribs [**6-25**]. Multiple
pulmonary contusions and lacerations. Right transverse process
fractures of L1-L4.
[**11-6**] Angio: T9 parenchymal blush -> 12 coils, T10 -> 6mm plug,
T11 transected pseudoaneurysm -> 6 coils
[**11-7**] CT HEAD: WETREAD - interval increase in intra- and
extra-axial hemorrhage
[**11-7**]:TTE:The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
a small pericardial effusion.
[**11-8**]: HCT: Minimal change from the previous study with
redemonstrated
extensive, multifocal intra- and extra-axial hemorrhage and
cerebral edema, in pattern suggestive of both contusions and
[**Doctor First Name **], without evidence of new intracranial hemorrhage.
[**11-10**] CXR: As compared to the previous radiograph, the position
of the endotracheal tube is unchanged. The tip is located
projecting 2.1 cm above the carina. This is relatively low, the
tube could be pulled back by approximately 1 cm. Unchanged
course of the nasogastric tube and of the left subclavian access
line. Minimal decrease in extent of the pre-existing large left
pleural effusion, mild increase in extent of the pre-existing
moderate-to-large right pleural
effusion, with increasing atelectatic consolidation of the right
lower lung. Unchanged size of the cardiac silhouette. No
detectable additional parenchymal abnormality.
[**11-10**] HCT: pending
[**11-11**] CXR: The ET tube tip is low, 2 cm above the carina. The
left subclavian line tip is at the level of mid SVC. The NG tube
tip is in the stomach. There is no change in pulmonary edema,
bilateral pleural effusions, although minimal improvement of the
right base aeration is noted as well as status post embolization
of right posterior intercostal arteries.
[**11-12**] CXR: b/l large pleural effusions unchanged. bibasilar
opacities. mild pulmonary edema. overall no significant changes.
[**11-14**]: CXR: Worsening moderate pleural effusions. Bibasilar
atelectasis, worsened on the left. New right mid lung
atelectasis, less likely consolidation.
[**11-16**]: CXR - white out RML and RLL
[**11-17**]: CXR-Improved aeration of right middle lobe. Persistent
bilateral pleural effusions and lower lobe atelectasis.
[**11-18**]: CXR: Right hemidiaphragm is more sharply seen. This may
merely reflect the semi-upright rather than supine portable
technique. The appearance is consistent with pleural fluid and
volume loss at the right base. Retrocardiac opacification with
blunting of the left costophrenic angle is again consistent with
volume loss and effusion. Left chest tube remains in place and
there is no definite pneumothorax.
[**11-19**]: CXR - small left pneumothorax (after L CT to waterseal)
[**11-21**]: CXR: In comparison with the earlier study of this date,
there is little change in the moderate pneumothorax on the left.
Opacification in the retrocardiac area is consistent with a
substantial volume loss in the left lower lobe and small
effusion. A moderate right layering effusion is again seen.
Brief Hospital Course:
Patient evaluated in ED, trauma survey revealed the following
injuries:
post R rib fx with ant displacement
mult pulm contusions and lacs
Right tp fractures of L1-L4
posterior mediastinal hematoma
occipital skull fx
L occipital condyle fx
B/L subgaleal hematomas
R temporal parenchymal contusion
L SDH w/ assoc'd 6mm rightward shift
He was admitted tot he trauma ICU
ICU Course:
[**11-6**]: admission to TSICU. to IR for coil embolization of
bleeding intercostal vessels. post-IR head CT showed worsening
intra- and extra-axial hemorrhage. post-IR, hct and lactate
improving.
[**11-7**]: left subclavian TL placed, TF started
[**11-8**]:repeat HCT showed minimal change, kept on mannitol. When
switched to CPAP, his ICP increased and he became bradycardic.
As a result, he was kept on the ventilator and minimal sedation.
[**11-9**]: able to wean to CPAP without elevation in ICP, subsequent
ABGs looked good. bronch performed to evaluate persistent
hemoptysis. only hyperemia and small amount of clot seen.
[**11-10**]: TF increased to 80ml/h since propofol gtt decreased
[**11-11**]: extubated, bronch'd, had to be reintubated. aline resited
to L radius. spiked fever, pan-cultured.
[**11-12**]: bolt d/c'd by neurosurgery, vanc subsequently d/c'd.
started mannitol wean. TFs restarted. started motrin for
persistent fevers (spiking through tylenol). pt self-d/c'd L
radial aline, replaced.
[**11-13**]: trach/peg scalp lac washout. D/c dilantin.
[**11-14**]: family meeting; TF restarted
[**11-15**]: Transferred to floor
[**11-17**]: Back to TSICU for resp distress; put back on the
ventilator;USG chest showed bilateral pleural fluid; right sided
thoracentesis done; 650 cc of serosanguinous fluid
removed;sample sent for fluid analysis and gram stain & culture;
episode of SVT+; fluid bolus given.
[**11-18**]: Remained stable, tube feeds concentrated, flagyl DC'd.
[**11-21**]: BAL grew at coag + staph, will keep on vanc x 4 days due
to the fact that he is PCN allergic. Walked with PT, kept in
unit for increased secretions and intermittent desat. His PTX
was somewhat improved.
He was transferred to the floor as he no longer required ICU
level care.
Following transfer to the Trauma floor he began more treatment
with the Physical therapy service as well as Occupational
therapy. He was able to get up and walk but cognitively was
limited.
The Psychiatric service evaluated him daily and eventually his
sitter was weaned off and he was doing well on Respiradol only.
He will need continued evaluation and follow up after discharge
from rehab.
From a pulmonary standpoint he was able to cough up his
secretions but also required deep suctioning 5-6 times a day.
He was evaluated on multiple occasions for potential use of the
PMV however his secretions limited the use.
His nutrition was maintained with full strength Nutren at 40
ml/hr and was well tolerated, Again upon many evaluations by
the Speech and Swallow service he showed signs of frank
aspiration and therefore will need to be reassessed at rehab.
Due to his occipital condyle fracture he will need to stay in a
hard collar for 8 more weeks and at that time will have a repeat
head CT and further recommendations will be given. A small stage
2 pressure ulcer was noted on the left lower chin, probably from
the hard collar and the wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for
recommendaions. See page 1 referral for details.
From a cardiovascular standpoint he was started on low dose beta
blockade for persistent sinus tachycardia as high as 140. Since
inception his heart rate is in the 100-110 range. Hopefully as
his TBI resolves he will be able to come off the lopressor.
Otherwise he has had no cardiac issues.
After a long protracted hospital stay he was discharged to rehab
with the hope that his mental and physical issues will gradually
improve so that he may return home.
Medications on Admission:
none
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for pain, fever.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever, pain .
6. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
9. risperidone 1 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P Fall
1. Posterior right rib fracture
2. Pulmonary contusions
3. Right L [**12-19**] transverse process fracture
4. Posterior mediastinal hematoma
5. Occipital skull fracture
6. Left occipital condyle fracture
7. Bilateral subgaleal hematoma
8. Right temporal parenchymal contusion
9. Left subdural hematoma
10.Acute respiratory failure.
11.Malnutrition.
12.Scalp laceration.
13.TBI
14.Pneumonia
15.Stage 2 ulcer left lower chin
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital after falling about 10 feet
with multiple injuries including head trauma, broken bones and
internal injuries.
* You continue to improve with attentive nursing care, physical
therapy and occupational therapy.
* At this point, you need acute rehabilitation so that in time
you will be able to return home at your baseline prior to the
fall.
* As you continue to improve you will hopefully have your trach
tube removed as well as your feeding tube. You will need to
work hard at rehab to achieve these goals. Be patient.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-16**] weeks.
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment with Dr. [**Last Name (STitle) **] in 8 weeks. You will need a non
contrast Head CT prior to that appointment. The secretary will
arrange that for you.
Call the Cognitive Neurology dept. at [**Telephone/Fax (1) 1690**] for a follow
up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] after your discharge
from rehab.
Completed by:[**2113-12-5**]
|
[
"486",
"518.81",
"801.24",
"861.21",
"901.81",
"E882",
"873.0",
"707.09",
"E849.0",
"263.9",
"348.5",
"707.22",
"807.00",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"43.11",
"39.79",
"01.10",
"34.91",
"86.28",
"88.44",
"96.05",
"96.6",
"96.04",
"38.93",
"31.1",
"96.72",
"88.42",
"34.09",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12030, 12100
|
7020, 10923
|
286, 783
|
12576, 12576
|
2170, 2792
|
13341, 13934
|
1619, 1623
|
10978, 12007
|
12121, 12555
|
10949, 10955
|
12761, 13318
|
1638, 2151
|
231, 248
|
811, 1205
|
3719, 6997
|
12591, 12737
|
1227, 1296
|
1312, 1603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,239
| 130,496
|
18919
|
Discharge summary
|
report
|
Admission Date: [**2151-10-27**] Discharge Date: [**2151-11-6**]
Date of Birth: Sex: M
Service:
PROCEDURE PERFORMED: Pancreatic duodenectomy.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Diabetes mellitus.
3. Pancreatitis adenocarcinoma.
HOSPITAL COURSE: Mr. [**Known lastname 24698**] is a 62-year-old male who
presented with obstructive jaundice and underwent
preoperative workup and was found to have a mass suspicious
for pancreatic adenocarcinoma. He was taken to the Operating
Room where he underwent a pancreatic duodenectomy on
[**2151-10-27**]. He was admitted to the Intensive Care Unit after
surgery. He remained in the ICU for 24 hours with pain
control via an epidural. He was transferred to the floor on
postoperative day two. His perioperative course was
uncomplicated.
On postoperative day five his nasogastric tube put out
minimal fluid. He underwent an upper GI which demonstrated
adequate emptying from his gastric jejunostomy. The NG tube
was removed. There was no leak. The epidural was
discontinued. He was started on a clear liquid diet that was
slowly advanced over the next two days until he was able to
tolerate a regular diet. His final pathology report came
back with a node-positive, margin-positive lesion. This
information was discussed with the patient.
He was discharged home on [**2151-11-6**]. He will follow up with
Dr. [**First Name (STitle) **] in one week. At that time we will make a
referral to a hematologist/oncologist close to his home in
[**Hospital1 1474**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 30156**]
MEDQUIST36
D: [**2152-1-18**] 18:31
T: [**2152-1-20**] 17:42
JOB#: [**Job Number 51728**]
|
[
"577.1",
"575.11",
"157.0",
"272.0",
"197.8",
"250.00",
"401.9",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
192, 267
|
285, 1800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,658
| 114,657
|
5822
|
Discharge summary
|
report
|
Admission Date: [**2108-12-30**] Discharge Date: [**2109-1-4**]
Date of Birth: [**2023-5-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
CC: weakness/Low Hct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85-year-old female with The patient is a 85 yo F with a PMHx
significant for CHF, CAD, MV disease s/p replacement on
warfarin, afib presents with weakness, nausea/vomiting x1 and
large hematocrit drop.
.
The patient was in her usual state of health until roughly a few
months prior to presentation. At that time she developed dyspnea
on exertion that has been getting progressively worse. 1 week
prior to presentation the patient noted intermittent nausea.
Since that time she has a decreased oral intake. The day of
admission she had nausea, emesis x1 and diffuse weakness. At
that time she presented to [**Hospital1 18**] EW. The patient denies blood in
emesis or stool. The emesis appeared like cottage cheese, which
was what she had for dinner. She denies SOB at rest,
lightheadedness, chest pain, palpitations, epistaxis, hematuria,
back pain or other sypmtoms. Of note, she has not had any recent
change in medication.
.
In the EW, initial vitals were: T 97.2, HR 58, BP 108/61, RR 19,
SaO2 97% RA. Given her initial complaints of weakness and
shortness of breath the patient was given 325mg ASA and EKG was
done and negative. Hct very low so concern of GIB. Guaiac
negative. NGL initially negative but then turn positive with
bright red blood. Cleared with 800cc fluid. GI consulted who
recommended ICU admit for potential GIB. CTAP without RP bleed.
NGL pulled. Patient started on pantoprazole ggt. The patient
became hypotensive with systolic blood pressures in 90s. The
patient was given 2L NS and 2u pRBCs. The patient was
transferred to floor with HR 74, BP 125/83, RR 17, SaO2 97%RA.
.
Currently, the patient feels well and is without symptoms. She
denies any intermittent nausea, vomiting, bowel movement or
other symptoms.
.
Review of systems: + weakness, nausea, vomiting, DOE, chronic R
leg swelling. Last colonoscopy [**2090**].
Past Medical History:
Past Medical History (per OMR):
1. Diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. Osteoarthritis
5. Osteoporosis
6. Congestive heart failureEF 45%
7. Depression
8. Spinal stenosis
9. Obesity
10. Mitral valvular disease s/p replacement ([**2090**]; INR goal [**1-3**])
11. Left foot drop in [**6-/2103**]
12. Renal insufficiency
13. Vitamin D deficiency
14. Leg edema
15. Falls
16. Atrial fibrillation
17. ? Interstitial lung disease
Social History:
Patient currently resides at the [**Hospital3 **] [**Hospital3 **]
center. She worked at the [**Hospital **] Hospital for 26 years as a
secretary for the maintenance department. She never married and
does not have any children. Her closest living relative is her
younger cousin in [**Name (NI) **]. She has an approximate 10 year smoking
history, quitting at age 29. She drinks alcohol rarely and does
not use illicit drugs.
Family History:
Significant for an MI in her mother at age [**Age over 90 **]. She otherwise did
not have siblings and does not know her father's medical
history.
Physical Exam:
VS: Temp: 97.6 BP: 132/60 HR: 77 RR: 14 O2sat: 98% RA
GEN: pleasant, elderly, comfortable, NAD
HEENT: PERRL, anicteric, MMM, op without lesions, poor
dentition, no supraclavicular or cervical lymphadenopathy, low
jvd
NECK: no thyromegaly or thyroid nodules
RESP: Bibasilar crackles, no wheezes, good air movement, no
accessory muscle use
CV: RR, nl rate, mechanical valve apex
ABD: soft, obese, nontender, nondistended, +b/s, no organomegaly
EXT: WWP, right leg edema > left leg edema (chronic), dry skin,
no cyanosis or clubbing
SKIN: dry skin, rash in groin and under breasts
NEURO: Cn II-XII grossly intact.
RECTAL: per EW, guaiac neg brown stool
Pertinent Results:
ADMISSION LABS:
.
Brief Hospital Course:
85-year-old female with CHF, CAD, AFib, MVR on warfarin with
nausea/vomiting x1 and large hematocrit drop of unclear
etiology.
.
# Low hematocrit: large hematocrit drop from baseline 33 last in
[**Month (only) **] to 18 on presentation. She denied frank hematemesis or
BRBPR on time of presentation and she was guiac negative. NGT
lavage was done, initially negative, then returned BRB, cleared
with 800cc of fluid. INR on presentation was 5.4. SBPs at this
time came down to 90s, from 110s. CT Scan showed no evidence of
RP bleed. Patient was started on IV PPI gtt and admitted to the
MICU. On arrival to the unit, she was given 2L NS and 2 units
PRBCs. Hcts were then stable at 27-29 for remainder of
admission. GI was consulted, and patient refused inpatient
EGD/colonoscopy. She was extensively described the benefits of
these studies in her setting and was made aware of the risks of
not doing these studies, yet still refused. It was determined
that she will get a virtual colonoscopy as an outpatient, and
possibly an Upper GI series. She was discharged on PO BID PPI
and with GI follow-up.
.
# Mitral valve disease s/p mechanical MV replacement:
supratherapeutic INR on admission > 5. Coumadin restarted at 3
mg once a day when INR returned < 3. INR 1.9, will be bridged
on Loveox injections once a day until INR > 2.5.
.
# Acute on chronic renal insufficiency: Baseline creatinine
1.5-1.6. Was elevated to > 2, now back to baseline at time of
discharge, like pre-renal etiology from hypovolemia.
.
# Chronic congestive heart failure: DOE and pulmonary edema on
CXR, based on patient's symptoms at baseline, likely Stage III.
Now back on metoprolol, aspirin, olmesartan. Will continue to
hold lasix until tomorrow AM as patient not clinically
decompensating currently.
.
#. Hypernatremia: Na maxed out at 151. Likely secondary to
decreased PO intake as patient had been NPO for several days.
She has started a full diet since. She was given 1 L D5W, Na
returned to 143 the next day, and remained normal for rest of
admission.
.
# Leg swelling: Appears chronic. R>L. LENI in EW. Negative for
DVT. Chronic venous stasis dermatitis seems stable.
.
# DM2: Insulin sliding scale while renal function unstable.
Outpatient regimen of glipizide started today.
Medications on Admission:
1. Acetaminophen ER 650mg PO q8H
2. Alendronate 70mg PO qWeekly
3. Amiodarone 200mg PO daily
4. Aspirin 81mg PO daily
5. Benicar 20mg PO daily
6. MVI daily
7. Diabetic tussin EX PO q4H prn
8. Fexofenadine 60mg PO daily
9. Fluoxetine 60mg PO daily
10. Glipizide 15mg PO AM, 10mg PO HS
12. Nystatin powder [**Hospital1 **]
13. Pravastatin 80mg PO daily
14. Warfarin 3mg PO daily
15. Docusate 100mg PO daily
16. Oxycodone/acetaminophen 5/325mg PO prn
17. Albuterol 90mcg 2 puffs q4-6 prn
18. Lasix 40 mg [**Hospital1 **]
Discharge Medications:
1. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. glipizide 10 mg Tablet Sig: 1.5 Tablets PO qAM.
3. glipizide 10 mg Tablet Sig: One (1) Tablet PO every evening.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
6. Diabetic Tussin DM 10-100 mg/5 mL Liquid Sig: Two (2)
teaspoons PO every four (4) hours as needed for cough.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Endocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
10. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for constipation.
11. acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours: 2 tabs every morning,1 tab in afternoon, t tab at
bedtime.
12. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
On Saturday.
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
14. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
17. multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
19. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
20. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
22. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q24H
(every 24 hours).
Disp:*5 syringes* Refills:*1*
23. Outpatient Lab Work
Pleas check INR on Monday [**1-7**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI Bleed, likely lower eitology
Congestive heart failure
Mechanic Mitral valve on coumadin, initially with
supratherapeutic INR, now subtherapeutic.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of low blood counts
secondary to a bleed in you stomach. You were transfused blood
and your blood counts recovered. Because of the bleed, it was
recommended that you have an endoscopy and colonoscopy. You
refused these studies, and agreed that you were aware of the
risks of not performing these studies. You will see the GI
doctors in about a month for possible non-invasive imaging if
your stomach and intestines. Because of the bleed, your
coumadin was also held. In order to "bridge" you to therapeutic
levels, you will have to get once daily injections of another
blood thinner called Lovenox until your INR is high enough.
Visiting nurses will help you with this. You should get your
INR checked on Monday [**2109-1-6**].
.
We made the following changes to your medications:
ADDED lovenox once a day
ADDED Pantoprazole 40 mg once a day
DECREASED Lasix dose to 40mg once a day, pending weights may
need to increase dosage back to 40mg PO BID.
Continue coumadin at 3mg PO daily until next INR check.
.
It was a pleasure taking care of you during your hospital stay.
.
A visiting nurse will help to weigh yourself every morning, and
will [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2109-1-10**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Urine culture pending at the time of discharge.
Patient will need follow up virtual colonoscopy arranged
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2109-1-16**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.7",
"790.92",
"584.9",
"578.9",
"250.00",
"427.31",
"585.9",
"276.0",
"V43.3",
"428.22",
"V58.61",
"428.0",
"E934.2",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8766, 8823
|
3975, 6252
|
290, 296
|
9016, 9016
|
3932, 3932
|
10436, 11169
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3097, 3245
|
6821, 8743
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8844, 8995
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6278, 6798
|
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3260, 3913
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9993, 10413
|
2083, 2173
|
229, 252
|
324, 2064
|
3948, 3952
|
9031, 9143
|
2195, 2639
|
2655, 3081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,961
| 135,111
|
51101
|
Discharge summary
|
report
|
Admission Date: [**2154-12-31**] Discharge Date: [**2155-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
R hip pain s/p fall
Major Surgical or Invasive Procedure:
ORIF R intratrochanteric fracture
History of Present Illness:
Ms. [**Known lastname 106126**] is a [**Age over 90 **] yo Russian speaking F with a h/o CAD s/p
CABG x5, HTN, BPPV, HL, CLL, breast CA resident of [**Hospital 100**] Rehab
presenting s/p mechanical fall last night with R hip pain. The
patient states that she was at her dresser, leaning over and
fell. She admits to pain in the left hip and she has multiple
scrapes on her R knee. An x-ray performed at her nursing home
showed a right intratrochanteric fracture. The patient denies
hitting her head, denies loss of consciousness, chest pain,
dyspnea or lightheadedness. The patient ambulates with a walker
and has a history of recurrent falls. The patient admits to
falling approximately 10 days ago. She was seen at [**Hospital 882**]
Hospital for a laceration of her left hand, which was glued with
skin glue, and a dressing was applied.
The patient had a recent admission [**11-17**] for left lacrimal gland
abscess/cellulits and currently on ceftin. The patient was seen
in the emergency department by orthopedics, and was scheduled
for the OR the subsequent day.
Past Medical History:
l. CAD s/p 5 vessel CABG
2. Stable angina.
3. Arthritis.
4. Hypertension.
5. Cataracts.
6. Glaucoma.
7. Hypercholesterolemia.
8. History of prior infarction.
9. CLL
10. Breast ca
[**58**]. h/o MRSA UTI
Social History:
Social History: The patient lives at [**Hospital6 459**]. Her
family is involved. The patient does not smoke or drink.
Family History:
noncontributory
Physical Exam:
PE: 98.8 F 78 146/78 22 92% RA
Gen: Thin elderly woman in NAD
HEENT: mucosa mildly dry
Cardiovascular: normal rate, regular rhythm, 2/6 systolic murmur
Lungs: CTA anteriorly
Abd: soft, nt/nd +bs, mild general ttp. foley in place
Extr: R hip externally rotated, tender to palpation R hip. MAEW.
no LE edema, weak distal pulses, good gross sensation. + scrapes
R knee
neuro: A&O x3, no decrease in sensation
Pertinent Results:
Admission labs:
[**2154-12-31**] 02:27PM PT-12.6 PTT-23.6 INR(PT)-1.1
[**2154-12-31**] 02:27PM PLT SMR-NORMAL PLT COUNT-196
[**2154-12-31**] 02:27PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2154-12-31**] 02:27PM NEUTS-55 BANDS-1 LYMPHS-36 MONOS-5 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2154-12-31**] 02:27PM WBC-10.6# RBC-3.17* HGB-10.9* HCT-31.7*
MCV-100* MCH-34.4* MCHC-34.5 RDW-15.2
[**2154-12-31**] 02:27PM CK-MB-NotDone cTropnT-0.05*
[**2154-12-31**] 02:27PM CK(CPK)-29
[**2154-12-31**] 02:27PM estGFR-Using this
.
Discharge Labs:
.
Pertinent Imaging:
CXR ([**2154-12-31**]): Impression: Findings consistent with fluid
overload including pulmonary vascular engorgement and small left
pleural effusion.
.
R hip x-ray ([**2154-12-31**]): Impression: Intertrochanteric fracture,
with minimal distraction and varus angulation.
.
R Knee x-ray ([**2154-12-31**]): Impression: No evidence of fracture
about the knee.
.
Hip Xray: HISTORY: Fracture.
Seven intraoperative radiographs of the right proximal femur
were obtained without a radiologist present. These demonstrate
successive steps of open reduction and internal fixation of an
intertrochanteric fracture. For additional details, please
consult the operative report.
Brief Hospital Course:
Ms. [**Known lastname 106126**] is a [**Age over 90 **] year old with significant cardiac history
admitted with fall and right nondisplaced hip fracture, admitted
to medicine for medical clearance for orthopedic surgery on the
following day, and medical management.
.
Right hip fracture: Admitted to medicine for pre-operative
clearance. [**Doctor Last Name **] Cardiac Risk Assessment for non-cardiac
surgery: Patient gets 5 points for age >70. Falls into class I,
borderline class II. Risk of MI, CHF, VT: 0.6%-3%, risk of
cardiac death 0.2%-1%. She was treated with peri-operative beta
blocker. She went to the OR on [**1-1**]. She did well through
surgery with no complications. Follow up hip xrays were done.
Her hematocrit have been stable x 3 checks. POD 1 she had
substantial pain with movement. She was written for standing
pain control with tylenol 1000mg PO Q8AM, 2PM, and 10PM and
oxycodone 2.5mg PO Q8AM, 2PM, and 10PM; with PRN for
breakthrough and "anticipated pain events" (such as PT). Her
pain became well controlled and she had no confusion on the
regimen. She was continued on iron and aranesp and treated with
lovenox 40mg SQ daily for DVT prophylaxis.
.
Hyponatremia: Patient is hyponatremic at baseline and requires
fluid restriction at rehab. She has h/o breast cancer and h/o
leukemia per family. There was some evidence of volume overload
prior to surgery, however she now does not require oxygen and
appears euvolemic. Low Na was treated with Na and frequent
monitoring.
.
Urinary Frequency: Had UTI prior to admit. UA and urine culture
were negative this admission.
.
Osteoporosis: Per Xrays, fracture appears to be osteoporotic in
nature (not pathologic, as this would be a concern in the
setting of hx of breast cancer). While in house she was
continued on vitamin D 1000mg IU Qday (she was on this as
outpatient), calcium [**Hospital1 **]. Vitamin D level was pending at time
of discharge. If this is <30, will need to replete with higher
doses until >30 (can be done as outpatient). Then can safely
start bisphosphonate after Vitamin D is greater than 30.
.
Falls: Multifactorial. Patient is on scheduled lorazepam 0.5mg
[**Hospital1 **], primidone (unclear indication) as outpatient, and son [**Name (NI) 382**]
insists that she continue these medications. Outpatient PCP
should have risk/benefit discussion regarding increased risk of
falls and these medications. Family also mentions that she
refuses to wear incontinence products and has urinary frequency
symptoms. They feel this may have led to fall.
.
CAD: (Per cath [**2141**] - 3 vessel disease). No symptoms this
admission. Telemetry is unremarkable. Continued current medical
management with isosorbide, atenolol. PCP to address need of
aspirin as outpatient (was not on this prior to hospitalization)
.
H/O breast cancer with sternal lump: Defer to PCP to address as
outpatient.
.
Lacrimal gland abscess: Continued eye antibiotics
.
Prevention/Dispo: Encouraged incentive spirometry, out of bed to
chair, elevate heels while in bed.
.
DNR/DNI
MICU COURSE
- Admitted [**12-31**] from [**Hospital 100**] Rehab after fall, with
non-displaced intertrochanteric fracture and left hand
laceration
- Had mildly elevated troponin (<0.1) on admission
- [**1-1**] had ORIF right hip by orthopedics
- [**1-3**] CXR demonstrated left retrocardiac opacity, also with
increasing fever curve; levofloxacin started
- [**1-6**] developed abdominal pain and distention; KUB suggested
volvulus, but barium study demonstrated freely passing contrast;
GI consulted. Mildly hypotensive overnight [**Date range (1) 11104**], resolved
with fluid. Several episodes of diarrhea.
- [**1-7**] rectal tube placed for [**Last Name (un) 3696**]/colonic ileus. CT
abd/pelvis performed. ABG 7.51/34/71 with lactate 1.1
- [**1-8**] R SFA occlusion noted on CT scan; vascular surgery
consulted and recommended no intervention. C. diff positive;
metronidazole 500mg TID started. Renal team consulted for
hyponatremia and increasing creatinine (increased 0.8 to 1.2)
thought secondary to hypovolemia
- [**1-9**] creatinine increased to 2.0, sodium decreased from 125
to 120; ABG checked 7.48/21/118 with lactate 8.4, anion gap 16.
Hematocrit jumped from 29 on [**1-7**] to 41 on [**1-9**].
On [**1-9**], she was transferred to the MICU for altered mental
status, at which time a lactate was checked and was found to be
8.4. Her clinical exam changed; she developed rebound
tenderness. Surgery was consulted; the patient and the family
did not wish to pursue surgery, and no invasive procedures (e.g.
central lines) were persued. She expired at 5:47am on [**1-10**].
Medications on Admission:
ceftin 500mg [**Hospital1 **] till [**1-1**]
Vigamox 1drop [**Hospital1 **] left eye till [**1-16**]
Polysporin eye ointment [**Hospital1 **] left eye till [**1-16**]
iron 325 daily
tylenol 650mg q4prn +975 [**Hospital1 **]
zocor 40mg daily
ativan .5mg [**Hospital1 **]
dulcolax supp daily prn
Vit D 1000 daily
Tums 650mg [**Hospital1 **]
anusol 25mg daily prn
atenolol 25mg daily
Imdur 30mg daily
primidone 50mg qhs
senna 17.2mg qhs
miralax prn
MOM 30cc TID prn
aranesp 40mcg qthurs
.
hyrogel to Left hand open areas and telfa and dry dressing
Discharge Medications:
N/A
Discharge Disposition:
Extended Care
Discharge Diagnosis:
N/A
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"560.89",
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"276.1",
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"413.9",
"375.00",
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"486",
"584.9",
"V45.81",
"V10.3",
"008.45",
"V02.59",
"365.9",
"788.41",
"204.10",
"E849.0",
"820.21",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.09",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
8878, 8893
|
3606, 8255
|
283, 319
|
8940, 8949
|
2285, 2285
|
9001, 9007
|
1825, 1842
|
8850, 8855
|
8914, 8919
|
8281, 8827
|
8973, 8978
|
2895, 3583
|
1857, 2266
|
224, 245
|
347, 1425
|
2301, 2878
|
1447, 1670
|
1703, 1809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,078
| 172,729
|
2958
|
Discharge summary
|
report
|
Admission Date: [**2193-9-3**] Discharge Date: [**2193-9-9**]
Date of Birth: [**2128-5-26**] Sex: F
Service: SURGERY
Allergies:
Motrin / Percocet / Protonix / Iron Dextran Complex / Statins:
Hmg-Coa Reductase Inhibitors / Ceftriaxone / Methadone
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Admitted post-op.
Major Surgical or Invasive Procedure:
Bilateral nephrectomy, liver cyst fenestration.
History of Present Illness:
The patient is a 65-y.o. female with ESRD secondary to PKD with
frequent UTI, kidney stones, chronic back pain and rupture and
the patient requested bilateral nephrectomy prior to a live
donor renal transplant.
Past Medical History:
ESRD [**2-4**] PKD, Nephrolithiasis, History of HTN (no longer on
meds), Chronic sinusitis, pancreatic/hepatic cysts, breast CA,
toxoplasmosis, rectocele and rectal prolapse
PSH: L mastectomy and LAD, spinal fusion, TAH, Mesenteric LN bx,
RUE AVF s/p multiple interventions over last 2 years
Social History:
She has occasional alcohol, but no IV drugs, or tobacco.
Family History:
Noncontributory.
Pertinent Results:
[**2193-9-3**] 11:41AM PLT COUNT-180
[**2193-9-3**] 11:41AM WBC-20.0*# RBC-4.03* HGB-11.0* HCT-34.7*
MCV-86 MCH-27.4 MCHC-31.8 RDW-16.3*
[**2193-9-3**] 11:41AM CALCIUM-7.9* PHOSPHATE-7.1*# MAGNESIUM-1.9
[**2193-9-3**] 11:41AM GLUCOSE-159* UREA N-53* CREAT-4.6*#
SODIUM-142 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
Brief Hospital Course:
The patient tolerated surgery well and was admitted to the ICU
on [**2193-9-3**]. After improvement, she was transferred to the floor
on [**2193-9-5**]. Her post-operative course was uncomplicated, with
gradual return to regular diet, and on [**2193-9-9**], she was
discharged home with dialysis teaching.
Medications on Admission:
Doxepin 25, Epogen qweek, Dilaudid PRN, Plaquenil 400, Iron
Sucrose 100mg w/ clinic visits, Ativan 1mg w/ procedures,
Nitroglycerin 0.3 SL PRN, Omeprazole 40, Zofran 4prn, Citrucel
500", CA-D3 500-200tab
Discharge Medications:
1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Epoetin Alfa 10,000 unit/mL Solution Sig: Two (2) mL
Injection once a week.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Iron Sucrose 100 mg/5 mL Solution Sig: Five (5) mL
Intravenous as directed with clinic visits.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every four (4) hours as needed for pain.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
9. Citrucel 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -200 unit
Tablet Sig: One (1) Tablet PO once a day.
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
12. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Polycystic Kidney Disease
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or come to the emergency room if you
develop fever, chills, nausea, vomiting, diarrhea, or any other
concerning symptoms or if you find redness, swelling, or
purulence around your incisions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2193-9-20**] 2:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **] (NHB)
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2193-10-28**] 2:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2193-11-4**] 2:20
Completed by:[**2193-9-9**]
|
[
"V49.83",
"V64.41",
"568.0",
"V45.4",
"403.91",
"275.9",
"V10.3",
"585.6",
"V13.01",
"285.21",
"573.8",
"458.29",
"710.9",
"753.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.54",
"54.59",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3245, 3251
|
1482, 1791
|
392, 441
|
3321, 3328
|
1124, 1459
|
3591, 4089
|
1087, 1105
|
2045, 3222
|
3272, 3300
|
1817, 2022
|
3352, 3568
|
335, 354
|
469, 681
|
703, 997
|
1013, 1071
|
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