subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
59,638
| 179,276
|
38110
|
Discharge summary
|
report
|
Admission Date: [**2177-8-7**] Discharge Date: [**2177-8-18**]
Date of Birth: [**2103-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dizziness and weakness
Major Surgical or Invasive Procedure:
[**2177-8-12**] Urgent Four Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending artery, with
vein grafts to ramus, obtuse marginal and posterior descending
artery)
History of Present Illness:
This is a 73 year old male who has a history of multiple strokes
in the past, last in '[**75**] with minor defecit of left leg
weakness, DMII, hypercholesterolemia, and hypertension presents
to outside hospital reporting generalized weakness, inability to
ambulate with his cane due to fatigue, and a near syncopal
episode.He ruled in for NSTEMI and radiographic evidence of
heart failure. He was found to have acute anemia and transfused
packed red blood cells. He was admitted to the OSH ICU and later
was cathed. Cardiac cath revealed 3 vessel disease. He was
transferred to [**Hospital1 18**] for cardiac surgical evaluation of coronary
artery revascularization.
Past Medical History:
- History of CVA x 3 - last '[**75**] with (L)LE weakness
- Type II Diabetes Mellitus
- Hypertension
- Dyslipidemia
Social History:
Lives with: wife, has 5 children.
Occupation: Construction company owner
Tobacco: denies
ETOH: denies
Family History:
Father died at 57yo of heart failure. Mother died at 86 yo-"old
age". He has two brothers, both living - 1 with history of MI,
the other has high blood pressure.
Physical Exam:
Preop Exam:
BP Right:128/75 Pulse:80 Resp:18 O2 sat: 99% on RA
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 [] Irregular [x] Murmur 2/6 SEM
Abd: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: None
None[x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2177-8-7**] WBC-11.6* RBC-3.67* Hgb-11.6* Hct-33.9* Plt Ct-252
[**2177-8-7**] PT-12.9 PTT-23.4 INR(PT)-1.1
[**2177-8-7**] Glucose-289* UreaN-48* Creat-1.8* Na-138 K-3.9 Cl-98
HCO3-27
[**2177-8-7**] ALT-24 AST-54* LD(LDH)-432* AlkPhos-109 Amylase-89
TotBili-1.0
[**2177-8-7**] %HbA1c-6.8* eAG-148*
[**2177-8-8**] Echocardiogram:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the anterior septum and
anterior walls, distal inferior wall, and apex. The remaining
segments contract normally (LVEF = 35 %).There is an apical left
ventricular aneurysm. Mild spontaneous echo contrast but no
masses or thrombi are seen in the left ventricular apex. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**2-8**]+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
[**2177-8-8**] Head CT Scan:
There is no evidence of acute major vascular territorial
infarct. There is no intra- or extra-axial hemorrhage, obvious
masses, mass effect, or shift of normally midline structures.
Moderate atrophy is seen causing prominence of ventricles and
sulci. Osseous and soft tissue structures are unremarkable.
IMPRESSION: 1. No acute intracranial pathology. 2. Left
parieto-occipital hypoattenuation likely from old infarct. 3.
Chronic small vessel ischemic disease, and moderately severe
atrophy.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with NSTEMI and congestive heart
failure. Given recent Plavix, surgery was delayed and he
underwent extensive preoperative evaluation. He remained pain
free on intravenous Heparin. Preoperative antibiotics were given
for a positive urinalysis. Head CT scan showed no acute
pathology. Neurology evaluation was consistent with dementia,
most likely multiple infarct dementia. He was cleared for
surgery by the Neurology service but remained high risk for
stroke based on his risk factors and previous history of
strokes. After extensive evaluation, his family agreed and gave
surgical consent to proceed with surgical revascularization. The
remainder of his preoperative course was uneventful.
On [**8-12**], Dr. [**Last Name (STitle) **] performed urgent coronary artery bypass
grafting surgery. See operative note for details. Following
surgery, he was brought to the CVICU for invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated without incident. Given dementia, narcotics were
avoided. He otherwise maintained stable hemodynamics and
transferred to the SDU on postopertive day one.
Blood glucoses were initially elevated, but came under better
control on resuming home doses of metformin and glipizide, in
addition to Lantus and sliding scale insulin. Lantus was
discontinued upon discharge.
BUN and Creatinine rose and were monitored closely. creatinine
peaked at 1.9 with baseline of 1.5. Foley was maintained to
closely monitor urine output. When the foley was removed, he
failed a void trial, despite a bladder scan for 800cc, foley was
replaced and Flomax was started. he will need a repaet voding
trial at rehab.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility and rehab was recommended
prior to return to home.
By the time of discharge on POD #6 the patient was ambulating
with assistance, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Hospital **]
rehab in [**Location (un) 701**] in good condition with appropriate follow up
instructions.
Medications on Admission:
Aggrenox 25/200(2), Metformin 1000(2), HCTZ 25(1), Quinipril
40(1), Glipizide 5(2), Clorazepate 7.5(1), Lipitor 20(1),
Atenolol 50(1)
Discharge Medications:
1. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days: or until at pre-op weight 169#'s.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days: while on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] of [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
NSTEMI
Congestive Heart Failure
Cerebrovascular Disease
Dementia
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Preoperative Urinary Tract Infection
Atrial Fibrillation
Discharge Condition:
Alert and oriented x1-2 nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Repeat voiding trial in next one or two days.
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:
Dr. [**Last Name (STitle) **] on [**2177-9-18**] @ 1PM
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 85044**] in [**2-8**] weeks, call for appt
Cardiologist: Dr. [**Last Name (STitle) **] in [**2-8**] weeks, call for appt
Completed by:[**2177-8-22**]
|
[
"290.40",
"285.9",
"729.89",
"250.00",
"437.0",
"401.9",
"410.71",
"272.4",
"438.89",
"427.31",
"428.0",
"599.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7753, 7824
|
4123, 6265
|
344, 554
|
8076, 8308
|
2366, 4100
|
9112, 9379
|
1525, 1689
|
6450, 7730
|
7845, 8055
|
6291, 6427
|
8332, 9089
|
1704, 2347
|
282, 306
|
582, 1251
|
1273, 1390
|
1406, 1509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,230
| 116,631
|
44461
|
Discharge summary
|
report
|
Admission Date: [**2174-1-28**] Discharge Date: [**2174-2-7**]
Date of Birth: [**2101-7-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
extended R colectomy
History of Present Illness:
72 yo F presenting with 4 days of bloody diarrhea and diffuse
abdominal pain. The symptoms started 3 days ago after a trip to
[**Location (un) 5622**]. She and other family members stopped at a
fast-food restaurant on the way home and all members reported
diarrhea and abdominal pain later that evening. The patient had
two episodes of vomiting that evening, then later diarrhea,
which quickly became bloody. The diarrhea is described as
explosive. She estimates ~5 bouts of diarrhea for the last few
days. The blood turned the bowl a reddish color. She has not
moved her bowels since early this AM. She also complains of
sharp pain, diffusely, that has grown progressively worse since
onset. The pain does not radiate. It is worse in the lower
abdomen. She denies any prior history of bloody diarrhea. She
denies any fevers or chills. She has not had any more vomiting
since the first evening. She also has not eaten or drank much
since onset of symptoms. Of note, she has had a significantly
decreased appetite over the last year and reports a 25 pound
weight loss during this time. She attributes this to the
Alzheimer's medication she started a while back, which causes
her to have no appetite. She had a normal colonoscopy in [**2168**].
She does not have any prior history to suggest cardiovascular
disease.
Past Medical History:
Aortic stenosis, Hypertension, Hypercholesterolemia,
Hypothyroidism, Anxiety, Insomnia, Arthritis, s/p
Hysterectomy(hospital course complicated by gram negative
sepsis), s/p Vaginal Suspension
Social History:
Married with three adult children. She is the primary caretaker
for her husband, who recently is recovering from a severe
illness. She recently has been under a lot of stress at home.
Family History:
Negative for premature coronary artery disease
Physical Exam:
Day of discharge
VS. 98.4 98.4 73 132/74 18 94 RA
Gen: NAD
Card: RRR No M/R/G
Lungs: CTAB
ABD: +BS soft, non-distended, appropriately tender
Wound C/D/I
Pertinent Results:
[**2174-1-28**] 04:40PM PT-13.1 INR(PT)-1.1
[**2174-1-28**] 04:40PM PLT SMR-LOW PLT COUNT-133*
[**2174-1-28**] 04:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2174-1-28**] 04:40PM NEUTS-65 BANDS-20* LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ATYPS-6* METAS-0 MYELOS-0
[**2174-1-28**] 04:40PM WBC-7.6 RBC-4.21 HGB-13.1 HCT-38.7 MCV-92
MCH-31.2 MCHC-34.0 RDW-14.6
[**2174-1-28**] 04:40PM LACTATE-2.0
[**2174-1-28**] 04:40PM COMMENTS-GREEN TOP
[**2174-1-28**] 04:40PM TOT PROT-6.7
[**2174-1-28**] 04:40PM cTropnT-<0.01
[**2174-1-28**] 04:40PM ALT(SGPT)-23 AST(SGOT)-35 TOT BILI-0.6
[**2174-1-28**] 04:40PM estGFR-Using this
[**2174-1-28**] 04:40PM GLUCOSE-143* UREA N-52* CREAT-2.4*#
SODIUM-138 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2174-1-28**] 05:22PM VoidSpec-UNLABELED
[**2174-1-28**] 07:28PM URINE GRANULAR-[**2-24**]* HYALINE-[**2-24**]*
[**2174-1-28**] 07:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2174-1-28**] 07:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2174-1-28**] 07:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2174-1-28**] 07:28PM URINE GR HOLD-HOLD
[**2174-1-28**] 07:28PM URINE HOURS-RANDOM
[**2174-1-28**] 08:14PM LACTATE-1.6
Brief Hospital Course:
The pt presented to [**Hospital1 18**] from her PCP's office secondary to
bloody stool and abd pain. She was admitted to the TICU for
assessment. She was made NPO except meds and was started IVF and
a foley was placed.
.
A CT scan of her abdomen and pelvis on [**1-28**] indicated: Bowel wall
thickening and surrounding stranding/fluid involving the cecum,
ascending and proximal transverse colon, compatible with
colitis. Pneumatosis within the cecum was worrisome for an
ischemic etiology. There was no evidence of free intraperitoneal
air or portal venous gas detected. Stool samples were sent to
rule out C.dif and all were negative. She was transferred to
[**Hospital Ward Name 1950**] 5 for continued assessment.
.
The patient was clinically well with only mild abdominal pain
and no fever or leukocytosis. However on [**2-1**] she has had
increasing abdominal pain and tenderness with right-sided
peritonitis, and a repeat CT scan showed persistent pneumatosis
of the ascending and proximal transverse colon as well as
significant stranding within the mesentery. The patient was
placed on telemetry secondary to ischemic bowel and
plans for surgery were discussed with the patient and her
husband. She was pre-op'd and underwent an extended R colectomy
on [**2174-2-2**].
.
She returned to [**Location **] 5 from the PACU and was made NPO except
meds. She had a foley, IV hydration and a PCA. With the return
of bowel function and flatus the patient was started on sips and
advanced as tolerated. On the day of discharge, the patient was
tolerating a regular diet, had continued passage of flatus, her
pain was well controlled on an oral pain regimen.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
AMOXICILLIN - 500 mg Tablet - 3 Tablet(s) by mouth 1 hour prior
to dental work
ATORVASTATIN [LIPITOR] - 40 mg Tablet - [**12-24**] Tablet(s) by mouth
once a day
DONEPEZIL - 10 mg Tablet - 1 Tablet(s) by mouth with food daily
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays nostril once a
day
KETOCONAZOLE - 2 % Cream - apply to effected area twice a day
LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth
once a day
MEMANTINE [NAMENDA TITRATION PAK] - 5 mg (28)-10 mg (21)
Tablets,
Dose Pack - 1 Tablets(s) by mouth as directed on the package
Titration Pack
MEMANTINE [NAMENDA] - 10 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day - No Substitution
QUETIAPINE [SEROQUEL] - 25 mg Tablet - 1 Tablet(s) by mouth
twice
a day
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth in the morning
VITAMINC C - (Prescribed by Other Provider) - Dosage uncertain
ZOSTER VACCINE LIVE (PF) [ZOSTAVAX] - 19,400 unit Recon Soln -
IM
deltoid x 1
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
MULTIVITAMINS - (OTC) - Tablet, Chewable - 1 Tablet(s) by
mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - 1,000 mg-5
unit Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 2 weeks: Please do not exceed more
than 4000 mg in 24 hrs. .
8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
ischemic R bowel
.
Secondary:
Hypertension, Hypothyroidism, Alzheimer's dementia
PSH: Aortic valve replacement (Bovine), Hysterectomy [**2134**]'s
c/b bladder injury, Bladder suspension.
Discharge Condition:
Stable.
Tolerating a regular diet.
Pain well controlled with oral medications.
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 vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment with
Dr. [**Last Name (STitle) 1924**] .
-Steri-strips will be applied and they will fall off on their
own. Please remove any remaining strips 7-10 days after
application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] [**Telephone/Fax (1) 7508**] office to make a follow
up appointment in [**12-24**] weeks to have your staples removed.
2. Please call your PCP, [**Name10 (NameIs) 10531**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9347**], to make
a follow up appointment in 1 week or as needed.
.
Scheduled appointments:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95298**], MD Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2174-2-14**] 3:00
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**]
Date/Time:[**2174-6-14**] 3:00
3. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-9-15**] 3:00
Completed by:[**2174-2-7**]
|
[
"331.0",
"584.9",
"401.9",
"557.0",
"276.51",
"244.9",
"272.0",
"567.21",
"424.1",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
7642, 7693
|
3748, 5409
|
324, 347
|
7933, 8014
|
2364, 3725
|
9669, 10489
|
2125, 2173
|
6731, 7619
|
7714, 7912
|
5435, 6708
|
8038, 9183
|
9198, 9646
|
2188, 2345
|
270, 286
|
375, 1691
|
1713, 1907
|
1923, 2109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,877
| 185,567
|
20057
|
Discharge summary
|
report
|
Admission Date: [**2159-7-3**] Discharge Date: [**2159-7-20**]
Date of Birth: [**2076-2-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
non-healing ulcer LLE
Major Surgical or Invasive Procedure:
LLE diagnostic angiogram 6/24
L SFA-->Peroneal bpg with R cephalic arm vein [**7-13**]
History of Present Illness:
83yo M, h/o IDDM, CKD (stage 3) and PVD, who presents for
elective angiogram. The patient is a poor historian. He has a
history of calf claudication for which he received a right
femoral to peroneal bypass with in situ saphenous graft in [**2153**].
He has done well until ~3-4 months ago when he noticed LLE pain
in the calf and foot with an ulcer developing on the left outer
border of the foot. He was seen in the clinic. Given his renal
insufficiency, he is being admitted pre-procedure for renal
protective measures for a scheduled angiogram tomorrow.
Past Medical History:
PMH: DM-2, PAD, HTN, HLD, GERD, CKD (stage 3)
PSH: Pacemaker, Left hip replacement, L knee Arthroscopy, R
femoral to peroneal in situ saphenous vein graft [**1-/2153**]
([**Doctor Last Name **]), CABG, appendectomy
Social History:
Patient lives with his wife in [**Name (NI) **], MA. He reports
smoking a pipe for 20 years but quit 20 years ago. Denies any
EtOH use or recreational drugs.
Family History:
Patient was an orphan and thus is not aware of family hx of
cardiac diseases. His adult children, however, are healthy and
without cardiac diseases.
Physical Exam:
AFVSS
Gen: NAD
CV: reg
Chest: sternotomy incision well healed
Pulm: no resp distress
Abd: R sided vertical incision well healed, S/NT/ND
Ext: bilateral edema R/L. L foot dusky with dry skin and medial
aspect of foot with dry eschar ~2.5 cm in diameter tender to
palpation, no drainage or fluctuance
Fem DP PT graft
Left palp faint dop
Right palp dop dop palp
Pertinent Results:
[**2159-7-3**] 09:40PM BLOOD WBC-7.9 RBC-3.29* Hgb-10.4* Hct-32.4*
MCV-98# MCH-31.7 MCHC-32.2 RDW-14.3 Plt Ct-204#
[**2159-7-3**] 09:40PM BLOOD PT-16.0* PTT-32.4 INR(PT)-1.4*
[**2159-7-3**] 09:40PM BLOOD Glucose-197* UreaN-47* Creat-1.7* Na-139
K-4.2 Cl-104 HCO3-27 AnGap-12
[**2159-7-3**] 09:40PM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
[**2159-7-20**] 05:49AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.8* Hct-33.4*
MCV-94 MCH-30.6 MCHC-32.5 RDW-15.1 Plt Ct-166
[**2159-7-20**] 05:49AM BLOOD Glucose-233* UreaN-58* Creat-1.5* Na-141
K-3.9 Cl-100 HCO3-34* AnGap-11
[**2159-7-20**] 05:49AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1
Brief Hospital Course:
83yo M with DM, PVD, was admitted pre-operatively for elective
angiogram. Renal protective measures included mucomyst and
bicarbonate drip. He underwent diagnostic LLE angiogram [**7-5**] by
Dr. [**Last Name (STitle) 1391**] showing patent PFA, patent SFA with distal
occlusion, occluded popliteal throughout, and single-vessel
peroneal run-off from PFA collaterals; please see procedure
report for details. Accordingly he would require a
Fem-->Peroneal bypass. Post-procedure he developed midly
elevated creatinine (1.7 on admission, 1.3 at nadir, then rose
to 1.9), so his diuretic was held. He then developed mild CHF,
manifested as BL lower extremity edema, and with normalizing
creatinine was progressively diuresed over the next several
days. Cardiology consult reviewed his outpatient cardiac
history, a TTE was obtained showing LVEF 35-40%, mod pulm HTN,
and increased wedge pressure, and he was eventually cleared
medically for surgery. His prior CABG and RLE bypass had
consumed his leg veins, and vein mapping revealed better vessels
in his LUE.
He therefore underwent a L Fem-->peroneal bypass with RUE arm
vein on [**2159-7-13**] by Dr. [**Last Name (STitle) **] (covering for Dr. [**Last Name (STitle) 1391**],
who was away at the time and the patient preferred to have the
bypass performed asap). He received a R IJ CVL due to limited
venous access, and was monitored via a R axillary arterial line
since further distal access attempts were unsuccessful and the
other three limbs being unavailable (two involved in the
procedure and the RLE having a prior bypass was contraindicated
for femoral arterial line placement). Procedure proceeded
fairly straightforward; please see operative report for details;
at the conclusion he had a palpable vein graft pulse medially
and dopplerable signal distally. Post-operatively he had
sustained hypotension, responding to crystalloid volume but
requiring neosynephrine drip. Cardiac enzymes were cycled and
negative and repeat TTE was grossly unchanged without any focal
wall motion abnormalities. [**Last Name (un) **] stim test was normal. He
eventually turned the corner hemodynamically by POD 2. He was
transferred to the VICU on POD 3. Due to the IVF volumes given
in response to the earlier hypotension, diuresis was later
successfully initiated with lasix gtt then lasix 80 [**Hospital1 **] for
several days. He currently appears dry and is off diuretics,
although may need to resume his home dose of Bumex shortly.
The left lateral foot ulcer was covered with dry gauze. It was
initially covered with antibiotics which were discontinued on
POD 1. Podiatry consult recommended santyl cream, which is
being implemented, and a foot XR showed no osteomyelitis.
[**Last Name (un) **] consult managed his diabetes and insulin regimen during
his hospital stay. Physical therapy evaluated him
post-operatively and determined need for rehab placement. He
was noted by bedside RN to have difficulty swallowing, was
evaluated by swallow consult and video swallow study who
approved him for grounds solids, thin liquids, and crushed meds.
DVT prophylaxis was maintained with heparin SQ, and GI
prophylaxis with PPI. By POD 7 he was tolerated a diet,
undergoing PT, appeared appropriately diuresed, on his home
medications, and deemed suitable for discharge to rehab.
Medications on Admission:
Prilosec 20'', Lantus 5u QAM, Bumetanide 1', ASA 81', Coreg
6.25'', MVI', Vit C', Zocor 40', Tums 500 Q6H prn, Cosopt 1gtt
each eye QAM, lisinopril 2.5', glipizide 10'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for reflux.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
11. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily).
12. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
13. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: at breakfast.
14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
below units Subcutaneous qac: 71-100mg/dL: 0 Units
101-150: 2 Units 151-200: 3 Units
201-250: 4 Units
251-300: 5 Units
301-350: 6 Units
351-400: 7 Units.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) dose Inhalation Q6H (every 6 hours) as
needed for congestion/wheeze.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for congestion/wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
peripheral arterial disease
non-healing ulcer BL [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]
CAD
HTN
hyperchol
chronic renal insufficiency, stage III (baseline Cr 1.7)
GERD
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:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1391**] (vascular surgeon) in 1 week, on
[**2159-7-27**], at his clinic in [**Doctor Last Name 365**]. Please call on Monday [**2159-7-23**]
for the specific time. He will remove the staples from your
incisions at that time.
Follow-up with Podiatry, Dr. [**Last Name (STitle) **], as outpatient. Please
call [**Telephone/Fax (1) 543**] for an appointment.
|
[
"428.23",
"585.3",
"272.0",
"428.0",
"403.90",
"V45.02",
"707.22",
"V43.65",
"416.0",
"V45.81",
"707.15",
"707.03",
"440.24",
"530.81",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"88.42",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
7879, 7965
|
2670, 6013
|
335, 424
|
8196, 8196
|
2035, 2647
|
11198, 11601
|
1447, 1598
|
6231, 7856
|
7986, 8175
|
6039, 6208
|
8379, 10766
|
10792, 11175
|
1613, 2016
|
274, 297
|
452, 1015
|
8211, 8355
|
1037, 1254
|
1270, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,123
| 182,149
|
8043
|
Discharge summary
|
report
|
Admission Date: [**2128-1-8**] Discharge Date: [**2128-2-11**]
Date of Birth: [**2051-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
External pacemaker placement, right brachial [**2128-1-14**]
ICU stay with intubation
CVVH and dialysis
History of Present Illness:
This is a 76-year-old gentleman with CAD, s/p quadruple [**Month/Day/Year 28750**]
in [**2106**], AV replacement, 2 stents, gout, prostate CA, AAA, afib
nd GI bleed in [**2124**] and [**9-23**] who presented to ED with fever to
103.9. The patient stated that he had felt well on the day prior
to admission. On the evening of [**1-6**], the patient had an acute
onset of episodic subjective fevers and rigors that prompted him
to seek care in the ED.
Initial temp in the ED was 104. Labs were notable for WBC count
of 15.7(97%N, no bands), HCT of 44 (baseline 30), platelets 149,
INR 2.7, Creatinine 1.5 from baseline of 1.1, mild
transaminitis, LDH of 460 and alk phos 195, lactate of 2.5. UA
was negative; blood cultures drawn. CXR unremarkable. Patient
given Vanc, Cefepime, Gentamycin with concern for endocarditis
given prior AVR. On transfer, 101.1 69 90/39 rechecked 107/48 RR
14 94% on RA.
On arrival to the floor, patient was in no acute distress and
appeared non toxic. In addition to the chills/rigors, he stated
that he had myalgias. Denies any Upper respiratory symptoms.
Reports lumbar back pain, that has been chronic for years. No
changes in his ambulatory status. No recent travel history or
sick contacts.
On review of systems, notable for absence of chest pain,
worsening dyspnea (has some on baseline), paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. All of the other review of systems were
negative.
Past Medical History:
# CAD s/p CABG (LIMA>>>LAD, SVG>>>/OM/D1/RCA) ; recently stented
3DES
# Diastolic heart failure with hypertension and hyperlipidemia
# GIB -1/06EGD / colonoscopy:erosive gastritis, while
colonoscopy
showed diverticulosis, ectasias in rectum, mild radiation
proctitis, and grade one hemorrhoids. 2nd [**3-20**] episode: EGD
showed gastritis and ulcers with unremarkable biopsy. 3rd
episode: EGD show gastritis. Patient suppose to get capsule
study but never followed up.
# St. [**Male First Name (un) 923**] Mechanical AVR in [**2106**]
# Atrial Fibrillation noted 1 month ago, cardioverted
# Prostate ca s/p lupron tx
# Gout
# 4.4 cm AAA, last imaged [**7-19**]
# Prior ETOH abuse (a case of beer a day). He stopped drinking
heavily about 8-9 years ago [**2116**] GIB after drinking an excess
amount of alcohol, endoscopy revealing several stomach ulcers,
s/p 6 units PRBC.
# Cataracts, s/p surgery bilaterally
# Borderline glaucoma
# Hematuria approximately 6-7 months ago (currently consulting
with a urologist and oncologist). Patient reports having a
cystoscopy that was unremarkable.)
# Hx of Cellulitis of right leg
# Hx of mild hepatitis
# Recent shingles
Social History:
Retired worker at [**Company 2676**] where he was exposed to microwaves
and various heavy metals. Smoked 3 packs/day x 10-12 years, quit
approximately 35 years ago. EtOH (as above). No drug use.
Family History:
Father died of CAD at age 65.
Physical Exam:
Admission Physical Examination:
Gen: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6 cm.
Lymph: No axillary or submandibular LNs
CV: RRR w/ II/VI SM at RUSB. No thrills, lifts. Unable to
auscultate S3 or S4.
Chest: CTAB
Abd: Soft, NTND. No HSM or tenderness. No pulsating mass. Unable
to auscultate bruit. No CVA tenderness
Ext: No c/c/e. R hand 5th digit with distal splinter hemorrage;
L hand 3rd digit with splinter hemorrages near cuticle. Osler
node noted at 1st digit R hand.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: CN II-XII intact. 5/5 strength in all extremities
Pertinent Results:
ADMISSION:
[**2128-1-8**] 02:26AM BLOOD WBC-15.7*# RBC-5.06 Hgb-13.6*# Hct-44.3#
MCV-88# MCH-27.0# MCHC-30.8* RDW-20.4* Plt Ct-145*
[**2128-1-8**] 02:26AM BLOOD Neuts-95.7* Lymphs-1.5* Monos-2.0 Eos-0.6
Baso-0.3
[**2128-1-10**] 08:25AM BLOOD Fibrino-602*
[**2128-1-8**] 02:26AM BLOOD Glucose-126* UreaN-33* Creat-1.5* Na-140
K-4.2 Cl-101 HCO3-25 AnGap-18
[**2128-1-8**] 02:26AM BLOOD ALT-49* AST-79* LD(LDH)-461* AlkPhos-195*
TotBili-1.0
[**2128-1-8**] 02:26AM BLOOD Calcium-9.5 Phos-1.9*# Mg-1.7
[**2128-1-10**] 08:25AM BLOOD Hapto-55
[**2128-1-8**] 09:20PM BLOOD CRP-202.0*
ECHO [**2128-1-9**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is depressed (<20 cm/s). Overall left ventricular
systolic function is normal (LVEF>55%). There are simple
atheroma in the distal aortic arch and descending thoracic
aorta. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal disc
motion. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or definite vegetation is
seen on the mitral valve. An eccentric, posteriorly directed jet
of moderate (2+) mitral regurgitation is seen. An eccentric jet
of mild-moderate tricuspid regurgitation is seen directed toward
the interatrial septum. There is no pericardial effusion.
IMPRESSION: Mitral leaflet thickening without definite discrete
vegetation or abscess. Eccentric jet of moderate mitral
regurgitation. Mild to moderate tricuspid regurgitation.
Extensive simple aortic atheroma.
[**2128-1-27**]:
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
borderline normal free wall function. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. A bileaflet aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. Trace
aortic regurgitation is seen. [The amount of regurgitation
present is normal for this prosthetic aortic valve.] The mitral
valve leaflets are moderately thickened. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. An eccentric,
posteriorly directed jet of moderate (2+) mitral regurgitation
is seen. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis, especially on a
bileaflet aortic valve.
Compared with the prior study (images reviewed) of [**2128-1-8**],
the severity of mitral and tricuspid regurgitation has
increased. The right ventricular function may be slighlty less
vigorous.
Liver U/S [**2128-1-9**]:
RIGHT UPPER QUADRANT ULTRASOUND: The liver is homogeneous in
echotexture
without evidence of a focal liver lesion. There is no
intrahepatic biliary
ductal dilatation, and the common bile duct measures 4 mm. The
main portal
vein is patent, with antegrade flow. The head and neck of the
pancreas are
unremarkable, but the distal pancreas is not visualized due to
bowel gas.
The gallbladder demonstrates multiple shadowing stones, but
there was no
[**Doctor Last Name **] sign, gallbladder wall thickening, or pericholecystic
fluid. The
gallbladder is overall not largely dilated.
IMPRESSION: Cholelithiasis without definite evidence for
cholecystitis.
Renal U/S [**2128-1-14**]:
RENAL ULTRASOUND: The right kidney measures 11.8 cm and left
kidney measures 13.8 cm, with no hydronephrosis, masses, or
stones. There is a small 2.8-cm simple cyst arising
exophytically from the lower pole of the left kidney. The
bladder is moderately decompressed, however, unremarkable.
IMPRESSION: Normal renal ultrasound without evidence of
hydronephrosis or
abscess.
RUQ U/S [**2128-1-9**]:
RIGHT UPPER QUADRANT ULTRASOUND: The liver is homogeneous in
echotexture
without evidence of a focal liver lesion. There is no
intrahepatic biliary
ductal dilatation, and the common bile duct measures 4 mm. The
main portal
vein is patent, with antegrade flow. The head and neck of the
pancreas are
unremarkable, but the distal pancreas is not visualized due to
bowel gas.
The gallbladder demonstrates multiple shadowing stones, but
there was no
[**Doctor Last Name **] sign, gallbladder wall thickening, or pericholecystic
fluid. The
gallbladder is overall not largely dilated.
IMPRESSION: Cholelithiasis without definite evidence for
cholecystitis.
TEE [**2128-1-9**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is depressed (<20 cm/s). Overall left ventricular
systolic function is normal (LVEF>55%). There are simple
atheroma in the distal aortic arch and descending thoracic
aorta. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal disc
motion. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or definite vegetation is
seen on the mitral valve. An eccentric, posteriorly directed jet
of moderate (2+) mitral regurgitation is seen. An eccentric jet
of mild-moderate tricuspid regurgitation is seen directed toward
the interatrial septum. There is no pericardial effusion.
IMPRESSION: Mitral leaflet thickening without definite discrete
vegetation or abscess. Eccentric jet of moderate mitral
regurgitation. Mild to moderate tricuspid regurgitation.
Extensive simple aortic atheroma.
Bleeding Study [**2128-1-18**]
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 90 minutes were obtained. A left
lateral view of the pelvis was also obtained.
Blood flow images show evidence of an abdominal aortic aneurysm,
which per OMR notes is known.
Dynamic blood pool images show no evidence of active bleeding at
90 minutes, at which point the patient refused further imaging.
On the lateral view obtained at 90 minutes, there is some
increased activity seen posteriorly in the pelvis, but this is
felt to most likely represent oblique projection of iliac
vessels.
The spleen is noted to be prominent with intense tracer
activity, which can be seen with portal hypertension.
IMPRESSION: No evidence for active bleeding at 90 minutes, at
which point the patient refused further imaging.
Splenomegally and abdominal aortic aneurysm are noted, as
described above.
Labs at discharge:
8.3>30.2< 131
PT 29, PTT 58.2, INR 1.9
143/3.9/106/24/39/1.6<82
Alb 3.3, Ca 8.5, Phos 3.3, Mg 1.7
[**1-23**] Hapto 128
[**1-19**] ddimer 1214
[**2-7**]: ALT 24, AST 36, AlkPhos 128,
[**2-9**]: 1.1
[**2-9**]: fibrino 280, FDP 0-10
[**1-20**]: ESR 113
[**1-20**]: HBsAg neg, sAb neg, BcAb neg, IGM HBc neg
ANCA neg
[**Doctor First Name **] neg
[**1-7**]: CRP 202
[**1-19**]: C3 102, C4 27
[**1-27**] AntiGBM neg
[**1-20**] ANCA Anti-PR3 and Anti-MPO ANCA Negative (See Note)
Brief Hospital Course:
76-year-old gentleman with CAD, s/p CABG x 4 '[**06**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 3
'[**24**], AV replacement, h/o prostate CA, AAA, presented to the ED
with fevers to 103.
#. IE: MSSA Endocarditis, based on Duke Criteria (1 major, 3
minor). Patent with Mechanical AVR from [**2106**]. Unclear source
of bacteremia, but had high grade bacteremia with unknown
source. Peripheral stigmata (splinter hemorrhage and ? Osler
nodes) were present on initial exam. No clinical signs of heart
failure during the admission except peripheral edema. TTE
([**1-7**]) and TEE ([**1-8**]) were negative for signs of vegetation or
valvular incompetence. The patient was treated with
Vancomycin/Cefepime/Gentamycin on presentation to ED, and
continued on Vancomycin and Gentamycin on [**1-7**]. Patient
transitioned to Nafcillin 2g IV q4hrs on [**1-8**] and Moxifloxacin
was started on [**1-12**] with PO Rifampin was started on [**1-13**].
Both were stopped on [**1-14**]. Nafcillin was stopped on [**1-18**] and
the patient was changed to Vancomycin due to AIN. He was then
transitioned to Cefazolin on [**1-22**] for better MSSA coverage with
planned course through [**3-12**]. He was on Vancomycin in place of
Cefazolon for his MICU course and then transitioned back to
Cefazolin. A PICC line was placed approximately [**1-19**]. He was
dosed Cefazolin post-HD while on dialysis. His Cefazolin was
dosed at 2G Q8H at discharge with plan through [**3-12**]. His LFTs
will have to be checked weekly as described in his d/c
paperwork. The patient was followed by infectious disease
throughout the beginning of his hospitalization.
# DAH/Hypoxemic Respiratory
Failure/Ventilation/Intubation/Hemoptysis
Patient was transferred to the Intensive Care Unit on [**1-27**] and
intially intubated for airway protection given copius
hemoptysis. Initial concern for vasculitis or Anti-GBM versus
volume overload in the setting of anticoagulation. Given concern
for vasculitis/Anti-GBM patient dosed with high dose steroids
(Solumedrol 1000mg IV Daily for 3 days). Pt ANCA negative,
AntiGBM negative. Bleeding improved with steroids and diuresis.
In total patient reguired two units while in the ICU. Steroids
tapered per Renal recommendations for treatment of AIN. SP
extubation patient did well with minimal hemoptysis. The
etiology of hemorrhage is unclear and likely multifactorial.
Exact cause of diffuse alveolar hemorrhage is unclear however
appearred to be related to pulmonary edema in the setting of
anticoagulation. Vaculitis was initially thought most likely,
given renal failure, rash and pulmonary hemorrhage, but
investigations for this were relatively unimpressive: ESR from
15 to 100s, but negative [**Doctor First Name **], ANCA, anti-GBM and unimpressive
pathology of skin and kidney. Patient completed Vanco/Cefepime
for hospital acquired pneumonia for an 8-day course before being
transitioned back to Cefazolin as above.
# Heart Block/afib: Patient was admitted in baseline atrial
fibrillation. He developed intermittent heart block with both
junctional and ventricular escape beats. Overnight on
[**11-26**] he developed Torsades, which spontaeneous resolved
and was transfered to the CCU. His QTc at the time was 600 and
Moxifloxacin and Rifampin were stopped at that time. First a
temporary femoral (right) pacemaker was placed and then a right
brachial screw-in pacemaker was placed with plans to convert to
permament pacemaker after anitbiotics are completed in the end
of [**Month (only) 956**]. Patient's QTc decreased to 460s subsequently. His
Metoprolol was increased to 50mg [**Hospital1 **] on [**2-10**] due to asymtomatic
NSVT on telemetry up to 13 beats overnight as well as ?AVNRT.
#. Acute on Chronic Renal Failure: Cr 1.5 on presentation;
trending up to the 2s-3s. He had a renal u/s which was negative
for abscess and hyrdo. Renal was consulted and felt that it was
likely AIN due to Nafcillin given time course with component of
prerenal due to poor fwd flow. There were negative urine eos
however an abundance of WBC casts on UA. Medications were
renally dosed and it was decided that the renal failure could
take up to several weeks to resolve and if necessary a renal
biopsy could be done. Mr. [**Known lastname 28747**] was started on Prednisone
60mg daily on [**1-24**] with a planned 6 week course. At discharge he
was changed to 10mg daily with course through [**2-15**]. His Protonix
was stopped on [**1-25**] because this was thought to also be
contributing to AIN. Upon transfer to the ICU on [**1-27**] he was
initially on CVVH then transitioned to HD. Renal biopsy without
changes consistent with AIN or vasculitis, but already given a
few days of high-dose steroids. An insulin sliding scale was
started in the setting of hyperglycemia from steroids. A
Prednisone taper was started and he was maintained on HD. A
tunnelled line was placed in his left IJ upon return to the
floor from the ICU which was subsequently converted to a
tunnelled line and d/c'd on [**2-10**] when it was deemed that he no
longer needed dialysis. His Cr on discharge was 1.6.
# Anemia: Patient developed anemia during his admission, with
black guiaic + stools and diarrhea on [**11-19**] likely due to GIB
given recent guiaic + stools and hx of GIB. Patient was
transfused 3 U of PRBC. Hct stabilized on [**1-20**] and he began
having normal stools. The patient also had a few episodes of
nose bleeds and coughing up a small amount of blood with
bleeding around his PICC and pacemaker site. This was thought
to be due to difficult to titrate heparin with occasionally high
PTTs. The GI bleeds were thought to be secondary to hx of
radiation to prostate and chronic friable GI mucosa in that
area. He was changed from PPI to Ranitidine on [**1-25**]. He was
treated with 2U PRBC in the ICU for the diffuse alveolar
hemorrhage. His Hct remained stable for multiple days prior to
discharge and was 30 at discharge.
# CAD: Patient was continued on his statin. Beta-blocker and
asa were intermittently held in the setting of bleeds. Ace-i
was held in the setting of acute renal failure. His
ace-inhibitor should probably be restarted as an oupatient.
# Thromocytopenia: At beginning of admission, patient had labs
suggesting DIC with platelets 101, elevated coags, mildly
elevated FDPs, but normal fibrinogen. Besides the bleeding
stated above, he did not have evidence of clotting. His
platelets were stable in the 130s at discharge.
#. LFT abnormalities: Mild transaminitis on presentation, new
since [**2124**] that can be attributed to Amiodarone that was
discontinued recently as outpatient. Patient's bilirubin
(Direct) continued to rise after admission. Unclear etiology,
RUQ u/s negative for intrahepatic abcess or ductal dilatation.
Clinically, patient with without [**Doctor Last Name 515**] or abdominal
tenderness. Spoke w/ radiologist who feels confident about
having good views on RUQ u/s to r/o abcess or cyst. Source of
increased direct bilirubin was unclear as cell lysis would cause
an indirect elevation. Levels increased with starting rifampin
and then decreased again once it was stopped. His LFTs were
monitored during admission due to starting Cefazolin.
# Leukoclastic dermatitis/vasculitis: On [**1-20**], the patient
developed a b/l LE peticheal rash which spread from his feet up
to his abdomen. He was biopsied by dermatology who felt it was
leukocytoclastic vasculitis most likely caused by nafcillin
versus endocarditis. He was started on Prednisone on [**1-24**] as
above. After treatment began with steroids we saw great
improvement. Thought to be due to Nafcillin or Allopurinol ??????
case reports of Warfarin also, but much less likely.
# Joint pain: On [**1-21**], the patient began developing joint pain in
his hands and right knee, likely secondary to vasculitis or
possibly from edema alone. It began to improve on [**1-23**].
# Acute Diastolic Heart Failure: Thought to be due to sodium
load from nafcillin intially. Patient was weaned off of oxygen
at the beginning of his admission. No new murmurs on exam to
suggest such an etiology. Patient has eccentric jet of MR [**First Name (Titles) **] [**Last Name (Titles) 28753**]o. CXR was unremarkable. Patient was restarted on his home
lasix which was increased to 60mg IV BID on [**1-24**]. CVVH and HD
were subsequently started as above. His last need day of
dialysis was [**2-6**]. His lasix was 40mg at discharge. It may be
increased as an outpatient if he continues to have lower
extremity edema. He should be weighed daily and the kidney
doctors should be notified of increases since lasix may have to
be increased.
# Hematuria: Patient had pink urine at admission. Prostate not
enlarged at admission, no nodules, non tender. UA with Mod
blood. Hematuria thought possibly related to elevated INR.
Hematuria worsened secondary to biopsy in the ICU in context of
coagulopathy. Hematuria improved in the days following biopsy.
He will likely need outpatient cystoscopy as he had hematuria at
admission.
#. AVR (St. [**Male First Name (un) 1525**]): Patient was maintained on a Heparin gtt for
most of his admission given the concern of bleeding. His
Coumadin was restarted on [**1-22**]. Then held soon thereafter for a
GIB. Initially anticoagulation was again reversed in the
setting of diffuse alveolar hemorrhage. Heparin gtt restarted
withh PTT goal of 50-70. He was restarted on Coumadin on [**2-5**].
No further bleeding. His INR goal is now [**2-18**] due to bleeeding
with goal of 2.5-3.5. His INR was 1.9 at discharge.
#. Hypertension : Patient was started on Amlodipine 5mg daily on
[**1-22**] with SBPs 110-130. His ace-i was held due to renal failure
but may be started as an outpatient.
#. Funguria: Though patient was asymptomatic and without a
foloey, given complexity of his course he was given fluconazole
200mg X1 on [**1-22**].
#. Hyperlipiemia : Continued statin.
# Gout: No episodes this admission. His Allopurinol was
initially held and then restarted and renally dosed before being
d/c'd dur to concern for AIN.
# Abd pain: Patient had occassional abodminal pain. He was
restarted on his home Carafate which was then stopped once he
started HD.
#. Code: Full changed to DNR/DNI after MICU stay and remained
DNR/DNI for remainder of hospital course.
#. Communication: wife [**Name (NI) 382**]: [**Telephone/Fax (1) 28754**]; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28755**] (daughter
and nurse) [**Telephone/Fax (1) 28756**]
Medications on Admission:
Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID
Furosemide 80 mg PO BID
Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS as needed for
insomnia.
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Warfarin 5mg/5mg/2mg rotating schedule daily
Aspirin 81 mg daily
Sucralfate
Ferrous Sulfate 325 mg [**Hospital1 **]
Pantoprazole 40 mg Q24H
Quinapril 20mg po daily
Discharge Medications:
1. Outpatient [**Hospital1 **] Work
weekly CBC, BMP, LFTs starting [**2-14**].
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**] and the Renal doctors [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 11957**]
and the PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8719**].
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin sliding scale
continue fingersticks 4 times a day while on Prednisone
sliding scale:
for breakfast, lunch, dinner: 2U starting at >151, increasing by
2U with each 50pt increase in glucose, ending at 8U for glu>350.
for bedtime: 1U starting at >151, increasing by 1U with each
50pt increase in glucose
4. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane Q4H (every 4 hours) as needed for Sore Throat.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Outpatient [**Telephone/Fax (1) **] Work
daily INR until INR is stable and between [**2-18**] X48H. Weekly with
other [**Month/Day (3) **] draws thereafter.
12. Outpatient [**Name (NI) **] Work
PTT every 5 hours with goal 50-70. Can stop once Heparin is
turned off.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for left sided head/neck pain.
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
4 days: start on [**2-12**] and continue through [**2-15**].
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. CefazoLIN 2 g IV Q8H
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Heparin sliding scale
Heparin IV Sliding Scale
Continue infusion (starting Now), currently at 800 units/hr
Diagnosis: Mechanical Valve
Patient Weight: 81.83 kg
Initial Bolus: 0 units IVP
Initial Infusion Rate: 800 units/hr
Target PTT: 50-70 seconds
PTT <30: 200 units Bolus then Increase infusion rate by 350
units/hr
PTT 31-49: 50 units Bolus then Increase infusion rate by 150
units/hr
PTT 50-70: at goal, continue current infusion
PTT 71-100: Reduce infusion rate by 50 units/hr
PTT >101: Hold 60 mins then Reduce infusion rate by 200 units/hr
21. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
22. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]-[**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
-infectious endocarditis from MSSA
-acute renal failure due to allergic interstitial nephritis
-GIB
-torsades s/p screw in pacemaker placement
-leukoclastic vasculitis, skin, secondary to Nafcillin or IE
-diffuse alveolar hemorrhage
Seconary Diagnoses:
-CAD
-AVR
-AAA
-afib
Discharge Condition:
Mentating well.
Ambulating well and independently.
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of fever. While you were here you were diagnosed with
an infection of your heart valve and started on antibiotics.
You will be on antibiotics for 6-8 weeks. You are on Cefazolin
2G IV every 8 hours ([**Date range (1) 28757**]). This dose may have to be
increased if your kidney function improves.
Your INR should be checked daily until it is [**2-18**] for >48 hours
at which point your Heparin can be stopped. Your PTT should be
checked regularly from a peripheral blood draw since it is
inaccurrate off of your PICC line. Your BMP and LFTs should be
checked in 3 days ([**2-14**]). You should have weekly CBC, BMP, LFTs
therafter.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**], and the Renal doctors [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 11957**]
and your Primary Care Doctor Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8719**].
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to
on [**Name8 (MD) 138**] MD in when clinic is closed.
While you were here you also had kidney failure likely due to
Nafcillin (an antibiotic) but possibly because of the infection.
You were seen by the kidney doctors and started on Prednisone
for this. The Prednisone should be continued as described
below. You were changed from Protonix to Ranitidine because
Protonix could also cause this problem. [**Name (NI) **] were on dialysis for
a temporary period of time.
You also had a small amount of blood loss in your stool and
around your PICC and pacemaker sites while you were here. You
required 3 units of a blood transfusion. In order to attempt to
prevent this problem again, your PTT level, if high from your
PICC line, should be checked peripherally. The PTT level should
be checked every 6 hours with a goal of 50-70.
While you were here you also had a rash called, leukoclastic
vasculitis which was probably due to the antibiotic Nafcillin,
which you had been on or from your heart infection. You were
seen by dermatology and started on Prednisone and it started to
improve. It was worse on [**1-23**] when it was on both of your legs
and some on your abdomen.
While you were here you had bleeding in your lungs called
diffuse alveolar hemmorrhage, likely from increased fluid from
renal failure and from the Heparin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Some of your medications were changed.
You should CONTINUE to take:
-Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
-Aspirin 81 mg daily
-Oxycodone 5mg as needed up to twice a day
You should START taking:
-Cefazolin 2G IV Q8H until [**3-12**] or as per your ID doctor
-Amlodipine 5mg daily
-Bisacodyl 10mg daily as needed for constipation
-Docusate 100mg twice a day
-Heparin sliding scale with goal PTT 50-70. It is currently at
800 units/hr
-Prednisone 5mg daily starting [**2-12**] with last day [**2-15**]
-Insulin sliding scale: please see attached. This can stop when
you stop taking the Prednisone and your glucose is below 200
consistently.
-Lorazepam 0.5 mg nightly as needed for insomnia
-Metoprolol 50mg twice a day
-Senna 1 tab up to twice a day as needed for constipation
You should CHANGE:
-Pantoprazole and START Famotidine 20mg daily
-Lasix 80mg twice a day and START Lasix 40mg daily (your doctors
[**Name5 (PTitle) **] increase this dose if you continue to have swelling or any
fluid on your lungs)
-Your Coumadin dose should NOW be 3mg daily. Since your INR goal
is now lower at 2-3, this dosing may need to be changed. In the
past it was 5mg/5mg/2mg on a rotating schedule.
You should STOP taking:
-Allopurinol
-Ambien (this caused you to get very confused and pull at your
pacemaker)
-Quinapril 20mg po daily, though your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to
restart this medication or another ace-inhibitor later
-Sucralfate
-Ferrous Sulfate
Followup Instructions:
You have the following appointments:
Electrophysiology/Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2128-3-4**] at 820am
Address: [**Street Address(2) 7160**], [**Hospital Ward Name **] 4, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
At this appointment planning for your future pacemaker will take
place. This is the person that should be contact[**Name (NI) **] if there are
any problems with your current pacemaker.
Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], Infectious Disease MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2128-2-23**] 10:30
You have an appointment with Dr. [**First Name (STitle) 1356**] in gastroenterology on
[**2-25**] at 11:40am. Their number is [**Telephone/Fax (1) **]. The office is at [**Last Name (NamePattern1) 10357**]. [**Location (un) **] E.
You have an appointment with a urologist. You may need a
cystoscopy since you had blood in your urine when you were
admitted. You have an appointment with: [**Hospital1 1474**] Urology, [**Telephone/Fax (1) 28758**]. 31 [**Name (NI) 10936**] Brothers [**Name (NI) **], [**Name (NI) 28759**]. Your appointment
is: Dr. [**Last Name (STitle) 22656**] on [**2-27**] at 2pm.
You will have to follow up with the kidney doctors [**2-24**] at 4pm
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 28760**]. Their number is [**Telephone/Fax (1) 10135**].
Call Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] for a follow-up appointment within one
week after discharge. His phone number is [**Telephone/Fax (1) 8725**].
|
[
"427.1",
"996.61",
"041.11",
"V58.61",
"E930.0",
"V10.46",
"428.33",
"427.31",
"428.0",
"286.6",
"599.71",
"446.29",
"486",
"518.81",
"053.19",
"V43.3",
"V45.81",
"E934.2",
"274.9",
"578.9",
"285.1",
"421.0",
"272.4",
"786.3",
"038.11",
"584.9",
"580.89",
"426.0",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.22",
"99.62",
"55.23",
"39.95",
"33.24",
"96.6",
"88.72",
"96.04",
"38.95",
"37.78",
"86.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
26031, 26097
|
11887, 22487
|
321, 426
|
26434, 26486
|
4194, 11369
|
30560, 32237
|
3406, 3437
|
22962, 26008
|
26118, 26413
|
22513, 22939
|
26510, 30537
|
3452, 3462
|
3484, 4175
|
275, 283
|
11388, 11864
|
454, 1991
|
2013, 3177
|
3193, 3390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,534
| 181,366
|
2881
|
Discharge summary
|
report
|
Admission Date: [**2120-10-25**] Discharge Date: [**2120-10-31**]
Date of Birth: [**2055-7-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Sepsis, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65F w/ h/o metastatic breast cancer to breast and lungs
currently receiving CMT (cycle 1, day 19), brought to the ED by
rehab for abnormal labs. She was found to be neutropenic, anemia
and thrombocytopenic. At the rehab, vitals were reportedly T
100.4, HR 107, BP 92/42. There is also a concern for possible
confusion and urine incontinence. Per patient, she is has not
experienced any confusion, and was refusing to cooperate for the
last few days because she was angry that her physicians have not
been forthcoming with her prognosis. She is usually incontinent
of bowel and bladder, and denies diarrhea, abdominal pain,
brbpr, melena, dysuria, or hematuria. She has not felt any
fevers or chills and has otherwise been feeling fine and had
been expecting to be discharged from rehab on Sunday. She denies
cough, SOB, chest pain, headache, photophobia, neck stiffness.
She has a left port which is not painful and is used for
chemotherapy.
Of note, she was recently admitted in [**Month (only) **] for frequent falls,
which were initially believed to be due to seizures, however,
EEGs were negative. She was diagnosed with orthostasis/autonomic
dysfunction and deconditioning and discharged to rehab.
ED course: T 100.6, EKG NSR at 83 w/ TWF, received vancomycin,
cefepime and IVF. CT head was negative for an acute process.
Past Medical History:
ONCOLOGY HISTORY:
[**2108**]: Stage II right sided, invasive ductal adenocarcinoma,
ER-/Her2+ on initial core biopsy (done [**2108-1-17**]), but
ER-/HER2NEGATIVE on the excised breast specimen done [**2108-2-17**]
(please see below). She underwent 4 cycles of adriamycin and
cyclophosphamide followed by radiation therapy, completed in
[**2108**].
[**2119-1-20**]: Presented with ear complaints and nasal congestion,
initially thought to be related to swimmer's ear. She was given
a
course of antibiotics and nasal sprays with no resolution.
Symptoms evolved to include pain with mouth opening and
ultimately jaw restriction; right jaw area seemed swollen. CT
sinus/mandible scan on [**2119-1-26**] showed an irregular lucency in the
right mandibular ramus. [**2119-2-10**] biopsy by FNA showed groups of
atypical epithelial cells consistent with poorly-differentiated
carcinoma. A PET scan on [**2119-2-10**] showed a left lower lobe lung
mass, a left pleural lesion, a dome of the liver lesion and the
right mandibular ramus. On [**2119-2-13**], the left lung lesion was
biopsied and showed adenocarcinoma with immunostaining positive
for Cytokeratin 7 in the tumor cells, but negative for
cytokeratin 20, CDX-2, TTF-1, Mammoglobin, GCDFP, ER and PR
immunostains. HER2 amplification was not found. Because the
TTF-1
immunostain is negative, a lung primary is thought to be
unlikely. She is also followed by an ENT physician, [**Name10 (NameIs) **] [**First Name (STitle) **]
[**Name (STitle) **]. Her recent chemotherapy treatment history follows:
METASTATIC CANCER TREATMENT HX
FIRST LINE THERAPY:
[**2119-2-20**]: Started on trial 09-312; This is a Phase 3 Randomized
Study of Gemcitabine and Carboplatin with or without BSI201 in
patients with triple negative metastatic breast cancer. [**Male First Name (un) **]
was randomized to Arm B: Gemcitabine, Carboplatin, and BSI201;
[**2119-3-10**] - Cycle 1 D1
Completed 9 cycles, stopped due to progression; Patient did have
treatment delays and dose reductions due to
thrombocytopenia-ENDED [**2119-10-20**]
SECOND LINE THERAPY:
Paclitaxel 80mg/m2 weekly, 3 week on/1 week off.
[**2119-11-10**] - [**2120-7-15**] - received approximately 9 cycles, needed
Neupogen support with 3rd cycle for neutropenia. Stopped due to
progression seen in by new liver and brain mets.
Now she also received radiation therapy.
Social History:
Works as a nurse/community liason for a company. With long time
partner [**Name (NI) **],no children.
-Smoking Hx: Never
-Alcohol Use: 1 glass red wine per night
-Recreational Drug Use: None
Family History:
Mother had breast cancer at age 85.
Father thought to have lung cancer. She has 2 brothers and one
sister.
Physical Exam:
VS: 96.6, 100/70, 77, 18, 97% 2L
Gen: thin F in NAD
HEENT: right mandibular mass, atraumatic, sclera anicteeric
Neck: supple
CV: RRR, no edema
Lungs: decreased BS at left mid-lower lung fields, no
crackles/wheezes noted, no retractions, good effort
Abd: +BS, soft, NTND, no mass/hsm, no rebound/guarding
Ext: no c/c/e
Neuro: A&O x 3
Pertinent Results:
[**2120-10-25**] 03:10AM LACTATE-1.7
[**2120-10-25**] 02:55AM GLUCOSE-102* UREA N-20 CREAT-0.6 SODIUM-139
POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-34* ANION GAP-10
[**2120-10-25**] 02:55AM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.5*
[**2120-10-25**] 02:55AM WBC-0.2*# RBC-2.53* HGB-7.4* HCT-21.5*#
MCV-85 MCH-29.1 MCHC-34.3 RDW-17.8*
[**2120-10-25**] 02:55AM NEUTS-16* BANDS-0 LYMPHS-68* MONOS-12* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-9* OTHER-4*
[**2120-10-25**] 02:55AM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-OCCASIONAL
[**2120-10-25**] 02:55AM PLT SMR-VERY LOW PLT COUNT-27*#
[**2120-10-25**] 02:55AM PT-14.7* PTT-22.0 INR(PT)-1.3*
CXR: left lower lobe opacity, enlarged from [**7-10**] (my read)
CT head (prelim read): 1. No acute process. 2. Known
metastatic disease.
Brief Hospital Course:
65F w/ h/o metastatic breast cancer to brain & lungs presenting
with neutropenic fever, anemia and thrombocytopenia.
.
# Neutropenic fever: admitted for febrile neutropenia (temp
100.6 in ED, ANC 38). denied all symptoms including subjective
fevers. started empirically on vanc/cefepime and pancultured but
no obvious source for infection was found, cultures were neg,
and CXR negative initially. On the evening of hospital day 3 pt
began to desat to the 80s but improved with oxygen via nasal
cannula. The next morning, pt desatted again to the 80s and was
less responsive to oxygen, but O2 sats improved after nebs and
lasix. CXR showed new area suspicious for pneumonia so coverage
broadened to vanc/zosyn to cover anaerobes. ANC was much
improved at that time (up to 2139 from 216 the day prior) so her
poor saturation was thought to be secondary to mounted immune
response to pneumonia that was present. The following day she
desatted to 70s and became tachycardic to 140s. She continued
to desat after receiving nebs and was transferred to the [**Hospital Unit Name 153**].
.
# Respiratory Distress:
While in the [**Hospital Unit Name 153**], the patients antibiotic coverage was
adjusted. She expressed wishes to change her code status to
full code. She continued to retain CO2 and her respirations
became more labored. The possibility of intubation was again
discussed with the patient and she reported that she did not
want to be intubated. This was confirmed with her health care
proxy. The following morning, the patient continued to have
difficulty breathing and was increasingly altered mental status.
The decision to change her care to comfort was made following
discussions with her health care proxy. She passed away
peacefully in the presence of friends the following day.
# Anemia: Thought to be secondary to chemotherapy. Hct was 21.5
upon admission but decreased to 20.1 during course of admission,
prompting transfusion of 1 unit PRBC. Hct improved
appropriately after this.
# Metastatic breast cancer to liver, lungs, brain: pt was
undergoing chemo at the time of admission. She was continued on
seizure prophylaxis and valproic acid.
# Falls: Pt has a history of falls with negative neurologic work
up. Thought to be multifactorial, [**2-21**] possible seizures,
deconditioning, and orthostasis/autonomic dysfunction. She was
continued on fludrocortisone and seizure prophylaxis and this
was not an active issue.
Medications on Admission:
Cyclophosphamide
Dexamethasone 6g mg po bid
Fludrocortisone 0.1 mg po daily
Keppra 500 mg po TID
Omeprazole 20 mg po daily
Trazodone 50 mg po qhs
Valproic acid 500 mg po TID
Calcium
Ibuprofen prn
Pyridoxine prn
Sodium chloride 1 g TID
Vitamin E
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercapneic hypoxemic respiratory failure
Breast Cancer
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"V87.41",
"V15.3",
"337.9",
"284.11",
"345.90",
"V15.88",
"293.0",
"507.0",
"V13.02",
"780.61",
"E933.1",
"482.9",
"518.81",
"197.7",
"198.3",
"V49.86",
"V10.3",
"197.1",
"276.8",
"197.0",
"038.9",
"995.92",
"197.2",
"785.52",
"276.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8446, 8455
|
5660, 8119
|
335, 341
|
8555, 8564
|
4788, 5637
|
8620, 8756
|
4312, 4420
|
8414, 8423
|
8476, 8534
|
8145, 8391
|
8588, 8597
|
4435, 4769
|
267, 297
|
369, 1699
|
1721, 4087
|
4103, 4296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,529
| 115,035
|
5833
|
Discharge summary
|
report
|
Admission Date: [**2132-3-11**] Discharge Date: [**2132-4-14**]
Date of Birth: [**2057-6-14**] Sex: F
Service: MEDICINE
Allergies:
Talwin Nx / Heparin Agents
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Liver Biopsy--> no complications
Central line placement.
History of Present Illness:
Patient is a 74 yo woman with PMH of rheumatic heart disease,
breast cancer, DM2, AFib who was transferred to [**Hospital1 18**] on [**2132-3-11**]
from [**Hospital **] Hospital for semi-elective valve replacement.
Patient had been in her USOH until couple years ago, when her
son noticed DOE. She had not noticed this as a problem at the
time. The patient began noting more concerning symptoms in
[**Month (only) **]/[**2131-10-23**] when began noticing she would become SOB
on more minimal exertion. She presented to her cardiologist re:
these concerns in [**2131-11-22**], at which time he did an ECHO
that demonstrated LVH, EF=55-60%, mod-severe MR, mod AR, ?pulm
valve stenosis, mild TR. At this time, per patient, she was
urged to consider valve replacement surgery, but the patient
initially refused. Over the past couple months, pt has noted
worsening of her SOB so that she now feels some SOB at rest. A
couple weeks ago she also noted some swelling in her ankles and
orthopnea. ROS also negative for CP/pressure, TIA sxs.
Therefore, pt re-presented to her cardiologist, now requesting
surgery for her sxs.
Pre-op w/u prior to presentation included cardiac cath at
[**Hospital 47**] hospital on [**2132-3-10**], which demonstrated no
significant CAD, severe AS, mod-severe MR, elevated filling
pressures, decreased CO at 3.24 (Fick), decreased CI at 1.56
(Fick), PCWP 24, RA mean 18, PA 49/26, RV 53/6.
Patient was admitted to CT surgery service on [**2132-3-11**] and
transfered to CCU for optimization of clinical status prior to
surgery after developing fever to 101.5. Started on vanc and
zosyn for empiric coverage. Found to have enterococcus in urine
and treated with Zosyn-->levaquin for 10 day course. Course them
complicated by dropping HCT. GI consulted and pt found to have
gastic varicies. Pt anticoagulated with heparin for Afib and
anticipating surgery. course again complicated by rising LFT's.
Pt had liver bx on [**3-31**] for elevated LFT's. path pending. HF
service consulted for CHF, volume overload in setting of
elevated creat and decreased Na. Pt started on Niseritide with
goal of taking off 10 lbs prior to surgery.
Past Medical History:
1.) Rheumatic heart disease
2.) DM2 - on oral hypoglycemics
3.) Breast cancer - initially dx in [**2117**], s/p mastectomy and
placed on tamoxifen. Then recurred in [**2123**], s/p surgical
resection, chemo, radiation. Since that time mammograms have
been negative.
4.) AFib - ?dx 1 month ago, on atenolol for rate control
5.) HTN
6.) TAH
Social History:
No tobacco, EtOH, drug use. Lives alone, son lives nearby.
Husband just died of heart problems in [**2131-11-22**]. Had a
daughter that died of cancer. 2 other children.
Family History:
NC
Physical Exam:
VS T:97 P:84 BP:99/66 (leg) RR:16 O2Sat:100%2L
GENERAL: Anasarca, pleasant and talkative, speaking in full
sentences. NAD
HEENT: MMM, pupils equal
NECK: supple, no LAD, elevated JVD.
CARDIOVASCULAR:irreg, irreg, [**3-27**] blowing systolic murmur.
LUNGS:Diffuse rales to 2/3 up. Decreased BS at bases.
ABDOMEN: Obese, edema, soft, NT, NABS
EXTREMITIES:Anasarca, pale, non-palp pulses, warm.
NEURO:A&Ox3. Non-focal.
Pertinent Results:
[**2132-3-11**] 08:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-3-11**] 01:15PM GLUCOSE-167* UREA N-30* CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
[**2132-3-11**] 01:15PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-69
AMYLASE-65 TOT BILI-0.6
[**2132-3-11**] 01:15PM LIPASE-33
[**2132-3-11**] 01:15PM WBC-9.2 RBC-3.72* HGB-10.3* HCT-30.8* MCV-83
MCH-27.7 MCHC-33.5 RDW-16.7*
[**2132-3-11**] 01:15PM PLT COUNT-186
[**2132-3-11**] 01:15PM PT-14.5* PTT-26.2 INR(PT)-1.3*
.
Carotid u/S: IMPRESSION: Minimal plaque with a left less than
40% carotid stenosis. The right carotid was not evaluated due to
the central line.
.
ECHO: The left atrium is moderately dilated. There is mild
symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is mildly depressed. [Intrinsic left ventricular
systolic function is likely more depressed given the severity
of valvular regurgitation.] Right ventricular systolic function
is normal. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets are severely thickened/deformed. There is
moderate to severe aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate thickening of the mitral valve
chordae. Moderate to severe (3+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated. There is moderate pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no
echocardiographic signs of tamponade.
.
LENI: IMPRESSION: No evidence for DVT.
.
CT abd: IMPRESSION:
1. Left pleural effusion, without right pleural effusion.
Etiology of this is unclear and a chest x-ray is recommended for
further evaluation.
2. Right groin hematoma. No drainable fluid collection is seen.
3. No evidence for retroperitoneal hemorrhage.
.
CXR: The cardiac silhouette is markedly enlarged but stable.
There remains a moderate-sized left pleural effusion with
adjacent atelectasis in the left lower lobe. A small right
pleural effusion is also noted and is not seen on the previous
study. Note is made of prior left mastectomy and axillary lymph
node dissection as well as asymmetrical apical thickening on the
left, possibly related to prior radiation therapy.
.
CTA abd: IMPRESSION:
1. Multiple splenic hilar varices extending to the proximal
greater curvature of the stomach becoming gastric varices with
splenorenal shunt. No evidence for splenic vein thrombosis or
splenomegaly. No evidence for esophageal varices. The
combination of these findings, along with a large inferior vena
cava with contrast reflux into the hepatic veins, bilateral
pleural effusions, and pericardial effusions suggest right heart
failure and volume overload.
2. Low-density left adrenal lesion consistent with an adrenal
adenoma.
.
Brief Hospital Course:
Given severity of mitral and aortic valve disease, pt
expressing CHF sxs, progressive over past 6 months plan was for
valve replacement with MVR and AVR once medically stable. Pt had
cath at OSH prior to surgery which showed normal coronaries. Pt
was diuresed intially in the CCU with swan guidance. However,
prior to surgery pt found to have a UTI which was treated with 7
days of Levaquin. Pt cleared the UTI but her HCT slowly began to
drop and she was found to be GUIAC positive. Pt was on a heparin
gtt at this point in anticipation of surgery. Gi service was
consulted and felt that pt should have a colonoscopy and EGD
prior to the surgery to assess risk. Colonoscopy revealed
hemorroids and the EGD revealed large gastric varicies. There
was concern to severe liver damage given the secondary findings.
Therefore the patient underwent a liver biopsy on [**2132-3-31**] to,
again, asses for risk of surgery. The biopsy showed grade III
fibrosis while would put her at 30-50% mortality risk for this
surgery. This made the patient no longer a condidate for this
surgery. Lipitor was also discontinued for hepatic dysfunction.
The patient was fluid resuscitated during the GI bleed and
subsequently became markedly fluid overloaded and anasarcic. She
was started on smal doses of IV lasix and transfered to the
medicine service. At this point her Na was gradually dropping
with a nadir of 120 due to CHF and volume overload. In addition,
the pt was going into worsening reanl fialure with her
creatinine of 3 from a baseline of 1.3. The CHF service was
consulted and recommended starting Niseritide as pt did not seem
to be responding to this. The patient was aslo started on
Amiodarone for her afib and a low dose BB for better rate
control to improve cardiac output. The patient had gained 10kg
as well. The pt continued to gain wgt on the Niseritide with no
improvement in her sodium. The renal service was consulted for
assitance with diuresis, hyponatremia and worsening renal
failure. They recommended an aggressive regimen of Lasix 160 IV
qd abd Diuril 250 IV QD. The patient received this regimen for
approximately one week with very good response. She lost 15kg of
fluid and was diuresing 2L per day. The Diuril was discontinued
and the pt was placed on an IV Lasix taper with the goal of
finding an oral regimen that she could be discharged on. Her
creatinine came back down to baseline after the diuresis as
well. The patient was converted to Lasix 80mg PO BID with good
response. Plan would be to address afterload reduction with
ACE-I or Imdur and hydralazine after consultation with Dr.
[**Last Name (STitle) 1290**] on [**4-17**].
Pt has DM2 and was maintained on a sliding scale during this
admission but added back oupt glyburide on 2 days prior to
discharge with good response and FS<180 but will likely need a
second [**Doctor Last Name 360**] since we cannot use metformin any longer with her
chronic renal failure.
While the patient was on the Heparin gtt awaiting surgery
she developed thrombocytopenia. A heparin antibody was checked
and was positive. The patient was switch to argatroban for
anticoagulation and the pt was diagnosed with HIT. Hematology
was consulted for assistance with furture anticoagulation. The
patient remained on the argatrogan for 10 days and was started
on coumadin therapy towards the end of her admission for
continued anticoagulation given her afib and risk of thrombosis
after HIT. Thrombocytopenia resolved as coumadin was restarted
and INR increased to INR 2.0 on admission. Plan is to maintain
INR 2.0-3.0 on doses of coumadin 7.5-10mg per Heme/Onc and she
will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] on [**4-25**] in [**Hospital **] clinic.
During this admission the patient was noted to be somewhat
depressed at times. She did note that her husband had recently
passed away and she was having difficulty dealing with the
extent of her admission. Psychiatry was consulted and the
patient was started on Remeron. She had confusion with this and
was given Haldol for agitation. She seemed to have symptoms of
akethesia with this so Haldol was avoided for the remainder of
the admission. Pt was then started on Seroquel at night. Within
3 days she developed a Leukopenia which resolved after stopping
this medication. After this, the patient decided that she did
not want to try any other medications and would deal with her
depression through talk therapy when able. The patient did have
further episodes of frustration and at one point reversed her
code status to DNR/DNI and wanted to return home as CMO.
However, after further discussion with psychiatry and the
palliative care service the patient stated that she was just
very uncomfortable and if efforts such as removing foley and
getting better food were met she was very pleased and requesting
full medical treatment. A family meeting was held with the
patients son and brother and goals of care discussed.
The patient is a FULL CODE.
Medications on Admission:
Medications:
At Home:
ASA 81mg QD
Synthroid 100mcg QD
Atenolol 50mg QD
Lipitor 10mg QD
Glyburide 10mg [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Triamterene/HCTZ 37.5/25mg QD
On Transfer:
Insulin SC
Levothyroxine Sodium 100 mcg PO DAILY
Lorazepam 0.5 mg PO Q8H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Metoprolol 12.5 mg PO BID
Amiodarone HCl 200 mg PO TID
Milk of Magnesia 30 ml PO Q6H:PRN
Aspirin EC 81 mg PO DAILY
Mirtazapine 15 mg PO HS
Atorvastatin 10 mg PO DAILY
Nesiritide 0.015 mcg/kg/min IV INFUSION
Bisacodyl 10 mg PO/PR DAILY:PRN
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID
Simethicone 40-80 mg PO QID:PRN
Guaifenesin [**4-30**] ml PO Q6H:PRN
Tucks Hemorrhoidal Oint 1% 1 Appl PR DAILY
Heparin IV
TraZODONE HCl 50 mg PO HS:PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal DAILY PRN ().
10. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection 2X/WEEK (WE,SA).
13. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO DAILY (Daily).
18. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Rehab, [**Hospital 1110**] Campus
Discharge Diagnosis:
Aortic Valve stenosis
Mitral valve stenosis
Congestive Heart Failure
Atrial Fibrillation
Hepatic congestion
Heparin induced thrombocytopenia
diabetes type II
Discharge Condition:
Stable.
Discharge Instructions:
Please return to the hospital if you experience chest pain,
shortness of breath, nausea/vomiting/diarrhea or any other
severe symptoms. Please call your doctor if you have any
questions about your symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1290**] at 9:30am on [**4-17**].
Please have your son accompany you to this appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2132-4-25**] 1:00
Please follow-up with your primary care doctor in [**12-24**] weeks.
|
[
"280.0",
"571.5",
"397.0",
"456.8",
"573.0",
"287.4",
"V58.61",
"V15.3",
"250.00",
"311",
"V45.71",
"398.91",
"584.9",
"455.0",
"E934.2",
"599.0",
"401.9",
"427.31",
"041.04",
"578.1",
"244.9",
"396.2",
"281.1",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"45.23",
"38.93",
"50.11",
"45.13",
"00.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14104, 14181
|
6637, 11663
|
306, 364
|
14383, 14393
|
3567, 6610
|
14648, 15012
|
3112, 3116
|
12474, 14081
|
14202, 14362
|
11689, 12451
|
14417, 14625
|
3131, 3548
|
247, 268
|
392, 2546
|
2568, 2909
|
2925, 3096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,024
| 198,289
|
10118
|
Discharge summary
|
report
|
Admission Date: [**2149-11-8**] Discharge Date: [**2149-11-19**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Type 3 endo leak with rupture of abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
Revision of previously placed modular aortic
stent graft with 32 x 125 aorto uni iliac graft on the right
and a 16 x 95 Endograft extender cuff on the left via
bilateral femoral cutdowns and arteriography
History of Present Illness:
This 88-year-old gentleman underwent placement
of a modular bifurcated aortic stent graft for abdominal
aortic aneurysm about 5-1/2 years ago. He subsequently
developed left limb occlusion and had a thrombectomy of the
limb and placement of a balloon expandable stent in the left
common iliac artery at a point of kinking. The balloon
expandable stent was actually within the left limb of the
previously-placed graft. He had not been seen in this
institution since [**2146**] and was med flighted up from the
[**Hospital 1474**] Hospital this evening, complaining of abdominal and
flank pain with some hypertension. He was found to have a
large type 3 endo leak due to component separation with
contained rupture of his abdominal aortic aneurysm. He is now
being taken emergently to the operating room.
Social History:
pos smoker (Remote)
neg alcohol
Family History:
n/c
Physical Exam:
O VITAL SIGNS:T 96.4, BP 133/64, P 82,RR 18, SaO2 100% RA
+BM yesterday
GEN: Elderly male, sitting up in chair feeding himself a hearty
lunch. NAD
HEENT: NCAT, EOMI, oral mucosa moist without exudate
RESP: CTA, no wheezes, no crackles, no rhonchi, good air
exchange throughout.
COR: Irregularly irregular, no mumurs, no gallops, no rubs
ABD: soft, non-distended, nontender, no masses, no guarding, BS
+
EXT: 1+ edema feet bilaterally, no cyanosis
SKIN : Heels without erythema.
NEURO: Alert, oriented to self, place (time not assessed).
Mildly confused and inattentive, but considerably improved over
past exams. No facial asymmetry. No dysarthria. Moves all
extremities equally.
Pulses: palp DP/PT BL
Pertinent Results:
[**2149-11-14**] 05:30AM BLOOD
WBC-11.5* RBC-3.86* Hgb-11.8* Hct-35.7* MCV-93 MCH-30.6
MCHC-33.0 RDW-14.7 Plt Ct-291
[**2149-11-11**] 03:16AM BLOOD
PT-13.3 PTT-31.3 INR(PT)-1.1
[**2149-11-19**] 05:35AM BLOOD
Glucose-93 UreaN-30* Creat-1.0 Na-137 K-4.2 Cl-103 HCO3-26
AnGap-12
[**2149-11-19**] 05:35AM BLOOD
Calcium-8.5 Phos-2.8 Mg-2.3
[**2149-11-11**] 11:00PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-6.0 Leuks-SM
URINE RBC-[**6-1**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2
URINE Hours-RANDOM UreaN-1415 Creat-106 Na-20 TotProt-24
Prot/Cr-0.2
[**2149-11-11**] 11:00 pm URINE Source: Catheter.
URINE CULTURE (Final [**2149-11-13**]): NO GROWTH.
[**2149-11-17**] 9:00 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
ADDENDUM: The measurements of 3D reformats performed in the
imaging lab are as follows: The AAA diameter largest central
line axis is 71 x 78 mm, the AAA diameter largest in axial view
is 71 mm, the AAA volume is 306 cc, the lowest renal artery to
aortic bifurcation volume is 341 cc, the lowest renal artery to
iliac bifurcation volume is 381 cc. The lowest renal artery to
stent top distance was 29.2 mm, the stent end to right iliac
bifurcation distance was 42 mm, the stent end to left iliac
bifurcation distance was 53 mm.
HISTORY: 88-year-old male status post repair of an endoleak.
FINDINGS:
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are several scattered mediastinal lymph nodes with the
largest measuring 18 x 8 mm in a pretracheal location. There is
an 11 x 8 mm pulmonary opacity in the left apex likely
representing fibrotic scarring. There is a calcified granuloma
in the right upper lobe (image 46, series 3). There are multiple
calcified pleural plaques. There are bibasilar effusions and
passive atelectasis of the lower lobes.
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are several subcentimeter low-attenuation foci in both
kidneys, likely cysts. There is a 26 x 17 mm low-attenuation
focus at the lower pole of the left kidney. In addition, there
is a 7 x 9 mm exophytic low-attenuation focus at the lower pole
of the left kidney. The foci at the lower pole of the left
kidney are worrisome for neoplasm.
The liver, gallbladder, spleen, adrenal glands, and pancreas
appear unremarkable. There is a 104 x 58 mm right paraaortic
hematoma in the mid abdomen, previously 95 x 54 mm (image 81,
series 5). There is almost complete resolution of the
perisplenic hematoma. There is stable perirenal stranding and
thickening of the Gerota's fascia.
CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST:
The prostate gland measures 60 x 47 mm. There are multiple
calcific foci within the prostate gland. There is perirectal
stranding and minimal free fluid in the pelvis, unchanged since
the prior examination. There are fluid collections in the
inguinal regions in keeping with the recent endovascular repair.
MUSCULOSKELETAL:
There are multilevel degenerative changes present in the spine.
There is a small ventral abdominal hernia.
CT ANGIOGRAM:
There is extensive atherosclerosis present in the coronary
arteries, thoracic, abdominal aorta and its branches. The
coronary arteries arise from the normal expected anatomical
location. There is a stent present in the proximal right
coronary artery.
The ascending aorta at the level of the right main pulmonary
artery measures 37 x 37 mm. The aorta at the level of the left
inferior pulmonary vein measures 30 x 31 mm. There are multiple
ulcerated plaques present in the descending thoracic and the
abdominal aorta.
The abdominal aorta at the level of the celiac artery measures
31 x 27 mm. There is atherosclerotic plaque present at the
origin of the celiac artery. The superior mesenteric artery is
patent. There is a single patent right renal artery and a single
patent left renal artery.
The stent in the abdominal aorta starts just above the superior
mesenteric artery. The infrarenal abdominal aortic aneurysm
measures 82 x 73 mm, previously 80 x 74 mm. There is
high-attenuation material within the thrombus in the abdominal
aorta suggestive of an endoleak.
There is extensive atherosclerosis present in the iliac arteries
which are ectatic. The right common iliac artery before the
bifurcation measures 17 mm in maximum transverse diameter.
CONCLUSION:
1. Minimal interval increase in the size of the infrarenal
abdominal aortic aneurysm with appearances suggestive of an
interim endoleak as described above.
2. Two low-attenuation foci at the lower pole of the left kidney
are worrisome for neoplasm and may be further assessed with a
dedicated renal MRI.
3. Bibasal effusions and a small pericardial effusion with
passive atelectasis of the lower lobes.
4. Calcified pleural plaques, mediastinal lymph nodes and 12 x 8
mm ill- defined opacity in the left upper lobe likely represents
fibrosis, however, a repeat chest CT in six months would be
helpful to assess stability.
Brief Hospital Course:
This 88-year-old gentleman underwent placement of a modular
bifurcated aortic stent graft for abdominal aortic aneurysm
about 5-1/2 years ago. He subsequently
developed left limb occlusion and had a thrombectomy of the limb
and placement of a balloon expandable stent in the left common
iliac artery at a point of kinking. The balloon expandable
stent was actually within the left limb of the
previously-placed graft. He had not been seen in this
institution since [**2146**] and was med flighted up from the [**Hospital 1474**]
Hospital this evening, complaining of abdominal and flank pain
with some hypertension. He was found to have a
large type 3 endo leak due to component separation with
contained rupture of his abdominal aortic aneurysm. He is now
being taken emergently to the operating room.
[**11-9**]
PROCEDURE: Revision of previously placed modular aortic stent
graft with 32 x 125 aorto uni iliac graft on the right and a 16
x 95 Endograft extender cuff on the left via bilateral femoral
cutdowns and arteriography.
The patient tolerated this procedure remarkably well and was
taken to the recovery room still intubated and in stable
condition.
While in the CVICU he was weaned off pressure support and
extubated
[**11-10**]
Transfered to the VICU for further management
recieved blood products / secondary to blood loss form OR
[**11-11**]
pt recieved lasix for SOB / CXR did show some fluid in the lungs
haloperidol for confusion
[**11-12**]
foley DC'd
[**11-13**]
BB adjusted for HR control / pt slightly tachycardic
[**11-14**] - [**11-15**]
PT / rehab screening
[**11-17**]
premedicated for CTA
[**11-17**]
Pt confused: Geriatrics consult obtained - swconadary to
recieving benadryl for CTA / Pt has dye allergy
1) Continue zyprexa 2.5mg PO QHS PRN agitation. Do NOT discharge
patient on this medication, as his sleep/wake cycle will not be
as disturbed after he has left the hospital.
2) Wait for PCP to [**Name9 (PRE) **] aricept as an outpatient. I gave the
patient's son the card to our Memory Clinic here at [**Hospital1 18**], if
they should be interested in an evaluation with us.
3) Continue to encourage hydration. Since BUN/Cr slightly
elevated from baseline prior to CT, would not be surprised if he
has a "bump" in BUN/Cr 48 hours after CT. However, this should
also normalize on its own.
5) Tylenol PRN for pain. If has continuous pain, would schedule
tylenol 1000mg PO TID at 8AM, 2PM, and 10PM. [**Month (only) 116**] use low dose
oxycodone 2.5mg PO Q6H PRN breakthrough pain if necessary.
6) Avoid all anticholinergics (including benadryl when possible)
and benzos. Avoid restraints and foley catheter use, as you are
doing.
7) Avoid disruption to sleep/wake cycle - keep out of bed to
chair during the day, and dim lights at night. Schedule
medications so that he does not need to be awoken at night.
8) If patient becomes agitated, please use sitter for
reassurance and reorientation. Avoid restraints as this will
only make delirium worse.
9) Agree with family's desire for [**Hospital 3058**] rehab - this will
help patient go back to previous high functioning level and will
give son some respite (he lives with son).
Pt stable for DC to rehab
Medications on Admission:
[**Last Name (un) 1724**]: coumadin 5?, cardizem CD 120', cardura 8', aricept 5'hs
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Type 3 endo leak with rupture of abdominal aortic aneurysm.
post operative confusion
anemia secondary to blood loss from OR requiring Blood
tranfusion
CHF - requiring lasix
AFib, HTN, alzheimer's
Discharge Condition:
good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-25**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-28**] weeks for
post procedure check and CTA
What to report to office:
??????1 Numbness, coldness or pain in lower extremities
??????2 Temperature greater than 101.5F for 24 hours
??????3 New or increased drainage from incision or white, yellow or
green drainage from incisions
??????4 Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
??????1 Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
([**Telephone/Fax (1) 2867**]. Dr [**Last Name (STitle) **]. 1130 at 12 /11 / 07 / you have an
appointment scheduled
|
[
"608.86",
"293.0",
"441.3",
"331.0",
"285.1",
"401.9",
"E878.8",
"428.0",
"996.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
10586, 10653
|
7235, 10453
|
322, 528
|
10896, 10903
|
2169, 7212
|
13515, 13635
|
1426, 1431
|
10674, 10875
|
10479, 10563
|
10927, 12930
|
12956, 13492
|
1446, 2150
|
223, 284
|
556, 1361
|
1377, 1410
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,208
| 106,124
|
25067
|
Discharge summary
|
report
|
Admission Date: [**2150-10-5**] Discharge Date: [**2150-10-20**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with a left internal mammary
artery graft to the left anterior descending and reverse
saphenous vein graft to the right coronary artery, marginal
branch, and first diagonal branch of the left anterior
descending
History of Present Illness:
Ms. [**Known lastname 62909**] is an 82-year-old female with worsening symptoms of
dyspnea on exertion and chest tightness who underwent cardiac
catheterization that showed left main and three-vessel disease.
She is presenting for revascularization.
Past Medical History:
Arthritis
Hypertension
Gout
Gastroesphageal Reflux Disease
Chronic renal insufficiency (creatinine 1.6)
Degenerative Joint Disease
Diverticulosis
Anemia
Venous insufficiency
Social History:
Patient denies smoking, occasional ETOH
Physical Exam:
Neuro: Grossly Intact, Awake and alert
Lungs: Clear to auscultation bilaterally -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS -r/r/g
Ext: Warm, no edema
Pertinent Results:
[**2150-10-20**] 06:20AM BLOOD WBC-14.0* Hct-28.8*
[**2150-10-19**] 09:20AM BLOOD WBC-13.1* RBC-3.19* Hgb-9.7* Hct-30.9*
MCV-97 MCH-30.5 MCHC-31.6 RDW-15.4 Plt Ct-487*
[**2150-10-20**] 06:20AM BLOOD UreaN-37* Creat-1.6* K-3.9
[**2150-10-19**] 09:20AM BLOOD UreaN-35* Creat-1.6* K-3.8
[**2150-10-19**] 08:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2150-10-19**] 08:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
The patient was admitted to the hospital and taken to the
operating room the following day. The patient underwent a
coronary artery bypass graft x 4. She tolerated this procedure
well. For full operative details, please see operative note. The
patient was transferred to the CSRU immediately after surgery in
stable condition. Later on op day, pt was weaned from mechanical
ventilation and sedation and extubated. On post-op day #1, the
patient's chest tube and central lines were removed. On post-op
day #2, her diuresis and b-blockers were continued, she was
weaned off supplemental oxygen and was transferred to the floor
in stable condition. On post-op day #3, pt appeared to be slowly
improveing, epicaridal pacing wires were removed, and the
patient was encouraged to get oob and ambulate. Pt. was
recovering well and awaiting rehab placement from POD #[**5-15**].
During this time though, her WBC started to trend upwards (w/out
increase in temp) and on POD #9 serosang. drainage was noticed
coming from her sternal incision. Appropriate cultures were
taken and pt was placed on antibiotics. PICC Line was placed on
POD #10 and antibiotics (Vanco/Levo) were cont. for the rest of
her hopsital course. B-blocker was adjusted for maximal BP
control and diuretics titrated until pt was at pre-op wt. From
POD #[**11-18**] pt's WBC was trending down and pt appeared she would
be transferred to rehab facility. On POD #13 though, her WBC was
once again elevated, a CXR and UA were negative and her
midsternal incision was clean and dry. Subsequently her WBC fell
to 13, and she was ready for discharge.
Medications on Admission:
1. Celebrex 200mg PO QDaily
2. Maxide
3. Toprol XL 50mg PO BID
4. Norvasc 20.mg PO QDaily
5. Lisinopril 40mg PO QDaily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours) for 7 days.
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2203**] [**Hospital **] Nursing Home - [**Location (un) 2203**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 4
Hypertension
Gastroesophageal Reflux Disease
Chronic Renal Insufficiency
Discharge Condition:
Stable
Discharge Instructions:
[**Month (only) 116**] shower, wash incision with mild soap and water and pat dry.
No baths, lotions, creams or powders.
Call with temperature more than 101.4, redness or drainage from
incisions, or weight gain more than 2 pounds in one day or five
in one week.
No lifting more than 10 pounds or drivig until follow up with
surgeon.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Follow up with Dr. [**First Name (STitle) **] in 2 weeks.
See Dr. [**Last Name (STitle) 13175**] in 2 weeks
Completed by:[**2150-10-20**]
|
[
"401.9",
"414.01",
"274.9",
"285.9",
"530.81",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4526, 4628
|
1772, 3378
|
277, 525
|
4805, 4813
|
1248, 1749
|
5194, 5493
|
3547, 4503
|
4649, 4784
|
3404, 3524
|
4837, 5171
|
1073, 1229
|
230, 239
|
553, 804
|
826, 1001
|
1017, 1058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,330
| 157,887
|
46994
|
Discharge summary
|
report
|
Admission Date: [**2141-12-2**] Discharge Date: [**2142-1-11**]
Date of Birth: [**2076-9-25**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
fall with MS change
Major Surgical or Invasive Procedure:
[**2141-12-2**]: left craniotomy for evacuation of acute SDH
[**2141-12-4**]: IVC filter placement
[**2141-12-29**]: Tracheostomy
[**2141-12-29**]: PEG
[**2142-1-5**]: Bronchoscopy with washing
History of Present Illness:
This is a 65 year old man with schizophrenia who was recently
transferred to rehab from the Neurosurgery service s/p
suboccipital craniotomy and clot evacuation following cerebellar
bleed after TPA for presumed stroke. He also had VPS placement
during that admission for hydrocephalus. He had fall on [**11-28**]
with significant chnage when compared to older imaging. He was
started on warfarin for bilateral DVTs and had a fall at rehab.
CT head demonstrated left acute subdural hematoma. with midline
shift and neurosurgery was consulted.
Patient was stable at rehab until he was found down at roughly
15:00 after last being seen well about 40 minutes prior. Patient
had apparently fallen after trying to stand up and sustained a
head injury. At the rehab facility he had complained of right
head pain but per them seemed to be at his usual neurological
baseline. He had not been receiving warfarin at rehab due to
supratherapeutic INR last 2.3. Vitals at that time were 140/81
94
98% RA.
He was transferred to teh [**Hospital1 18**] ED and initially he was able to
follow commands but did not open his eyes with initial vitals 85
157/80 18 100% RA. CT showed a left sided acute SDH with midline
shift and edema. INR was 2.1 and he was reversed. He
progresively
declined such that he would initially groan and intermittently
follow commands and latterly at the time of my assessment became
unresponsive to sternal rub preceded by fidgety movements of the
hands and latterluy extensor posturing in the UE with GCS 4 E1
V1
M2. HE also had a hypertensive spiek with HR stable/borderlien
bradycardic and SBP 190s -200s. He was intubated in the ED and
repeat scan showed a possible bleeding vessel with considerable
enlargememnt in the ASDH and worse midline shift. BP improved
with sedation. Given worsening in scan and clinical status, he
was tarnsferred directly to teh OR for an emergent left
craniotomy and clot evacuation.
Past Medical History:
Recent hospitalisation under neurosurgery at [**Hospital1 18**] and
discharged
[**11-30**] with initial presentation with speeh arrest and developed
large cerebellar bleed sp TPA [**2141-11-7**]
s/p suboccipital craniotomy for clot evacuation [**11-9**]
s/p VPS insertion for hydrocephalus and CSF leak [**11-17**]
* HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)
Social History:
Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history.
Family History:
Brother w/ h/o admission to a psychiatric hospital.
Physical Exam:
On Admission:
BP: 157/80 HR: 85 R 18 O2Sats 100% RA
BP spiked acutely from 155/80 at 1700 up to 200/89 at 1756
Gen: Initially eyes closed and moving arms tehn developed
fidgety
movements predominantly in the hands and then latterly extensor
posturing. Eyes closed throughout. Left anterior frontal
hematoma
4x4cm.
HEENT: Pupils: Initialy 2.5mm bilateral and reactive and then
2mm
and sluggish prior to intubation
EOMs roving eye movements
Neck: Supple.
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. Normal S1/S2 without murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Calves soft - known DVTs
Neuro:
Mental status: Drowsy and obeying commands initially and then
rapidly only intermittently following commands and finally
unresponsive to sternal rub
Cranial Nerves:
I: Not tested
II: Pupils equally round and weakly reactive to light, 2 to
1.5mm bilaterally prior to intubation. Eyes closed and no fields
done.
III, IV, VI: Roving eye movements
V, VII: Face symmetric
VIII: Unable to assess
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Likely normal
XII: Unable to assess given inability to followi commands.
Limb exam:
Grossly normal tone when GCS was suficinetly high and having
spontaneous movements.
Motor:
Wsa able to resist in UE and LE at initial assessment by me
Sensation: Latterly no movement to noxious.
Reflexes: Hyporeflexic throughout.
Plantar reflexes mute bilaterally
Cerebellar: Unable to assess
Discharge exam:
Pertinent Results:
[**2141-12-2**] 05:00PM PT-22.3* PTT-31.2 INR(PT)-2.1*
[**2141-12-2**] 05:00PM PLT COUNT-391
[**2141-12-2**] 05:00PM NEUTS-64.6 LYMPHS-27.7 MONOS-5.3 EOS-2.0
BASOS-0.4
[**2141-12-2**] 05:00PM WBC-9.3 RBC-4.21* HGB-12.2* HCT-37.5* MCV-89
MCH-29.0 MCHC-32.5 RDW-13.2
[**2141-12-2**] 05:00PM estGFR-Using this
[**2141-12-2**] 05:00PM UREA N-13 CREAT-0.9 SODIUM-138 POTASSIUM-4.4
CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
[**2141-12-2**] 05:20PM LACTATE-1.4
[**2141-12-2**] 10:12PM PT-16.1* PTT-26.9 INR(PT)-1.4*
[**2141-12-2**] 10:12PM PLT COUNT-333
[**2141-12-2**] 10:12PM NEUTS-73.3* LYMPHS-21.0 MONOS-5.2 EOS-0.3
BASOS-0.2
[**2141-12-2**] 10:12PM WBC-8.6 RBC-3.35* HGB-9.7* HCT-29.6* MCV-88
MCH-28.9 MCHC-32.7 RDW-13.4
[**2141-12-2**] 10:12PM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-3.2
MAGNESIUM-1.9
[**2141-12-2**] 10:12PM ALT(SGPT)-19 AST(SGOT)-14 ALK PHOS-96 TOT
BILI-0.7
[**2141-12-2**] 10:12PM GLUCOSE-215* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12
[**2141-12-2**] UPRIGHT AP VIEW OF THE CHEST: The heart size is mildly
enlarged with a left ventricular predominance, but unchanged.
The mediastinal and hilar contours are stable. Pulmonary
vascularity is not engorged. There is minimal patchy opacity in
the retrocardiac region, most likely reflective of atelectasis.
No pleural effusion or pneumothorax is present. A catheter is
seen coursing over the right hemithorax.
[**2141-12-2**] 16:30 CT Head IMPRESSION:
1. Large, new, acute subdural hematoma overlying left cerebral
hemisphere
with mass effect and 7-mm rightward shift of normally midline
structures.
Basal cisterns are patent with no evidence of transtentorial
herniation.
2. Slightly improved areas of subarachnoid hemorrhage.
3. Small amount of intracranial hemorrhage, with blood layering
in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle.
4. Stable appearance of post-surgical changes related to
hematoma evacuation and suboccipital craniectomy. Stable fluid
collection within the post-surgical bed.
[**2141-12-2**] CHEST, SINGLE AP PORTABLE SEMI-UPRIGHT VIEW.
An ET tube is present, tip in satisfactory position
approximately 5.7 cm above the carina. No pneumothorax is
detected. A linear density overlying the right lung likely
reflects a VP shunt catheter unchanged.
[**2141-12-2**] 18:49 CT Head: IMPRESSION: Worsening SDH
1. Increased hyperdense material anteriorly within in the left
hemispheric
extra-axial collection is likely redistribution of blood
products or
additional new blood. Hypodense foci within are concerning for
on-going
hemorrhage and unclotted blodd related to coagulopathy.
2. Increased rightward shift of midline structures, now 17 mm,
previously 7 mm.
3. Stable subarachnoid and left intraventricular hemorrhage.
[**2141-12-2**] CT cervical spine: No fracture or malalignment
[**2141-12-2**] 21:48 CT Head: IMPRESSION:
1. Status post evacuation of a left subdural hematoma via left
frontal
craniotomy, with no evidence of new acute hemorrhage or large
vascular
territorial infarction. Pneumocephalus as described above.
Attention on
close followup if no intervention is contemplated.
2. Interval improvement of mild rightward shift of midline
structures
persitent to some degree .
3. Unchanged subarachnoid hemorrhage within the right frontal
and vertex.
[**2141-12-3**] MRI Brain: IMPRESSION:
1. Infarcts in the brainstem. Areas of decreased diffusion in
the left cerebellar hemisphere, corresponding to the previously
noted hypodense area on CT studies. These likely represent
evolving blood products. There is mild mass effect on the
fourth ventricle on the left side with distortion.
2. Persistent left subdural fluid collection, with
pneumocephalus causing
mass effect on the cerebral hemispheres, along with
post-surgical changes and fluid collection in the soft tissues,
not significantly changed compared to the recent CT head study.
Improvement in the mass effect on the left lateral ventricle
compared to the prior CT head study.
[**2141-12-3**] MRI Cervical Spine: IMPRESSION:
1. Multilevel multifactorial degenerative changes with
moderate-to-severe
canal stenosis at C3-4 level with some degree of deformity on
the cervical
spinal cord. Multilevel moderate-to-severe neural foraminal
narrowing as
described above. Assessment for subtle cord signal intensity
changes is
limited; no gross focal lesions in cord.
2. C7-T1: Increased signal intensity in the disc and adjacent
endplates.
3. No ligamentous injury apparent.
[**12-4**] CT Head- IMPRESSION: Status post evacuation of subdural
hematoma with small amount of residual or procedure related
hemorrhage and fluid. Post-procedure pneumocephalus. Small
amount of hemorrhage with left lateral ventricle posteriorly. No
shift of midline structures. Stable appearance of known
subarachnoid hemorrhage.
[**12-10**] MRI Brain: unchanged from previous MRI brain. Old
infarcts in the brainstem are stable.
[**12-10**] Chest Xray portable: FINDINGS: The ET tube is 3 cm above
the carina. Left PICC line tip is in the SVC. Lung volumes are
slightly low. There is pulmonary vascular redistribution and
volume loss at both bases. There is no effusion and no definite
infiltrate.
[**12-11**] Chest xray: Since [**2141-12-10**] pulmonary vascular
congestion has improved and there is no pulmonary edema
[**12-12**]: Chest xray stable
[**12-17**]: CT Head: IMPRESSION:
1. Status post evacuation of left frontal subdural hematoma with
increased
left frontal collection beneath the craniotomy site up to 15 mm.
2. No new bleeding with continued evolution of right-sided
subarachnoid
hemorrhage.
3. Unchanged appearance of the left occipital craniectomy and
left cerebellar hypodensities from prior hemorrhage.
4. Right frontal approach ventriculostomy catheter unchanged
appearance
within the frontal [**Doctor Last Name 534**] of the right lateral ventricle without
hydrocephalus.
5. No shift of midline structures.
6. Subgaleal fluid in the left frontal and temporal regions
adjacent to the craniotomy site, likely post-surgical in
etiology.
CHEST (PORTABLE AP) Study Date of [**2141-12-20**] 3:18 AM
FINDINGS: Endotracheal tube ends approximately 5.5 cm above the
carina and is adequately placed. Orogastric tube is seen to
course below the diaphragm into the stomach and is appropriate.
Left PICC line ends at mid SVC. Bilteral lung volumes are
better. Since [**2141-12-17**], there are no new interval lung
changes. Bibasal atelectasis is similar. Since the patient is
rotated, assessment of the cardiomediastinal silhouette was
limited, however, no gross changes.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2141-12-21**]
8:58 AM IMPRESSION: Deep vein thrombosis again seen in one of
the two posterior
tibial veins in the left calf. The remainder of the deep veins
of both legs are normal.
CXR [**2141-12-22**]
Endotracheal tube terminates approximately 5.8 cm above the
carina, left PICC line ends at lower SVC, and orogastric tube is
seen to course below the diaphragm into the stomach, though
distal end is beyond the radiograph, all are appropriate. Since
[**2141-12-20**], bibasal atelectases, left more than right,
have improved. No new lung opacities of concern. Mild pulmonary
vascular and mediastinal congestion hasresolved. Heart size
normal. Mediastinal and hilar contours are unremarkable.
[**2141-12-23**] MRI brain with and without contrast
IMPRESSION:
1. No evidence of an acute infarct seen.
2. Evolution of blood products in the left cerebellum and
presence of blood products in the ventricles, in the right
occipital [**Doctor Last Name 534**].
3. Subdural hematoma left greater than right side unchanged.
Changed but
with evolution of blood products.
4. No evidence of change in the ventricular system which remains
slightly
prominent.
[**2141-12-25**] CXR: no changes
[**2141-12-26**] CXR: IMPRESSION: Little interval change from one day
prior. Persistent left basilar opacities, likely atelectasis. No
convincing evidence of pneumonia or pulmonary edema.
[**2141-12-28**] CXR: no changes
[**2141-12-29**]: no changes
[**2141-12-31**]: The patient has been extubated and a tracheostomy tube
was placed. The tube is in correct position. No evidence of
complications, notably no pneumothorax. In the interval, the
nasogastric tube has also been removed, the left-sided PICC line
is in unchanged position. Unchanged ventriculoperitoneal shunt.
Unchanged mild-to-moderate atelectasis at the left lung base.
The presence of a small left pleural effusion cannot be
excluded.
[**2141-12-31**] CT head noncontrast IMPRESSION:
1. No interval increase in thickness or extent of the left
frontoparietal
subdural fluid collection, without acute component or increased
mass effect.
2. Right transfrontal ventriculostomy terminates in the frontal
[**Doctor Last Name 534**] of the right lateral ventricle, as before, without change
in ventricular size or shape.
3. Fluid collection at the site of the suboccipital craniectomy
stable in
appearance, with no rim-enhancement to suggest infection.
4. Bilateral mastoid effusions with fluid-opacification of the
left middle
ear cavity, as on the MR study of [**2141-12-23**].
[**2142-1-1**] CXR:
In comparison with study of [**12-31**], there is no change in the
appearance of the tracheostomy, though it is difficult to
evaluate given the obliquity of the patient. The PEG device is
not appreciated. The overall appearance of the heart and lungs
is essentially unchanged
[**2142-1-2**] CXR
As compared to the previous radiograph, there is no relevant
change. No
evidence of pneumonia. No pulmonary edema. Borderline size of
the cardiac
silhouette with mild fluid overload. No pleural effusions.
Unchanged
tracheostomy tube, unchanged left central venous access line,
unchanged
ventriculoperitoneal shunt.
[**2142-1-3**] CXR
1. Persistent mild pulmonary vascular congestion.
2. Possible new left small pleural effusion or consolidation for
which an
upright radiograph is necessary for further evaluation
[**2142-1-4**] CXR
Previously reported questionable left pleural effusion or
consolidation is no longer evident. No new areas of
consolidation to suggest a source of infection.
[**2142-1-5**] CXR
In comparison with the study of [**1-4**], the tracheostomy tube
remains in place and there is pneumomediastinum or pneumothorax.
Central
catheter remains in place. There is the suggestion of some vague
opacification in the retrocardiac region that could represent
some atelectatic changes. Mild fullness of pulmonary central
vessels raises the possibility of elevated pulmonary venous
pressure.
[**2142-1-5**] LENS
DVT involving bilateral CFV, left proximal SFV, and one of the
left PTV's.
Brief Hospital Course:
Mr. [**Known lastname **] was taken emergently from the ER to the Operating
Room for evacuation of enlarging acute SDH. His coagulopathy
was reversed with FFP, initial INR 2.1 and subsequent post
transfusion INR of 1.4. He was also given 3 days of Vitamin K.
Postoperatively he remained intubated for periods of apnea.
His exam slowly improved to withdrawal of all 4 extremities and
purposeful left arm movement.
On POD2 the patient underwent placement of IVC filter as he
cannot be anticoagulated given his acute SDH evacuation and
multiple falls. Post-procedure the patient had multiple
episodes of seizure activity involving right arm rhythmic
jerking and right facial twitching that resolved with Dilantin
300mg IV and ativan 2mg IV. His dilantin dose was increased to
200mg IV BID.
On POD3 [**12-5**] the patient was placed on continuous EEG
monitering which showed frequent seizures in the setting of
corrected dilantin level > 10, that did not resolve with
dilantin boluses. Epilepsy team was consulted for
recommendations and cessation of seizures occured after Ativan
IV and IV Keppra bolus. His dilantin dose was increased and he
was placed on standing Keppra 1500mg [**Hospital1 **]. He remained on
Continuous EEG monitoring.
On [**12-6**] the patient's neurological exam was stable but poor.
His EEG monitoring continued and was negative for active
seizures. Corrected dilantin level was 16.6.
On [**12-7**] vent settings were being weaned and neurological exam
was stable. EEG was again negative for seizures on current
regimen. As a result, on [**12-8**], neurology discontinued EEG
monitoring.
Patient continued to require respiratory and nutritional support
via tube feeding. It was plan to have PEG/Trach, however family
have not been available for consent as of [**12-12**]. Social work
involved and is trying to schedule a famly meeting to discuss
goals of care.
On [**12-10**] the patient's mental status continued to be depressed
with a minimal exam and so he underwent an MRI of the brain to
assess for the possibility of new strokes. MRI was stable and
did not show new strokes.
As the patient was not able to follow commands and had a
difficult airway, the ICU team did not feel that he was a
candidate for extubation, compounded by an increase in
secretions due to VAP, the decision was made to proceed to trach
and PEG. His sister and guardian was consulted for consent
however she expressed an unwillingness to make medical decisions
for him. Social work and ethics teams were consulted on how
best to proceed.
On [**12-13**] staples/suture were removed. His dilantin level was
corrected at 9 therefore his standing dose was increased. He
remained neurologically stable awaiting guardianship/plan per
social work and ethics. On [**12-14**] his dilantin level was 8.3
corrected so he was bolused 500mg of fosphenytoin. On [**12-15**]
dilantin was corrected to 13. Neurologically he seems more awake
and opened eyes to voice. His BAL from [**12-13**] grew coag + staph
aureus and enterobacter so ancef was d/c'd and changed to
vanc/cefepime/cipro. Cipro was later d/c'd given it's properties
of lowering the seizure threshold. Hi secretions continued to be
prominent on [**12-16**], therefore extubation was not attempted. On
[**12-17**] he was noted to have some ? seizure activity with twitching
of the LUE and left eye/face. This self resolved and a
neuromedicine consult was called and EEG was continued. On the
morning of 11.7 he was noted to have probable seizure activity
evidenced by twitching of the right eye and mouth. He was given
ativan and per neuromed consult recs was bolused with vimpat.
later on he developed LUE and left facial twitching and was
given ativan.
On [**12-19**] a court hearing was held regarding his guardianship. His
exam was stable and he had no seizures overnight into [**12-19**].
During the court hearing he was appointed a guardian and plan
was set to begin the process of obtaining consent for trach and
PEG.
On [**12-21**] his dilantin level was corrected to 10 so he was
bolused and given an increased dose. Also LENI's were performed
for routine monitoring and was consistent with deep vein
thrombosis again seen in one of the two posterior
tibial veins in the left calf. The remainder of the deep veins
of both legs
are normal.
On [**12-22**], The patient was on a continuous EEG which was read per
the neurology service with frequent worseing spikes and the
lacasomide was increased to 300 [**Hospital1 **]. Neurology recommended an
MRI to evaluate the patient for possible worsening infarct which
might be a source of the EEG findings. The VP shunt was verified
to be at a setting of 2.5 prior to MRI. The patient continued on
lacasomide 300 mg IV BID, ativan(standing)1 mg IV QID,keppra 2g
[**Hospital1 **],Fosphenytoin 300 mgIV Q8H(on hold [**12-22**]) per Neurology's
recommendations. Dilantin level was sent which was 9.8. The
patient was awaiting formal appointed guardianship for decision
regarding trach and peg placement. On Exam, the patient was
intubated, there was no eye opening, pupils were equal and
reactive, the patient localized to noxious in the left upper
extremity. The patient exhibits minimal withdrawal in the right
upper and left upper extremity. He continues to not follow
commands. (on standing ativan 1mg QID per neurology). A chest
xray was performed which showed improvement in atelectasis and
consolidation.
He remained on EEG on [**12-23**] and [**12-24**] which neurology said
showed unchanged seizure activity. His dilantin was increased to
350mg TID as well. On [**12-26**] his guardian was officially
appointed and consent was obtained for trach and PEG, also he
was placed on versed for supression x 24 hours and on [**12-27**] it
was weaned off. On [**12-28**] he was more awake on exam and was
awaiting trach and PEG planned for [**12-29**]. On [**12-29**] he underwent
Trach and PEG placement by general surgery and toelrated it
well. Also his EEG's for [**12-26**], [**12-27**], and [**12-28**] were reviewed
and all showed moderate to severe encephalopathy but there were
no electrographic seizures.
On [**12-29**] the patient underwent Trach and PEG and tube feeds were
restarted and titrated to goal on [**12-30**]. On [**12-31**] he was noted
to have developed hematuria in the evening and urology was
consulted to assist in management. there was a question of
traumatic foley palcement versus urethral erosion. He had
continuous bladder irrigation and his urine cleared. On [**1-1**]
the patient was febrile to 102.3 and a fever workup was
inititated. He was started on empiric antibiotics for pneumonia
as the patient continued to have copious secretions. He
continued to have epsiodes of fevers on [**1-2**] while on triple
antibiotics. He is awaiting rehab palcement.
On [**1-5**] he exhibited twitching in his face and left side.
Dilantin was again recommended by Neurology. This behavior
continued in to [**1-6**] and Ativan was given. ID was consulted as
well and they left recommendations for treatment which were not
followed. Neuromedicine was again called and the felt that he
should not be treated for this. Formal recommendations recieved
on [**1-7**] were to give standing Ativan 2mg q4hours x 24 hours
while attempting to attain goal Dilantin level of 20. His dosing
was increased to 250mg TID. On [**1-8**] his Dilantin level 18.4
corrected and he had continued drainage fro his trach site.
cultures were sent and his antibiotics were changed to nafcillin
only. On [**1-9**] his Dilantin level was 16.8 corrected he and
recieved a 500g Dilantin Bolus.
On [**1-10**], patient's VP shunt was dialed down to 1.0. Now DOD,
he is afebrile VSS, he is neurologically stable. He is set for
d/c to [**Hospital1 1501**] in stable condition and will follow-up accordingly.
Issues by system:
Neurologic:
- neuro checks Q4 hrs
- Keppra [**2130**] [**Hospital1 **]; Vimpat 300 [**Hospital1 **], fosphenytoin 250 TID, ativan
2mg q4h until dilantin levels are at 17-20; monitor renal
function since may have to adjust AED
- Taper ativan to off within the next week as long as he is
seizure free
Cardiovascular:
- goal SBP 100-160
- amlodipine 10 qday, metoprolol 25 daily, stopped lisinopril,
spironolactone and hydralazine on [**1-11**]
- Ok to stop amlodipine if still hypotensive
Pulmonary:
- episodes of apnea on CPAP, back on MMV. Wean vent as tolerated
- per radiology, small nodule RUL, needs follow up eventually
- purulent secretions from trach, improving on current
antibiotics
Gastrointestinal / Abdomen:
- continue bowel regimen
- PEG site has improved
- famotidine ppx
Nutrition:
- TF Glucerna 90ml/hr
Renal:
- foley restarted due to poor output s/p lasix. Put out 1100cc
when foley inserted
- ~17L positive- lasix gtt, monitor K and HCO to avoid worsening
met alkalosis
- primary metabolic alkalosis w/ inappropriate respiratory
compensation, on aldactone 50 and is tolerating well
- diuresis was held due to rising Crea (1.6 on [**1-11**])
- Hematuria: f/u with urology for outpt cystoscopy
Hematology:
- continue ASA 81mg/SQ heparin
- s/p IVC filter [**12-4**] (has DVT)
- Hct stable
- LENI: DVT involving bilateral CFV, left proximal SFV, and one
of the left PTV's are thought to be superficial. Vascular
surgery recommend repeat LENIS prior to [**2142-1-15**]
Endocrine:
- NPH 50/50
- monitor FS
Infectious disease:
- completed course for PNA
- having purulent secretions around trach site (Culture as of
[**1-10**] respiraory flora and STAPH AUREUS COAG +.
- purulent discharge from PEG insertion site, monitor
- nafcillin([**1-2**]- ): complete 14 day course until [**2142-1-16**]
- d/c'ed cefepime ([**Date range (1) 99653**], [**Date range (1) 99654**]) and gentamicin
([**Date range (1) 24439**] )
Tubes/Lines/Drains: L PICC, trach, PEG
- d/c'ed T/L/D's: a-line ([**12-15**]), foley
Dispo:
- Guardian [**Name (NI) 402**] [**Name (NI) 36653**], [**Telephone/Fax (1) 99655**], [**Telephone/Fax (1) 99656**]
Wounds: L craniotomy
Medications on Admission:
acetaminophen 650 mg Q6hrs PRN pain
insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: At dinner.
insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection four times a day.
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
amlodipine 10mg PO DAILY
lisinopril 10 mg PO DAILY
metoprolol tartrate 50 mg PO BID
docusate sodium 100MG PO BID
pantoprazole 40 mg daily
chlorhexidine gluconate 0.12 % Mouthwash Sig: 15 ML Mucous
membrane [**Hospital1 **]
warfarin 7.5mg - had not been getting at rehab due to high INR
olanzapine 5 mg Tablet, Rapid Dissolve PO QHS
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. acetaminophen 325 mg Suppository Sig: 1-2 tabs Rectal Q6H
(every 6 hours) as needed for fever, pain.
7. levetiracetam 100 mg/mL Solution Sig: [**2130**] ([**2130**]) mg PO BID
(2 times a day).
8. lacosamide 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q6H
(every 6 hours).
12. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q4H (every 4 hours): discontinue on [**2142-1-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Left acute subdural hematoma
Brain stem infarct
Seizures
left tibilal Deep Vein Thrombosis
malnutrition
respiratory failure
pneumonia
Hematuria
leukocytosis
post-op pyrexia
metabolic alkalosis
Hypervolemia
Tachypnea
hyperglycemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
******* YOU HAVE A PROGRAMMABLE VP SHUNT THAT IS SET AT 1.0
*******
Your shunt settings can be changed with a magnet, please avoid
magnets. If you have a MRI, you will need your shunt to be
re-programmed.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Keep incision clean and dry
?????? You may shower before this time using a shower cap to cover
your head.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
You have been discharged on Keppra (Levetiracetam), you will not
require blood work monitoring.
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:
??????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.
Epilepsy/Stroke Follow-up: Please follow-up neurology. Please
call [**Telephone/Fax (1) 99657**] week with a Head CT scan.
Urology follow-up: Please call ([**Telephone/Fax (1) 99658**] to schedule an
outpatient cystocopy when appropriate.
Completed by:[**2142-1-11**]
|
[
"288.60",
"295.30",
"E885.9",
"518.81",
"401.9",
"780.62",
"780.39",
"V45.89",
"362.01",
"V15.84",
"V15.82",
"432.1",
"250.50",
"300.00",
"997.31",
"041.11",
"311",
"348.5",
"599.70",
"707.20",
"362.53",
"263.9",
"852.21",
"786.03",
"V58.67",
"276.4",
"707.03",
"041.3",
"V15.88",
"E879.8",
"453.42",
"E849.7",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.72",
"38.97",
"38.7",
"33.24",
"43.11",
"31.1",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
27771, 27842
|
15977, 25995
|
328, 524
|
28116, 28116
|
5220, 7574
|
29565, 30032
|
3662, 3716
|
26726, 27748
|
27863, 28095
|
26021, 26703
|
28256, 29542
|
3731, 3731
|
5201, 5201
|
269, 290
|
552, 2482
|
4512, 5183
|
10629, 15954
|
3745, 4346
|
28131, 28232
|
2504, 3198
|
3214, 3646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,702
| 136,918
|
48715
|
Discharge summary
|
report
|
Admission Date: [**2190-2-10**] Discharge Date: [**2190-2-20**]
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Vicodin / Theophylline / lisinopril /
Oxycodone
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Cholelithiasis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Ms. [**Known lastname **] is an 89 yo woman with history of bronchiectasis,
MAC s/p 18 months of treatment, completed 3 months ago, here s/p
ERCP for choledocholithiasis, after prior CCY in [**2186**]. She had
presented to the ED on [**1-14**] with abdominal pain, and discharged
home after 2 sets of negative enzymes and a negative nuclear
stress test. She continued to have intermittent pain, and saw
her pcp, [**Name10 (NameIs) 1023**] was concerned for pancreatic source, and she
underwent abdominal CT on [**1-25**] which showed a gallstone. She was
referred for ERCP.
.
She underwent ERCP today, with sphincterotomy, without
complications, although she was nauseated and dizzy/vertigo
after the procedure, and had a new oxygen requirement of 4 L,
with O2 sat of 84%. She received dilaudid 0.5 mg X 1 , zofran 4
mg IV X 2, haloperidol 0.5 mg IV X 1.
.
At present she feels ill, but cannot point to any specific
symptom.
.
On review of systems, prior to her procedure, she had a cough
for the past 1 week, which she thought was either a cold or
allergies. It was non-productive with no hemoptysis. She has
felt more lethargic as well. She has not had any fevers or
chills, no SOB, no further chest pain, no orthopnea, PND, and
stable baseline LE edema. No recent weight gain or loss, no
urinary symptoms, no constipation with BM yesterday, no rashes.
ROS otherwise reviewed in 6 other systems and negative.
Past Medical History:
From OMR:
# Bronchiectasis, most recent FEV1 55% 5/09
# Tuberculous peritonitis and prior pulmonary TB with upper lobe
scar
# Mycobacterium avium colonization, s/p 18 months of rx with
ethambutol, azithromycin and rifampin, through [**12-3**]
# h/o Duodenal ulcer
# Ruptured appendix [**2117**]
# Chronic venous disease - s/p left leg venous ligation
# Chronic Renal Insufficiency (baseline 1.4-1.7)
# Osteopenia
# Urinary incontinence
# Hypothyroidism
# GERD
# Herpes zoster around the T7 dermatome on her left side ~[**2172**],
no complications
.
Surgical history:
# Status post total abdominal hysterectomy for fibroids ([**2144**])
# Status post laproscopic cholecystectomy [**2187-6-7**]
Social History:
The patient lives alone in an apartment, her nephew and his
family lives downstairs. He is her health care proxy. She
remains independent with activities of daily living. She
retired in [**2175**] as an administrator at the [**Doctor Last Name 32496**] School for
the Blind in [**Location 4288**], MA. No walking assist devices used.
Uses hearing aids at home.
-no tobacco
-no etoh
-no ivdu
Family History:
Family history of gallstones. Her brother died of pancreatic
cancer.
Physical Exam:
Exam
VS T current 96.0 BP 170/86 HR 94 RR 22 94% RA
O2sat
.
Gen: Somnolent, in NAD
HEENT: Pupils 2 mm, minimally reactive, EOMI. No scleral
icterus. No conjunctival injection. Mucous membranes dry. No
oral ulcers appreciated.
Neck: Supple, no LAD, no JVP elevation.
Lungs: bilateral crackles, dry, [**11-23**] of lung fields bilaterally,
few anteriorly, with few inspiratory wheezes, and prolonged
expiratory phase, with wheezes with forced expiration. No
rales. Normal respiratory effort, speaking in full sentence.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: abdomen distended, tympanitic, non tender, positive
bowel sounds, no masses appreciated.
Extremities: warm and well perfused, trace bilateral lower
extremity edema, R>L
Neurological: alert and oriented X 3, EOMI. Full strength in
lower extremities, follows all commands, gait not tested.
Skin: No rashes or ulcers. No jaundice.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
Admission labs, pre ERCP, [**2190-2-10**] 11:30AM:
UREA N-27* CREAT-1.5* SODIUM-142 POTASSIUM-4.4 CHLORIDE-103
TOTAL CO2-27 PHOSPHATE-3.5
ALT(SGPT)-29 AST(SGOT)-41* ALK PHOS-102 AMYLASE-120* TOT
BILI-0.7 DIR BILI-0.2 INDIR BIL-0.5 LIPASE-35
.
CBC
WBC-7.2 RBC-4.22 HGB-12.8 HCT-40.7 MCV-97 MCH-30.3 MCHC-31.4#
RDW-12.4
PLT COUNT-239#
.
Coagulation
PT-12.3 PTT-34.5 INR(PT)-1.1
.
ERCP [**2-10**]:
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
A moderate dilation was seen at the biliary tree.
A filling defect was noted in the common hepatic duct consistent
with stone. Rest of the biliary tree appeared unremarkable.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A single pigment stone was extracted successfully using an
extraction balloon.
Otherwise normal ercp to third part of the duodenum
.
CXR, AP [**2-10**]: final read pending, reviewed by me, chronic lung
disease, no effusions, no obvious new large infiltrates.
.
EKG NSR, 89, nl axis, no acute ischemic changes, ordered and
reviewed by me.
CT CHEST:
IMPRESSION:
1. Multifocal areas of pulmonary consolidation, concerning for
an acute
infectious process, likely bacterial pneumonia.
2. Mild bronchiectasis and small airways thickening, unchanged.
3. Interval increase in the size and number of the mediastinal
adenopathy.
4. Bilateral small simple pleural effusions.
5. Extensive coronary arterial calcification.
LENIS:
FINDINGS: [**Doctor Last Name **]-scale and color Doppler assessment of the
bilateral common
femoral, superficial femoral, popliteal, posterior tibial and
peroneal veins
was performed. There is normal compressibility, flow and
augmentation.
IMPRESSION: No bilateral lower extremity DVT.
CXR. PICC PLACEMENT:
FINDINGS: Right PICC terminates within the mid superior vena
cava. Heart
size remains normal. Bilateral multifocal alveolar opacities
persist, with
upper and mid lung predominance. These findings are concerning
for multifocal
pneumonia and show mild interval improvement compared to the
prior study.
Small pleural effusions are not appreciably changed.
[**2190-2-15**] 3:43 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2190-2-16**]**
MRSA SCREEN (Final [**2190-2-16**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Brief Hospital Course:
Ms. [**Known lastname **] is an 89 yo woman with prior history of
bronchiectasis and pulmonary MAC, here s/p ERCP for
choledocholithiasis (with prior CCY), with post-procedure
hypoxia.
.
# Multifocal Pneumonia/HCAP/Hypoxemia: CXR & exam consistent
with multifocal pneumonia. There was no culture data to guide
antimicrobial therapy; the patient was continued on broad
spectrum antibiotics including vancomycin, cefepime, flagyl,
azithromycin. There was some consideration that pulmonary edema
was also contributing to her hypoxemia. She had a high oxygen
requirement while she was in the ICU and at one point was on
BiPAP. She was diuresed approximately 3.5 L, which did not
drastically improve her respiratory status. A TTE demonstrated
right ventricular cavity dilation with free wall hypokinesis and
moderate pulmonary artery hypertension. Normal left ventricular
cavity size and regional/global systolic function. The patient
was weaned to approximately 2L nasal cannula and her lung exam
improved with IV antibiotics. It was decided that she would be
committed to an 10 day course of IV antibiotics; a PICC was
placed. She was unable to produce a sputum sample that was
satisfactory for evaluation for PCP, [**Name10 (NameIs) 6643**] was considered on the
differential.
- She will complete Vanco/Cefepime/Flagyl/Azithromycin through
[**2190-2-22**]
- Nebulizers and wean 02 as able
- Cont chronic inhalers
- Aggressive PT/OT
- Consider periodic lasix as needed. Goal I/Os even to slightly
negative
.
# Thrush: The patient was noted to develop thrush during her
antibiotic course which was treated with nystatin. An HIV test
was checked and was NEGATIVE
- Can DC once resolved
#Choledocholithiasis: The patient is now s/p ERCP with stone
removal on [**2190-2-10**]. She can be considered for an outpatient
cholecystecomy.
- Follow up with PCP post discharge to consider surgery referral
.
# Sinus tachycardia: The patient was noted to be tachycardic
which was initially attributed to her infectious process. Her
tachycardia worsened during periods of dyspnea, so it it was
also thought to reflect her respiratory status. This was
attributed to her infection, deconditioning, and frequent
nebulizers. HR ranged from 100s to 120s with activity by
discharge
.
CHRONIC DIAGNOSES:
# Bronchiectasis: The pat- continue bronchodilators as above.
.
# Hypothyroidism - continue levothyroxine
.
# GERD - continue omeprazole
Patient was mentating well at discharge. In good spirits but
concerned about overall wellbeing
Medications on Admission:
Confirmed with patient on admission, but did not clarify doses
of vitamins.
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - one inhalation once or twice daily
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth daily
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 (One) Tablet(s) by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - inhale 1 capsule mouth once a day
TOLTERODINE [DETROL LA] - 4 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth once a day
ASCORBIC ACID [VITAMIN C] - 1,000 mg Tablet - 1 Tablet(s) by
mouth once a day
ASPIRIN 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
B COMPLEX VITAMINS [VITAMIN B COMPLEX]
MULTIVITAMIN
Discharge Medications:
1. levothyroxine 50 mcg 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 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizers Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
7. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
8. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-23**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
9. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
10. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) losenge
Mucous membrane four times a day as needed for sore throat.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): until healed.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours): through [**2190-2-22**].
21. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
One (1) injection Intravenous Q8H (every 8 hours): through
[**2190-2-22**].
22. azithromycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): through [**2190-2-22**].
23. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours): through [**2190-2-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Healthcare associated PNA
Hypoxemia
Choledocholithaisis
Bronchiectasis
Hypertension
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 came to [**Hospital1 18**] for an ERCP and a stone was extracted. You
were then found to have a severe pneumonia and were started on
broad spectrum antibiotics and you required time in the ICU.
With antibiotics and medical treatment your breathing improved.
You are now being discharged to rehab to complete your recovery.
Need to complete a full 10 day course of antibiotics.
Nebulizers and inhalers should be continued. Oxygen should be
weaned as able
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2205**]
- within 2 weeks after discharge
|
[
"585.9",
"112.0",
"574.90",
"389.9",
"511.9",
"494.1",
"530.81",
"V12.01",
"412",
"428.0",
"562.10",
"V02.3",
"428.33",
"V02.54",
"780.4",
"403.90",
"244.9",
"799.02",
"733.00",
"486",
"346.90",
"414.01",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"38.93",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
12379, 12445
|
6404, 8933
|
295, 301
|
12573, 12573
|
3968, 6381
|
13241, 13387
|
2894, 2965
|
9799, 12356
|
12466, 12552
|
8959, 9776
|
12756, 13218
|
2980, 3949
|
241, 257
|
329, 1749
|
12588, 12732
|
1771, 2467
|
2483, 2878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,309
| 196,970
|
20718
|
Discharge summary
|
report
|
Admission Date: [**2139-9-19**] Discharge Date: [**2139-9-28**]
Date of Birth: [**2094-3-7**] Sex: F
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing / Ceftazidime
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2139-9-19**]: cadaveric kidney transplant
History of Present Illness:
45F presents for possible kidney transplant. She is in
good health without any feelings of cold and no recent exposure
or sick contacts, no recent hospitalizations. She suffers a
history of hypertensive nephropathy who has been on peritoneal
dialysis for since [**2135**].
Past Medical History:
hypertensive nephropathy, hemodialysis [**2133**]-[**2135**],
peritoneal dialysis since [**2135**], hypertension, nontoxic goiter,
PPD positive in the past
PSH: cervical cancer s/p total abdominal hysterectomy,
peritoneal
dialysis catheter placement
Social History:
She works full time as a nurse.
Family History:
Mother cervical cancer, HTN, father liver cancer, grandmother
endometrial cancer, sister thyroid and parathyroid cancer
Physical Exam:
Temp 98.4 HR 94 BP 145/84 RR 18 100% RA
Gen AAO x3
Pulm CTA b/l
CVS RRR
Abd s/nt/nd, incisions well healed, PD catheter in place
Laboratory Values:
Chem 7
135 | 106 | 80 <
5.5 | 16 | 14.4
Ca: 10.0 Mg: 2.4 P: 5.2
ALT: 13 AP: Tbili: Alb: 4.0
AST: 17 LDH: Dbili: TProt:
CBC
8.5 > < 308
31.4
PT: 11.9 PTT: 28.9 INR: 1.0
Type and cross for 2 units sent, blood bank notified
CXR pending
EKG pending
T lymphocytotoxic crossmatch ordered and sent to [**Hospital1 756**]
Pertinent Results:
[**2139-9-19**] 10:50AM BLOOD WBC-8.5 RBC-3.46* Hgb-10.1* Hct-31.4*
MCV-91 MCH-29.0 MCHC-32.1 RDW-15.8* Plt Ct-308
[**2139-9-28**] 05:46AM BLOOD WBC-5.8 RBC-2.37* Hgb-6.9* Hct-21.7*
MCV-92 MCH-29.3 MCHC-31.9 RDW-14.4 Plt Ct-168
[**2139-9-21**] 03:19AM BLOOD PT-12.9 PTT-30.1 INR(PT)-1.1
[**2139-9-28**] 05:46AM BLOOD Glucose-86 UreaN-35* Creat-3.8* Na-135
K-4.7 Cl-105 HCO3-24 AnGap-11
[**2139-9-21**] 03:19AM BLOOD ALT-42* AST-56* LD(LDH)-742* AlkPhos-44
TotBili-0.3
[**2139-9-28**] 05:46AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6
[**2139-9-24**] 02:28PM BLOOD calTIBC-185* Hapto-221* Ferritn-397*
TRF-142*
[**2139-9-28**] 05:46AM BLOOD tacroFK-9.7
Brief Hospital Course:
On [**2139-9-19**], she underwent renal transplant into right iliac
fossa with placement of a ureteral stent. Induction
immunosuppression was given (ATG,SolumedroL). Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Of note, the donor was a 53-year-old gentleman who
was
quite large 220 pounds 6 foot 2. Biopsy showed 6%
glomerulosclerosis, normal
vascular disease. The kidney was high-risk by the center because
the donor had
been in a committed homosexual relationship. HIV testing was
negative. Please refer to the operative note for complete
details. Given the large size of the donor, the kidney was
placed intraperitoneally.
Postop, urine output was on the low side, but output increased
over subsequent days averaging 2400-1450. Creatinine trended
down to 3.8 by post op day 9. Diet was advanced slowly, but was
not well tolerated due to nausea and emesis. Cellcept was
suspected and dose was divided on a 4x/day schedule without
improvement of nausea. Cellcept was switched to myfortic on
[**9-25**], but this was not tolerated. Myfortic was stopped with
significant improvement of nausea. Diet was then well tolerated.
Imuran was started in place of the cellcept. A total of 4 doses
of ATG (75mg each)was given. Prograf was initiated on postop day
1 and adjusted per trough levels. Dose was increased to 9mg [**Hospital1 **]
on [**9-28**] (9.7).
She had a fair amount of edema and lasix was given on the few
days prior to discharge. Lasix 40mg was ordered daily for 3 days
postop discharge.
Hematocrit trended down to 23 and epogen was started on [**9-23**].
Hct decreased further to 21.7 on [**9-28**]. One unit of PRBC was
administered.
The incision had a clear fluid drainage when she stood up. This
was expected due to the intraperitoneal approach. Pain was
managed with oral dilaudid as she did not tolerate percocet.
She was discharged to home in stable condition. She was
ambulatory. Vital signs were stable. She did well with self
medication teaching. Of note, the ureteral stent was removed at
the bedside as the strings were hanging out the urethra on [**9-24**].
Medications on Admission:
Renagel 800', valsartan 320', levothyroxine 25', hectorol
2.5qweek, lisinopril 10'
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
11. Epogen
you will have to check with Transplant coordinator at your next
office visit about epogen injection clinic
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
14. Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD now s/p kidney transplant
cellcept intolerant
Discharge Condition:
Stable
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomitnig, diarrhea, constipation, inability
to keep down food, fluids or medications, pain over the kidney
site.
Monitor the incision for redness, drainage or bleeding. You
currently have some drainage, please keep the area covered and
change the dressing twice daily and more often as needed. Please
call if it seems the drainage is excessive.
No heavy lifting
You are being given a script for lasix, please weigh yourself
daily and track urine output. Drink enough fluids to keep urine
light yellow. Call the transplant office if the swelling does
not decrease or you note that your weight goes up and not down
Labs at the [**Hospital Unit Name **] lab every Monday and Thursday
No driving if taking narcotic pain medication
Followup Instructions:
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-10-6**] 1:20
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-10-12**] 2:50
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-10-19**] 2:50
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 819**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Appointment should be in
[**8-7**] days
Completed by:[**2139-9-30**]
|
[
"V10.41",
"564.00",
"787.01",
"E933.1",
"403.91",
"795.5",
"276.2",
"285.9",
"241.9",
"585.6",
"V45.11",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
5893, 5899
|
2312, 4439
|
304, 351
|
5994, 6003
|
1644, 2289
|
6876, 7447
|
998, 1120
|
4573, 5870
|
5920, 5973
|
4465, 4550
|
6027, 6853
|
1135, 1625
|
260, 266
|
379, 656
|
678, 931
|
948, 982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,265
| 120,573
|
21916
|
Discharge summary
|
report
|
Admission Date: [**2190-10-1**] Discharge Date: [**2190-10-7**]
Date of Birth: [**2140-7-31**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
[**First Name3 (LF) **] of breath
Major Surgical or Invasive Procedure:
1) Pericardiocentesis
2) u/s guided liver bx
History of Present Illness:
50 year old man with history of [**First Name3 (LF) 499**] cancer lymph node negative
s/p resection, XRT and chemo [**2183**] who presented to an outside
hospital with c/o [**Year (4 digits) 7186**] of breath x 6 weeks. The patient is
a drummer in a heavy metal band and noticed that he had been
more "winded" after practices. Over the week prior to
presentation, he said that he would get short of breath walking
approximately 400 yards. He had previously worked in
construction so this was unusual for him. 1-2 days prior to
presentation he noticed that he would have chest pain and
breathing would become more painful when he would lie on his
back.
He denied dizzyness, lightheadedness, vision changes, LOC,
palpitations, nausea, vomiting, abdominal pain, difficulty
urinaring, change in bowel or bladder habits, or lower extremity
edema.
He said other things he had noticed over the past 2-6 weeks
included: sweats when he would lie down, "hot flashes", shaking
chills, (he never took a temperature at home), daily migrating
headaches lasting several hours, 10 lb weight loss over 2
months.
He has a significant travel history in the past 2-3 years,
especially to south east [**Female First Name (un) 8489**]. Most recently he has come back
from [**Country 3396**] in mid [**Month (only) 956**] - he had travelled into rural
areas during the trip but denied any illnesses during or after.
He presented to an OSH on [**9-28**] and was noted to be tachycardic
and anemic with non-specific EKG changes. He was admitted for
further workup. A CXR showed cardiomegaly, a retrocardiac
infiltrate/atelectasis, and ?pericardial effusion per report.
An ECHO done on [**9-30**] showed an EF >55%, mild LVH, and a 4-5cm
circumferential pericardial effusion, respiratory variation R+L
ventricle, and R atrial collapse. He was transferred to [**Hospital1 18**]
for pericardiocentesis.
Past Medical History:
1. [**Hospital1 **] CA s/p resection, XRT, chemo [**2183**]
2. Anemia - recently diagnosed
3. Tachycardia
4. Chronic shoulder pain - no trauma history
Social History:
The patient has worked in construction for many years but
retired in [**7-18**] ("it's a young man's job"). He lives in a
studio in [**Location (un) 4628**], but lived in [**Location **] NH for many years. His
sister lives [**Name2 (NI) 3592**].
He very occasionally uses alcohol.
He was a long time heavy smoker (age 24 to approximately 1 month
ago) averaging about [**1-15**] ppd.
He denies IVDU, but did use other recreational drugs as a high
school student. He denies drug use for many years.
Family History:
Father - [**Name (NI) **] cancer
Sister - [**Name (NI) **] cancer
Physical Exam:
On admission to CCU:
Vitals: T 99.4, P 115, BP 129/91, MAP 104, RR 23-26, 95-96% RA
Gen: pleasant, middle aged man, reclining in bed, NAD
HEENT: PERRL, MMM, OP clear, no jaundice
Neck: No JVD
CV: tachycardic, regular, 2/6 systolic murmur at LLSB
Lungs: clear on anterior exam
Abd: soft, distended, +BS, ?hepatomegaly, R groin soft, no bruit
Ext: w/wp, no edema, strong pulses. Left shoulder: denies
current pain, no pain with palpation, full ROM, [**5-19**] strenth with
internal and external rotation.
Neuro: AOx3
Pertinent Results:
Serum
[**2190-10-1**] 05:44PM GLUCOSE-135* UREA N-10 CREAT-0.7 SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2190-10-1**] 05:44PM ALT(SGPT)-33 AST(SGOT)-47* LD(LDH)-463* ALK
PHOS-249* TOT BILI-0.9
[**2190-10-1**] 05:44PM TOT PROT-6.4 ALBUMIN-3.3* GLOBULIN-3.1
CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.8
[**2190-10-1**] 05:44PM WBC-8.5 RBC-3.50* HGB-8.9* HCT-27.7* MCV-79*
MCH-25.5* MCHC-32.2 RDW-14.8
[**2190-10-1**] 05:44PM PLT COUNT-560*
[**2190-10-1**] 05:44PM PT-14.5* PTT-28.8 INR(PT)-1.3
Pericardial Fluid
[**2190-10-1**] 03:31PM OTHER BODY FLUID TOT PROT-5.6 GLUCOSE-62
LD(LDH)-3800 AMYLASE-38 ALBUMIN-2.7
[**2190-10-1**] 03:31PM OTHER BODY FLUID WBC-3650* RBC-0 POLYS-19*
LYMPHS-79* MONOS-0 MACROPHAG-2*
Pre-pericardiocentesis ECHO ([**10-1**])
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets (3) are mildly thickened but not
stenotic. The
mitral valve leaflets are mildly thickened. There is a large
pericardial
effusion. The effusion appears circumferential. No right
ventricular diastolic
collapse is seen. There is sustained right atrial collapse,
consistent with
low filling pressures or very early tamponade. There is left
atrial collapse.
Echocardiographic signs of tamponade may be absent in the
presence of elevated
right sided pressures. There is significant, accentuated
respiratory variation
in mitral/tricuspid valve inflows, consistent with impaired
ventricular
filling.
Pericardiocentesis ([**10-1**]):
**PRESSURES
RIGHT ATRIUM {a/v/m} 20/19/19 9/6/4
RIGHT VENTRICLE {s/ed} 33/19
PULMONARY ARTERY {s/d/m} 33/19/27
PULMONARY WEDGE {a/v/m} 28/21/19
AORTA {s/d/m} 130/85/102
PERICARDIUM {m} 19 -2
**CARDIAC OUTPUT
HEART RATE {beats/min} 110 107
RHYTHM SINUS SINUS
COMMENTS:
1. Hemodynamics on entry showed equalization of pressures in the
RA and
pericarium, which is diagnostic of pericardial tamponade.
2. Pericaridal needle was inserted into the pericardial space
under
pressure and ECG guidance. 888 cc of bloody fluid was aspirated
and sent
for cytology, chemistry and microscopy.
3. Hemodynamics after the pericardiocentesis showed resolution
of the
tamponade physiology.
4. Echocardiogram done after the pericardiocentesis showed a
small
pericardial effusion with no echocardiographic evidence of
tamponade.
FINAL DIAGNOSIS:
1. Pericardial tamponade.
Post-pericardiocentesis ECHO ([**10-1**]):
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. The mitral valve leaflets are structurally normal.
There is a small
residual posterior pericardial effusion. There are no
echocardiographic signs
of tamponade.
A round extrinsic mass (approximately 3 cm in diameter) abutting
and
compressing the right atrium is now seen
Compared with the findings of the prior study (tape reviewed) of
[**2190-10-1**], most of the fluid in the pericardial sac has been removed.
An extrinsic
mass compressing the right atrium is now seen.
Brief Hospital Course:
1.Cardiovascular
-- Pericardial Effusion: patient presented with SOB, exercise
intolerance, and nonspecific systemic sx including fevers,
chills, sweats, and weight loss. He presented to an OSH and was
found to be anemic and tachycardic, with non specific EKG
changes. An ECHO showed a collapsing RA concerning for
tmponande, and he was transferred to [**Hospital1 18**] for
pericardiocentesis. 888cc bloody fluid sent for analysis,
patient subjectively much improved after tap. Drain in place
overnight draining sanguinous fluid, removed in AM. Repeat ECHO
[**10-2**]. Fluid with too many RBC to count, and 3600 WBC, 19N/79L.
Etiology: metastatic vs. infectious (TB, HIV, other viral) vs.
hypothyroid vs. mediastinal radiation (XRT for [**Month/Year (2) 499**] CA?).
Cytology was negative for malignancy.
-- Rate/Rhythm: sinus tachycardia - question of possibly [**2-15**]
anemia - received 1 unit of blood, fluid boluses without change;
may be secondary to RA mass (compensatory for decreased in flow)
-- Mass: 3cm extrinsic mass compressing RA - ?etiology - chest
CT to better visualize in AM once drain is removed.
-- Pump: EF >55%
2. Respiratory: good oxygen saturations on room air; CXR - no
evidence of metastatic disease; long smoking hx - COPD - nebs
PRN
3. Renal: creatinine stable
4. GI: h/o [**Month/Day (2) 499**] CA - has not had good f/u since late 90s. CEA
elevated. Multiple liver lesions on CT. Liver bx [**10-7**] showed
multiple necrotic metastases.
5. Heme: anemia just diagnosed on [**9-29**] at OSH. Fe studies from
OSH [**Location (un) 381**] Fe.
6. Musculoskeletal: left shoulder pain worse than basline
shoulder pain and only on L - possibly referred from cardiac
mass. ?[**Last Name (un) 2043**] met. oxycontin, oxycodone.
7. ID: sx of fevers, chills, sweats in past two weeks, afebrile.
PPD to be placed. Cultures drawn, negative at time of
discharge.
8. FEN: cardiac diet
9. Proph: bowel regimen.
10. Access: right groin sheath pulled
11. Communication: with patient
Medications on Admission:
Tylenol prn
Ibuprofen prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
6. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
metatstatic cancer
pericardial effusion
Discharge Condition:
improved - no [**Last Name (un) 7186**] of breath, shoulder pain well controlled
Discharge Instructions:
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath, chest pain, worsening
abd pain, depression, anything that concerns you.
Followup Instructions:
Call [**2190**] to make an appointment with Dr. [**Last Name (STitle) **] for next
week.
You have an appointment with Dr. [**Last Name (STitle) **], a GI oncologist, on
[**10-22**] at 10:30. [**Hospital Ward Name 23**] building [**Location (un) **]. You can call [**Telephone/Fax (1) 57447**] and speak with [**Doctor First Name 30513**] if you need to change your
appointment.
|
[
"423.9",
"496",
"285.9",
"719.41",
"198.89",
"197.7",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
9659, 9665
|
6882, 8892
|
344, 390
|
9749, 9831
|
3627, 6043
|
10036, 10419
|
3010, 3077
|
8968, 9636
|
9686, 9728
|
8918, 8945
|
6060, 6859
|
9855, 10013
|
3092, 3608
|
271, 306
|
418, 2302
|
2324, 2476
|
2492, 2994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,156
| 127,108
|
54939
|
Discharge summary
|
report
|
Admission Date: [**2134-8-16**] Discharge Date: [**2134-9-7**]
Date of Birth: [**2053-6-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Subdural Hematoma
Seizures
VISA bacteremia
MRSA pneumonia
ESRD
Major Surgical or Invasive Procedure:
HD catheter placement
endotracheal intubation
left craniotomy w/ subdural hematoma evacuation and subdural
drain placement
tracheostomy
History of Present Illness:
Mr. [**Known lastname 112205**] is an 81 year old man with a PMH s/f ESRD with
dialysis, HLD, COPD, Afib, Hypothyroidism, CAD s/p MI, and
gastric ulcer who presents to [**Hospital3 **] with a history of
unsteady gait. Per OSH ED reprot, patient called for assitance
getting off the floor, because his elederly wife was not able to
help him get up. He was not sure why fell, and could not recall
if he hit his head. On CT here, was found to have a subdural
hemtaoma 1.1 cm with 2 mm midline shift. At the time, neurolgoic
exam was normal, save for opacitfication in the L cornea, and R
pupil 2 mm. There is no HCP. During work up there had a
tonic-clonic seizure with eyeward gaze upwards including all 4
extremities, followed by resolutin of seizure activity after 1
mg of ativan, but remained post-ictal for more than 8 minute,
intubated using lidocine, fentyl, etomodate, and succ. sz,
intubated for airway protection [**1-14**] loss of reflexes, CVL at
OSH, phentoin load with 400 mg IV. After the phenytoin load and
persistently there after the pt became hypotensive to 67
systolics. He then received 2L IVF, then started on dopamine. Of
note, troponin I at OSH was 1.08, with a CK-BM 0.5
Patient has history of end-stage renal disease and is maintained
on dialysis. According to outside records, the patient had had
several falls over the past few days, finally prompted him to
present to the [**Hospital **] Hospital. During evaluation at that time,
he was found to have a 1.1 cm subdural hematoma, with 2 mm of
midline shift. The patient and the family did not want transfer
to a tertiary Medical Center at that time, there for psychiatry
was consulted to assess the patient's competance. During this
consultation, the patient sustained a generalized seizure.
Seizure duration was 4 minutes, and stopped after 1 mg of
Ativan. The patient was intubated after the seizure as he did
not appropriately awake for airway protection. After intubation,
the patient had episodes of hypotension, a left IJ was placed,
and the patient was started on dopamine. Upon ED presentation at
our institution, the patient was on 15 of dopamine with a heart
rate in the 130s, blood pressure of 100/50. Patient was
oxygenating well. He received 1 g of IV Dilantin load at the
outside hospital.
In the ED, initial VS were 126 107/44 20 100%. On transfer,
102.3 110 105/50 12 100%. In our ED, he was started on
fent/versed, and neurosurgery evaluated, who indicated that
there was nothing to do surgically; they recommended a repeat
head CT and phenytoin level in the AM. He was started on
Vancomycin and Levofloxacin for a possible shock state, in
addition to phenylephrine. He also had a temperature in the ED
to 102.5, and was given 650 mg PR Tylenol.
An ABG in the ED showed 7.35/41/277. U/A showed trace leuks,
small blood, 6 RBCs, 5 WBCs, few bacteria, and 100 protein.
Lactate was 1.3. Trop on arrival was 0.31. Lytes were notable
for a potassium K 5.4, and a Creatitine of 5.2, with a non-anion
gap metabolic acidosis. WBC was 11.4, HCT 28.5, plt 222 with an
elevated MCV. INR was elevated to 1.3. A bedside U/S in the ED
showed a plump IVC, no pericardial/pleural/peritoneal fluid, and
a very large liver. A CXR was read as having mild pulmonary
edema, with moderate cardiomegaly, with a LIJ central venous
line which ends at the junction of the brachiocephalic veins.
Blood and urine cultures were pending.
Of note, he was admitted from [**Date range (1) 73945**] to [**Hospital3 2568**] for
tachycardia and difficulty breathing in rapid Afib. He was
ultimately adjusted to increased his dose of metoplol to [**Hospital1 **] for
better HR and BP control. Additionally, a discussion was had
with the patient regarding his reluctance to take coumadin given
his low HCT and poor compliance with INR checks. They were also
held in the setting of history of GI [**Last Name (un) **] dand reocccurant
falls.
On arrival to the MICU, he is intubated and sedated
Past Medical History:
ESRD with dialysis T, Th, Sat
HTN
Hypercholesterolemia
COPD
Atrial Fibrilation
Hypothyroidism
CAD s/p MI
Gastric ulcer
Social History:
Lives at home with his family. No home services. Speaks Englsh.
Is a non-smoker, alcohol occasionally.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Constitutional: intubated, sedated,
HEENT: R pupil 2mm minimally reactive, L pupil surgical
Chest: coarse B
Cardiovascular: regular tachycardia
Abdominal: mildly distended, soft
Skin: no rash
Neuro: purposeful movement noted of B upper extremities, lower
extremities withdrawing to pain.
Physical Exam on Discharge:
VS - 98.7 136/80 80 22 96 3L
GENERAL - chronically ill appearing man, awake, eyes blink in
response to threat, patient is interactive this AM and answers
questions by shaking head and mouthing yes and no, thumbs up
HEENT - craniotomy site c/d/i, clouding on L eye (cataract),
sclera anicteric, MMM
NECK - tracheostomy in place
LUNGS - diminished breath sounds throughout, no accessory muscle
use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, g-tube in place, + BS
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), evidence of chonic venous stasis dermatitis
NEURO - eyes open spontaneously
Labs: See below
Pertinent Results:
[**2134-8-16**] 01:50PM PT-14.1* PTT-23.2* INR(PT)-1.3*
[**2134-8-16**] 01:50PM NEUTS-88.7* LYMPHS-7.0* MONOS-4.0 EOS-0.1
BASOS-0.3
[**2134-8-16**] 01:50PM NEUTS-88.7* LYMPHS-7.0* MONOS-4.0 EOS-0.1
BASOS-0.3
[**2134-8-16**] 01:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2134-8-16**] 01:50PM ALBUMIN-3.0* CALCIUM-7.9* PHOSPHATE-5.0*
MAGNESIUM-2.0
[**2134-8-16**] 01:50PM CK-MB-2
[**2134-8-16**] 01:50PM cTropnT-0.31*
[**2134-8-16**] 02:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-TR
[**2134-8-16**] 02:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2134-8-16**] 04:00PM TYPE-ART PO2-277* PCO2-41 PH-7.35 TOTAL
CO2-24 BASE XS--2
[**2134-8-16**] 08:00PM LACTATE-0.8
[**2134-8-16**] 08:00PM TYPE-ART TEMP-39.0 PH-7.32*
[**2134-8-16**] 08:00PM PHENYTOIN-5.0*
[**2134-8-16**] 08:00PM TSH-0.20*
[**2134-8-16**] 08:00PM VIT B12-441 FOLATE-9.6
[**2134-8-16**] 11:21PM PHENYTOIN-11.5
[**2134-8-16**] 11:21PM ALBUMIN-2.7* CALCIUM-8.2* PHOSPHATE-4.7*
MAGNESIUM-2.2
[**2134-8-16**] 11:21PM GLUCOSE-74 UREA N-52* CREAT-5.3*# SODIUM-140
POTASSIUM-5.2* CHLORIDE-110* TOTAL CO2-18* ANION GAP-17
[**2134-8-25**] 04:20AM BLOOD WBC-6.8 RBC-2.72* Hgb-8.6* Hct-28.4*
MCV-104* MCH-31.5 MCHC-30.3* RDW-19.8* Plt Ct-246
[**2134-8-25**] 04:20AM BLOOD Glucose-81 UreaN-31* Creat-4.7*# Na-140
K-3.9 Cl-105 HCO3-21* AnGap-18
[**2134-8-23**] 04:27AM BLOOD CK(CPK)-20*
[**2134-8-25**] 04:20AM BLOOD Calcium-8.5 Phos-3.8# Mg-2.2
[**2134-8-26**] 05:33AM BLOOD WBC-7.3 RBC-2.53* Hgb-7.9* Hct-27.1*
MCV-107* MCH-31.4 MCHC-29.3* RDW-20.3* Plt Ct-274
[**2134-8-26**] 05:33AM BLOOD Glucose-87 UreaN-43* Creat-6.5*# Na-143
K-4.2 Cl-108 HCO3-23 AnGap-16
[**2134-8-26**] 05:33AM BLOOD Phenyto-3.1*
[**2134-8-26**] 07:51AM BLOOD Vanco-26.7*
[**2134-9-1**] 04:54AM BLOOD WBC-7.0 RBC-2.78* Hgb-8.9* Hct-28.6*
MCV-103* MCH-32.1* MCHC-31.3 RDW-22.8* Plt Ct-292
[**2134-8-29**] 03:05AM BLOOD Neuts-80.3* Lymphs-12.5* Monos-6.1
Eos-0.3 Baso-0.9
[**2134-9-1**] 04:54AM BLOOD PT-13.5* PTT-21.0* INR(PT)-1.3*
[**2134-9-1**] 04:54AM BLOOD Glucose-77 UreaN-18 Creat-3.5* Na-137
K-4.9 Cl-99 HCO3-26 AnGap-17
[**2134-8-28**] 03:16PM BLOOD CK-MB-2 cTropnT-0.43*
[**2134-8-29**] 03:05AM BLOOD CK-MB-2 cTropnT-0.47*
[**2134-8-29**] 11:55AM BLOOD CK-MB-2 cTropnT-0.47*
[**2134-8-29**] 08:07PM BLOOD CK-MB-2 cTropnT-0.45*
[**2134-8-30**] 04:30AM BLOOD CK-MB-2 cTropnT-0.40*
[**2134-9-1**] 04:54AM BLOOD Albumin-3.0* Calcium-8.1* Phos-4.3 Mg-2.0
[**2134-9-1**] 04:54AM BLOOD Phenyto-5.0*
[**2134-8-20**] 02:01AM BLOOD Phenyto-6.9* Phenyfr-1.5 %Phenyf-22*
[**2134-8-30**] 04:38PM BLOOD Type-ART pO2-171* pCO2-39 pH-7.39
calTCO2-24 Base XS-0
[**2134-9-1**] 05:18AM BLOOD Type-ART Temp-37.1 Rates-18/5 Tidal V-400
PEEP-5 FiO2-40 pO2-153* pCO2-42 pH-7.42 calTCO2-28 Base XS-3
-ASSIST/CON Intubat-INTUBATED
Microbiology:
[**2134-8-30**] 2:51 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2134-8-31**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
[**2134-8-29**] 12:25 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2134-8-29**]**
GRAM STAIN (Final [**2134-8-29**]):
[**10-7**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2134-8-29**]):
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
[**2134-8-28**] 3:56 pm BLOOD CULTURE Source: Line-dialysis.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-28**] 9:12 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
__________________________________________________________
__________________________________________________________
[**2134-8-24**] 7:54 am BLOOD CULTURE Source: Line-HD Lijne.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-24**] 7:54 am BLOOD CULTURE Source: Line-HD Line.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-24**] 6:00 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-23**] 4:27 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-23**] 1:16 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2134-8-25**]**
GRAM STAIN (Final [**2134-8-23**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2134-8-25**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
__________________________________________________________
[**2134-8-21**] 4:20 am BLOOD CULTURE Source: Line-piv.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2134-8-20**] 7:00 pm CATHETER TIP-IV Source: right femoral HD .
**FINAL REPORT [**2134-8-22**]**
WOUND CULTURE (Final [**2134-8-22**]): No significant growth.
__________________________________________________________
[**2134-8-20**] 2:45 pm BLOOD CULTURE Source: Line-dialysis.
**FINAL REPORT [**2134-8-26**]**
Blood Culture, Routine (Final [**2134-8-26**]): NO GROWTH.
__________________________________________________________
[**2134-8-20**] 2:05 pm BLOOD CULTURE Source: Line-dialysis.
**FINAL REPORT [**2134-8-26**]**
Blood Culture, Routine (Final [**2134-8-26**]): NO GROWTH.
__________________________________________________________
[**2134-8-20**] 2:01 am BLOOD CULTURE #2.
**FINAL REPORT [**2134-8-26**]**
Blood Culture, Routine (Final [**2134-8-26**]): NO GROWTH.
__________________________________________________________
[**2134-8-20**] 2:01 am BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT [**2134-8-26**]**
Blood Culture, Routine (Final [**2134-8-26**]): NO GROWTH.
__________________________________________________________
[**2134-8-19**] 5:12 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2134-8-19**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2134-8-22**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
LEGIONELLA CULTURE (Final [**2134-8-26**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
__________________________________________________________
[**2134-8-19**] 11:20 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2134-8-25**]**
Blood Culture, Routine (Final [**2134-8-25**]): NO GROWTH.
__________________________________________________________
[**2134-8-19**] 3:38 am BLOOD CULTURE Source: Line-HD line.
**FINAL REPORT [**2134-8-25**]**
Blood Culture, Routine (Final [**2134-8-25**]): NO GROWTH.
__________________________________________________________
[**2134-8-18**] 4:20 pm BLOOD CULTURE Source: Line-dialysis.
**FINAL REPORT [**2134-8-24**]**
Blood Culture, Routine (Final [**2134-8-24**]): NO GROWTH.
__________________________________________________________
[**2134-8-18**] 3:40 pm BLOOD CULTURE Source: Line-dialysis.
**FINAL REPORT [**2134-8-24**]**
Blood Culture, Routine (Final [**2134-8-24**]): NO GROWTH.
__________________________________________________________
[**2134-8-18**] 1:31 pm BLOOD CULTURE Source: Line-vip port #2.
**FINAL REPORT [**2134-8-24**]**
Blood Culture, Routine (Final [**2134-8-24**]): NO GROWTH.
__________________________________________________________
[**2134-8-18**] 9:24 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2134-8-24**]**
Blood Culture, Routine (Final [**2134-8-24**]): NO GROWTH.
__________________________________________________________
[**2134-8-17**] 10:01 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2134-8-17**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2134-8-19**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2134-8-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
LEGIONELLA CULTURE (Final [**2134-8-24**]): NO LEGIONELLA
ISOLATED.
__________________________________________________________
[**2134-8-17**] 10:30 am BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT [**2134-8-23**]**
Blood Culture, Routine (Final [**2134-8-23**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # 353-7875E [**2134-8-16**].
Anaerobic Bottle Gram Stain (Final [**2134-8-20**]):
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
[**2134-8-17**] 10:30 am BLOOD CULTURE Source: Line-tlc #2.
**FINAL REPORT [**2134-8-23**]**
Blood Culture, Routine (Final [**2134-8-23**]): NO GROWTH.
__________________________________________________________
[**2134-8-16**] 1:16 pm BLOOD CULTURE
**FINAL REPORT [**2134-8-19**]**
Blood Culture, Routine (Final [**2134-8-19**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # 353-7875E
[**2134-8-16**].
Aerobic Bottle Gram Stain (Final [**2134-8-17**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2134-8-17**] AT
0440.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2134-8-17**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
__________________________________________________________
[**2134-8-16**] 2:00 pm BLOOD CULTURE
**FINAL REPORT [**2134-8-21**]**
Blood Culture, Routine (Final [**2134-8-21**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
LINEZOLID , Daptomycin , [**Month/Day/Year 112206**] AND TELEVANCIN
SENSITIVITIES
REQUESTED BY DR. [**Last Name (STitle) **]. Daptomycin MIC = 0.50
MCG/ML.
VANCOMYCIN Sensitivity testing confirmed by Sensititre.
SENSITIVE TO TELAVANCIN sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVE TO [**Last Name (NamePattern1) 112206**] sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
[**First Name9 (NamePattern2) 112206**] [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**] interpretations are based on
manufacturer's guidelines that are FDA approved.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final [**2134-8-17**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2134-8-17**] AT
0440.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2134-8-17**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Imaging:
CT Head [**8-16**]: IMPRESSION:
1. No significant interval change in size of left-sided
subdural hematoma.
No evidence of subfalcine herniation.
2. Status post right ethmoidectomy and largely opacified right
frontal sinus.
Chest CTA [**8-19**]: IMPRESSION:
1. Acute pulmonary embolism in a left segmental and right
subsegmental
pulmonary artery.
2. Signs of mild decompensated congestive heart failure.
Lower extremity venous u/s [**8-23**]: IMPRESSION:
Bilateral nonocclusive deep venous thrombosis as above.
CT Head [**2134-8-21**] IMPRESSION:
Essentially unchanged 8-mm right subdural hematoma.
CXR [**8-21**]
FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are unchanged. Unchanged size of
the cardiac silhouette with bilateral small pleural effusions.
The transparency in the right upper lobe has substantially
improved, likely reflecting improvement of the pre-existing
pneumonia. However, the parenchymal opacities at the left and
right lung bases persist. In addition, the diameter of the
vascular structures has increased, likely reflecting
mild-to-moderate pulmonary edema. No evidence of pneumothorax.
CXR [**8-26**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. All visible changes on the radiograph can be explained
by change in
patient position. There is moderate cardiomegaly with
mild-to-moderate
pulmonary edema and bilateral pleural effusions as well as
moderate
cardiomegaly. The monitoring and support devices, including the
Dobbhoff
catheter and the left PICC line as well as the double-lumen
dialysis catheter
on the right are constant. No new parenchymal opacities.
Head CT [**8-30**]: IMPRESSION: Expanding left subdural hematoma with
12 mm rightward subfalcine herniation. Basal cisterns remain
patent with possible mild effacement of the left lateral aspect
of the suprasellar cistern.
Head CT [**8-31**]: IMPRESSION:
1. Status post left craniotomy and drain placement with tip of
drain in the frontal subdural space, with expected extracranial
subcutaneous emphysema and blood products within scalp overlying
the craniotomy site.
2. Expected post-surgical changes including significant
pneumocephalus, with largest locule overlying the left frontal
lobe, and residual blood products in extra-axial space. Linear
hyperdensity at the vertex, new, likely represents surgical
material.
3. Similar degree of mass effect and sulcal effacement of the
left frontal
lobe.
4. 10 mm rightward shift of normally-midline structures,
previously was 13 mm.
5. No central herniation.
CT Head [**2134-9-2**]: 1. Unchanged size of left subdural collection
with a small amount of intervally developed hyperdensity within
the subdural space consistent with a small amount of bleeding
after drain removal.
2. Sulcal and ventricular effacement is unchanged with decreased
rightward shift of midline structures from 10 to 9mm and
unchanged right frontal hypodensity.
3. Expected post-surgical changes from craniotomy with decrease
in degree of pneumocephalus.
CXR [**2134-9-4**]: Tracheostomy and right hemodialysis catheter are in
place as well as the IVC filter and gastrostomy. The heart size
is enlarged, unchanged. Mediastinum is stable. No interval
progression of pulmonary edema is demonstrated, in contrary
slight decrease in vascular engorgement is noted as compared to
the prior study. Still present right basal opacity and left
perihilar opacity might reflect infectious process or residue of
pulmonary edema.
Labs on Discharge:
Brief Hospital Course:
Mr. [**Known lastname 112205**] is an 81 year old man with a PMH s/f ESRD with
dialysis, HLD, COPD, Afib, Hypothyroidism, CAD s/p MI, and
gastric ulcer who presents with hypotension, found to have a
subdural hematoma
# Respiratory Failure: Arrived to MICU intubated. By report
patient was intubated for airway protection in setting of
seizure, upon arrival to MICU his ABG was normal and he was no
longer seizing. Patient was successfully extubated on hospital
day two. Following extubation the patient was noted to have
several episodes of wheezing, dyspnea and tachypnea which
responded to nebulizer treatments. On hospital day four patient
experienced increased work of breathing requiring intubation.
Following intubation patient was sent for CTA of the chest
secondary to his tachypnea, dyspnea and tachycardia. He was
noted to have a segmental PE on CTA (see below). On hospital day
9 the patient was successfully extubated. On hospital day 10 pt.
tolerated supplemental oxygen via nasal cannula with SpO2 in
high 90s on 3Lnc. Pt was transferred back to the medicine floor
on [**2134-8-27**]. On the morning of [**2134-8-28**], pt was found to be in
respiratory distress (anterior crackles on exam, tachycardia
122-140; RR 36; sat 98% face tent), appropriate w/u was done at
that time including ABG, CXR, EKG/trops, blood cx x2/urine cx;
transferred back to MICU. In the MICU was reintubated, satting
100% on CPAP with FiO2 40%. Tracheostomy placed on [**9-1**].
Initially required vent setting for 2 days and then was stable
of 40% O2 trach mask. He was transferred back to the medicine
floor on [**2134-9-4**]. His respiratory status was monitored and he
remained stable on 40% trach mask.
# Bacteremia: The patient meets SIRS criteria with fevers and
tachycardia, but did not have an elevated RR nor WBC count. He
was started on empiric vancomycin and Zosyn for sepsis
physiology. He was subsequently noted to have gram positive
cocci bacteremia with the most likely source being his tunneled
dialysis catheter line. The tunneled line was discontinued and
antibiotics where continued. Repeat blood cultures remained
negative and patient had a temporary femoral dialysis line
placed for dialysis. Sensitivities on blood cultures showed
patient to be infected with VISA, patient was started on
Daptomycin on [**2134-8-19**] with plan for 6 week course. After
confirmation of negative surveillance cultures the patient had a
new tunneled right IJ line placed by IR.
# Pneumonia: Patient noted to have MRSA on BAL, was restarted on
Vancomycin on [**2134-8-22**] for coverage of MRSA pneumonia. Plan for 8
day course to cover for ventilator-associated pneumonia. Last
day of vancomycin on [**2134-8-29**].
# Pulmonary embolism: Patient noted to have segmental PE by CTA
chest. Anti-coagulation contraindicated due to subdural
hematoma. Patient received biltaeral LENIs which did not show
evidence of DVT. Follow-up LENIs on [**8-23**] did show DVTs and
patient underwent IVC filter placement on [**8-23**].
# NSETEMI: Tropinin leak to 0.47 and dynamic ECG changes.
Patient not started on heparin and not treated with ASA given
SDH. Patient was monitored on telemetry with no events noted.
# SDH: Per neurosurg no surgical intervention indicated
initially. Plan for follow up with Dr. [**First Name (STitle) **] with repeat CT
Head 1 month after injury. Head CT on [**8-30**] showed expanding SDH
with significant midline shift and subfalcine herniation. Had
left craniotomy w/ SDH evacuated and subdural drain placed on
[**8-31**]. On [**9-1**], was noted to have seizure activity x3, was loaded
with Keppra. Placed on continuous EEG per neuro recs. Neuro
would like to see him as an outpatient: Please call [**Telephone/Fax (1) 1669**]
for an appointment. He will need a non contrast head CT at
follow up. This exam will be scheduled and coordinated by
neurosurg office.
# Seizure: Likely secodnary to SDH, no prior history of seizure.
Patient was started on Dilantin and follow up levels were
checked. In setting of hypoalbuminemia a free dilantin level was
measured and correlated to his total serum dilantin level.
Dilantin dose titrated based off of level. Per neurosurgery will
need continued seizure prophylaxis at least until his follow up
appointment (likely to need at least 3 month course). Began
having seizure activity [**9-1**] s/p evacuation of left SDH and
drain placement. Was loaded with Keppra. Per neuro recs, started
on continuous EEG, which was d/c when patient no longer having
seizures. Dilantin was tappered off and he was maintained on
Keppra 500 mg [**Hospital1 **] with extra dose of 250 mg after dialysis.
# Atrial fibrilation: diltiazem 30mg TID was added to home
metoprolol dose with adequate rate control.
# Non-anion gap acidosis: Resolved, was likely secondary to
fluid resuctiation versus renal failure
# Macrocytic Anemia: trended, Hematocrit remained stable over
course of admission. Folate and B12 were normal on admission.
Repeat on [**2134-9-5**] were XX.
# Elevated INR: Not on Coumadin. Treated with vitamin K to
correct coagulopathy in setting of subdural bleed. Patient's INR
normalized and was discarged with latest INR of XX.
# ESRD: Dialysis initially held upon presentation as patient was
bacteremic and any line placed would provide source for
worsening of bacteremia. Temporary femoral line placed when
dialysis became necessary. This was discontinued and pt.
received tunneled dialysis catheter on [**8-23**]. Dialysis regimen of
Tuesday, Thursday, Saturday.
Transitional Issues:
- He was started on warfarin and bridged with heparin
- He should have his INR checked every 3 days with goal INR [**1-15**],
he should remain on heparin IV weight based protocol until INR>2
for 2 consecutive days.
-He should continue Warfarin for at least 6 months, and then
re-evaluated by his primary care doctor.
- He will need a non contrast head CT at follow up with
Neurosurgery
-He has outpatient appointments with neurology and should
continue his keppra
-He should continue his antibiotics (daptomycin) until [**9-30**]
Please check the following labs weekly until patient finishes
course of daptomycin on [**2134-9-29**]. Please fax results to
infectious disease office at ([**Telephone/Fax (1) 4591**].
-CBC with differential
-Chem 7
-ESR/CRP
-CPK
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient DC Summary from [**Hospital1 **].
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
4. Aspirin 81 mg PO DAILY
5. Calcitriol 0.25 mcg PO WITH DIALYSIS
6. Calcium Acetate 667 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
8. Furosemide 40 mg PO BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Lorazepam 1 mg PO HS:PRN anxiety
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Mirtazapine 15 mg PO HS
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 1 TAB PO DAILY
16. sertraline *NF* 25 mg Oral Daily
17. Simvastatin 20 mg PO DAILY
18. Tamsulosin 0.4 mg PO HS
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP Frequency is
Unknown
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Senna 1 TAB PO DAILY
4. Daptomycin 500 mg IV Q48H
RX *daptomycin [CUBICIN] 500 mg 500mg IV q48 q48h Disp #*12 Unit
Refills:*0
5. Diltiazem 30 mg PO TID
please hold for SBP < 100
RX *diltiazem HCl [Cardizem] 30 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
6. Heparin IV per Weight-Based Dosing Guidelines
7. Lanthanum 500 mg PO TID W/MEALS
RX *lanthanum [FOSRENOL] 500 mg 1 tablet(s) by mouth tid with
meals Disp #*30 Tablet Refills:*0
8. LeVETiracetam 500 mg PO BID
9. OLANZapine 5 mg PO DAILY:PRN agitation
10. Warfarin 3 mg PO DAILY16
Please give 3mg starting [**9-8**] daily
11. Acetaminophen 650 mg PO Q6H:PRN fever, pain
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
13. Aspirin 81 mg PO DAILY
14. Calcitriol 0.25 mcg PO WITH DIALYSIS
15. Calcium Acetate 667 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
17. Lorazepam 1 mg PO HS:PRN anxiety
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Mirtazapine 15 mg PO HS
20. Multivitamins 1 TAB PO DAILY
21. Polyethylene Glycol 17 g PO DAILY
22. Sertraline *NF* 25 mg ORAL DAILY
23. Simvastatin 20 mg PO DAILY
24. Tamsulosin 0.4 mg PO HS
25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP [**Hospital1 **]:PRN rash
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Subdural Hematoma
Pulmonary embolus
End stage renal disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Intermittently responds to commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 112205**],
You were admitted to [**Hospital1 18**] for a bleed in your head as well as a
clot in your lungs. You had a seizure as well. Please keep
your appointments listed below and take your medications as
listed.
Followup Instructions:
Department: RADIOLOGY
When: TUESDAY [**2134-11-2**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2134-11-2**] at 1:45 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Location (un) 2274**] [**Hospital1 **]
Address: [**Country 23010**], 3RD FL, [**Hospital1 **],[**Numeric Identifier 23011**]
Phone: [**Telephone/Fax (1) 23012**]
Your Primary Care Physician office is working on a follow up
appt in the neurology department within the following week. You
will be called at home by Dr [**Last Name (STitle) 88224**] [**Name (STitle) **] [**Doctor First Name **] with the
appointment. If you have not heard from the office within 2
business days, please call them directly to book at
[**Telephone/Fax (1) 23012**].
Completed by:[**2134-9-7**]
|
[
"276.2",
"415.19",
"244.9",
"428.0",
"276.8",
"276.69",
"496",
"261",
"V49.86",
"348.39",
"459.81",
"E888.9",
"997.31",
"410.71",
"038.12",
"780.39",
"273.8",
"V09.80",
"272.4",
"366.9",
"518.81",
"852.21",
"348.9",
"E879.1",
"E879.8",
"790.92",
"585.6",
"453.41",
"281.9",
"453.6",
"428.31",
"995.92",
"427.31",
"414.01",
"785.52",
"293.0",
"V45.11",
"999.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"96.6",
"38.97",
"38.95",
"33.23",
"43.11",
"01.31",
"96.72",
"02.91",
"96.71",
"31.1",
"39.95",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
31934, 32006
|
23427, 28955
|
364, 501
|
32110, 32110
|
5790, 8956
|
32527, 33679
|
4760, 4778
|
30631, 31911
|
32027, 32089
|
29765, 30608
|
32258, 32504
|
4793, 4807
|
15850, 23383
|
15703, 15814
|
8994, 9667
|
11167, 13657
|
5138, 5771
|
28976, 29739
|
262, 326
|
23404, 23404
|
529, 4482
|
4821, 5110
|
32125, 32234
|
4504, 4624
|
4640, 4744
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,483
| 139,440
|
422
|
Discharge summary
|
report
|
Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-15**]
Date of Birth: [**2107-10-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Swan-Ganz catheter placement
Endotracheal intubation
History of Present Illness:
59 year old gentleman with a past medical history of CAD s/p
CABG in [**2151**] with LIMA to LAD and RIMA to RCA, hyperlipidemia,
htn, and smoking. The patient was having symptoms of shortness
of breath and chest pain, unclear for how long and decided to go
to his PCP who he had not seen in over two years. On route to
the office, his symptoms worsened and he called his doctor who
advised him to pull over and call 911. Taken by Ambulance to
[**Hospital1 **] ER at 1130. There he received 325 aspirin, 4 morphine
and nitroglycerin drip. Arixtra (Fondiparinux) was also given.
EKG revealed ST depressions in leads I, aVL, V3-V6. ST elevation
in AVR. CK 99, MB and troponin unknown. The patient had worsened
dyspnea and hypoxia, had pulmonary edema on CXR and was
electively intubated (etomidate, succinylcholine). Integrilin
started and sent for catheterization. Left heart cath via right
femoral artery reportedly with 95% lm occlusion, native RCA and
LAD are both occluded. LIMA and RIMA appeared patent.
.
Pt received 40 IV lasix and transferred to [**Hospital1 18**] for further
intervention. Became hypotensive to SBP 70-80 and was placed on
neo gtt on route. On arrival to cath lab pt still pressor
dependent. Cath revealed critical >95 percent stenosis at L main
near junction of LCx and ramus. Bare metal stent placed. SBP
improved after placement of this stent and pt weaned off
pressor.
.
Also of note, pt had traumatic intubation. In addition, at first
Foley could not be placed--abd was getting distended. Foley
placed by urology after dilation of ureteral meatus (had some
meatal stenosis).
Pt currently intubated and sedated, unable to provide history
and does open eyes and seems to respond to voice.
Past Medical History:
Diabetes, Dyslipidemia, Hypertension, Smoking
CABG, in [**2151**] anatomy as follows: RIMA to RCA, LIMA to LAD
Social History:
He is divorced with one sone. S current tobacco use 3 packs a
day for >20 per wife. Drinks three mixed alcoholic beverages
every night.
Family History:
Family history is unknown.
Physical Exam:
VS: T 97.5 , BP 112/62 , HR 55-60 , RR , O2 95 % on Pressure
support 10 with PEEP 5, tidal volumes 550 and breathing at rate
24.
ABG: pH 7.41/ pCO2 38/pO2 70/HCO3 25
Gen: Intubated, sedated male Caucasian. Obese.
Head: NCAT.
Eyes: Sclera anicteric.
Mouth: Intubated. Dried blood and clot around lips
Neck: Supple. Obese with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: Diffuse wheezes and rales, decreased BS at bases.
Abd: Obese
Ext: R foot reddish, slightly dusky. L foot nl. No femoral
bruits.
Pulses:
Right: DP dopplerable.
Left: DP dopplerable
Pertinent Results:
[**2167-3-12**] 04:00PM BLOOD WBC-14.2* RBC-4.26* Hgb-15.4 Hct-44.4
MCV-104* MCH-36.1* MCHC-34.6 RDW-14.8 Plt Ct-205
[**2167-3-15**] 05:55AM BLOOD WBC-7.4 RBC-3.40* Hgb-12.5* Hct-35.7*
MCV-105* MCH-36.7* MCHC-34.9 RDW-14.3 Plt Ct-144*
[**2167-3-12**] 04:00PM BLOOD Neuts-88.6* Bands-0 Lymphs-7.7* Monos-3.1
Eos-0.4 Baso-0.2
[**2167-3-13**] 12:01PM BLOOD PT-13.8* PTT-32.3 INR(PT)-1.2*
[**2167-3-15**] 05:55AM BLOOD PT-12.5 PTT-29.3 INR(PT)-1.1
[**2167-3-12**] 04:00PM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-134
K-5.5* Cl-104 HCO3-21* AnGap-15
[**2167-3-15**] 05:55AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-136
K-4.2 Cl-103 HCO3-24 AnGap-13
[**2167-3-12**] 04:00PM BLOOD ALT-29 AST-41* CK(CPK)-204* AlkPhos-75
Amylase-29 TotBili-1.5 DirBili-0.3 IndBili-1.2
[**2167-3-13**] 02:00AM BLOOD CK(CPK)-333*
[**2167-3-15**] 05:55AM BLOOD CK(CPK)-187*
[**2167-3-12**] 06:23PM BLOOD CK-MB-26* MB Indx-8.6* cTropnT-0.44*
[**2167-3-13**] 02:00AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.7
[**2167-3-15**] 05:55AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9
[**2167-3-12**] 04:00PM BLOOD %HbA1c-5.2
.
CHEST (PORTABLE AP) [**2167-3-12**] 6:33 PM
CHEST (PORTABLE AP)
Reason: Please assess for ETT position and for pulmonary edema.
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with CHF, intubated for pulmonary edema.
REASON FOR THIS EXAMINATION:
Please assess for ETT position and for pulmonary edema.
SINGLE AP PORTABLE VIEW CHEST:
REASON FOR EXAM: Assess for pulmonary edema, patient post CABG.
COMPARISON: None.
ETT tip projects 6.4 cm above the carina and the tip is out of
view below the diaphragm. There is moderate pulmonary edema.
Bibasilar opacities likely atelectasis. The bases were not
included on the film. Swan-Ganz catheter tip is in the left main
pulmonary artery.
.
Cardiac Catheterization: COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
critical left main disease. The LMCA had a 95% stenosis
involving the
ostium of the LCX and the ramus. The LCX had moderate diffuse
disease
and the LAD was totally occluded proximally and filled via the
LIMA. The
RCA was not engaged.
2. Limited resting hemodynamics revealed elevated right and left
sided filling pressures with an RA of 20 and a PCWP of 24. The
cardiac
index was reduced at 1.9 L/min/m2.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the LMCA involving teh LCX
and ramus
origins with two 3.0 x 18 mm VISION BMS in a kissing style.
Final
angiography revealed no residual stenosis in the stents, no
dossection
and TIMI III flow (See PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Cardiogenic shock as evidenced by acidosis, hypotension
requiring
pressors and low cardiac output
3. Successful stenting of the LM into the LCX and the ramus with
BMS.
.
ECG:
Ectopic atrial bradycardia. Extensive inferolateral ST-T wave
changes. Consider myocardial injury/ischemia. Compared to the
previous tracing of [**2151-12-24**] the rhythm is now ectopic atrial
bradycardia and the inferolateral ST-T wave changes are new.
Clinical correlation is suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 144 86 488/477 -17 -9 -144
.
Echo:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF 70%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Brief Hospital Course:
59 year old gentleman with CAD s/p CABG admitted with MI, with
heart failure and cardiogenic shock now status post PCI to 95%
lesion at LMCA at LCx and ramus origin.
.
#) CAD/Ischemia: Reports 1.5 weeks of CP before reporting to
OSH. s/p CABG in the past, now s/p BMS X2 in a kissing style to
LMCA at LCX and Ramus origins to open 95% lesion. He completed a
course of integrillin, and was continued on aspirin,
clopidogrel, atorvastatin, lisinopril. Metoprolol was initially
held because the patient was bradycardic after his myocardial
infarction and intervention. Metoprolol was eventually added on
hospital day #3 once his heart rate increased. He was initially
continued on isosorbide dinitrate, but this was discontinued
prior to discharge. The patient remained chest pain free for
the duration of his hospitalization.
.
#) Heart failure: Patient was in cardiogenic shock at
presentation and in cath lab. On arrival to the CCU the patient
was no longer in cardiogenic shock. His PA catheter was showing
borderline pulmonary hypertension, and a wedge of 16. ECHO on
hospital day #2 showed EF 70%, and unable to determine focal
wall motion because of poor study. Valves were without
abnormality. Likely etiology of his flash pulmonary edema at
presentation was diastolic dysfunction in setting of acute MI,
along with possible acute mitral reguritation, which
subsequently resolved after cardiac catheterization. The
patient was continued on metoprolol and lisinopril.
.
#)Respiratory Status: The patient was intubated on arrival. He
was extubated by hospital day #2. The patient continued with
wheezes on exam, which were alleviated with albuterol and
ipratropium nebulizers.
#) Rhythm: bradycardia resolved. BB as above.
.
#)Hypertension: By hospital day #4, the patient's systolic blood
pressures were ranging 130-150's. He was continued on
metoprolol, and his lisinopril was increased from 10mg to 20mg
daily.
.
#) Hypertension. ace-i and BB as above. titrate prn.
.
#) Oral bleeding, hct stable, follow hct.
.
#) Urethral stenosis: Foley catheterization was difficult at
presentation, and a urologist was required to place a 14F foley,
after which 1000cc of urine was immediately drained.
Medications on Admission:
CURRENT MEDICATIONS:
Aspirin
Plavix
Integrilin
Medications at home:
ASA
Lisinopril
Lipitor
Metoprolol
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 1 months.
Disp:*30 Patch 24 hr(s)* Refills:*1*
6. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-26**] puff Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute myocardial infarction
Cardiogenic shock
Discharge Condition:
Good. Ambulating with no chest pain. Breathing normally on
room air and tolerating a regular diet.
Discharge Instructions:
You were admitted to the hospital with chest pain and shortness
of breath. You were found to be having a heart attack. You
received a bare metal stent to one of your coronary arteries.
Your chest pain has resolved.
.
Please take your medications as prescribed.
.
Please follow-up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-26**] weeks. He
will need to refer you to a cardiologist.
Please strongly consider to stop smoking. This will be
beneficial for your heart.
.
Please call your doctor or return to the hospital if you develop
chest pain, shortness of breath, or other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 3603**] in one to two weeks.
|
[
"414.01",
"305.1",
"427.89",
"873.43",
"401.9",
"250.00",
"292.0",
"598.9",
"E879.8",
"410.71",
"V45.81",
"272.4",
"424.0",
"785.51",
"496",
"518.81",
"428.0",
"553.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"36.06",
"99.19",
"00.66",
"56.91",
"57.94",
"00.46",
"37.23",
"88.56",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
10464, 10470
|
7031, 9235
|
283, 361
|
10560, 10662
|
3096, 4301
|
11353, 11522
|
2411, 2439
|
9388, 10441
|
4338, 4395
|
10491, 10539
|
9261, 9261
|
5682, 7008
|
10686, 11330
|
9329, 9365
|
2454, 3077
|
233, 245
|
4424, 5665
|
9282, 9308
|
389, 2108
|
2130, 2242
|
2258, 2395
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,611
| 172,738
|
46608
|
Discharge summary
|
report
|
Admission Date: [**2138-7-10**] Discharge Date: [**2138-7-17**]
Date of Birth: [**2073-5-10**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Bactrim
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 98977**] is a 65 yo woman with history of chronic
diastolic CHF, pulmonary hypertension, mixed obstructive and
restrictive pulmonary disease, obstructive sleep apnea (uses
CPAP), Type II diabetes, and chronic kidney disease who presents
with 2 days of nausea, hypokalemia, and hypercalcemia.
She has had chronic shortness of breath felt to be related to
volume overload from chronic diastolic CHF. Her metolazone was
increased to 2x/week about 2 weeks ago. Since then she reports
decreasing weight (has lost about 7 lbs). One week ago, she
began to develop more fatigue and felt that her legs began to
buckle more frequently. Also endorses worsening leg cramping.
She has also felt nausea for the last several days and vomited
once two days ago. She was seen by her PCP yesterday who
checked electrolytes. She was called by her PCP this morning
due to hypokalemia and hypercalcemia and told to come into the
ED.
In the ED, initial vitals were T 98.2, BP 181/75, HR 59, RR 18,
O2sat 97% RA. Lab results were significant for stable troponin
(0.09), K of 2.7, and calcium of 12.5. In the ED she endorsed
shortness of breath and CXR showed evidence of pulmonary edema.
She received KCl 60 meq po and 40 meq IV, verapamil SR 240 mg po
and Carvedilol 12.5 mg po prior to transfer to the medicine
floor.
Currently she reports feeling tired with slight nausea. She
reports her breathing feels pretty good. She feels she can walk
150 feet without getting short of breath, but states her
functional status has declined significantly after a rehab stay
in [**4-2**] after an ankle fracture.
Review of sytems:
(+) Per HPI. Also endorses having chills for 9 months,
intermittent fleeting chest achiness that feels "empty" in
character, also with constipation
(-) Denies fever, headache, sinus tenderness, rhinorrhea or
congestion. Denied diarrhea or abdominal pain. No recent change
in bowel or bladder habits. No blood in stool. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
#. DM Type 2 - Insulin dependent
- c/b retinopathy, neuropathy, and nephropathy
- followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **] and her A1c as high as 14 and
has come down to to 9.1
#. CKD Stage IV: Baseline Cr 2.1-3.2
#. Charcot deformity of the right ankle
#. Hypertension
#. Mixed restrictive & obstructive pulm disease (2L oxygen at
night)
#. Pulmonary Hypertension (TR grad 32 mmHg [**2137-7-8**] TTE)
#. Chronic diastolic CHF
#. Hyperlipidemia
#. Hypothyroidism
#. Polymyalgia rheumatica
#. Fibromyalgia
#. s/p TAH for fibroids
#. Depression
#. GERD
#. OSA on CPAP (7 with 2L oxygen) - Per recent slepe study, many
episodes of oxygen desaturation at 70% oxygen saturation.
#. Cataracts s/p surgery [**2138-6-24**]
Social History:
The patient currently lives in [**Location 10059**], MA by herself. Has a
home health aide 12 hours daily who drives, cooks, cleans, helps
patient bathe and get dressed. She is divorced with 2 children.
Closest relative is brother who lives in [**Location (un) 55**]. She is
a former secretary. She quit tobacco 12 years ago, with 40+
pack-year history. Denies etoh and illicit drug use, states she
used to drink alcohol and also quit 12 years ago. Per review of
OMR, has a prior history of abusing vicodin and oxycodone.
Family History:
Father with heart problems in his 50s, died from GBM in 60s.
Mother died of "ascending aneurysm." Multiple family members
with [**Name (NI) 2320**].
Physical Exam:
VS: 142/88 75 18 98%2L
GENERAL: Obese female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Pupils equal with slight
stranding of cornea in right eye at site of recent cataract
surgery. EOMI. Conjunctiva were pink, no pallor or cyanosis of
the oral mucosa. MM appear moist
NECK: Supple with JVP difficult to interpret.
CARDIAC: RR with distant heart sounds. 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.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: Trace peripheral edema in BLE.
Pertinent Results:
Admission Labs:
[**2138-7-10**] 10:30AM WBC-11.4* RBC-3.37* HGB-9.7* HCT-29.9* MCV-89
MCH-28.9 MCHC-32.5 RDW-16.8*
[**2138-7-10**] 10:30AM NEUTS-71.2* LYMPHS-17.5* MONOS-8.8 EOS-2.1
BASOS-0.5
[**2138-7-10**] 10:30AM PLT COUNT-318
[**2138-7-10**] 10:30AM ALBUMIN-3.8 CALCIUM-12.5* PHOSPHATE-5.5*
MAGNESIUM-2.6
[**2138-7-10**] 10:30AM GLUCOSE-209* UREA N-72* CREAT-4.4* SODIUM-137
POTASSIUM-2.7* CHLORIDE-87* TOTAL CO2-40* ANION GAP-13
[**2138-7-10**] 06:30PM TSH-10*
[**2138-7-10**] 06:30PM PTH-17
Studies:
[**2138-7-10**] ECG: Normal sinus rhythm, rate 60. Intraventricular
conduction delay of left bundle-branch block type. Leftward
axis. Q-T interval prolongation. Generalized non-specific
repolarization abnormalities. Compared to the previous tracing
of [**2138-3-16**] Q-T interval prolongation is new and there are
mid-precordial U waves consistent with hypokalemia.
[**2138-7-10**] CXR: Cardiomegaly, mild congestion, trace left pleural
effusion. Nodular opacities in the right mid lung, possibly
representing healing rib fractures, though true pulmonary
nodules cannot be excluded. *****A CT of the chest is
recommended to further evaluate. Findings and recommendations
were communicated with housestaff.*****
[**2138-7-15**] Renal Ultrasound: 1. Right simple renal cysts. 2.
Normal-appearing left kidney. 3. No evidence of obstructive
renal disease.
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 98977**] is a 65 yo woman with history of chronic
diastolic CHF, pulmonary HTN, mixed obstructive and restrictive
pulmonary disease, OSA on CPAP, T2DM, and CKD who presented with
nausea, hypokalemia, and hypercalcemia with hospital course
complicated by CCU transfer for bradycardia and hypotension.
#. Hypokalemia: On admission she was hypokalemic to 2.7. This
was felt to be related to an increase in her metolazone dosing
prior to admission. Metolazone was held and her potassium was
supplemented and returned to [**Location 213**] range. She will be
discharged on potassium supplements 20 meq po daily at the
recommendation of the renal team. Patient should have her
electrolytes monitored within one week of discharge.
#. Hypercalcemia: She had hypercalcemia on admission felt to be
related to intravascular volume depletion and increase in recent
metolazone dosing. She had a normal PTH level. Her calcium
supplements were held, as was her metolazone and she was gently
rehydrate and her calcium levels improved.
#. Acute on Chronic Diastolic CHF: Due to her electrolyte
abnormalities, she was gently rehydrated with 2 liters of normal
saline over 2 days. She gradually became short of breath with
this fluid and her oxygenation worsened. Her Lasix was
restarted in intravenous form and her oxygenation improved. She
was initially given her home carvedilol and verapamil but then
developed bradycardia so these were held. She was changed to a
lower dose of verapamil and labetalol. Her home lasix was
restarted.
#. Syncope and bradycardia: She developed bradycardia to the
40's on [**2138-7-13**] and had an episode of syncope without trauma.
She was found to be in complete heart block with junctional
escape rhythm felt to be due to accumulation of nodal blocking
agents in setting of worsening renal failure. She became
hypotensive during this episode and she was transferred to the
CCU. She was placed on a dopamine drip transiently for
hypotension. Her verapamil dose was decreased and her
carvedilol was switched to labetalol. Her heart rate
subsequently remained in normal range.
#. CKD Stage IV: Creatinine elevated on admission to 4.4 from
recent baseline of 4.0. Her creatinine has trended up slowly
over last 3 years. Initially her creatinine slightly improved
with gentle rehydration but then worsened again with diuresis
with IV Lasix due to SOB and hypoxia. It improved again to her
recent baseline. She had a negative renal ultrasound. There
was some discussion with the patient that she may been dialysis
in the near future and renal team was consulted. Patient will
need outpatient workup including hep screen and PPD. She
underwent venous mapping of her upper extremities during this
admission. If patient chooses to continue her predialysis
workup at [**Hospital1 18**], recommend scheduling an appointment with
transplant surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3618**].
# OSA: Continued on home BiPap at 18/16 with vented mask
#. Charcot foot: Continued AFO brace when OOB
#. T2DM: She has uncontrolled DM. She is on a complicated
insulin regimen with 22 units NPH in the morning, 38 units
lantus at night plus humalog ISS. She was continued on this
regimen. Blood sugars were well controlled.
#. Hypertension: She was hypertensive in the ED but improved to
normotensive on her home carvedilol, hydralazine, and verapamil.
She then became bradycardic and hypotensive and it was felt
that these agents may be accumulating due to renal failure. Her
blood pressures became labile and she was transferred to the
CCU. Her hydralazine and carvedilol were stopped and replaced
with labetalol and prazosin. Her verapamil dose was also
decreased. She was discharged home on labetolol 100 mg po bid,
prazosin 1 mg po bid, and verapamil 40 mg po tid. On this
regimen her systolic blood pressure ranged from 120-170.
Recommend her blood pressures continue to be monitored in the
outpatient setting so antihypertensives can be adjusted
accordingly.
#. Anemia: Remained at her recent baseline initially but then
fell from 29 to 22. She was given 1 unit PRBCs without
complication and her hematocrit subsequently remained stable.
She received a single dose of ferrous gluconate 125 mg IV and
was started on daily ferrous sulfate and vitamin C supplements.
On day of discharge patient's hematocrit was 27.
#. Hypothyroidism: Continued on levothyroxine 75mcg po daily
initially and then this dose was increased to 88 mcg po daily
due to high TSH and low T3.
#. Polymyalgia rheumatica: Continued on 7mg prednisone daily
#. Depression: Continued duloxetine.
#. Cataracts s/p surgery [**2138-6-24**]: Continued her home eye drops
#. Code status:: Full code, confirmed
#. Contact: Brother [**Name (NI) **] [**Name (NI) 951**] [**Telephone/Fax (1) 98978**]
Medications on Admission:
Carvedilol 12.5mg po bid
Duloxetine 90mg po daily
Furosemide 80mg po qam, 40mg po qpm
Hydralazine 75mg po tid
Lantus 38 units qhs
NPH 22 units with breakfast
Humalog ISS 6-24 units with meals per sliding scale
Levothyroxine 75mcg po daily
Metolazone 2.5mg po twice per week
Prednisone 7mg po daily
Crestor 20mg po daily
Omeprazole 40mg po daily
Verapamil SR 240mg po bid
Caltrate 600 1 tab po daily
Tramadol ER (Ryzolt) 200mg po daily
Docusate
MVI 1 tab po daily
Senna
Vitamin D3 1000units po daily
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO every morning:
And 1 tab (40mg) every evening.
3. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units
Subcutaneous every evening.
4. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Twenty
Two (22) units Subcutaneous every morning.
5. Humalog 100 unit/mL Solution Sig: Insulin sliding scale
Subcutaneous three times a day.
6. Prednisone 1 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ryzolt 200 mg Tab, Multiphasic Release 24 hr Sig: One (1)
Tab, Multiphasic Release 24 hr PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
15. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
16. Prazosin 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*2*
17. Moxifloxacin 0.5 % Drops Sig: [**1-25**] Ophthalmic qhs ().
18. Bacitracin 500 unit/g Ointment Sig: One (1) Ophthalmic qhs
().
19. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic HS (at bedtime).
20. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
22. Outpatient Lab Work
Please draw chem 10 and CBC on [**2138-7-21**]. Please forward
results to Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 6457**] fax [**Numeric Identifier 98979**]
23. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Primary Diagnosis:
Hypokalemia
Hypercalcemia
Bradycardia with complete heart block
Anemia
Secondary Diagnosis:
Type 2 Diabetes Mellitus
Chronic kidney disease, stage IV
Hypertension
Chronic Diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Oxygen saturation at rest is 96% on room air.
Discharge Instructions:
You were admitted to the hospital with low potassium levels and
high calcium levels in your blood. You were given IV fluids and
potassium supplementation and your electrolyte levels improved.
It was felt that these levels were due to your recent increase
in your dose of metolazone.
You also had an episode of slow heart rate and some of your
medications were changed to prevent this in the future.
Your blood counts were low during your admission. You were given
1 unit of blood and started on iron supplementation.
.
Changes to your medications:
STOPPED calcium carbonate and vitamin D
STOPPED metolazone
STOPPED carvedilol
STOPPED hydralazine
STARTED labetalol 100mg by mouth twice daily
STARTED prazosin 1mg by mouth twice daily
STARTED Potassium chloride 20 mEq (1 pill per day)
STARTED Ferrous Sulfate 325 mg by mouth daily
STARTED Ascorbic acid 500 mg by mouth daily
DECREASED verapamil to 40mg by mouth three times daily
INCREASED levothyroxine to 88mcg by mouth daily
Followup Instructions:
It is very important that you have your labs drawn on [**Numeric Identifier 766**],
[**2138-7-21**]. The results should be forwarded to your primary
care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**].
You have the following appointments scheduled in follow-up:
Name: [**Last Name (LF) 3617**], [**First Name3 (LF) 4375**] S. MD
When: [**First Name3 (LF) **], [**8-4**], 1:30PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
** You were also found to have opacities on your chest x-rays
that could be nodules in your lung. It was recommended that you
get an outpatient CT scan for evaluation. Please have your
primary care provider order this study **
Department: PODIATRY
When: [**Telephone/Fax (1) **] [**2138-7-21**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
When: [**Last Name (LF) **], [**7-14**], 11AM
Address: 1 [**Location (un) **] PL,[**Apartment Address(1) 93647**], [**Location (un) **],[**Numeric Identifier 91120**]
Phone: [**Telephone/Fax (1) 7318**]
*Please call office if you cannot make appointment to
reschedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"357.2",
"327.23",
"729.1",
"250.62",
"426.0",
"250.52",
"311",
"428.33",
"725",
"E944.3",
"276.8",
"585.4",
"403.90",
"244.9",
"713.5",
"584.9",
"427.89",
"250.42",
"416.8",
"496",
"530.81",
"428.0",
"362.01",
"285.21",
"V58.67",
"272.4",
"276.1",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13736, 13788
|
5938, 10855
|
304, 311
|
14036, 14036
|
4537, 4537
|
15268, 16893
|
3688, 3839
|
11404, 13713
|
13809, 13809
|
10881, 11381
|
14264, 14786
|
3854, 4518
|
14815, 15245
|
249, 266
|
1996, 2362
|
339, 1978
|
13921, 14015
|
4553, 5915
|
13828, 13900
|
14051, 14240
|
2384, 3130
|
3146, 3672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,987
| 130,374
|
39239
|
Discharge summary
|
report
|
Admission Date: [**2159-2-21**] Discharge Date: [**2159-3-1**]
Date of Birth: [**2099-10-31**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
1. Increased abdominal pain
2. Increase erythema and warmth around ostomy site
Major Surgical or Invasive Procedure:
[**2159-2-22**]:
Exploratory laparotomy, left colon resection, revision the
reciting of colostomy, excisional debridement of the abdominal
wall and VAC placement.
History of Present Illness:
Patient is a 59-year-old female who presents with one week of
spreading erythema and warmth around the ostomy. Her ostomy has
been function. She denies nausea or vomiting. She started to
have increasing pain. The pain became too intense so she came
the emergency department. She has not been checking her
temperature but she had night sweats two nights ago. She noticed
that she was getting dizzy so she check her blood pressure was
low so that was another reason that she came to the emergency
department. She has not had her colostomy reversed previously
because her surgeon did not feel comfortable with all her
medical problems.
Past Medical History:
PMH:
1. Diverticulitis
2. Osteoarthritis
3. Osteoporosis
4. Pulmonary Fibrosis
5. Severe rheumatoid arthritis
.
PSH:
1. Right hip replacement
2. End colostomy for diverticulitis 5 years ago.
3. Hand surgery
Social History:
Lives with her son. She experimented with smoking many years
ago for a year off and on. She used to abuse alcohol for pain
relief but has not had a drink since she started taking pain
medications.
Family History:
Mother had pancreatic cancer
Physical Exam:
PHYSICAL EXAMINATION:
On Admission:
Vital Signs: T 98.5 HR 88 BP 138/82 RR 16 O2 Sat 96
General: No acute Distress
Lungs: Clear to Auscultation bilaterally
Cardiac: Regular rate and rhythm, S1/S2
Abdomen: Soft, nondistended, tender over an diffuse area of
erythema which is warm and fluctuant. The ostomy is pink and not
retracted or prolapsed
Rectal: Normal tone, no gross blood, guaiac negative
On Discharge:
VS: T 97.4, HR 95, BP 144/86, RR 18, O2 Sat 96% RA
General: Calm, cooperative. NAD
CV: RRR, S1/S2, No m/r/g, no carotid bruit
Lungs: CTAb
Abdomen: RUQ ostomy is pink, patent. Midline incision and old
LUQ ostomy sites covered with sponge dressing and VAC drain
attached to suction.
Ext: Normal distal pulses
Neuro: AAOx3, PERRL, Cranial nerves II-XII grossly intact
Pertinent Results:
[**2159-2-21**] 09:46PM GLUCOSE-190* UREA N-26* CREAT-1.3* SODIUM-142
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-18* ANION GAP-16
[**2159-2-21**] 09:46PM WBC-19.7* RBC-3.64* HGB-10.7* HCT-32.2*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.6*
[**2159-2-21**] 09:46PM PLT COUNT-374
[**2159-2-21**] 09:46PM PT-11.2 PTT-17.5* INR(PT)-0.9
[**2159-2-21**] 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-2-24**] 07:45AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.4* Hct-29.0*
MCV-88 MCH-28.4 MCHC-32.2 RDW-15.2 Plt Ct-395
[**2159-2-24**] 07:45AM BLOOD Plt Ct-395
[**2159-2-26**] 07:50AM BLOOD Glucose-75 UreaN-14 Creat-0.9 Na-141
K-4.4 Cl-102 HCO3-29 AnGap-14
[**2159-2-26**] 07:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.3*
[**2159-2-22**] 12:58 am SWAB ABDOMINAL WOUND.
GRAM STAIN (Final [**2159-2-22**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): YEAST(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2159-2-25**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
HAFNIA ALVEI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAFNIA ALVEI
|
AMPICILLIN------------ 16 R
AMPICILLIN/SULBACTAM-- 16 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary):
ANAEROBIC GRAM NEGATIVE ROD(S). MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2159-2-22**], the
patient underwent exploratory laparotomy, left colon resection,
revision the reciting of colostomy, excisional debridement of
the abdominal wall and VAC placement, which went well without
complication (reader referred to the Operative Note for
details). VAC was originally placed on 125 mmHg suction. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor NPO, NG tube to low wall suction, on IV fluids and
antibiotics, with a Foley catheter and a ostomy bag in place,
and Dilaudid PCA for pain control. The patient was
hemodynamically stable.
.
Post-operative pain was initially well controlled with Dilaudid
PCA, which was converted to IV and later to oral pain medication
when tolerating clear liquids. The NG tube was discontinued on
POD# 1, and the patient was started on sips of clears on POD# 1.
Diet was progressively advanced as tolerated to a regular
diabetic diet by POD# 5. The Foley catheter was discontinued at
midnight of POD# 4. The patient subsequently voided without
problem. VAC dressing was changed Q72H during hospital stay, and
wound started to heal nicely. New ostomy site is pink and
patent.
.
During this hospitalization, the patient ambulated early with
assistance, and then independently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient's blood sugar was monitored regularly
throughout the stay; sliding scale insulin was administered when
indicated. Patient blood sugar was elevated secondary to steroid
therapy for rheumatoid arthritis and pulmonary fibrosis. Patient
declined to have insulin teaching during this hospitalization
per patient's nurse. Patient was verbaly instructed to follow
diet recommendations, patient's PCP was [**Name (NI) 653**], and follow up
appointment was scheduled. Patient was instructed about sign and
symptoms of diabetis, and diet recommendations was given.
Patient verbalized understanding. Labwork was routinely
followed; electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Ativan 1 mg PO Daily prn anxiety
2. Prednisone 25 mg PO Daily
3. Fluoxetine 20 mg PO Daily
4. Lisinopril 20 mg PO Daily
5. Trazodone 50 mg PO QHS prn insomnia
6. Oxycodone 15 mg PO Q4-6 hours prn pain
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*0*
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Perforated parastomal hernia.
2. Diverticulitis s/p end colostomy
3. Severe Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
* You will continue to have Sponge VAC dressing in your wounds
which will be changed by VNA service.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 1575**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Date/Time: [**2159-3-15**] 1:45 pm
Location: ASSOCIATES INTERNAL MEDICINE Address: [**State 86842**], [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 13350**]
.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2159-3-14**] 1:45. [**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 86843**],
[**Location (un) 620**], [**Numeric Identifier 3002**].
Completed by:[**2159-3-1**]
|
[
"569.69",
"562.10",
"569.81",
"311",
"569.61",
"515",
"715.90",
"569.83",
"401.9",
"285.9",
"733.00",
"714.0",
"V58.65",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"45.79",
"46.13",
"46.52"
] |
icd9pcs
|
[
[
[]
]
] |
8788, 8851
|
4869, 7455
|
394, 559
|
8995, 8995
|
2530, 4719
|
9899, 10578
|
1685, 1716
|
7710, 8765
|
8872, 8974
|
7481, 7687
|
9143, 9143
|
9773, 9876
|
1731, 1731
|
1753, 1753
|
2144, 2511
|
9176, 9757
|
275, 356
|
587, 1223
|
1767, 2130
|
4758, 4846
|
9010, 9119
|
1245, 1453
|
1469, 1669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,429
| 191,715
|
50954+59300
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-1-6**] Discharge Date: [**2160-1-14**]
Service: CARDIOTHORACIC
Allergies:
Niacin / Hayfever
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
redo sternotomy/AVR [**1-8**]
History of Present Illness:
84 year old male with extensive PMM complaint of progressively
worsening fatigue. Most recent cardiac catherization revealed
[**Location (un) 109**] 1 and echocardiogram with decreased left ventricular
function.
Past Medical History:
HOH
[**12/2152**]: Prostate CA with radiation
Radiation Proctitis with multiple colon cauterizations
GERD
Anemia
Gall Bladder surgery
Hand Surgery
? hernia repair as a child
history of gout
CABG
[**Doctor Last Name 9376**] disease
[**2148**]: s/p TIA/mild CVA- no residual
Elevated homocysteine
NIDDM
Social History:
Retired
Lives with Spouse
[**Name (NI) 105883**] denies
ETOH social
Family History:
brother and sisters with CAD < 55 years old
Physical Exam:
Admission
General: well appearing and no acute distress
Skin: unremarkable
HEENT EOMI PERRLA NCAT
Neck Supple full ROM
Chest CTA bilat
Heart RRR 4/6 SEM
Abd soft ND NT +BS
Ext warm well perfused no edema
Neuro a/o x3 MAE nonfocal
Pertinent Results:
[**2160-1-13**] 06:10AM BLOOD WBC-8.2 RBC-2.89* Hgb-8.8* Hct-25.2*
MCV-87 MCH-30.5 MCHC-34.9 RDW-16.0* Plt Ct-121*
[**2160-1-7**] 11:39AM BLOOD WBC-9.7 RBC-2.12*# Hgb-6.8*# Hct-19.7*#
MCV-93 MCH-31.9 MCHC-34.4 RDW-15.0 Plt Ct-143*
[**2160-1-14**] 08:25AM BLOOD PT-18.3* INR(PT)-1.7*
[**2160-1-13**] 06:10AM BLOOD Plt Ct-121*
[**2160-1-13**] 06:10AM BLOOD PT-17.2* INR(PT)-1.6*
[**2160-1-12**] 07:00AM BLOOD PT-15.0* INR(PT)-1.3*
[**2160-1-7**] 11:39AM BLOOD Plt Ct-143*
[**2160-1-7**] 11:39AM BLOOD PT-15.0* PTT-40.8* INR(PT)-1.3*
[**2160-1-8**] 06:14PM BLOOD Fibrino-291
[**2160-1-13**] 06:10AM BLOOD Glucose-96 UreaN-30* Creat-1.1 Na-143
K-3.8 Cl-105 HCO3-29 AnGap-13
[**2160-1-7**] 01:30PM BLOOD UreaN-17 Creat-0.8 Cl-110* HCO3-24
[**2160-1-13**] 06:10AM BLOOD Mg-1.6
[**2160-1-8**] 06:14PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
CHEST (PORTABLE AP) [**2160-1-11**] 9:13 PM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p AVR
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
CHEST RADIOGRAPH
Comparison with [**2160-1-10**].
Left-sided chest tube has been removed. The left hemidiaphragm
has returned to its normal position. No pneumothorax. Small
atelectasis right. No pulmonary opacities, no signs of cardiac
failure.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2160-1-13**] 11:07 AM
Technically difficult study
Atrial fibrillation
Intraventricular conduction defect - left bundle branch block
type
Late R wave progression
Consider anteroseptal infarct - age undetermined
Since previous tracing of [**2160-1-7**], now irregular rhythm, QRS
wider
Clinical correlation is suggested
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 0 148 400/452 0 -25 139
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105884**]Portable TTE
(Focused views) Done [**2160-1-8**] at 12:38:16 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2075-10-3**]
Age (years): 84 M Hgt (in): 66
BP (mm Hg): 90/50 Wgt (lb): 175
HR (bpm): 80 BSA (m2): 1.89 m2
Indication: Hypotensive s/p 25 mm Mosaic [**Company 1543**] Porcine AVR.
Evaluate for tamponade.
ICD-9 Codes: V42.2, 424.1
Test Information
Date/Time: [**2160-1-8**] at 12:38 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2007W077-0:23 Machine: Vivid [**8-10**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Ascending: *4.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
TR Gradient (+ RA = PASP): *30 mm Hg <= 25 mm Hg
Findings
This study was compared to the report of the prior study (images
not available) of [**2148-12-27**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Mildly depressed
LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Moderately dilated ascending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Borderline
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is difficult to assess but appears mildly
depressed (LVEF= 40 %). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is moderately
dilated. A bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2148-12-27**], a bioprosthetic AVR is now present.
The severity of mitral and tricuspid regurgitation has
decreased, although image quality is technically suboptimal.
Overall left ventricular function appears at least mild to
moderately depressed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2160-1-8**] 14:14
Brief Hospital Course:
Mr [**Name13 (STitle) 97422**] was admitted the evening before surgery. The next
am he was brought to the operating room and underwent a redo
sternotomy and aortic valve replacement. Please see operative
report for further details. He tolerated the procedure well
except for complete heart block with swan ganz insertion, and
was transferred to the CSRU for invasive monitoring. He
required pressors and fluid for blood pressure management and
returned to the operating room on post operative day one for
bleeding and removal of clot. Om post operative day 2 he was
weaned from sedation, awoke neurologically intact, and was
extubated. His platlet count had decreased to 58 and HIT was
sent that was negative. He also went into atrial fibrillation
and was started on beta blockers for rate control, no amiodarone
was given due to heart block intra and post op day 1. Diuretics
were started and he was gently diuresised towards his
preoperative weight. On post operative day three chest tubes
were removed and he was transferred to the post operative floor.
He continued to remain in atrial fibrillation and coumadin was
started for anticoagulation. Physical followed him during
entire post-op course for strength and mobility. His beta
blockers continued to be adjusted for rate control and he was
ready for discharge to rehab on post operative day five.
Medications on Admission:
fish oil 1 gm [**Hospital1 **]
ASA 81 daily
Metformin 500 [**Hospital1 **]
Prilosec 20 [**Hospital1 **]
Glipizide 10 [**Hospital1 **]
Lipitor 40 hs
zetia 10 hs
atenolol 12.5 hs
lisinopril 20 hs
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
restart at d/c per RDT.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
16. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Adjust dose to target INR of [**3-9**].5
please give 2.5mg on [**1-14**] and [**1-15**] and check INR [**1-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Aortic stenosis s/p redo sternotomy/AVR(tissue)
Complete Heart Block
Post operative atrial fibrillation
PMH: Prostate CA s/p radiation/radiation proctitis, GERD,
Anemia, GOUT, Gilberts dz, CVA/TIA, DM2, homocysteinuria,
PSH: CABGx6, CCY, RIH repir, Lft rad aneurysm repair
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 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] after discharge from rehab
Dr [**Last Name (STitle) **] in 4 weeks please call to schedule [**Telephone/Fax (1) 1504**]
Dr [**Last Name (STitle) **] [**Name (STitle) **] after discharge from rehab
Completed by:[**2160-1-14**] Name: [**Known lastname 17250**],[**Known firstname 7121**] Unit No: [**Numeric Identifier 17251**]
Admission Date: [**2160-1-6**] Discharge Date: [**2160-1-14**]
Date of Birth: [**2075-10-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin / Hayfever
Attending:[**First Name3 (LF) 674**]
Addendum:
As evidenced by his echos, Mr. [**Known lastname **] has chronic systolic
CHF.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2160-2-15**]
|
[
"250.00",
"426.6",
"412",
"997.1",
"428.22",
"V45.81",
"274.9",
"530.81",
"998.0",
"427.31",
"428.0",
"V10.46",
"998.11",
"414.01",
"285.9",
"424.1",
"277.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"35.21",
"99.07",
"34.03",
"34.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
11733, 11935
|
6939, 8305
|
238, 270
|
10455, 10462
|
1249, 2199
|
10973, 11710
|
939, 984
|
8549, 10048
|
2236, 2260
|
10158, 10434
|
8331, 8526
|
10486, 10950
|
999, 1230
|
191, 200
|
2289, 6916
|
298, 512
|
534, 837
|
853, 923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,331
| 182,301
|
31059
|
Discharge summary
|
report
|
Admission Date: [**2117-6-22**] Discharge Date: [**2117-7-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
87 year old man with known severe 3-vessel CAD, PVD and CRI
(creatinine 2.0 baseline, now 2.3) presented [**6-20**] to outside
hospital with 10/10 sharp chest pain w/ mild SOB but no other
accompanying symptoms. Cardiac cath performed [**4-5**] for crescendo
angina and pt found to have 100% proximal RCA, 40% LM, 95%
proximal LAD, 80% OM1--no stents were placed and surgery was
deferred for medical management. Echo [**4-5**] showed LVEF 20-30%.
Medical management was unsuccessful and pt had continued
episodes of chest pain. At outside hospital, Troponin I peaked
at 0.72 and he was noted to have R > L pleural effusion on CT.
Patient has had no further chest pain since [**6-20**] and currently
reports 0/10 pain. He was transferred to [**Hospital1 18**] for possible
cardiac cath and stenting on enoxaparin, plavix, aspirin and
outside medications. He will also be reevaluated by cardiac
surgery for possible CABG.
.
On review of systems he denies SOB, chest pain, h/a, cough,
fevers/chills, [**Last Name (un) 103**] pain, diarrhea, burning with urination,
black stools or BRBPR. He sleeps with 2 pillows for help with
dizzyness but denies orthopnea or PND. He has constipation, last
BM this morning. He does report decreased appetite over last
week with ?15-lb weight loss over last week, no nausea or
vomiting.
.
Of note, nurse from outside hospital believes that the patient
underwent a swallowing study during the admission which was
abnormal and he was on thickened liquids and pureed food. Pt
reports some dysphagia with solid foods but which dislodge with
liquids.
Past Medical History:
CAD
hypertension
hyperlipidemia
PVD
prostate cancer 6-7 years ago, unclear treatment, TURP per
outside hospital records
CRI, BL Cr 1.9
COPD (?inhalers)
polymyalgia
diverticulosis
hernia repair
bilateral pleural effusions
psoriasis
Right SFA occlusion by ABIs in [**Month (only) 116**]
Social History:
Quit smoking 50 years ago (30-pack-year hx); married for 61
years and lives iwth wife and daughter
Family History:
not elicited
Physical Exam:
VS: T97.1 BP128/72 HR70 RR20 O295% (?2L)
Gen: elderly gentleman, sense of humor, no apparant distress
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink
Neck: Supple with no visible JVP; soft R carotid bruit
CV: distant heart sounds, irrge rhythm, no audible murmurs
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND
Ext: no edema bilat
.
Pulses:
Right: Carotid 1+ DP 2+
Left: Carotid 1+ DP 2+
Pertinent Results:
LABORATORY DATA:
144 106 31 AGap=19
------------< 103
4.9 24 2.1
CK: 57 MB: Notdone Trop-T: 0.18
Ca: 9.9 Mg: 2.3 P: 4.0
.
8.7 > 39.3 < 229
.
PT: 11.9 PTT: 29.6 INR: 1.0
.
EKG: rate 59, PACx1, sinus rhythm, new ST seg elevation V2-5 and
T-wave upright in V2-4 (prior inversion), Q-waves in septal
leads, no ST seg depressions, nml intervals
.
2D-ECHOCARDIOGRAM [**4-5**]:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Severely depressed LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Focal apical hypokinesis of RV free wall.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimally increased gradient c/w minimal AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR. Prolonged (>250ms) transmitral E-wave decel time. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is severely depressed (ejection fraction 20-30 percent)
secondary to extensive apical akinesis (involving the entire
apical half of the left ventricle) and severe hypokinesis of the
anterior septum and anterior free wall; there is some sparing of
the basal posterior wall. Right ventricular chamber size is
normal. There is focal hypokinesis of the apical free wall of
the right ventricle. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
Impression: severe left ventricular contractile dysfunction
.
CARDIAC CATH performed on [**2117-4-8**] demonstrated:
1. Selective coronary angiography in this right dominant patient
revealed severe three vessel CAD. The RCA was proximally
occluded with distal left to right collaterals. The LMCA had
diffuse calcification with a distal taper of 40%. The LAD was a
very calcified diffusely diseased vessel with a 95% ostial
lesion with heavy calcification that extended into LCX origin.
The LCX was diffusely diseased with a 80% lesion in OM1.
2. Limited resting hemodynamics revealed elevated LVEDP of
26mmHG with systemic blood pressure of 125/55. There was no
gradient across the aortic valve and the rhythm was sinus.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with tight ostial LAD
and
occluded RCA
2. Diastolic dysfunction.
Brief Hospital Course:
87 yo male with EF <20%, CRI, COPD and severe 3-vessel disease
s/p cypher stenting of LMCA and LAD requiring IABP. IABP
removed day 2 post cath with baseline SBP's 88-110. Condition
stable but guarded given severe CHF and difficulty balancing
cardiac function and renal perfusion.
.
#) ACS: ST elevation in anterior leads (change from prior) and
severely stenotic LAD on cath [**2117-4-8**], old Q-waves septal leads.
Surgery did not want to operate during last admission, but
medical management was unsuccessful. Cardiac catheterization and
cypher stenting of LMCA and LAD was performed with placement of
IABP. IABP removed post cath day 2 with overall stable blood
pressures since.
- discharge on ASA 325 daily, Plavix 75 daily, Atorvastatin 80mg
daily
-not on ACEI at this time given poor renal function
-NTG sublingual prn chest pain
.
#) Heart Failure with EF <20%, course complicated by poor
cardiac output and resulting renal hypoperfusion and pulmonary
congestion.
-Started on Carvedilol 6.25mg [**Hospital1 **] which he tolerated well, would
continue at this dose
-not started back on lasix as he has had elevated creatinine due
to renal hypoperfusion. Recommend following daily weights and
dosing lasix gently if weight increasing. Currently euvolemic
or slightly hypovolemic at weight of 60.5kg.
-Encourage po intake, see speech and swallow recommendations
below
-caution with IVF given very poor ejection fraction, pleural
effusions and baseline impaired pulmonary function due to COPD
.
#) CRI:(BL 1.9-2.0) Creatinine 2.4 on discharge which is down
from peak of 2.6 [**2117-7-1**]. Urine electrolytes, FENa and FEUrea
suggest that elevation due to prerenal etiology likely
combination of CHF with poor forward flow and element of volume
depletion.
-have not been giving lasix as likely volume depleted, prerenal
with poor po intake.
-holding ACEI
-please continue to encourage po
.
#) Hyperlipidemia: continue ezetemide 10 and atorvastatin 80 mg
daily
.
#) h/o prostate CA: he has some difficulty with urination
however no retention since removal of foley.
.
#) COPD: no change during admission
- continue ipratropium and albuterol inhalers
- Albuterol Nebs PRN
.
#) dysphagia: pt reports h/o dysphagia for solid foods but able
to wash down with liquids. Speech and swallow evaluated twice
with no witnessed aspirations during either evaluation. Given
multiple nursing reports about concern for aspiration a diet of
nectar thick liquids and puree consistency solids was
recommended.
.
#) FEN: nectar thick liquids and puree consistency solids
recommended
.
#) Code: DNR/DNI
.
#) Contact: wife [**Name2 (NI) **] or daughter [**Name (NI) **] ([**Telephone/Fax (1) 73346**]
.
.
.
Medications on Admission:
ASA 81 daily
Enoxaparin 65mg PO BID
Ezetimide 10mg PO daily
Atorvastatin 10mg PO daily
Isosorbide mononitrate 90mg daily
Lisinopril 2.5 mg daily
Toprol XL 50 mg daily
Finasteride 5 mg daily
Clopidogrel 75 mg daily
Iron 300mg daily
Protonix 40mg daily
NGL SL PRN
Inhalers as outpt (Ipratroprium bromide on last discharge)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 doses: hold for sbp < 100, hr < 55.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
Primary:
Acute Coronary Syndrome, ST-elevation
Heart Failure
Secondary:
Chronic Obstructive Pulmonary Disorder
Hyperlipidemia
Chronic Renal insufficiency (Cr 2.0)
Peripheral vascular disease
history of prostate cancer
Discharge Condition:
Fair
Discharge Instructions:
You were admitted with an acute heart attack. You underwent
cardiac catheterization (pictures of the blood vessels in your
heart were taken).
.
Continue your medications as indicated. Your atovastatin was
increased from 10mg to 80mg daily. We started you on a new
medication called carvedilol; take 6.25mg of carvedilol twice
daily. We stopped the following medications and you should NOT
continue to take them: isosorbide dinatrate, lisinopril, toprol
xl.
.
Please follow-up with your primary care physician and your
cardiologist. Call them to make an appointment 1-2 weeks after
your discharge.
.
If you develop any concerning symptoms such as persistent pain,
bleeding or difficulty breathing, please contact your physician
or go to the emergency department.
Followup Instructions:
You have an appointment with your cardiologist
[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 13254**]
[**2117-8-3**] @ 11:45 AM
|
[
"696.1",
"787.2",
"496",
"729.1",
"V10.46",
"443.9",
"428.0",
"458.9",
"585.9",
"427.89",
"403.90",
"414.01",
"410.71",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"37.61",
"36.06",
"37.23",
"37.78",
"00.41",
"00.46",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10497, 10567
|
6081, 8778
|
273, 298
|
10829, 10836
|
2804, 5934
|
11651, 11816
|
2346, 2360
|
9150, 10474
|
10588, 10808
|
8804, 9127
|
5951, 6058
|
10860, 11628
|
2375, 2785
|
222, 235
|
326, 1905
|
1927, 2214
|
2230, 2330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,771
| 130,895
|
46734+58940
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-4-23**] Discharge Date: [**2173-5-14**]
Date of Birth: [**2112-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
MSSA endocarditis, nafcillin desensitization
Major Surgical or Invasive Procedure:
Pars plana vitrectomy [**2173-5-10**]
Intravitreal antibiotic injection, [**2173-5-7**] & [**2173-5-10**]
Transesophageal echocardiogram, [**2173-4-24**] & [**2173-4-29**]
History of Present Illness:
60F w/ ESRD on HD, DM she was transferred from OSH ICU for
further management of endocarditis and MSSA bacteremia. Very
limited historian and most of history obtained from OSH records.
She was at HD when developed T 101.4 which grew 4/4 bottles
MSSA. She was intiially at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] and was started on
Vanc/Gent and TTE revealed thickened mitral valve with
vegetation. She then became hypotensive to 70/50 requiring a low
dose levophed and was transferred to [**Hospital1 2177**] ICU on [**4-22**].
.
At [**Hospital1 2177**] ICU, she was desensitized to PCN and started on
nafcillin. ID consult recommended against continuing gent. She
had some loose stools, was empirically started on flagyl, but
then C. dif neg X 1 and flagyl stopped. U/S of AVF negative for
abscess; however, renal felt that if she peristantly spiked
temps, then she should have tagged WBC scan to rule out AVF
infection.
.
Upon arrival to [**Hospital1 18**], she has no complaints, answering only
yes/no answers. She denies pain, SOB, palpitations, fever,
chills, N/V, diarrhea.
Past Medical History:
ESRD on HD T/Th/Sat
CAD s/p IMI
DM2
HTN
hyperlipidemia
s/p CCY
Social History:
-Lives at home, independently
-never smoked
-no EtOH
-no drug use
Family History:
father with prostate CA
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: afebrile, SBP 90-100s
GENERAL: very flat affect, NAD
HEENT: Normocephalic, atraumatic. MM dry. OP clear.
CARDIAC: reg rate nl S1S2 II/VI holosystolic murmur at apex
LUNGS: CTAB
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain
SKIN: no splinters, oslers
NEURO: oriented to being in a hospital and name. Does not know
date. Decreased LE strength, right>left
PSYCH: Listens and follows only simple commands, but answers
mainly only yes or no; stares off blankly
Pertinent Results:
OSH Micro: 4/4 bottles MSSA
.
Blood Cx negative [**Date range (1) 99198**]
.
[**2173-5-11**] 6:55 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2173-5-12**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2173-5-12**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) **] @ 5:30A [**2173-5-12**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
.
RPR non-reactive [**4-26**]
.
OSH ECHO: LVEF 45%, MV thickened with [**Month/Day (4) 61539**] densities which
prolapse into LA. 2+ MR, trace AR and thickening of leaflets. PI
present. 3+ TR, PA pressure 51; RA pressure 15
.
Cardiology Report ECG Study Date of [**2173-4-23**] 9:59:44 PM
Sinus rhythm. Left axis deviation. Inferior wall myocardial
infarction probably
old. Poor R wave progression - cannot rule out old anteroseptal
myocardial
infarction. Compared to the previous tracing of [**2169-8-26**] there is
no significant
diagnostic change.
.
TEE [**2173-4-24**]
No atrial septal defect is seen by 2D or color Doppler. There is
mild global left ventricular hypokinesis (LVEF = 45-50 %). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic valve abscess is seen. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is a large vegetation with calcifications on
the mitral valve (1.7cm in length) extending from the anterior
mitral annulus. No mitral valve abscess is seen. Moderate (2+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Large mitral valve vegetation consistent with
endocarditis. Moderate mitral regurgitation is present. No
abscess was apparent.
CT with contrast of head [**2173-4-25**]
IMPRESSION:
1. No acute intracranial process; specifically, no evidence of
abscess or
enhancing mass.
2. Ill-defined low-attenuation in right more than left
periventricular white matter, likely representing chronic
microvascular infarction.
3. No pathologic focus of enhancement.
CT with contrast of torso [**2173-4-27**]
IMPRESSION:
1. Slowly progressive patchy and nodular consolidations
predominating in the right upper lobe most likely represent an
indolent granulomatous process, possibly sarcoidosis though
granulomatous infection/bronchiolitis are other diagnostic
considerations.
2. Prominent retroperitoneal and pelvic lymph nodes, more
prominent compared to [**2164-1-24**] but of unclear etiology.
3. Massive right hydronephrosis and cortical thinning likely
secondary to
chronic right UPJ obstruction.
4. Findings raising the question of chronic pancreatitis.
5. Anasarca with bilateral small effusions and small ascites.
Doppler LE [**2173-4-28**]
IMPRESSION: No evidence of DVT in the bilateral lower legs.
___________________________________
MRA/MRI of brain [**2173-4-28**]
IMPRESSION: Multiple infra- and supratentorial foci of
restricted diffusion as described in detail above likely
consistent with thromboembolic ischemic events.
MRA OF THE HEAD: There is evidence of vascular flow in both
internal
carotids, the left vertebral artery is patent and also the
basilar artery, the right vertebral artery is not completely
visualized and possibly ends in PICA, however occlusion
secondary to arteriosclerosis cannot be completely excluded,
diffuse lack of signal is visualized in the distal branches also
possibly representing atherosclerotic disease, this is a limited
examination secondary to motion artifacts, therefore the distal
branches of the circle of [**Location (un) 431**] are not completely evaluated.
_______________________________________
TEE on [**2173-4-29**]
No thrombus is seen in the left atrial appendage. There is
moderate regional left ventricular systolic dysfunction with
inferior and inferolateral hypokinesis. Overall left ventricular
systolic function is moderately depressed (LVEF= 35-40 %). There
are complex (>4mm) atheroma in the aortic arch and descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are moderately thickened. There are 2 large vegetations
(1.7cm and 1.4 cm in lengths) and a third smaller vegetation
(0.3 cm) arising from the base of the anterior mitral valve
leaflet. Also seen is a possible small vegetation associated
with the right cusp of the aortic valve. Moderate (2+) mitral
regurgitation is seen. Due to acoustic shadowing, this study was
not adequate to exclude an abscess. There is a small pericardial
effusion. No definite abscess seen, but cannot be excluded with
certainty.
Compared with the findings of the prior study (images reviewed)
of [**2173-4-24**], the mitral valve vegetations appear larger and
left ventricular contractile function is more depressed along
with inferolateral hypokinesis.
IMPRESSION: Large vegetations consistent with endocarditis of
the mitral valve. This study was not able to exclude the
presence of an abscess.
____________________________________________
Tagged WBC scan [**2173-4-30**]
IMPRESSION:
Normal white blood cell study. No abnormal tracer uptake.
___________________________________________
CT abd/pelvis without contrast [**2173-4-30**]
IMPRESSION:
1. Massive right hydronephrosis and cortical thinning consistent
with a
classic longstanding ureteropelvic junction obstruction dating
back to at
least [**2163**].
2. Pelvic nodes are unchanged.
3. Possible chronic pancreatitis.
4. Anasarca with unchanged effusions.
___________________________________________
MR HEAD W/O CONTRAST [**2173-5-7**]
FINDINGS: Again multiple areas of slow diffusion are identified
in the white matter in the periventricular region including
involvement of the corpus callosum. The areas are seen in both
frontoparietal lobes as well as in the temporal lobe. Small
focus of signal abnormalities seen in the right cerebellum and
also in the left side of the brain stem. Overall the foci have
evolved since the previous study and no definite new
abnormalities are seen. There is no midline shift noted. Mild
brain atrophy identified.
IMPRESSION:
Evolution of previously noted acute subcortical infarcts in the
supra and
infratentorial regions. No new signal abnormalities are seen.
.
EEG [**2173-5-9**]
IMPRESSION: This is an abnormal routine EEG recording in the
awake and
sleeping states due to the slow background suggestive of a mild
encephalopathy. Metabolic disturbances, medications, and
infections are
among the most common causes. There were no lateralized or
epileptiform
features seen.
.
Brief Hospital Course:
#Methicillin-senstive staph aureus mitral valve endocarditis -
OSH blood cultures showed high-grade MSSA bacteremia and echo
demonstrated mitral thickening with 2+ MR [**First Name (Titles) **] [**Last Name (Titles) 61539**] densities
prolapsing into the left atrium LA. Ultrasound and tagged WBC
scan did not reveal a source of infection in the LUE AV graft.
She was had transient hypotension requiring levophed prior to
transfer. She was desensitized to nafcillin in the ICU. TEE
[**2173-4-24**] showed a 1.7 cm mitral valve vegetation, moderate MR but
no apparent abscess. Repeat TEE [**2173-4-29**] showed 3 vegetations (1.7
cm,1.4 cm,0.3 cm) on the mitral valve but could not definitively
exclude an abscess. Nafcillin was changed to vancomycin on
[**2173-5-1**] out of concern for drug fever. Daily surveillance blood
cultures remained negative. Daily EKGs and telemetry monitoring
did not show any evidence of conduction abnormality. The patient
expressed an unequivocal desire to forego valve replacement
surgery. Her family agreed. Given their preferences, as well as
high operative morbidity, that the patient defervesced on
antibiotic therapy, and that a repeat MRI did not show further
evidence of cerebral septic emboli, the medical team agreed to
continue with 6 weeks of antibiotic therapy (through [**2173-6-4**]).
She underwent repeat nafcillin desensitization on [**2173-5-12**] in the
MICU without complication. She may benefit from surveillance
cultures and repeat TEE at the conclusion of her antibiotic
course. She will follow-up with her PCP and ID as an outpatient.
.
#Endogenous staph aureus endophthalmitis, right eye - The
patient was evaluated by ophthalmology for right eye visual
complaints. She was found to have evidence of endophthalmitis on
exam and was treated immediately with intravitreal vancomycin
and then with PPV on [**2173-5-10**]. She will follow-up with
ophthalmology as an outpatient.
.
#Cerebral septic thromboembolic disease - MRI of the brain on
[**2173-4-28**] showed multiple infra- and supratentorial foci of
restricted diffusion consistent with thromboembolic ischemic
events. There were no focal neurological findings on
examination. Repeat MR on [**2173-5-7**] showed evolution of these
previously noted acute subcortical infarcts but no new signal
abnormalities. EEG showed mild non-specific encephalopathy. She
will follow-up with neurology as an outpatient.
.
#Clostridium difficile colitis - Started on flagyl [**2173-5-12**] to be
continued for 1 week beyond the course of nafcillin ([**2173-6-11**]).
Maintained on contact precautions.
.
#End-stage renal disease on hemodialysis - Continued HD Tu/Th/Sa
with vancomycin given per HD protocol.
.
#Diabetes mellitus type II - Well-controlled on an insulin
sliding scale.
.
#Hypertension - Well-controlled on reduced dose of metoprolol
12.5 mg [**Hospital1 **] which was started when the patient was
hemodynamically stable. Therefore, amlodipine and benicar were
discontinued.
.
#Transaminitis - ALT 77 AST 123 on [**5-13**]. Patient did not have
fever, nausea, abdominal pain or tenderness. Therefore, planned
to monitor expectantly and repeat LFT's [**5-17**].
Medications on Admission:
HOME MEDICATIONS:
Pantoprazole 40 daily
calcium acetate 1337 TID
amliodipine 10 daily
metoprolol 25 [**Hospital1 **]
Benicar 40 daily
ASA 81
.
MEDICATIONS on TRANSFER:
nafcillin IV Q4H
PPI
calcium acetate
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Insulin Lispro 100 unit/mL Solution Sig: One (1) inj
Subcutaneous ASDIR (AS DIRECTED): per attached sliding scale.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp<100, hr<55.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: please give if no BM in 2 days.
8. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
QID (4 times a day).
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. Ondansetron 8 mg IV Q8H:PRN nausea
11. Nafcillin 2 g IV Q4H
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection
injection Injection TID (3 times a day).
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**]
Drops Ophthalmic PRN (as needed) as needed for irritation.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): please administer AFTER hemodialysis on
tuesday/thursday/saturday
last dose [**2173-6-11**].
16. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q1H (every hour).
17. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
18. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
QHS (once a day (at bedtime)).
19. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic QID
(4 times a day).
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Primary
1) Methicillin-senstive staph aureus mitral valve endocarditis
2) Endogenous staph aureus endophthalmitis, right eye
3) Cerebral septic thromboembolic disease
4) Clostridium difficile colitis
Secondary
1) End-stage renal disease on hemodialysis
2) Diabetes mellitus type II
3) Hypertension
Discharge Condition:
Clinically improved with stable vital signs.
Discharge Instructions:
You were admitted to the [**Hospital1 **] with endocarditis, an
infection on one of the heart valves. Your infection caused
damage to your right eye, as well as small strokes in the brain.
Your infection was partially treated with antibiotics. You will
need to complete a total of 6 weeks of antibiotics (through
[**2173-6-4**]).
The following medication changes were recommended:
1) Nafcillin 2 grams every 4 hours through [**Last Name (LF) 2974**], [**6-4**].
2) Metoprolol was decreased to 12.5 mg twice daily.
4) Eye drops were started after your right eye surgery.
5) Amlodipine was discontinued.
6) Benicar was discontinued.
7) Calcium acetate was discontinued.
Please attend all of your follow-up appointments.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, passing out, chest pain, palpitations, cough,
wheezing, shortness of breath, abdominal pain, back pain, leg
swelling, rash, vision changes, numbness, weakness, tingling, or
other worrisome symptoms.
Followup Instructions:
Please follow-up with at the [**Hospital3 **] Clinic on Wednesday,
[**5-19**] at 9:30 AM. Please call [**Telephone/Fax (1) 253**] if you wish to
reschedule.
Please follow up with the [**Hospital1 18**] Department of Infectious
Diseases on at Thursday, [**5-27**] at 9 AM. Please call ([**Telephone/Fax (1) 10**] if you wish to reschedule.
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 9347**]
for an appointment at your earliest convenience.
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2173-6-7**] 1:50
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2173-6-9**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2173-10-8**] 11:40
Completed by:[**2173-5-14**] Name: [**Known lastname **],[**Known firstname 6532**] Unit No: [**Numeric Identifier 15886**]
Admission Date: [**2173-4-23**] Discharge Date: [**2173-5-14**]
Date of Birth: [**2112-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 211**]
Addendum:
Nafcillin to be substituted with oxacillin 2 grams IV q4h
through [**2173-6-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] [**Hospital **] Hospital
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2173-5-14**]
|
[
"038.11",
"250.00",
"591",
"421.0",
"041.11",
"585.6",
"360.00",
"995.91",
"434.11",
"008.45",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"14.73",
"39.95",
"96.6",
"14.75",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
18102, 18328
|
9487, 12659
|
316, 490
|
15451, 15498
|
2383, 5875
|
16600, 18079
|
1812, 1837
|
12914, 15055
|
15129, 15430
|
12685, 12685
|
15522, 16577
|
1852, 2364
|
12703, 12828
|
232, 278
|
518, 1626
|
5892, 9464
|
12853, 12891
|
1648, 1712
|
1728, 1796
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,099
| 174,161
|
45002
|
Discharge summary
|
report
|
Admission Date: [**2168-5-16**] Discharge Date: [**2168-5-25**]
Service: MEDICINE
Allergies:
Vicodin / Darvocet-N 100 / Morphine / Lactose / anti-histamines
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
direct admit for percutaneous arotic valve placement
Major Surgical or Invasive Procedure:
Aortice CoreValve placement
History of Present Illness:
Mrs. [**Known lastname **] is an active [**Age over 90 **] year old woman with a history of
hypertension, hyperlipidemia, previous breast ca and critical
aortic stenosis. She hadsignificant improvement in symptoms
following aortic balloonvalvuloplasty [**1-14**], but has had gradual
progression in symptoms overthe last 2-3 months and is currently
NYHA class [**3-10**] symptoms. She is deemed to be extreme risk for
AVR so is enrolled in the [**Company 1543**] CoreValve protocol for
percutaneous valve placement.
.
She states she has no SOB at rest or during sleep, sleeps with 2
pillows. She is able to ambulate around her home without sig SOB
but gets DOE with 1 flight of stairs and walking more than about
20 feet. SOB resolves with rest. Denies cough, sputum
production, fevers, chills or signs of infection. No recent leg
pain or redness, swelling, or symptoms of claudication.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope. She has a history of falls
but describes these as mechanical only.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
1. Severe Aortic stenosis s/p valvuloplasty x2
2. Dyslipidemia
3. Hypertension
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Past Medical History:
4. Breast CA (left partial mastectomy, on Arimidex) [**2164**]
5. Lactose intolerance
6. Severe osteoporosis
7. Cervical arthritis
8. Carpal tunnel syndrome
9. Blind right eye- R eye prosthesis
10. Cataract in left eye
11. Colon CA s/p bowel resection
12. GERD
13. Multiple falls
Past Surgical History:
- Aortic Valvuloplasty x2. last [**1-14**]
- Left breast partial mastectomy [**2164**]
- Right intertrochanteric hip fracture s/p Open reduction,
internal fixation with DHS construct. [**2162-12-24**]
- Right open carpal tunnel release [**9-8**]
- Left total knee replacement [**2152**]
- Bilateral cataract surgery
- Wide excision of lesion of left lower leg. (non-malignant)
- Partial colectomy for a malignant polyp in [**2134**]
Social History:
Her son is Dr. [**First Name8 (NamePattern2) **] [**Known lastname **], a [**Hospital1 18**] cardiologist.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Independent with ADL's, lives alone.
She is active for her age. She enjoys bridge, [**Location (un) 1131**] and
socializing with her friends
Family History:
father died of MI at 65
Physical Exam:
GENERAL: elderly lady in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. right eye is prosthesis, left
pupil sluggish. Left eye with EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 4/6 systolic murmur radiating to bilat
carotids. No thrills, lifts. No S3 or S4.
LUNGS: Pos kyphosis. Resp were unlabored, no accessory muscle
use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Feet warm
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 1+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 2+ PT 2+
.
Day of discharge:
Right groin with quarter sized hematoma at puncture site, no
ecchymosis or tenderness, no erythema. Positive bruit.
Left groin with mild ecchymosis, no tenderness or hematoma.
CV: RRR, 1/6 systolic murmur at LUSB, no radiation
RESP: crackles left base, clears with cough, no wheezes
ABD: soft, NT
Extremeties: no edema
Pertinent Results:
I. Labs
A. Admission
[**2168-5-17**] 07:30AM BLOOD WBC-4.2 RBC-3.61* Hgb-11.5* Hct-32.7*
MCV-91 MCH-31.8 MCHC-35.2* RDW-13.6 Plt Ct-181
[**2168-5-16**] 11:15AM BLOOD PT-13.0 PTT-29.4 INR(PT)-1.1
[**2168-5-17**] 11:39AM BLOOD Fibrino-326
[**2168-5-16**] 11:15AM BLOOD Glucose-100 UreaN-34* Creat-0.8 Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2168-5-16**] 11:15AM BLOOD ALT-17 AST-23 CK(CPK)-91 AlkPhos-79
TotBili-0.4
[**2168-5-16**] 11:15AM BLOOD Albumin-3.9
[**2168-5-16**] 11:15AM BLOOD %HbA1c-5.7 eAG-117
[**2168-5-19**] 05:19AM BLOOD TSH-2.0
B. Discharge
[**2168-5-25**] 06:15AM BLOOD WBC-5.0 RBC-3.32* Hgb-10.6* Hct-30.5*
MCV-92 MCH-32.0 MCHC-34.9 RDW-13.4 Plt Ct-175
[**2168-5-25**] 06:15AM BLOOD Plt Ct-175
[**2168-5-25**] 06:15AM BLOOD Glucose-85 UreaN-28* Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-30 AnGap-8
C. Urine
[**2168-5-24**] 10:29PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2168-5-24**] 10:29PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2168-5-24**] 10:29PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
II. Microbiology
[**2168-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2168-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2168-5-24**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-17**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen NOT PROCESSED
INPATIENT
[**2168-5-16**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen NOT PROCESSED
INPATIENT
[**2168-5-16**] URINE URINE CULTURE-FINAL INPATIENT
[**2168-5-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
III. Cardiology
A. Admission ECG
Cardiology Report ECG Study Date of [**2168-5-16**] 3:05:26 PM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with
ST-T wave changes. Since the previous tracing of [**2168-1-19**]
precordial lead
QRS voltage is less prominent.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 192 88 [**Telephone/Fax (2) 96201**]8
B. ECHO ([**2168-5-17**])
Pre valve deployment
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. Moderate to severe spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). with normal RV free wall
contractility. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is mild valvular mitral stenosis
(area 1.5-2.0cm2). Mild to moderate ([**2-7**]+) mitral regurgitation
is seen. Drs [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**] were notified in person of
the results on [**2168-5-17**] at 930 am.
Post valve deployment
Stented aortic valve seen extending from the LVOT into the
proximal aorta. Trace to mild central aortic insufficiency
present. The peak gradient across the aortic valve is 17 mm Hg
and the mean gradient is 9 mm Hg. Mild mitral insufficiency
seen. Drs [**Last Name (STitle) 914**], [**Name5 (PTitle) **] and [**Name5 (PTitle) **] were notified of the post
deployment findings.
C. C. Cath: final report pending
D. Post-core valve ECHO
The left atrium is normal in size. The left atrium is elongated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). There is a
mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. An
aortic CoreValve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace to mild aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
There is severe mitral annular calcification. There is mild
functional mitral stenosis (mean gradient 6 mmHg) due to mitral
annular calcification. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normally-functioning CoreValve aortic valve
prosthesis. Trace to mild central jet of aortic regurgitation.
Mild symmetric left ventricular hypertrophy with normal global
and regional biventricular systolic function.
IV. Radiology
A. Pre-op CXR
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: 89-year-old female with severe aortic
stenosis, preop
for percutaneous aortic valve replacement.
COMPARISON: [**2165-1-1**], reference also made to the scout from
cardiac CT and
coronary CTA from [**2168-4-7**].
FINDINGS: Frontal and lateral views of the chest are obtained.
Prominent
right hilum is without significant change from the scout view
from [**2168-4-7**],
and likely represents prominent confluence of vessels. No focal
consolidation, pleural effusion, or pneumothorax is seen. The
cardiac
silhouette remains borderline to mildly enlarged and the
thoracic aorta
tortuous. Degenerative changes are seen along the spine.
IMPRESSION:
1. Unchanged prominence of the right hilum, most likely
reflecting vascular
structures.
2. No acute cardiopulmonary process.
### Pending studies: Blood culture x 2 ([**2168-5-24**] and [**2168-5-25**])
Brief Hospital Course:
[**Age over 90 **]-year-old female with critical AS but decent functional
capacity admitted electively for percutaneous aortic valve
replacement.
.
# Critical AS: Patient admitted for corevalve placement that was
successful. She maintained adequate hemodynamics and remained in
normal sinus rhythm without complications at groin site except a
small hematoma as documented on discharge exam. Post-op she was
found to have wide pulse pressure (>100). A CXR at the time
revealed "CoreValve device overlying the LV outflow tract and
proximal aortic root, tip of the internal pacemaker at the level
of the RV, no pneumothorax, pulmonary edema or pleural
effusions". She was extubated on [**5-17**] without difficulty.
Except for an episode of Afib, she did not experience SOB or
lightheadedness or palpitations at rest. She was quickly able to
ambulate on the floor of the ICU without SOB or lightheadedness.
She was transferred to the floor and continued to work with PT.
Telemetry showed a brief episode of 2:1 Wenkebach for which she
remained in the hospital for further observation with no further
subsequent episodes. She was discharged with a KOH monitor.
# HTN: At home, she takes very small [**Month/Year (2) 4319**] of ACEi and BB. She
had significant hypertension post-op and was placed on nitro gtt
which was stopped on [**5-18**] during an episode of afib with
hypotension. After converting to sinus she was treated with
escalating [**Month/Year (2) 4319**] of enalapril and her Metoprolol was stopped.
Given SBP in the 170s-180s, her enalapril was uptitrated to 12.5
mg PO BID with SBP in the 150s on discharge.
# Fever
Patient had a low-grade fever of 100 the day prior to discharge.
A urinalysis was bland, and blood culture was drawn. There were
no focal signs or symptoms of infection except a sore throat.
Her vital signs were stable, and she was afebrile on discharge.
She wanted to leave the hospital, so she was told to report back
to the hospital should she have further fevers.
# RHYTHM: In NSR until [**5-18**] when she developed an episode of
afib in the setting of diuresis. She was hypotensive to the SBP
70s. She was treated with Amiodarone 150mg IV bolus X2 resulting
in conversion to sinus rhythm with the second dose. She was
started on an Amio gtt which was changed to Amiodarone PO. She
was discharged on amiodarone 200 mg PO qD.
# Hyperlipidemia: No recent lipid numbers available, she was
continued on her statin.
# Pump. Preserved EF. DOE and orthopnea thought [**3-9**] tight AS vs
CHF. Has been stable on low dose furosemide. States she follows
low Na diet at home and prepares many meals. She was kept on
strict daily weights and I/Os. She was diuresed for UOP >100
until [**5-18**].
She was continued on clopidogrel, enalapril, atorvastatin,
furosemide, and aspirin 81. Her metoprolol was discontinued.
# Hx of left breast CA, s/p partial mastectomy [**2164**]. Not an
active issue
She was continued on arimidex.
# Transitions of care
- outpatient safety labs for potassium given increased ACEi
dosage
- outpatient follow-up with cardiology and PCP
[**Name Initial (PRE) **] monitoring with KOH given episode of Wenkebach during
hospitalization
Medications on Admission:
Alendronate 70 mgs once weekly
Anastrazole 1 mgs daily
Lipitor 10 mgs qhs
Enalapril 2.5 mgs, 0.5 tabs [**Hospital1 **], 0.25 tab at night prn for high
BP
Furosemide 10 mgs daily
Metoprolol 12.5 mgs daily, 18.75 mg at night
Acetaminophen 325 mgs [**Hospital1 **] prn
Ascorbic acid 500 mgs daily
Calcium citrate-Vit D3 315mgs-200 unit tablet 2 tabs [**Hospital1 **]
Multivitamin 1 tab daily.
Glucosamine chondroiten DS 1 tab [**Hospital1 **]
Preservision one tab [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please check chemistry 10 panel within 10 days of discharge
Fax results to PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Address: [**Location (un) **],[**Apartment Address(1) 77889**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1713**]
Fax: [**Telephone/Fax (1) 96202**]
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*12*
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. enalapril maleate 5 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for pain.
11. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: Two
(2) Tablet PO twice a day.
12. PreserVision 7,160-113-100 unit-mg-unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Glucosamine Chondroitin MaxStr Oral
16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Aortic Stenosis s/p CoreValve Placement
Hypertension
Secondary Diagnosis:
Breast cancer
Dyslipidemia
osteoprosis
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 had a CoreValve aortic valve replacement to repair severe
aortic stenosis. Subsequent echocardiograms show the valve is
well placed and functioning as expected. You transiently had a
type of heart block, a problem with the electrical system of the
heart which is gone now. You also developed atrial fibrillation
transiently which is also now gone. We want you to wear a "[**Doctor Last Name **]
of Hearts" monitor and send telephone transmissions twice daily
to monitor for any further arrhythmias. Your blood pressure was
high after the CoreValve placement so we increased your
Enalapril to lower your blood pressure. Please refer to the
attached Discharge insruction after aortic valve implantation
for activiy and follow up instructions. Please weight yourself
every day in the morning, call Dr. [**Last Name (STitle) **] if weight increases
more than 3 pounds in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start taking [**Last Name (STitle) **] every day for at least 3 months and
possibly longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking [**Last Name (Titles) **]
unless Dr. [**Last Name (STitle) **] or [**Doctor Last Name **] tells you it is OK.
2. Increase your Enalapril to 12.5 mg twice daily to control
your high blood pressure.
3. Start taking Amiodarone to prevent the atrial fibrillation
from returning.
4. Stop taking Metoprolol as the amiodarone will slow your heart
rate as well.
5. Start taking aspirin 81 mg (baby dose) to work with the
[**Name (NI) **] to prevent blood clots.
6. Start taking Fluticasone nasal spray to prevent post nasal
drip. You can stop taking this when your sore throat and cough
improves.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2168-8-4**] at 10:00 AM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2168-8-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. [**Telephone/Fax (1) 4586**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2168-8-30**] at 12:50 PM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Location (un) **],[**Apartment Address(1) 77889**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1713**]
Appointment: Monday [**6-20**] at 11AM
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: FRIDAY [**2168-6-10**] at 1 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Campus: WEST Best Parking: [**Hospital Ward Name **] garage
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-17**] at 11:00 AM and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 12:00
noon
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"458.29",
"998.12",
"401.9",
"V10.05",
"272.4",
"354.0",
"530.81",
"733.00",
"V10.3",
"428.0",
"V45.78",
"427.89",
"780.62",
"428.22",
"424.1",
"366.9",
"721.0",
"427.31",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.64",
"35.96",
"37.23",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
15752, 15810
|
10406, 13597
|
323, 353
|
15986, 15986
|
4465, 10383
|
17915, 20236
|
3240, 3265
|
14125, 15729
|
15831, 15831
|
13623, 14102
|
16169, 17892
|
2465, 2899
|
3280, 4446
|
1954, 2107
|
231, 285
|
381, 1846
|
15924, 15965
|
15850, 15903
|
16001, 16145
|
2138, 2138
|
2160, 2441
|
2915, 3224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,228
| 128,013
|
40579
|
Discharge summary
|
report
|
Admission Date: [**2121-7-22**] Discharge Date: [**2121-7-27**]
Date of Birth: [**2063-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2121-7-22**]
Coronary Artery Bypass (Left Internal Mammary Artery to Left
Anterior Descending, saphenous vein graft to obtuse marginal 1,
saphenous vein graft to obtuse marginal 2)
History of Present Illness:
58 year old male that underwent cardiac catheterization in [**2112**]
at [**Hospital3 **] after presenting with shortness of breath. He
was found to had coronary artery disease and was treated
medically. He has continued with shortness of breath but
progressive worsening and mentioned it to is primary care
physician that sent [**Name9 (PRE) **] for stress test that was positive.
Additionally he reports progressive dyspnea with minimal
exertion and unable to climb a flight of stairs without stopping
and resting. He underwent cardiac catheterization today and is
referred for surgical evaluation.
Past Medical History:
Coronary Artery Disease s/p Inferior wall myocardial infarction
[**2112**]
Asthma
Chronic renal insufficiency
spinal stenosis
Hypertension
Hypercholesterolemia
Chronic obstructive pulmonary disease
Chronic systolic heart failure
Basal Cell Carcinoma
Past Surgical History
cervical - spine tips removed
Social History:
Lives with: Spouse
Contact: Wife [**Name (NI) 88820**] Phone # [**Telephone/Fax (1) 88821**]
Occupation: Works in parts department at [**Last Name (un) **] dealer
Cigarettes: Smoked no [] yes [x] last cigarette quit [**2109**] Hx: 51
pack year history
ETOH: < 1 drink/week [x] [**2-24**] drinks/week [] >8 drinks/week []
Illicit drug use: denies
Family History:
mother MI at 64 sudden death
Physical Exam:
Pulse: 61 Resp: 20 O2 sat: 97%
B/P Left: 97/50
Height: 5'4" Weight: 175#
Five Meter Walk Test unable - in cath lab on bed rest
General: No acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anteriorly
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 none
Varicosities: None [x]
Neuro: Alert and oriented x3 non focal unable to assess gait
Pulses:
Femoral Right: angioseal Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2121-7-22**] Echo: PRE-CPB: 1. The left atrium is normal in size. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No spontaneous echo contrast is seen
in the left atrial appendage. No thrombus is seen in the left
atrial appendage. 2. No atrial septal defect is seen by 2D or
color Doppler. 3. Left ventricular wall thicknesses are normal.
The left ventricular cavity is mildly dilated. 4. Right
ventricular chamber size and free wall motion are normal. 5. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. 6. There are three aortic valve leaflets. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. 7. Mild (1+)
mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results.
POST-CPB: On infusion of phenylephrine. AV pacing. Preserved
biventricular systolic function. Aortic contour is normal post
decannulation. I certify that I was present for this procedure
in compliance with HCFA regulations.
[**2121-7-27**] 01:10PM BLOOD WBC-4.6 RBC-3.89* Hgb-11.8* Hct-35.2*
MCV-90 MCH-30.4 MCHC-33.6 RDW-13.1 Plt Ct-165
[**2121-7-25**] 05:43AM BLOOD WBC-5.5 RBC-3.57* Hgb-11.3* Hct-33.1*
MCV-93 MCH-31.7 MCHC-34.2 RDW-13.4 Plt Ct-115*
[**2121-7-27**] 01:10PM BLOOD Glucose-115* UreaN-27* Creat-1.2 Na-137
K-5.0 Cl-95* HCO3-32 AnGap-15
[**2121-7-25**] 05:43AM BLOOD Glucose-128* UreaN-20 Creat-1.2 Na-137
K-5.1 Cl-100 HCO3-32 AnGap-10
[**2121-7-27**] 01:10PM BLOOD Mg-2.5
[**2121-7-25**] 05:43AM BLOOD Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 39151**] was a same day admit after undergoing pre-op work-up
prior to surgery. On [**7-22**] he was brought to the operating room
where he underwent a coronary artery bypass graft x 3. Please
see operative report for surgical details. Following surgery he
was transferred to the CVICU for invasive monitoring in stable
condition. He initially required Epinephrine, Levophed and
volume for hypotension. These medications were weaned off on
post-op day one. Within 24 hours he was weaned from sedation,
awoke neurologically intact and extubated. Beta-blockers and
diuretics were eventually started and he was diuresed towards
his pre-op weight. Chest tubes and epicardial pacing wires were
removed per protocol. On post-op day two he was transferred to
the step-down floor for further care. He did require reinsertion
of Foley catheter due to incomplete voiding. Flomax was started
and the patient voided successfully following removal of
catheter. He developed a right arm phlebitis and was given warm
packs. WBC remained normal. Phlebitis resolved. He continued to
slowly recover and work with physical therapy for strength and
mobility. On post-op day five he appeared to be doing well and
was discharged to home with VNA services. All the appropriate
medications and appointments were given.
Medications on Admission:
Plavix 75 mg daily
Lisinopril 5 mg daily
Niacin ER 1000 mg daily
Aspirin 325 mg daily
Albuterol Nebs TID prn SOB/Wheezing
Advair diskus 500/50 1 puff [**Hospital1 **]
Combivent 1 puff twice a day and prn
Cialis 20 mg as needed
Theophylline ER 400 mg HS
Spiriva 18 mcg 1 capsule inhaled daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
Disp:*60 Capsule, Extended Release(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. theophylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Disp:*30 * Refills:*2*
10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
11. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID () for 5 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, s/p Coronary Artery Bypass Graft x 3
PMH:
Inferior wall myocardial infarction [**2112**]
Asthma
Chronic renal insufficiency
Spinal stenosis
Hypertension
Hypercholesterolemia
Chronic obstructive pulmonary disease
Chronic systolic heart failure
Basal Cell Carcinoma
Past Surgical History
cervical - spine tips removed
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2121-7-30**]
10:30
Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2121-8-14**] 1:00
Cardiologist Dr.[**Last Name (STitle) 7526**] [**8-19**] at 9:30am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 21640**] in [**4-22**] 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:[**2121-7-27**]
|
[
"724.00",
"493.20",
"403.90",
"428.22",
"272.0",
"414.01",
"412",
"428.0",
"585.9",
"451.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
8106, 8155
|
4516, 5836
|
297, 482
|
8539, 8704
|
2664, 4493
|
9491, 10181
|
1827, 1857
|
6178, 8083
|
8176, 8518
|
5862, 6155
|
8728, 9468
|
1872, 2645
|
238, 259
|
510, 1113
|
1135, 1438
|
1454, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,336
| 114,672
|
35596
|
Discharge summary
|
report
|
Admission Date: [**2137-1-11**] Discharge Date: [**2137-1-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is an 85 yo male with h/o AVR (mechanical valve), Afib, AAA
5.9 cm not surgical candidate, admitted to [**Hospital1 1474**] for painless
jaundice. He had an ERCP with was unsuccessful at OSH,
therefore he was sent here for repeat ERCP and evaluation. He
had a stent removed, biopsies of a suspicious lesion, and new
stent placed. During the procedure, he became intermittently
hypotensive, with SBP in the 80s, requiring fluid boluses and
800 mcg of phenylephrine. He received Versed 2 mg, Propofol 100
mg, and fentanyl 75 mcg during the procedure. He received 800
mL of LR during the procedure. Post ERCP, he was in the
holding area, noted to be hypotensive to low 90s, and with a
concerning "wide complex rhythm". [**Hospital Unit Name 153**] was called to evaluate
and monitor the patient prior to transfer back to [**Hospital1 1474**]. At
the time of evaluation, the patient only complained of some
abdominal soreness, denied chest pain, SOB, lightheadedness, or
dizziness. SBP had already improved to 112/68. His rhythm was
V-paced. Cardiology was also at bedside to evaluate.
.
ROS: The patient denies any fevers, chills, weight change,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, or rash.
Past Medical History:
1) Asthma
2) Mechanical AVR on coumadin- currently held and on lovenox
3) Atrial Fibrillation s/p PPM
4) AAA 5.9 cm not surgical candidate
5) Anemia
6) Hyperlipidemia
7) Depression
8) ? seizure d/o
Social History:
lives at home with a roommate. denies ETOH or smoking.
Family History:
NC
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2137-1-11**] 03:20PM GLUCOSE-126* UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2137-1-11**] 03:20PM ALT(SGPT)-102* AST(SGOT)-175* LD(LDH)-212
CK(CPK)-17* ALK PHOS-451* AMYLASE-49 TOT BILI-13.6*
[**2137-1-11**] 03:20PM LIPASE-28
[**2137-1-11**] 03:20PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.4 CHOLEST-227*
[**2137-1-11**] 03:20PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.4 CHOLEST-227*
[**2137-1-11**] 03:20PM TRIGLYCER-156* HDL CHOL-13 CHOL/HDL-17.5
LDL(CALC)-183*
[**2137-1-11**] 03:20PM WBC-5.4 RBC-2.72* HGB-9.9* HCT-29.3* MCV-108*
MCH-36.4* MCHC-33.7 RDW-16.6*
[**2137-1-11**] 03:20PM NEUTS-69 BANDS-1 LYMPHS-15* MONOS-9 EOS-2
BASOS-2 ATYPS-0 METAS-0 MYELOS-2*
[**2137-1-11**] 03:20PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL
ERCP [**2137-1-11**]:
Impression: A plastic stent placed in the biliary duct was found
in the major papilla. The stent was removed with a snare and
sent for cytology.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was successful contrast medium
was injected resulting in complete opacification.
A single smooth stricture that was 35mm long was seen at the mid
CBD extending to the hilum. There was moderate post-obstructive
dilation.
A 10FR by 250cm SPYGLASS Choledochoscope was introduced into the
bile duct with success. The mucosa appeared irregular and
friable, suspicious for a malignant process. Three cold forceps
biopsy were taken from the stricture through the SPYGLASS
choledochoscope for histology.
A 10cm by 10FRmm Cotton [**Doctor Last Name **] biliary stent was placed
successfully using a 10FR stent introducer kit. Excellent bile
drainage was achieved
Otherwise normal ercp to second part of the duodenum
PLAN: Return to outside hospital under Dr. [**Last Name (STitle) 35828**] [**Name (STitle) **] care
Follow for response/complications
Please call if develops jaundice, black stools, fever, or
abdominal pain
juices today when awake, alert, and at baseline
Follow-up cytology results
Follow-up biopsy results
If malignancy confirmed will arrange ERCP and metal stent
insertion with Dr [**Last Name (STitle) **]
ECG [**2137-1-11**]: Multiple ECGs available for evaluation and telemtry
strip. Baseline underlying rhythm Atrial fibrillation. Some
ECG are V-paced. Difficult to determine whether there are any
ischemic changes on v-paced beats, but no obvious ST segment
changes. rate in 90s-100. Tele strip shows afib, then
subsequent likely V-paced rhythm.
Brief Hospital Course:
Assessment: This is a 85 year-old male with a history of
mechanical AVR, atrial fibrillation, AAA, who is transferred to
the [**Hospital Unit Name 153**] s/p ERCP c/b hypotension and concern for "wide complex"
rhythm.
# Hypotension: Patient's hypotension was thought to be
secondary to sedation and possibly volume depletion. He
underwent a rule-out for myocardial infarction that was
negative. He was given a 500cc normal saline bolus and his
blood pressure remained stable during his hospital stay. He did
not require vasopressors.
# Hypoxia: Patient had an oxygen requirement of 4L that was
thought to be secondary to pulmonary edema. He will likely need
gentle diuresis upon arrival at [**Hospital1 1474**] to help reduce his
oxygen requirement. Subjectively, he was not complaining of
shortness of breath.
# Ventricular-paced rhythm/AFIB: Patient has a history of afib
with V-paced rhythm. He did not complain of chest pain and also
ruled out for myocardial infarction. He was restarted on
lovenox after his ERCP on [**1-11**] at [**Hospital1 18**].
# Painless Jaundice: Patient underwent a repeat ERCP on the
evening of [**2137-1-11**] at [**Hospital1 18**]. A plastic stent placed in the
biliary duct was found in the major papilla. The stent was
removed with a snare and sent for cytology. Evidence of a
previous sphincterotomy was noted in the major papilla.
Cannulation of the biliary duct was successful. A single smooth
stricture that was 35mm long was seen at the mid CBD extending
to the hilum. There was moderate post-obstructive dilation. A
10FR by 250cm SPYGLASS Choledochoscope was introduced into the
bile duct with success.
The mucosa appeared irregular and friable, suspicious for a
malignant process.
Three cold forceps biopsy were taken from the stricture through
the SPYGLASS choledochoscope for histology. A 10cm by 10FRmm
Cotton [**Doctor Last Name **] biliary stent was placed successfully using a 10FR
stent introducer kit. Excellent bile drainage was achieved.
Otherwise normal ercp to second part of the duodenum. He should
return to [**Hospital1 1474**] under Dr. [**Last Name (STitle) 35828**] [**Name (STitle) **] care and his cytology
results should be followed-up.
# Mechanical AVR: Patient was restarted on lovenox after
discussion with the ERCP fellow.
# C. diff: Patient had diarrhea and his stool was positive for
c. diff. He was started on po flagyl.
Medications on Admission:
Albuterol 90 mcg 2 puffs IH q4H PRN
Enoxaparin 80 mcg [**Hospital1 **]
Finasteride 5 mg daily
Folic Acid 1 mg daily
Pantoprazole 40 mg daily
Phenytoin 200 mg QAM and 300 mg QHS
Simvastatin 80 mg QHS
Terazosin 5 mg daily
Discharge Medications:
1. Influen Tr-Split [**2135**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
ASDIR ML Injection ASDIR (AS DIRECTED).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) MG
Subcutaneous Q12H (every 12 hours).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO QAM (once a day (in the morning)).
9. Phenytoin 50 mg Tablet, Chewable Sig: Six (6) Tablet,
Chewable PO QHS (once a day (at bedtime)).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
C. diff colitis
Hypotension
.
Secondary:
Abdominal aortic aneurysm
Aortic valve repair
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of low blood pressure. Your blood
pressure has remained stable while you were an inpatient here.
We also performed an ERCP and we replaced the stent that was
placed in your bile duct at [**Hospital1 1474**]. We also took a biopsy of
some of the tissue. While you were here, we also diagnosed you
with C. diff, an infection of the bowel. To treat you for this,
we gave you antibiotics.
Followup Instructions:
Per primary team at [**Hospital 1474**] Hospital
Completed by:[**2137-1-13**]
|
[
"008.45",
"458.29",
"311",
"276.51",
"285.9",
"V58.61",
"427.31",
"V45.01",
"V43.3",
"156.8",
"493.90",
"441.4",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.14",
"97.05",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
9362, 9377
|
5386, 7804
|
271, 278
|
9537, 9546
|
2747, 5363
|
10009, 10089
|
1986, 1990
|
8075, 9339
|
9398, 9516
|
7830, 8052
|
9570, 9986
|
2005, 2728
|
223, 233
|
306, 1676
|
1698, 1897
|
1913, 1970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,716
| 156,711
|
15341
|
Discharge summary
|
report
|
Admission Date: [**2165-1-3**] Discharge Date: [**2165-1-11**]
Date of Birth: [**2105-7-23**] Sex: M
Service: [**Location (un) 259**] MEDICINE
HISTORY OF PRESENT ILLNESS: A 59-year-old male with
end-stage liver disease secondary to primary sclerosing
cholangitis with associated ulcerative colitis and a history
of ascites and hepatic encephalopathy, with a recent
admission for hepatic encephalopathy [**12-17**] to 19th,
who was transferred yesterday from an outside hospital with
change in mental status and found unresponsive by his family.
The patient was admitted to the SICU, given lactulose with
improved mental status.
REVIEW OF SYSTEMS: Negative for obvious cause of worsening
encephalopathy. Urinalysis at outside hospital with few
white blood cells. Chest x-ray shows a right effusion and
question of a retrocardiac density. Today the patient feels
improved. Denies focal symptoms. No abdominal pain, but
increased abdominal distention.
PAST MEDICAL HISTORY:
1. Primary sclerosing cholangitis.
2. Cirrhosis on transplant with ascites and encephalopathy.
3. Ulcerative colitis.
4. Cholecystectomy.
5. Hepatic encephalopathy.
6. Hepatitis C antibody positive, RNA of 0.
7. Duodenal ulcer.
8. History of Gram-negative sepsis.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Aldactone 150 q day.
2. Nadolol 20 q day.
3. Ursodiol 900 [**Hospital1 **].
4. Multivitamin.
5. Calcium carbonate.
6. Iron sulfate.
7. Pentasa 1,000 tid.
8. Protonix 40 q day.
SOCIAL HISTORY: No smoking, one drip of alcohol per week.
Lives alone.
FAMILY HISTORY: Coronary artery disease and breast cancer.
No colon cancer of inflammatory bowel disease.
EXAMINATION ON ADMISSION: Temperature 96.1, blood pressure
124/72, pulse 73, and 97% on room air. General: Tired,
easily arousable. HEENT: Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. Mucous membranes are moist. Pulmonary:
Decreased breath sounds at the right base, rales at the left
base. Cardiac: Regular, rate, and rhythm, no murmurs, rubs,
or gallops. Abdomen: Positive bowel sounds, distended,
tympanitic, and no tenderness. Extremities: No edema, warm.
Neurologic: No focal deficits.
DATA: White blood cell count 7.2, hematocrit 37, platelets
166, MCV 91. Differential is 78 polys, no bands, 8%
lymphocytes, INR 2.1. Sodium 139, potassium 3.7, chloride
112, bicarbonate 17, BUN 12, creatinine 0.7, 137 glucose,
albumin 2.4, calcium 7.9, phosphorus 2.8, magnesium 2.1, ALT
48, AST 44, total bilirubin 3.0, alkaline phosphatase 220,
amylase 61, lipase 110.
Urinalysis: No nitrates, moderate blood, and no leukocyte
esterase, [**11-21**] reds, 0-2 whites, few bacteria, and no
squamous epi's.
Chest x-ray showed retrocardiac density. Abdominal
ultrasound showed small ascites.
HOSPITAL COURSE: A 59-year-old male with end-stage liver
disease secondary to primary sclerosing cholangitis admitted
with worsening hepatic encephalopathy and left lower lobe
pneumonia.
1. Encephalopathy: The patient was given lactulose [**2-4**] bowel
movements a day and was started on Flagyl 500 mg po bid for
decontamination. He improved on this regimen, and was clear
in his mental status upon discharge.
2. ID: The patient did have no fever and a normal white
blood cell count, but did have some evidence of pneumonia on
examination and on his chest x-ray with a left lower lobe
infiltrate. He was initially given ceftriaxone 1 gram po q
day and was switched over to po Levaquin to complete a 10 day
course of antibiotics for his pneumonia.
A diagnostic and mildly therapeutic tap of his ascites was
done that did not show any evidence of SBP. One liter was
removed from his abdomen.
3. End-stage liver disease: The patient was continued on his
nadolol, ursodiol. He initially had his spironolactone held
for lower blood pressures in the 90s, but this was restarted
at 100 mg po q day. He was also continued on his Protonix 40
mg po q day.
4. Abdominal distention: Patient had a level of abdominal
distention that was greater than what would be if he just had
ascites. He had a KUB that did show increased intraluminal
bowel gas that was likely secondary to increased gas
production from his lactulose. He was started on Flagyl for
decontamination to also try to decrease the gas. One liter
of ascites was taken off this hospitalization by
paracentesis.
5. Ulcerative colitis: The patient had no symptoms referable
to this, and was continued on Pentasa 1,000 mg tid.
6. Nutrition: Mr. [**Known lastname 16189**] was not taking adequate nutrition
by a calorie count that estimated him around 400-500 calories
per day with a goal of 2,000 calories per day in the
hospital. He had a post-pyloric tube placed two times during
this hospitalization, but of which the tube was accidentally
pulled out by Mr. [**Known lastname 16189**]. It was decided that for
disposition, that he would be followed as an outpatient
Nutrition, Ms. [**Last Name (Titles) 41841**], and the liver service for calorie
count while he was on home food that he preferred more.
He will follow up in the Liver Center for outpatient
nutrition.
He was continued on his multivitamins and given Boost
supplementation.
The patient was discharged home after his encephalopathy
resolved after treatment with lactulose and Flagyl and
treatment of his pneumonia with ceftriaxone.
He will have VNA services at home. He will actually stay
with his sister.
He will follow up with Dr. [**Last Name (STitle) 497**] within a week.
DISCHARGE MEDICATIONS:
1. Spironolactone 100 mg po q day.
2. Flagyl 500 mg po bid.
3. Nadolol 20 mg po q day.
4. Ursodiol 900 mg po bid.
5. Pentasa 1,000 mg tid.
6. Protonix 40 mg po q day.
7. Iron sulfate.
8. Calcium carbonate.
9. Multivitamin.
10. Lactulose 15 mL titrated to three bowel movements a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Last Name (NamePattern1) 9352**]
MEDQUIST36
D: [**2165-1-14**] 15:40
T: [**2165-1-17**] 11:16
JOB#: [**Job Number 44569**]
|
[
"070.54",
"572.2",
"571.5",
"576.1",
"486",
"599.0",
"263.0",
"276.8",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1591, 1694
|
5584, 6148
|
2859, 5561
|
1321, 1501
|
667, 975
|
189, 647
|
1709, 2841
|
997, 1300
|
1518, 1574
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,183
| 115,178
|
20075
|
Discharge summary
|
report
|
Admission Date: [**2115-7-20**] Discharge Date: [**2115-8-1**]
Date of Birth: [**2048-7-14**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy and esophageal biopsy
Blood transfusions
Esophageal Ultrasound
History of Present Illness:
Pt is a 66 yo M with a h/o CAD (s/p CABG x 3 [**10-30**] and ICD
placement [**2-28**]), MVR, A.fib, HTN who presented to the ED w/
hematemesis. After the CABG in [**10-30**]' the patient noted a
lump in his throat. The sensation was persistent and he felt as
if his throat was closing. Over the next several months the pt
also began noting increase in belching and small amounts of
regurgitation. While eating he would bring up white frothy
contents. Recently, he noted an increase need to chew his
foods. He denies any difficulty swallowing liquids. On [**7-15**]
his [**Month/Year (2) 263**] was found to be subtherapeutic 1.4, so his coumadin was
increased from 1mg to 2mg and started on Lovenox 40mg QD. On
[**7-19**] his [**Month/Year (2) 263**] was 4.7, both coumadin and lovenox were stopped.
Later that day he had some coffee ground emesis and worsening
dysphagia. The following day he had grossly bloody emesis and
had noted dark stools for 2 days. He denies any recent weight
loss, abd pain, CP, F/C. No NSAID use.
In the ED he was given Vit. K and started on heparin drip. He
was hemodynamically stable. Given 1LNS and 1 unit PRBC's. A
gastric lavage was positive for blood. GI and Cardiology were
consulted. An EGD was performed which showed a 8 mm stricture
at the GE junction, with salmon colored mucosa, and a
frond-like/vilous non bleeding mass of malignant appearance.
The scope could not be passed the GE junction. He is
transferred to the floor to await biopsy results and further
plans. He is currently hemodynamically stable and on heparin
drip for anti-coagulation.
Past Medical History:
CABG x 3 ([**10-30**])
MVR
s/p ICD placement ([**2-28**])
A.fib
HTN
Hypothyroidism
Social History:
Denies ant T/A/D use. Lives with wife, has three children.
retired from [**Company 20830**]
Family History:
Denies any h/o cancer, CAD. Parents died when he was young,
unsure of causes.
Physical Exam:
PE T 98.9 BP 112/60 HR 68 RR 18 O2sats 100% RA
Gen: Pt sitting in chair, A&O times 3, NAD
HEENT: mmm, anicteric, clear OP, PERRL, EOMI
Neck: + EJ IV, no supraclavicular nodes, no JVD
Cardiac: RRR, + mechanical valve click, +S1/S2
Resp: crackles at the bases bilaterally, good air movement
Abd: Soft, NT, ND, +BS
Ext: no edema, 2+ DP, PT pulses bilaterally
Neuro: motor/sensory function grossly intact
Pertinent Results:
[**2115-7-20**] 01:30PM WBC-9.2# RBC-3.11*# HGB-9.7*# HCT-28.2*#
MCV-91 MCH-31.1 MCHC-34.3 RDW-15.5 NEUTS-81.4* LYMPHS-13.7*
MONOS-3.9 EOS-0.6 BASOS-0.4 PLT COUNT-219
[**2115-7-20**] 01:30PM PT-19.1* PTT-34.0 [**Month/Day/Year 263**](PT)-2.4
[**2115-7-20**] 01:30PM GLUCOSE-104 UREA N-50* CREAT-1.4* SODIUM-144
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
EGD
Findings:
Esophagus:
Lumen: An 8mm stricture was seen in the gastro-esophageal
junction. The scope did not traverse the lesion.
Mucosa: A salmon colored mucosa distributed in a localized
pattern, suggestive of Barrett's Esophagus was seen.
Protruding Lesions A frond-like/villous non-bleeding mass of
malignant appearance was found at the gastro-esophageal
junction. The scope could not traverse the lesion and the
examination was interrupted.
Stomach:Other Unable to visualize extent of mass or the stomach
fundus/body due to GE junction stricture.
Duodenum: Not examined
Impressions: Stricture of the gastro-esophageal junction
Barrett's esophagus
Mass in the gastro-esophageal junction
ECHO [**2115-2-6**]
Conclusions
1. The left atrium is mildly dilated.
2. Overall left ventricular systolic function is moderately
depressed. Anterior, septal and apical hypokinesis is present.
EF 35-45%
3. The aortic valve leaflets (3) are mildly thickened.
4. A bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients.
Cardiac Cath [**2114-11-21**]
FINAL DIAGNOSIS:
1. Three vessel and left main coronary artery disease.
2. Mild-moderate mitral regurgitation.
3. Severe global systolic and mild diastolic left ventricular
dysfunction.
COMMENTS:
1. Selective angiography of this right-dominant system revealed
three-vessel and LMCA disease. LMCA distal 40-50%. The LAD had
severe ostial and proximal diffuse diseased and was totally
occluded after D1. The distal LAD filled via left-to- left and
right-to-left collaterals. D1 70% stenosis at its ostium. LCX
had a 40% stenosis at the origin of a large OM1. The OM1 branch
had serial 70% lesions proximally. The RCA mid-vessel tubular
60% stenosis and a 70% stenosis just before the RPDA.
2. The LVEDP was 16 mmHg.
3. Left ventriculography revealed an ejection fraction of 29%.
There was anterobasal hypokinesis, anterolateral akinesis,
apical
dyskinesis/akinesis, inferior and posterobasal hypokinesis.
There was
mild to moderate ([**12-28**]+) mitral regurgitation.
Labs on Discharge:
[**2115-7-31**] 06:05AM BLOOD WBC-6.3 RBC-4.02* Hgb-12.6* Hct-37.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.2 Plt Ct-235
[**2115-7-20**] 01:30PM BLOOD Neuts-81.4* Lymphs-13.7* Monos-3.9
Eos-0.6 Baso-0.4
[**2115-8-1**] 06:10AM BLOOD PT-24.9* PTT-99.8* [**Month/Day/Year 263**](PT)-4.1
[**2115-8-1**] 06:10AM BLOOD Creat-1.4*
[**2115-7-31**] 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
Brief Hospital Course:
1.[**Name (NI) 54040**] Pt was initially admitted to the MICU. His blood
pressure was stable but on the low side for him, around
100/70's. His aspirin, coumadin, BB, ACEI, diuretic were all
held and he was given fluids. In the MICU [**Name (NI) 263**] was elevated so
it was reversed with Vit. K. He was given 2 units packed RBC's
(crit was 28.2) and his Hct remained stable without further
bleeding. Also started on PPI IV. He went for on EGD which
showed a 8mm stricture at the GE junction w/ non bleeding mass
of malignant appearance. Biopsy came back positive for
adenocarcinoma. For the remainder of the hospital he had no
bleeding and his HCT was stable.
2.Esophageal adenocarcinoma- Pt was diagnosed with
adenocarcinoma after EGD with biopsy. An esophageal ultrasound
showed that his stage was T2 with possible involvement of lymph
nodes. A CT scan did not show any evidence of metastases.
Several services including surgery, oncology, radiation oncology
were consulted. Follow up appointments as an outpatient include
Radiation oncology, thoracic oncology, and PET scan.
3. [**Name (NI) 54041**] Pt with MVR in [**10-30**]. He needed to be on
anticoagulation but because of the bleeding his [**Date Range 263**] was
reversed. After the EGD he was started on heparin and the PTT
was maintained between 60-80 as per cardiology recommendations.
After the EUS he was able to be transitioned to coumadin in
anticipation of discharge. Goal [**Date Range 263**] was 2.5-3.5 given the MVR.
It took several days to get Mr. [**Known lastname **] [**Last Name (Titles) 263**] therapeutic. Patient
was drinking boost in hospital which has vitmain k. On discharge
[**Last Name (Titles) 263**] 4.1 and patient is to see anticoagulation nurse in the am
after discharge.
4.HTN- Mr. [**Known lastname 48753**] blood pressure meds were initially held because
of bleeding and low BP. After he was stabilized and not
bleeding his blood pressure was monitored. The beta blocker was
added once his BP returned to the 120's/80's and slowly
increased to his normal dose of metoprolol 25 mg [**Hospital1 **].
5. CAD- Aspirin was held secondary to the bleeding. Continued
the statin. Beta blocker as above.
6. Pulmonary- On CT the patient was found to have evidence of
interstitial pneumonitis. He did have occasional crackles at the
bases but had O2 sats in the high 90's. PFT's were done which
exhibited a restrictive picture. Pulmonary was consulted they
felt he had IPF, however treatment was not warranted at this
time secondary to his need for cancer treatment. It was advised
that he follow up with pulmonology during his cancer therapy and
have regular PFT's.
7. Hypothyroidism- Continued his levothyroxine dose from home.
8. Rise in creatinine- Pt with creatinine to 1.4 at times during
hospitalization. Could be secondary to poor po and fluid intake.
Could be worked up as outpatient if though indicated.
9.PPx: Patient was on PPI and heparin until his coumadin was
therapeutic (morning of discharge)
Medications on Admission:
Levothyroxine 100mcg QD, Atenolol 25 mg QD, Lisinopril 20mg QD,
HCTZ 25mg QD, Zocor5mg QD, Coumadin 1mg QD
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*15 Tablet(s)* Refills:*0*
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*15 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO HS (at
bedtime): No coumadin tonight, repeat [**Hospital1 263**] [**2115-8-2**], further
medication adjustments [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 32624**] ([**Telephone/Fax (1) 54042**].
Disp:*30 Tablet(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Check Basic metabolic profile and communicate results to Dr.
[**Last Name (STitle) 54043**].
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal adenocarcinoma
Upper gastrointestinal bleeding
Anemia,acute blood loss
Elevated creatinine
Anticoagulation for mitral valve replacement
Barrett's esophagus
Coronary Artery Disease
Discharge Condition:
Stable, hematocrit stabilized, [**Last Name (STitle) 263**] 4.1 with followup [**Hospital 191**]
[**Hospital3 **].
Discharge Instructions:
1)Have your [**Hospital3 263**] checked on [**2115-8-2**] and results to be communicated
to [**Company 191**] Anticoagulation service, your coumadin will be adjusted
based on these results by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 32624**] ([**Telephone/Fax (1) 54042**].
2) You will need a repeat chemistry next week to check for
resolution of your creatinine, results to be followed by your
primary care physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54043**].
3) Your PET scan is schedule for [**2115-8-2**] at 1pm located in the
[**Hospital Ward Name 23**] center, [**Location (un) **]. Instructions for the procedure--
-No strenous exercise before the procedure
-You may take in only water for 6 hours before the scan, no food
or other liquids.
-
4) [**Known firstname **] [**Last Name (NamePattern1) 54044**] ([**2115**] will contact you regarding your
appointment in the Thoracic Oncology Group, if you do not
receive a call by [**2115-8-5**] please call the number above to confirm
this appointment time.
5) Radiation Oncology appointment today, [**2115-8-1**], at 3pm at the
[**Hospital Ward Name 23**] building, [**Location (un) 442**]
Followup Instructions:
Radiation oncology, Thoracic Oncology, and PET scan appointments
listed above.
Prior appointments include:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-12-16**] 2:00
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2115-12-16**] 2:30
|
[
"151.8",
"244.9",
"427.31",
"401.9",
"515",
"578.9",
"285.1",
"530.85",
"530.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9844, 9850
|
5692, 8713
|
321, 412
|
10085, 10201
|
2798, 4305
|
11445, 11931
|
2281, 2362
|
8871, 9821
|
9871, 10064
|
8739, 8848
|
4322, 5273
|
10225, 11422
|
2377, 2779
|
270, 283
|
5293, 5669
|
440, 2047
|
2069, 2154
|
2170, 2265
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,473
| 110,858
|
46934
|
Discharge summary
|
report
|
Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-26**]
Date of Birth: [**2130-9-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
# s/p ureterolysis (retroperitoneal fibrotic tissue) and
excision of ureteral stricture with primary reanastomosis of
ureter
# s/p placement of cook tulip inferior vena cava filter
History of Present Illness:
The patient is a 61 year old male with nephrolithiasis and
recent DVT who was admitted to the ICU after triggering for a
syncopal episode with falling Hct and concern for post-surgical
RP or intraabdominal bleeding. He has a history of
nephrolithiasis s/p lithotripsy and multiple prior urology
procedures. He subsequently developed a right upper ureteral
stricture with dense retroperitoneal fibrosis. He underwent
right ureteroscopy on [**2192-3-19**] and was found to have a tight UPJ
stricture which could not be stented. He was briefly admitted
on [**2192-3-22**] for right flank pain, which resolved. On [**2192-3-28**], he
was found to have a right posterior tibial DVT after presenting
to his PCP with calf pain, and was started on [**Date Range 99555**]. On
[**2192-4-9**], he underwent right upper ureterolysis with resection of
the stricture and ureteropyelostomy. His [**Date Range 99555**] was held for
the procedure and restarted the next day.
.
On [**2192-4-12**], he had an apparent syncopal episode during whch he
was diaphoretic, tachycardic to the 130s, and desaturated to 86%
on RA. EKG showed no significant change, CTA showed no evidence
of PE, and LE dopplers showed stable DVT in right posterior
tibial vein without extension. His Hct at that time was fairly
stable at 32.1, but his WBC count had increased from 7.4 on
[**2192-4-10**] to 14.0 that morning. His coags were normal. He ruled
out for MI with three sets of negative CEs.
.
This morning, he had another syncopal episode after morning
rounds. He sat up to void and while voiding he fell back on his
bed and was unresponsive for approximately 30 seconds per a
nurse [**First Name (Titles) 1023**] [**Last Name (Titles) **] the event. His EKG showed no new ischemic
changes. He was found to have BP 76/40 with sinus tachycardia
to 116 and satting 98% on RA. Abdominal US showed no evidence
of hydronephrosis and a small amount of fluid in the right lower
quadrant, along the patient's surgical incision site. He had
received his dose of [**Last Name (Titles) 99555**] this morning. His Hct was found to
be 26.2 from 32.1 the previous day. His WBC count had increased
to 19.2 with 88.7% neutrophils on diff. He was ordered for 2
units PRBCs and started on Ceftriaxone. Repeat labs a few hours
later at 12:44 showed Hct 23.9. His Cr had also increased to
1.7 from 1.2 in the morning. He received his blood from around
13:30 to 16:30 and was given D5-1/2NS at 75 ml/hr afterwards.
He was also given a 500 ml NS bolus in in the evening.
.
Repeat labs were drawn and he was scheduled for CT abdomen. He
was then transfered to the ICU. On ICU transfer, he was
tachycardic in the 120s-130s with BP in the 110s/70s. His IV
access was limited to a single PIV and attempts to gain
additional access were unsuccessful prior to his CT. He was
given NS boluses for a total of several liters. His
post-transfusion labs were notable for Hct 30.1, WBC 23.3, and
Cr 2.1. His CT showed a fairly large RP bleed and retained
contrast in the right kidney, but no hydronephrosis.
.
The patient reported abdominal tenderness on the right. He was
tired and wanted to sleep. He denied any palpitations or
lightheadedness. He had no other specific complaints. He
reports that he had BM yesterday and was passing flatus. He has
not had a BM today.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever or chills. Denies current headache,
rhinorrhea, or congestion. Denied cough, shortness of breath.
Denied chest pain, tightness, or palpitations. Denied nausea,
vomiting, or diarrhea. No dysuria. Denied arthralgias or
myalgias. Review of systems was otherwise negative.
Past Medical History:
# Nephrolithiasis
# DVT -- right posterior tibial diagnosed [**2192-3-28**] and started on
[**Month/Day/Year 99555**]
# Anxiety
# Migraines
Social History:
He is married and lives with his wife.
# Tobacco: None
# Alcohol: None
# Drugs: None
Family History:
No family history of DVT, PE, abnormal bleeding, or
coagulopathy.
Physical Exam:
VS: T 96.6, BP 123/83, HR 122, SpO2 93-96% on RA
Gen: Male in NAD. Resting comfortably. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. MMM, OP benign. NGT in place.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: Regular tachycardia with normal S1, S2. No M/R/G.
Chest: Respiration unlabored but somewhat tachypneic. CTAB
without crackles, wheezes or rhonchi.
Abd: Bowel sounds present. Moderately distended. Tender to
palpation near surgical site on right flank and RLQ. Surgical
incision with staples in place. No erythema and appears to be
healing well. Former drain site with small dressing C/D/I.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
.
Discharge PE:
AFVSS.
Gen: NAD
Neck: neck supple, suture removed; JVP not elevated
HEENT: NCAT, MMMs
Pulm: CTAB
CV: RRR, nml s1/2 no [**3-23**]/m/g/r
Ab: right flank incision healing well, dressing c/d/i
GU: no foley; dark brown urine
Back: trace sacral edema
Right Ext: 1+ edema non-tense; thigh slightly larger in girth
than left
Neuro: Grossly non-focal
Pertinent Results:
Admission Labs:
[**2192-4-9**] 06:55PM BLOOD WBC-13.7*# RBC-3.78* Hgb-12.4* Hct-36.6*
MCV-97 MCH-32.9* MCHC-34.0 RDW-12.0 Plt Ct-188
[**2192-4-9**] 06:55PM BLOOD Plt Ct-188
[**2192-4-9**] 06:55PM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-142
K-3.6 Cl-106 HCO3-28 AnGap-12
[**2192-4-12**] 10:27AM BLOOD CK(CPK)-312
[**2192-4-9**] 06:55PM BLOOD Calcium-8.4 Phos-4.5 Mg-1.8
.
Discharge Labs:
.
[**2192-4-26**] 06:40AM BLOOD WBC-11.0 RBC-3.09* Hgb-10.2* Hct-30.2*
MCV-98 MCH-32.9* MCHC-33.7 RDW-14.5 Plt Ct-340
[**2192-4-26**] 06:40AM BLOOD Neuts-82.3* Lymphs-10.1* Monos-4.6
Eos-2.7 Baso-0.4
[**2192-4-26**] 06:40AM BLOOD Plt Ct-340
.
Imaging:
[**2192-4-11**] CXR PA-L: No evidence of pneumonia. Bibasilar
atelectasis.
.
[**2192-4-12**] CT-PA: No evidence of pulmonary embolism.
.
[**2192-4-12**] LENIs: Positive DVT study with occlusion of the
posterior tibial veins on the right side. There is no extension
of the clot as compared to the prior scan on [**2192-3-28**].
.
[**2192-4-13**] Ab-US: Limited study due to patient discomfort over the
surgical incision site. No evidence of hydronephrosis in the
right kidney. Fluid is noted in the right lower quadrant, likely
related to recent surgery.
.
[**2192-4-13**] Ab/P-CT: 1. Status post right ureteral resection for
stricture, with two very large retroperitoneal hematomas with
internal hematocrit levels, one in the right abdomen flank and a
second associated with the right psoas muscle and inseperable
from/compressing the IVC and right iliac vein. Assessment for
vascular injury could be obtained with a contrast enhanced
study. 2. Retained contrast in a dilated right collecting system
and renal lower pole cortex, despite ureteral stent. 3.
Cholelithiasis. 4. Bilateral pleural effusions. 5. Stable right
inguinal subcutaneous low-density lesion. This could be further
assessed on non-emergent basis once acute issues resolve. 6.
Fluid layering in the lower esophagus, raises concern for
potential of aspiration.
.
[**2192-4-14**] CXR: Portable chest compared to multiple prior
examinations. Nasogastric tube has been placed, tip terminates
in the stomach. Eventration right hemidiaphragm. Mild
atelectasis right lung base. Left lung relatively clear. Heart
and mediastinum unremarkable
.
[**2192-4-14**] LENIs: 1. Marked subcutaneous edema, limiting exam.
2. Nonvisualization of right posterior tibial veins, were
previously
determined to be thrombosed.
3. No evidence of new DVT.
.
[**2192-4-15**] CXR: Frontal view of the chest compared to multiple
prior examinations. Nasogastric tube appropriate. Low lung
volumes. Mild atelectasis at both lung bases. Upper lung zones
are clear. Heart top normal in size.
.
[**2192-4-16**] CT Ab-P: 1. Status post right ureteral resection for
stricture.
2. Two large retroperitoneal hematomas expanding in size with
interval
increase in dense material within, can be hemorrhage; however,
cannot exclude urine leak. Right psoas muscle retroperitoneal
hematoma is inseparable and compressing the IVC, completely
encasing the lumen; no flow is seen below. Assessment for
vascular injury is suboptimal; cannot exclude vascular injury.
3. Persistent dilatation of the right collecting system. Right
ureteral stent in place. Few renal stones are seen, one in the
upper pole of the right kidney, few adjacent to the right stent.
4. Cholelithiasis. 5. Stable right subcutaneous inguinal lesion;
incompletely characterized. Findings were discussed with Dr.
[**Last Name (STitle) 141**] at 11 a.m. [**2192-4-16**] by phone (patient's primary
care physician) and with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA (urology), at 11:10
am on [**2192-4-16**].
Findings discussed with Dr. [**Last Name (STitle) 365**] at 12 pm on [**2192-4-16**] by
phone.
.
[**2192-4-16**] MRI Ab-P: 1. Extensive intraluminal thrombus identified
within the IVC which extends superiorly up to 3.6 cm below the
level of the origin of the right renal vein. 2. Extensive
intraluminal clot also noted to occlude the entire right
external iliac and common veins. Clot is also seen within the
left common iliac vein and isolated in the internal iliac vein.
The left external iliac vein is patent. 3. Two large
retroperitoneal hematomas identified in the right pararenal
space and anterior to the right psoas muscle which is intimately
associated with the IVC.
.
[**2192-4-21**] CXR PA-L: There is persistent elevation of the right
hemidiaphragm and small bilateral pleural effusions. The
cardiomediastinal silhouette is stable. The pulmonary
vasculature is normal. Calcified granuloma is again seen lying
between the second and third left anterior ribs, stable dating
back to [**2180-6-26**]. There is a small amount of left
retrocardiac opacity which likely represents atelectasis.
.
[**2192-4-22**] Duplex Ab-P: 1. Right nephroureteral stent in place,
without evidence of hydronephrosis or infection.
2. Moderate free fluid, consistent with evolving blood products.
3. Patent intrahepatic IVC. Mid and distal IVC not assessed by
ultrasound.
.
[**2192-4-22**] Renal US: 1. Right nephroureteral stent in place, without
evidence of hydronephrosis or infection.
2. Moderate free fluid, consistent with evolving blood products.
3. Patent intrahepatic IVC. Mid and distal IVC not assessed by
ultrasound.
.
[**2192-4-22**] CT-Ab-P: 1. Slight interval reduction in size of the
retroperitoneal hemorrhage.
2. Persistent thrombosis of the IVC and right common iliac vein.
3. IVC filter at the level of the renal veins
4. Right-sided JJ stent in situ.
.
[**2192-4-23**] CXR PA-L:
Focal new right retrocardiac opacity may reflect focal
atelectasis or pneumonia. Small bilateral pleural effusions are
stable.
.
[**2192-4-24**] CT Ab-P, LE: 1. No right lower extremity hematoma.
Extensive right lower extremity edema.
Expanded and hyperdense appearance of the deep veins of the
right lower
extremity consistent with thrombosis.
2. Retained contrast in the right renal lower pole is consistent
with
segmental changes of ATN or could possibly relate to thrombosis
of a renal
vein branch.
3. Stable right retroperitoneal hematoma.
4. Known IVC and pelvic venous thromboses poorly assessed on
this noncontrast examination.
Brief Hospital Course:
61M with a history of RLE DVT [**2192-3-28**], who was admited [**2192-4-9**]
for right upper ureterolysis, resection of stricture, and
ureteropyelostomy post-operative course c/b RP bleed
compromising IVC flow requiring ICU transfer and transfusions,
IVC clot s/p filter, transferred to medicine for low grade fever
of unknown origin - likely secondary to IVC clot burden.
.
ICU Course:
.
# Retroperitoneal Bleed: His Hct was 36.6 on admission and was
stable in the low 30s for several days after his surgery. His
Hct had dropped to 26.2 and then further to 23.9. He was sent
for CT abdomen, which showed a right RP bleed. Of note, he was
was on [**Month/Day/Year 99555**] 100 mg SC BID prior to his surgery for treatment
of a recent DVT, and restarted on [**Month/Day/Year 99555**] [**2192-4-10**], the day after
his surgery. He was transfused a total of 6 units PRBCs this
admission, with stabilization of his hematocrit in the high 20s.
His abdomen was distended with initial bladder pressure
elevated to 21 and subsequent resolution to 9. On CT scan, there
was concern for compression of the IVC by the attending
radiolgist. On transfer from the ICU, there was a plan for
reimaging of his abdomen to further assess for compression.
.
# SIRS: He met SIRS criteria with an elevated WBC count,
tachycardia, and tachypnea. His WBC count increased from 7.4 on
the day after his surgery to 19.1 this morning and subsequently
23.3. His diff showed 88.7% neutrophils and no bands. He was
afebrile and did not have any obvious localizing symptoms of
infection. His leukocytosis may be a stress response related to
his RP bleeding, but infectious causes were considered. Blood
and urine cultures were sent on [**2192-4-11**] after he had a temp of
100.3, with no growth on urine culture and no growth to date on
blood cultures. He was given a dose of Ceftriaxone prior to ICU
transfer and started on vancomycin and zosyn, which were
subsequently discontinued.
.
# Hypotension / Tachycardia: He was tachycardic on ICU transfer
with HR in the 120s-130s. His BP was in the 110s systolic, but
had reportedly dropped to the 70s during his syncopal episode.
He appeared volume depleted on exam and had only received a
small amount of IV fluids prior to ICU transfer. He was ruled
out for PE with a negative CTA and unchanged LE dopplers after
his first syncopal episode on [**2192-4-12**]. He has an abnormal EKG
at baseline with partial RBBB and diffuse ST-T changes in
multiple leads, with changes during his recent events. His
tachycardia improved, however he did have ST depressions and a
troponin leak, making this a positive stress test equivalent,
suggesting demand ischemia.
.
# Acute Renal Failure: His baseline creatinine is around 1.0 and
was 0.9 on admission [**2192-4-9**]. His creatinine increased to 2.1.
He appeared volume depleted on exam and was producing dark,
concentrated appearing urine with some blood. His CT abdomen
showed retained contrast in his right kidney, presumably from
his CTA on [**2192-4-12**], but no hydronephrosis. Per Urology, he
likely has a partial obstruction at his ureteral stent, possibly
from a small clot.
.
# DVT: He was found to have a right posterior tibial DVT on
[**2192-3-28**] after presenting to his PCP with right calf pain prior to
this admission. There was no clear precipitating event. He did
have a urology procedure several weeks before and a one day
hospital admission for flank pain the week before his DVT
diagnosis. The patient refused to wear a pneumoboot on his left
leg despite its importance being explained.
.
# Abdominal Distention: He reported having a bowel movement the
day before ICU transfer. His stomach appeared distended on CT
abdomen, and an NGT was placed with drainage of 600 ml nonbloody
fluid. His bladder pressure was elevated at 21 and subsequently
resolved to 9 with suction.
.
Medicine Course:
.
The patient was stabilized and transferred to the vascular
service, then transferred again to Medicine for work-up of
fever.
.
# Fever of unknown origin: On transfer physical exam and history
did not point to any clear source of infection; the patient's
abdomen was re-imaged, with no evidence of intrabdominal
infection. Blood cultures and urine cultures were noted to be
negative, with one UA positive for nitrites [**4-21**] while on Cipro
(started [**4-19**]). Antibiotics were broadened to
Ceftriaxone/Ampicillin empirically; the patient spiked a feverdd
on these antibiotics, at which point the corresponding [**4-21**] UCx
subsequently showed no growth and antibiotics were stopped. The
patient's fevers were attributed to IVC and DVT clot burden as
well as RP hematoma. The patient spiked again to 101F the night
before discharge, in keepin with his trend of low grade fevers
on and off antibiotics clustering in the evenings. WBC
downtrended off antbiotics, and on discharge was 11 with no
bandemia. Abdominal exam remained benign.
.
# RLE DVT, IVC Clot: After transfer to medicine, the patient's
anticoagulation with coumadin was restarted after conferring
with the urology team, vascular team, and PCP. [**Name10 (NameIs) 99555**] was given
for 24 hours as a bridge then stopped by request of the urology
service and PCP. [**Name10 (NameIs) **] is being discharged on coumadin for a
presumed course of 6 months at which point anticoagulation will
be reevaluted. INR goal is [**2-23**].
.
# Worsening Right LE edema: On transfer to the medicine service,
the patient had 2+ pitting edema of the right lower extremity in
the setting of a known R LE DVT. 24h after starting [**Month/Day (3) **] and
coumadin, the patient had worsening R thigh edema. CT-Leg showed
no evidence of bleed. The working diagnosis was edema due to R
external iliac and IVC clot impeding venous drainage. Edema
improved on coumadin ([**Month/Day (3) **] was stopped as detailed above) and
with leg elevation. A degree of the edema was also attributed to
a declining albumin; a high protein diet was recommended.
.
# RP bleed: Was not an active issue on the medicine service. s/p
8 units pRBCs. Hct stable. Radiographically improved on CT-Ab-P.
.
# RU Ureteral Stricture: Was not an active issue on the medicine
service. Discharged with follow-up with urology.
.
# Anxiety: Continued home dose klonopin.
.
# Migraines: Continued home dose Fiorcet prn.
.
Transitional Issues:
.
# INR: Coumadin to be dosed after discharge by rehab facility
for INR [**2-23**].
.
# Pending blood cultures: Blood and urine cultures [**Date range (1) 99556**] will
need follow-up after discharge.
.
# Urology follow-up: Discharged with follow-up with urology for
follow-up of ureterolysis, resection of stricture.
.
# Vascular follow-up: Discharged with follow-up with vascular
for further management of IVC filter and IVC clot.
.
# Icidental radiographic findings for outpatient follow-up:
-bilateral renal para-caliceal cysts
-few right renal stones
-cholelithiasis
-right inguinal subcutaneous low-density lesion
-Retained contrast in the right renal lower pole is consistent
with segmental changes of ATN or could possibly relate to
thrombosis of a renal vein branch. Renal function was stable at
the time of imaging.
.
# Code: Full Code
Medications on Admission:
Simvastatin
Clonopin
Citalopram
Fioricet
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
3. citalopram 10 mg Tablet Sig: 1.5 Tablets PO once a day.
4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-22**]
Tablets PO BID (2 times a day) as needed for Migraine Headache.
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. INR Check
Warfarin, target INR [**2-23**]
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day) for 3 days.
8. Electrolyte check
Check electrolytes [**2192-4-28**] and [**2192-4-30**] and fax results to Rehab
MD; replete K to > 4.0, Mg to > 2.0, Phos to > 3.0
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12h on
12h off to lateral right leg.
10. morphine 15 mg Tablet Sig: 0.5-1 Tablet PO every 6-8 hours
as needed for pain for 7 days.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. High Protein Diet
High protein diet
13. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for gas pain, indigestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
-Right ureteral stricture with dense retroperitoneal fibrosis
s/p ureterolysis of upper ureter and ureteropyelostomy.
-Retroperitoneal bleed
-IVC, right external iliac thrombosis and secondary fever
.
Secondary:
-Right lower extremity deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized for a right ureteral stricture for which
you underwent ureterolysis of the right upper ureter and
ureteropyelostomy. You tolerated the procedure well.
.
Your post-operative course was complicated by a retroperitoneal
bleed, which required that you be transferred to the ICU for
close monitoring, and that you receive blood transfusions.
Subsequent imaging showed that the bleed had stopped and that
the blood collection was becoming smaller.
.
Your post-operative course was also complicated by the
development of a large clot in your inferior vena cava and one
of your pelvic veins called the right external ilac vein. These
clots are what likely caused the edema in your right leg. To
prevent these clots from travelling into your heart and into
your lungs, an inferior vena cava filter was placed by
interventional radiology.
.
The clots are also what probably caused the fever that developed
several days after the surgery. Repeating imaging of your
abdomen showed no evidence of a post-operative infection. All of
the cultures drawn from your urine and blood have been negative
for infection. You were treated with antibiotics initially due
to concern for an infection in your urine, however the urine
cultures were negative as well. Moreover, although your fever
continued after stopping the antibiotics, your white blood cell
count showed a trend toward normalizing and you continued to
appear well; all of these factors reassure us that you do not
have an infection and that your fevers are being caused by the
clots in your IVC, external ilac, and even your pre-existing
clot in your right leg deep veins.
.
You were treated for your clots with coumadin - urology and your
primary care physician agree with this management. Your right
leg swelling initially worsened after starting the
anticoagulation, but repeat imaging showed no evidence of a
bleed. The swelling then improved. We suspect that the swelling
will persist for a number of weeks before getting better because
it will take time for the clot to dissolve. Lasix helped the
clot and you will continue this medication for a week after
discharge. Your swelling is also being made worse by your low
protein levels; it is important that you eat a high protein diet
after discharge.
.
The following changes were made to your medications. Continue
your other medications as previously prescribed.
# START: Coumading 5mg; the rehab facility will titrate the
medication according to your INR, with a target INR of [**2-23**]. You
will remain on this medication for at least 6 months; your PCP
will [**Name9 (PRE) 10748**] at that time whether to stop it.
# START: Lasix every other day for 5 days (3 total doses), then
stop.
# START: A high protein diet.
# START: Morphine oral for leg pain as needed
# START: Colace to prevent constipation while taking Morphine
# START: Lidocaine patch for leg pain as needed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2192-5-28**] 9:00
Department: INTERNAL MEDICINE
When: TUESDAY [**2192-5-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 365**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: UROLOGY PRACTICE ASSOCIATES
Address: [**Street Address(2) 18723**], [**Location (un) **],[**Numeric Identifier 18724**]
Phone: [**Telephone/Fax (1) 18725**]
Appointment: Wednesday [**2192-5-9**] 2:00pm
Department: VASCULAR SURGERY
When: THURSDAY [**2192-5-3**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"593.3",
"592.1",
"272.0",
"V58.61",
"995.93",
"300.00",
"285.1",
"584.5",
"453.42",
"780.2",
"273.8",
"998.11",
"780.60",
"346.90",
"593.89",
"453.41",
"E878.4",
"288.60",
"782.3",
"269.8",
"790.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.02",
"88.47",
"38.7",
"55.86",
"56.2",
"88.51",
"38.93",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
20471, 20556
|
11975, 18308
|
312, 495
|
20865, 20865
|
5755, 5755
|
24005, 25113
|
4469, 4537
|
19269, 20448
|
20577, 20844
|
19204, 19246
|
21016, 23982
|
6141, 11952
|
4552, 5379
|
18329, 19178
|
3880, 4186
|
5393, 5736
|
264, 274
|
523, 3861
|
5771, 6125
|
20880, 20992
|
4208, 4350
|
4366, 4453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
998
| 166,191
|
12862
|
Discharge summary
|
report
|
Admission Date: [**2152-6-26**] Discharge Date: [**2152-6-30**]
Date of Birth: [**2099-6-21**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
male who was admitted to an outside hospital on [**2152-6-21**] with
CHF and chest pain. The patient ruled out by cardiac
enzymes, but had a BNP greater than 1400. The patient was
started on Natrecor and sublingual nitroglycerin. On
[**2152-6-23**], he became hypotensive with systolic blood pressures
in the 80s, also had chest pain. CK, at that time, was 278
with troponin 9.3. No catheterization secondary to it being
the weekend. His hematocrit was 33 on [**2152-6-26**]. The patient
then had chest tightness. He received sublingual
nitroglycerin and IV Lopressor. The patient was then sent
here for management of CHF with consideration of CABG and
management of now acute renal failure. Otherwise, the
patient has a history of IDDM since age 7, CAD, MI x2,
refused CABG in [**8-5**], and history of CHF. Recent
echocardiogram revealed dilated LV with inferior akinesis,
which was new. The patient also had moderate MR, severe
pulmonary hypertension, and an EF of 30 percent. Otherwise,
the patient has had a CVA in the past. He has a history of
chronic renal insufficiency, peripheral vascular disease,
bilateral fem-[**Doctor Last Name **], status post amputation of his second toe
in both feet, neuropathy, retinopathy, GERD, and the patient
was admitted with chest pain and CHF. On [**2152-6-23**], the
patient had systolic blood pressures in the 80s. He had
chest pain. Sublingual nitroglycerin, morphine, and fentanyl
patch were given. He was admitted to the CCU, got IV
nitroglycerin, heparin gtt, Natrecor, Lasix, and made pain
free, ruled in; however, on the day of admission to the
[**Hospital1 18**], had new ST depressions in V4 through V6, received
sublingual nitroglycerin, became chest pain free, and his CHF
regimen was then changed to Natrecor and Bumex.
ALLERGIES: ATIVAN AND NSAID.
PAST MEDICAL HISTORY: His past medical history is
significant for type 1 diabetes, since the age of 7; MI x2,
CAD, refused CABG in [**8-5**], history of CHF with an EF of 30
percent, history of CVA, history of peripheral vascular
disease, status post bilateral fem-[**Doctor Last Name **], status post
amputation of second toe in both feet, history of neuropathy,
retinopathy, and GERD.
MEDICATIONS: The patient's medications on admission
included,
1. Natrecor 0.1 mg/kg/min.
2. Heparin 850 units/hour.
3. Nitrate 250 mg.
4. Bumex.
5. NPH, 24 units in the morning and 6 units in the evening.
6. PhosLo.
7. Aspirin 81 mg 1 p.o. q.d.
8. Zocor 80 mg 1 p.o. q.d.
9. Plavix 75 mg 1 p.o. q.d.
10. Protonix 40 mg 1 p.o. b.i.d.
11. Multivitamin.
12. Toprol XL 150 mg 1 p.o. q.d.
13. Also the patient at home is on Cozaar, Lasix,
glyburide, and Zestril.
SOCIAL HISTORY: He is retired, wife is a CCU nurse, has
children, no tobacco, no ETOH.
FAMILY HISTORY: His sister has a history of diabetes and has
had an MI in the past.
PHYSICAL EXAMINATION: Physical exam on admission includes
the following, heart rate 87, blood pressure 109/72,
temperature is 98.2 degrees, weight is 92.2 kg, saturating at
99 percent on 2 liters, respiratory rate is 12. Generally,
the patient is a very pleasant male, in no acute distress.
HEENT: Normocephalic, atraumatic. Extraocular movements are
intact. Oropharynx is clear with moist mucous membranes.
Neck is supple with no thyromegaly. JVD is to the jaw.
Cardiac Exam revealed regular rate and rhythm with a
holosytolic murmur at the apex radiating to the axilla. Lungs
are clear to auscultation with crackles one- half the
way up bilaterally. No wheezes or rales. Abdomen has good
bowel sounds, soft, nontender, and nondistended with no
hepatosplenomegaly. Extremities are free of any clubbing,
cyanosis, or edema. Second middle toe is missing
bilaterally. His extremities are cool, positive dopplerable
DPs bilaterally. Positive dopplerable right PT, but no left
PT.
The patient's EKG on admission, normal sinus rhythm; left
atrial enlargement; ST elevations in V1, V2; ST depressions
in V4, V5; T-wave inversion in V5, V6; Q wave in lead III.
Echocardiogram from [**2152-6-23**] revealed a dilated left
ventricle; inferior, inferolateral, distal, anterior, distal
anterior septal and apical akinesis, EF of 30 to 35 percent,
moderate MR, trace AI, mild TR, severe pulmonary
hypertension, left atrial enlargement compared to [**2151-11-28**],
inferior wall motion abnormalities, new left ventricular
function is worse and PA pressures are higher. On [**2152-8-5**],
the patient had a cardiac catheterization, which revealed a
codominant system, LMCA was normal, LAD with 80 percent
proximal stenosis, 90 percent D1 left circumflex, OM1 with 80
percent lesion, RCA 70 percent mid lesion. The patient's
telemetry was normal sinus rhythm. His data on admission,
white count 6.9, hematocrit 33.8, platelet count 191.
Calcium 10.0, sodium 139, potassium 3.8, chloride 101,
bicarbonate 26, BUN 85; creatinine is 5.8, baseline was 3.8.
HOSPITAL COURSE: Cardiac. The patient had an echocardiogram
performed on [**2152-6-27**], which revealed the following: An EF
of 20 percent, left atrium that is mildly dilated, mild
symmetric left ventricular hypertrophy, left ventricular
cavity size is normal, overall left ventricular systolic
function is severely depressed; and left wall motion was as
follows: The patient had resting regional left ventricular
wall motion abnormalities as follows, mid anteroseptal
akinetic, mid inferoseptal akinetic, mid inferior akinetic,
mid inferolateral akinetic, anterior apex akinetic, septal
apex akinetic, inferior apex akinetic, lateral apex akinetic.
One plus TR was seen, one plus MR. [**Name13 (STitle) **] underwent cardiac
catheterization on [**2152-6-27**], which revealed the following:
Right coronary diffusely diseased, proximal LAD diffusely
diseased, left main normal, distal LAD diffusely diseased, D1
diffusely diseased, mid circumflex discrete 70 percent
lesion, obtuse marginal discrete 80 percent lesion.
Selective coronary angiography demonstrated a right dominant
circulation with three-vessel coronary artery disease. The
LMCA had no angiographically apparent flow-limiting stenosis.
LAD was diffusely diseased in the proximal portion with a
more focal 80 percent stenosis and diffuse disease into the
distal vessel, first diagonal branch was diffusely deceased,
the left circumflex had a 60 to 70 percent mid vessel
stenosis, OM1 had focal 80 percent stenosis in proximal
portion, RCA was dominant diffusely diseased vessel, distal
RCA was subtotally occluded with TIMI 0-1 flow. Selective
angiography of the LIMA and RIMA demonstrated normal vessels
without angiographic evidence of flow-limiting
atherosclerotic disease, pull back of catheters from the left
subclavian artery demonstrated no evidence of a
hemodynamically significant stenosis in the major vessel.
Left ventriculography was deferred. The resting hemodynamics
demonstrated moderate pulmonary hypertension with a mean PAP
pressure of 40. Left and right sided filling pressures were
moderately elevated with mean RAP of 14, mean pulmonary-
capillary wedge pressure 29. Cardiac index is preserved at
2.6 liters per minute per sq. m. A 11.5 French and 19.15 cm
long Quinton dialysis catheter was placed in the right
femoral vein at the end of the case. Successful PTCA and
stent of the mid and proximal RCA with a 2.0 x 13 mm pixel
and then by 2.5 x 16 and then by 2.5 x 24 and 2.5 x 12 Taxus
stents back to the ostium. There was no residual stenosis,
no dissection with TIMI 3 flow noted.
Coronary artery disease status post NSTEMI, status post
cardiac catheterization.
The patient was maintained on aspirin, Plavix, Lipitor, and
Lopressor. He was continued on heparin gtt initially. For
afterload reduction, the patient was maintained on Isordil
and hydralazine. ACE inhibitor was not entertained given his
acute on chronic renal insufficiency. Carotid ultrasound was
obtained and revealed noncritical stenoses of his carotid
arteries bilaterally.
Congestive heart failure. The patient was maintained on
Natrecor gtt. Additionally, the patient had his femoral
Quinton pulled and a right IJ Quinton placed for
hemodialysis. The patient was maintained on hemodialysis and
had very good diuretic effect.
Renal failure. The patient was maintained on hemodialysis as
stated above. He had evidence of hyponatremia during his
hospitalization, which was felt secondary to congestive heart
failure as well as acute renal failure.
Insulin-dependent diabetes mellitus. The patient was
maintained on NPH regular insulin sliding scale and the NPH
was titrated up during his hospitalization.
Prophylaxis. The patient was maintained on heparin, bowel
regimen, and PPI.
DISCHARGE DIAGNOSES: Type I diabetes.
Hypertension.
End-stage renal disease.
Hypercholesterolemia.
Peripheral vascular disease.
Status post myocardial infarction with stents to the RCA.
FO[**Last Name (STitle) 996**]P: Dr. [**Last Name (Prefixes) **], CT Surgery, at [**Telephone/Fax (1) 170**].
The patient is to call on [**2152-7-4**] to schedule an appointment
within one week.
The patient was to continue on outpatient dialysis at
[**Location (un) 14248**]Dialysis Center beginning on [**2152-7-4**]. The
patient is to set up an appointment with his primary care
physician within one week of discharge.
DISCHARGE MEDICATIONS:
1. Calcium acetate 667 mg 1 p.o. t.i.d. with meals
2. Multivitamin 1 p.o. q.d.
3. Plavix 75 mg 1 p.o. q.d.
4. Aspirin 325 mg 1 p.o. q.d.
5. NPH, to be used as directed.
6. Toprol XL 25 mg to be taken 5 tablets 1 p.o. q.d.
7. Protonix 40 mg 1 p.o. q.d.
8. Atorvastatin 40 mg 1 p.o. q.d.
DI[**Last Name (STitle) 408**]E STATUS: He will be discharged to home. Will
follow up with Dr. [**Last Name (Prefixes) **] and have hemodialysis.
DISCHARGE CONDITION: Stable. He is oxygenating well on room
air. He is hemodynamically stable and had no further
episodes of chest pain, shortness of breath, or other cardiac
symptoms.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2152-8-31**] 12:58:35
T: [**2152-9-1**] 09:27:03
Job#: [**Job Number 39566**]
|
[
"584.9",
"530.81",
"707.14",
"410.71",
"428.0",
"443.9",
"416.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"99.20",
"37.23",
"00.13",
"36.01",
"36.07",
"39.95",
"38.95",
"88.52",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9995, 10431
|
3000, 3069
|
8917, 9513
|
9536, 9973
|
5144, 8895
|
3092, 5126
|
165, 2020
|
2043, 2894
|
2911, 2983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,724
| 178,990
|
12581
|
Discharge summary
|
report
|
Admission Date: [**2108-3-14**] Discharge Date: [**2108-3-20**]
Service: ACOVE
CHIEF COMPLAINT: Hypertensive urgency
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with a history of hypertension, diabetes type II,
chronic pain from peripheral neuropathy, deep venous
thrombosis who presented to [**Hospital6 2018**] on [**2108-3-13**] in the evening with complaints of slurred
speech, word finding difficulty, headache and nausea. The
dysarthria had been going on for about two days. The nausea
had been intermittent x2 weeks, but on admission was
constant. The patient lives at [**Hospital3 537**], where her
blood pressure was found to be 220 systolic while her
baseline is 160 to 170. She was transferred to [**Hospital6 1760**] for further evaluation.
On evaluation in the Emergency Department, the patient was
found to be neurologically intact, without signs of
dysarthria or aphasia. Nitropaste and intravenous labetalol
were given without much effect. Neurology consult was
obtained. The found that the patient was neurologically
intact, recommended CT of the head. CT of the head showed no
evidence of acute intracranial pathology. The patient was
given 160 mg of Diovan and atenolol 25, with no significant
change. Also, secondary to the patient's complaint of her
pain in her legs, she was given multiple doses of morphine
sulfate as well as Ativan. She at that time had some
decrease in her blood pressure from the 240s to 200s. The
patient was also given 5 of Norvasc, intravenous
nitroglycerin drip was started and a systolic blood pressure
of 160 to 170 was reached at a rate of 40 mcg an hour. The
patient was then transferred to the Medical Intensive Care
Unit due to a lack of beds on the cardiology floor.
PAST MEDICAL HISTORY:
1. Type II diabetes
2. Hypertension
3. Peripheral neuropathy
4. Peripheral vascular disease
5. Deep venous thrombosis
6. Hypothyroid
7. Status post right hip replacement 5 years ago
HOME MEDICATIONS:
1. Diovan 80 qd
2. Oxycodone 20 [**Hospital1 **]
3. Synthroid 0.75 qd
4. Glyburide 2.5 qd
5. Coumadin 6.5 q hs
DRUG ALLERGIES: PHENOBARBITAL
SOCIAL HISTORY: The patient lives at [**Hospital3 **] at
[**Hospital3 537**]. No alcohol or tobacco. Her primary care
physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient is a full code.
PHYSICAL EXAM ON ADMISSION TO MEDICAL INTENSIVE CARE UNIT:
VITAL SIGNS: Temperature 98.8??????, blood pressure 164/72, pulse
86, respiratory rate 16, O2 saturation 96%.
GENERAL: The patient is an elderly female in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils are reactive to
light. Extraocular movements intact. Mucous membranes dry.
NECK: Bilateral bruits. Neck supple, no jugular venous
distention.
CHEST: No wheezes or crackles, transmitted upper airway
sounds.
CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2,
3/6 systolic murmur at the left upper sternal border and
radiating into the carotids, no S3 or S4.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds.
EXTREMITIES: Petechiae on hands as well as feet, no
cyanosis, clubbing or edema.
NEUROLOGIC: The patient is alert and oriented x3. Cranial
nerves II through XII intact, decreased hearing. Motor was
[**1-24**] in all major muscle groups. Sensation intact to light
touch. Gait was not assessed on admission.
LABORATORY STUDIES ON ADMISSION: White count 6.4, hematocrit
33.7, platelets 239. PT 19.6, PTT 46.3, INR 2.7. Sodium
129, potassium 4.2, chloride 88, bicarbonate 29, BUN 17,
creatinine 0.9, glucose 94. 63% neutrophils, 25 lymphocytes,
8 monocytes.
IMAGING: CT of the head showed no acute intracranial
process, moderate mucosal thickening of left sphenoid sinus.
Electrocardiogram was normal sinus rhythm with normal access
and intervals, isolated Q wave in 3 and V1.
HOSPITAL COURSE:
1. CARDIOVASCULAR: HYPERTENSION: The patient was initially
administered multiple medications in the Emergency Department
including nitropaste, labetalol, Diovan 160, atenolol 25,
Norvasc 5 and a nitroglycerin drip was started. In the
Medical Intensive Care Unit the patient was initially on a
nitroglycerin drip, as well as some po labetalol and po
Diovan. She had an episode of hypotension with a systolic
blood pressure into the 70s, during which time she had mental
status changes. The nitroglycerin drip was stopped. She was
given a normal saline bolus and her blood pressure improved
and the patient became responsive. She then, half an hour
later, became unresponsive again but during this time her
systolic blood pressure was in the 130s. Nitroglycerin drip
was restarted for systolic blood pressure of 212. The
patient again became decreased, responsive and neurologic
work up commenced as described below. The patient was also
noted to have positive cardiac enzymes during that time with
a CK peak of 637, an MB of 16, troponin of 11.6 and an MB
index of 2.5. She went for an echocardiogram the following
day which showed an ejection fraction greater than 55%, mild
AF, trace AR and trace MR. [**Name13 (STitle) **] CKs and troponins trended
down through her hospital stay, and it was thought that the
positive enzymes were secondary to her transient hypotension.
2. NEUROLOGIC: The patient initially had a head CT that was
negative. She was evaluated by neurology who found her to be
neurologically intact. The patient then had some left sided
neurologic findings and decline in mental status after the
episode of hypotension. She had an MRI/MRA which showed no
acute infarct, but decreased flow through the right MCA.
Neurology then recommended keeping the patient's systolic
blood pressure in the 160 to 180 range. They hypothesized
that her symptoms were secondary to decreased flow during
hypotension in the setting of a decreased flow through the
right MCA. They also recommended an EEG and carotid
Dopplers. At the time of this dictation, results of carotid
Dopplers are pending. The EEG results are as follows: The
EEG showed an abnormality due to presence of intermittent
left temporal delta slowing suggestive of a subcortical
dysfunction over that region. There was also changes
consistent with a mild to moderate widespread encephalopathy.
No epileptiform features were seen. This was done on the
27th. The patient, on the 28th, was noted to be having an
improved mental status. She had been given significant
amounts of Ativan in the Emergency Department and on arrival
to the Medical Intensive Care Unit. This was discontinued on
the day of the 26th and the patient became more alert and
oriented and less agitated. On this day, she was transferred
to the floor. She did not require any medications for
agitation and her mental status slowly returned to baseline
per her family.
3. HEME: The patient has a history of deep venous
thrombosis. She was continued on Coumadin throughout her
hospital course. She was transiently on aspirin in the
setting of ruling in, however this was then discontinued.
Whether the patient should be on aspirin long term should be
discussed with the patient's primary care physician.
4. PULMONARY: The patient had a chest x-ray on the 26th
that was suggestive of possible pneumonia versus atelectasis
and a repeat two days later showed resolution of this. Her
O2 saturations remained good and no evidence of pulmonary
infection.
5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially hyponatremic and on a fluid restriction. Once she
came out of the Medical Intensive Care Unit and was taking
po's, her hyponatremia spontaneously resolved. Electrolyte
imbalances that were also noted in the Medical Intensive Care
Unit including hypophosphatemia, hypomagnesemia, hypokalemia
also resolved with some minimal repletion of potassium and
magnesium. The patient was taking good po's at the time of
discharge.
DISCHARGE DIAGNOSES:
1. Hypertensive urgency
2. Diabetes type II
3. Hypertension
4. Peripheral neuropathy
5. Peripheral vascular disease
6. Deep venous thrombosis
7. Hypothyroid
DISCHARGE MEDICATIONS:
1. Metoprolol 25 tid with goal systolic blood pressure 140s
to 160s
2. Coumadin 6.5 po q hs
3. Synthroid 0.75 po qd
4. Glyburide 2.5 po qd
5. Colace 100 po bid
6. Senna prn
7. Tylenol prn
8. OxyContin as previously taken
FOLLOW UP: The patient should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 7901**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2108-3-20**] 07:56
T: [**2108-3-20**] 08:34
JOB#: [**Job Number 38929**]
|
[
"437.2",
"428.0",
"458.2",
"250.60",
"244.9",
"276.1",
"357.2",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7964, 8129
|
8152, 8382
|
3930, 7943
|
2001, 2150
|
8394, 8777
|
108, 130
|
159, 1771
|
3473, 3913
|
1793, 1983
|
2167, 3458
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,843
| 198,429
|
40724
|
Discharge summary
|
report
|
Admission Date: [**2155-6-27**] Discharge Date: [**2155-6-27**]
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Unresponsive, cardiac arrest
Major Surgical or Invasive Procedure:
CPR, intubation
History of Present Illness:
87 year old man with a history of CAD s/p MI and stent, bladder
carcinoma in situ, who presents from nursing home found to be
unresponsive and found to be in cardiac arrest. Per collateral
history, he was receiving treatment for a UTI with ciprofloxacin
and azithromycin but otherwise in his usual state of health when
he was found to be unresponsive this morning at his nursing
home. EMS was called and CPR was initiated in the field. An
intraosseous line was placed and he was intubated and CPR was
initiated. CPR was continued for 30 minutes with one round of
ACLS achieved at nursing home. He arrived to the ED undergoing
chest compressions.
.
In the ED, he was found to have a pH 6.94/83/329, and lactate of
14.6, and HCT of 19.7, INR of 3.7, PLTs of 47. A nonsterile
femoral line was placed. 2 chest tubes were placed bilaterally
for emperic PTX treatment. A bedside echo was done by cardiology
which was apparently unremarkable. He was given 1gm epinephrine
boluses 7 times, 2 amps of sodium bicarbonate, and was started
on a levophed gtt, dopamine gtt, neosynephrine gtt, and
epinephrine gtt, and he was given 3L of NS, and 1 unit of blood
hanging. He lost his pulse twice, second time at 1115 but
responded to one last round of epi, making a total of 8 rounds.
His last set of vitals 130/90 HR 80s 100% on vent 15, FIO2 100%,
PEEP 5, Rate of 20.
.
In the MICU, he arrives intubated, sedated and with a pulse. His
initial vitals were BP 107/40, HR 60. Given the patient's
advanced age, lactate of 14.6, pH of 6.94, tenous blood
pressures despite 4 pressors, the MICU team has decided to not
escalate care and deem his code status as DNR/DNI as CPR is not
indicated. He was given 3L of NS, 2 unit of PRBCs.
Past Medical History:
1) Hypertension
2) Myocardial infarction s/p PCI
3) Coronary artery disease
4) Bladder carcinoma in situ, hematuria
.
Social History:
Lives in nursing home. Daughter [**Known firstname 15485**] is HCP. Unable to obtain
further.
Family History:
unable to obtain
Physical Exam:
On admission:
VS: Temp: BP: / HR: RR: O2sat
GEN: Intubated, sedated, thin elderly man
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
CV: RR, S1 and S2 wnl, no m/r/g
RESP: Diffuse, heavy rhonchi bilaterally
ABD: distended, soft, nt, no masses or hepatosplenomegaly, no BS
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Intubated, sedated
.
On discharge: expired
Pertinent Results:
[**2155-6-27**] 10:45AM BLOOD WBC-8.4 RBC-2.32* Hgb-5.8* Hct-19.7*
MCV-85 MCH-25.0* MCHC-29.4* RDW-15.9* Plt Ct-47*
[**2155-6-27**] 10:45AM BLOOD Plt Smr-VERY LOW Plt Ct-47*
[**2155-6-27**] 10:45AM BLOOD PT-36.8* PTT-27.2 INR(PT)-3.7*
[**2155-6-27**] 10:45AM BLOOD UreaN-62* Creat-1.7*
[**2155-6-27**] 10:45AM BLOOD Lipase-16
[**2155-6-27**] 10:49AM BLOOD Type-ART pO2-329* pCO2-83* pH-6.94*
calTCO2-19* Base XS--16
[**2155-6-27**] 10:49AM BLOOD Glucose-342* Lactate-14.6* Na-143 K-4.7
Cl-113*
[**2155-6-27**] 10:49AM BLOOD Hgb-7.0* calcHCT-21 O2 Sat-97 COHgb-2
MetHgb-0
[**2155-6-27**] 10:49AM BLOOD freeCa-2.06*
.
CXR:
1. Small bilateral pneumothoraces with bilateral chest tubes in
place.
2. Endotracheal tube tip terminates 2.6 cm from the carina, and
is slightly
low lying.
3. Diffuse airspace opacities bilaterally, which may reflect
pulmonary edema,
but an underlying infectious process cannot be excluded.
Brief Hospital Course:
87 year old man with a history of CAD s/p MI and stent, bladder
carcinoma in situ, who presents from nursing home found to be
unresponsive and found to be in cardiac arrest. Most likely
etiology of PEA was hypovolemic blood loss given presenting HCT
of 19.7 which is 20 points down from baseline (down from 37 on
[**2155-6-17**] per nsg home records). Would consider blood loss from
bladder CA/hematuria history, vs occult GI bleed. Consider QT
prolongation from recent cipro vs aspiration PNA/hypoxia as
other etiologies. Patient initially with an extremely poor
prognosis, with a lactate of 14.6, pH of 6.94, on four pressors
and MAPs of 50s, incompatible with life and consistent with
diffuse cell death. Urgent family meeting was held and decision
was made to make the patient DNR/DNI. He expired shortly
thereafter with family at bedside. Patient's PCP was [**Name (NI) 653**].
Medications on Admission:
1) ASA 325mg PO daily
2) Atenolol 25mg PO daily
3) Plavix 75mg PO daily
4) Colace 100mg PO BID
5) Proscar 5mg PO daily
6) Imdur 30mg PO daily
7) Senna 8.6mg PO daily
8) Flomax 0.4mg PO daily
9) Oxybutynin 5mg PO Q6H PRN bladder spasm
10) Ciprofloxacin 500mg PO BID [**6-23**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"188.9",
"V45.82",
"414.01",
"401.9",
"V49.86",
"285.1",
"412",
"512.8",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4920, 4929
|
3675, 4563
|
262, 279
|
4987, 4996
|
2734, 3652
|
5048, 5146
|
2292, 2310
|
4891, 4897
|
4950, 4966
|
4590, 4868
|
5020, 5025
|
2325, 2325
|
2706, 2715
|
194, 224
|
307, 2023
|
2339, 2692
|
2045, 2165
|
2181, 2276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,898
| 145,332
|
41106
|
Discharge summary
|
report
|
Admission Date: [**2164-4-17**] Discharge Date: [**2164-4-25**]
Date of Birth: [**2098-1-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents / cefepime / vancomycin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
EGD [**4-18**]
History of Present Illness:
66 year old male with a history of AAA repair w/ multiple
subsequent complications including spinal ischemia with
paralysis, PE, bowel perf w/ graft infection &
bacteremia/fungemia (bacteriodes, strep pneumo and [**Female First Name (un) **]) s/p
left colectomy with colostomy, renal failure requiring dialysis,
complete heart block requiring pacemaker and a subsequent course
complicated by pnuemonia and respiratory failure and
tracheostomy who presents from nursing home with fatigue, found
to have Hct of 12 (baseline Hct of 32). Pt notes increasing
weakness and decreased appetite x 3 days. Pt denies
palpitation, lightheadedness, fevers, chills, n/v, abd pain or
bloody stool from ostomy. He does note dark stool from his
ostomy but this is baseline. Denies any NSAID use, but is on
[**Last Name (un) **]. Denies any history of prior GI bleed.
Of note, he was recently admitted to [**Hospital1 18**] from [**3-20**] to [**2-/2081**]
for pneumonia and sacral osteomyelitis.
In the ED he was found to have guiac positive black stool in
his ostomy. An NG lavage was negative and he was transfused one
unit of PRBC's in the emergency department.
Transplant surgery was consulted in the emergency
department and found no aorto-enteric fistula on CT, but did
show a 15 x 6 cm large right gluteal hematoma.
.
In the ED, initial VS were: 97.5 88 107/49 18 97%
.
On arrival to the MICU, he is fatigued, but otherwise without
complaint.
Past Medical History:
AAA s/p repair with dacron graft
bowel perforation with colectomy and colostomy
T8 infarction
neurogenic bladder -> indwelling foley
s/p PEG placement
s/p tracheostomy
s/p pacemaker for complete heart block
hypertension - off BP meds
hyperlipidemia
COPD
osteoarthritis
recurrent pneumonia c/b respiratory failure
perihepatic fluid collection (s/p IR drainage growing
Clostridium)
sacral ulcers
Social History:
Lives at [**Location (un) **] facility. Married. 1 daughter. Smoked
until [**2163-1-29**]. Denied IVDU. He used to work as a wine
distributor, but is currently on disability.
Family History:
mom with ovarian cancer
father with hypertension
multiple family members with aneurysms
Physical Exam:
Physical Exam on admission:
GENERAL: No acute distress, ill- appearing.
HEENT: Moist mucous membranes.
HEART: S1, S2, no murmur, rub, or gallop.
LUNGS: Clear to auscultation bilaterally.
SKIN: The sacral decubitus has no significant drainage with
well appearing granulation tissue. The ischial decubitus has a
wound vacuum in place
GI: Soft, nontender, nondistended. Colostomy in place, PEG
tube
in place without surrounding erythema or fluctuance
EXTREMITIES: Warm, well perfused.
SKIN: No rash.
Physical Exam on discharge:
Physical Exam:
98, 124/68, 82, 20, 96% on RA
I/Os: 3580/ 2575 urine and 525 stool (getting prep for
conoloscopy)
GENERAL: Alert, interactive, no acute distress
HEENT: mucous membranes moist, Tracheostomy w/ cap in place.
HEART: RRR. Nl S1, S2, no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally, sl diminished at
bases. No w/r/r
GI: Soft, nontender, nondistended. Colostomy in place with
liquid stool with sediments, PEG tube in place without
surrounding erythema or fluctuance
SKIN: sacral wound with wound vac- draining serous drainage.
EXTREMITIES: Warm, well perfused, no pedal edema.
Pertinent Results:
Labs on admission:
[**2164-4-17**] 06:45PM BLOOD WBC-10.1 RBC-1.89*# Hgb-5.3*# Hct-16.9*#
MCV-89 MCH-28.2 MCHC-31.6 RDW-20.2* Plt Ct-246
[**2164-4-17**] 06:45PM BLOOD Neuts-87.0* Lymphs-7.3* Monos-4.7 Eos-0.6
Baso-0.3
[**2164-4-17**] 06:45PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+
Schisto-1+ Stipple-OCCASIONAL
[**2164-4-17**] 07:24PM BLOOD PT-11.0 PTT-28.0 INR(PT)-1.0
[**2164-4-17**] 06:45PM BLOOD Ret Aut-1.7
[**2164-4-17**] 06:45PM BLOOD Glucose-113* UreaN-66* Creat-0.6 Na-132*
K-5.3* Cl-99 HCO3-23 AnGap-15
[**2164-4-17**] 06:45PM BLOOD ALT-33 AST-26 LD(LDH)-119 AlkPhos-98
TotBili-0.1
[**2164-4-18**] 03:16AM BLOOD Calcium-10.0 Phos-2.6* Mg-2.0
[**2164-4-17**] 06:45PM BLOOD Hapto-181
DISCHARGE LABS:
[**2164-4-25**] 05:45AM BLOOD WBC-10.0 RBC-2.95* Hgb-8.6* Hct-27.2*
MCV-93 MCH-29.1 MCHC-31.5 RDW-16.7* Plt Ct-431
[**2164-4-25**] 05:45AM BLOOD PT-11.0 PTT-34.2 INR(PT)-1.0
[**2164-4-25**] 05:45AM BLOOD Glucose-112* UreaN-15 Creat-0.6 Na-134
K-4.5 Cl-103 HCO3-24 AnGap-12
[**2164-4-22**] 05:50AM BLOOD ALT-41* AST-33 AlkPhos-105 TotBili-0.1
[**2164-4-25**] 05:45AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
[**2164-4-24**] 06:12AM BLOOD Albumin-3.0* Calcium-9.5 Phos-2.9 Mg-1.7
[**2164-4-22**] 05:50AM BLOOD Hapto-144
[**2164-4-24**] 06:12AM BLOOD PSA-1.5
IMAGING:
CT Abdomen/Pelvis [**4-17**]:
1. No evidence for aortoenteric fistula. High-density material
in the rectum may be due to bleeding, correlate with rectal
examination.
2. Stable appearance to abdominal aortic repair. Stable
appearance to
mesenteric vessels, and renal arteries, which remain patent.
3. Right gluteal hematoma without evidence for active arterial
extravasation into the hematoma.
4. Soft tissue mass in the proximal right femur, incompletely
evaluated.
Dedicated musculoskeletal imaging is recommended.
5. Stable ventral wall defect.
Bilateral LENI's [**4-18**]:
IMPRESSION: No deep venous thrombosis in either lower extremity
CT OF RIGHT FEMUR:
FINDINGS: The right gluteal hematoma is unchanged in size and
incompletely
evaluated on this examination.
In the subtrochanteric femur, there is a 1.6 x 1.8 x 4.2 cm
enhancing oval
lesion within the medullary canal. The adjacent posterior cortex
of the
posterior femur has a permeative appearance over a length of 10
cm. No other worrisome focal osseous lesions.
There is a sclerotic eccentric lobulated ossified lesion in the
distal medial femur in keeping with a healed non-ossified
fibroma. There is rarefaction of the trabeculae in the superior
acetabulum, likey related to osteopenia.
There are mild vascular calcifications throughout the thigh.
There is marked enthesopathy at the greater trochanter and
periarticular calcifications at the medial aspect of the
femoroacetabular joint near the femoral head-neck junction.
There is enthesopathy at the origins of the right hamstring
tendons. There are mild degenerative changes at the pubic
symphysis and mild-to-moderate degenerative changes at the hip.
A Foley catheter is in place. There are calcifications within
the prostate.
IMPRESSION: Intramedullary enhancing proximal femoral lesion
with associated permeative destruction of the posterior femoral
cortex is concerning for a neoplastic process. Metastatic
disease, plasmacytoma, or lymphoma would be most likely in this
age group.
PROCEDURES:
#EGD [**4-18**]:
Mild esophagitis
Foreign body in the stomach
Angioectasia in the second part of the duodenum
Otherwise normal EGD to third part of the duodenum
#[**2164-4-24**]:
CT GUIDED RIGHT PROXIMAL FEMUR BONE LESION BIOPSY
Indication: Diagnosis of right proximal femur bone lesion.
Procedure: CT-guided right femoral bone lesion biopsy.
Technique: The patient was informed of possible benefits, risks
and
alternatives. Written consent was obtained. A pre-procedural
timeout was
performed using at least 3 patient identifiers including name,
birthday, and medical record number. Site and side of the
procedure, as well as procedure to be performed were confirmed
by the patient.
A localizing CT scan was performed. An appropriate skin entry
site was
selected and the area prepped and draped in the usual sterile
fashion. Local anesthesia in the form of 1% lidocaine was
injected into the skin and subcutaneous soft tissues. A skin
[**Doctor Last Name **] with 11G blade was made. A 16 gauge Bonopty device was
advanced into the bone lesion and 3 bone cores were obtained
with the Bonopty device. Then a spring-loaded biopsy device was
advanced through the same coaxial sheath into the bone lesion.
Needle position was confirmed by CT. Three soft tissue core
specimens were obtained and were also submitted for pathology;
the specimens were hand-delivered to the lab.
The needle was removed, the skin entry site cleaned and a
sterile bandage
applied. The patient tolerated the procedure well and was
transferred to the recovery area in satisfactory condition.
No IV sedation was administered as the patient is paraplegic and
has no
sensation below the waist.
FINDINGS:
1. Right femoral bone lesion.
2. CT images confirm biopsy needle within the lesion.
IMPRESSION: Successful CT-guided biopsy of right femoral lesion.
# FLEX SIGMOIDOSCOPY on [**4-25**]: the preliminary report was
normal.
Brief Hospital Course:
66 year old male with a history of AAA repair w/ multiple
subsequent complications including spinal ischemia with
paralysis, PE, bowel perf w/ graft infection &
bacteremia/fungemia (bacteriodes, strep pneumo and [**Female First Name (un) **]) s/p
left colectomy with colostomy, renal failure requiring dialysis,
complete heart block requiring pacemaker and a subsequent course
complicated by pnuemonia and respiratory failure and
tracheostomy who presents from nursing home with fatigue, found
to have Hct of 12 (baseline Hct of 32). He was then found to
have a right gluteal hematoma and dark stool from his ostomy and
a new Right femur mass concerning for metastatic process.
.
# Anemia: The patient presented with a hct 12 from a baseline of
32, and is s/p 5 units PRBC. Etiologies for this profound
anemia initially included GI bleed vs. large gluteal hematoma
vs. marrow suppression from either Bactrim or Linezolid.
Hemolysis labs were negative. EGD showed mild esophagitis,
foreign body in the stomach, angioectasia in the second part of
the duodenum without evidence of active bleed, which were not
felt to account for the low hematocrit. The patient denied any
melena or [**Female First Name (un) **] BRBPR, although he was noted to have dark output
from his ostomy. He had blood transfusion last on [**4-18**] with
appropriate response. He was on fundaparinux for DVT ppx after
he became a paraplegic over 1 year ago given that there was a
question of HIT. Given that he is far out from his initial
paraplegic event and his risk of bleeding, we decided to
continue to hold anticoagulation for now. His Linezolid was also
held given concern for BM suppression, however this was less
likely to be the cause given that other cell lines were normal-
so he was restarted on Linezolid as recommended by ID. His Hct
has been stable in the mid 20s for the last several days. His
ostomy output has changed from dark black to brown color. He was
prep to have a colonoscopy and a flexsigmoidoscopy done today;
however his stool output was still not clear and he refused to
have the rest of the prep. So he only had a flex-sigmoidoscopy
looking at his rectal pouch and this was normal. He was also
started on PPI which we have continued
- Continue Protonix 40mg Qday
- Hold fondaparinux given large gluteal hematoma
- Hold iron supplements to prevent dark stool
- Restarted on Linezolid per ID recs
- Continue to monitor hematocrit
.
# Soft tissue mass in proximal femur: CT abd/pelvis partially
showed a soft tissue mass in the right proximal femoral shaft
that occupies the marrow cavity. Also noted possible slight
cortical irregularity along the posterior margin of the femur.
Concerns for a neoplastic process in the RLE including
osteochondroma, osteosarcoma or chondrosarcoma. MRI unable to
be performed in the setting of a pacemaker. So did designated CT
of right femur and there is also findings concerning for
metastatic process. ? source, possible GI since had enhancing
rectal area seem on prior CT. So he was planning to have a
colonoscopy and flex-sigmoidoscopy today, however he was not
fully cleared by the prep and refused to have additional prep-
so he had only the flex-sig which at the rectal pouch and this
was normal. He will likely need to have another colonoscopy in
the future, especially if suspicon is high for GI malignancy.
PSA was normal.
- Pt going for CT guided biopsy of his R proximal femur mass on
[**4-24**]. Site on the posterior thigh is intact, no signs of
bleeding or hematoma. Results are pending and DR. [**Last Name (STitle) 6137**] will
be following up the results and will give further instructions
for follow-up.
- Pending final bone biopsy results [Addendum: this was negative
for malignancy]
.
# Sacral decubitis and left ischial ulcer: On last admisison he
was found to have sacral and left ischial osteomyelitis. Bone
cultures grew acinetobacter, pseudomonas, and coag neg staph. Pt
was intitially started on linezolid, meropenem, high-dose
Bactrim and tobramycin. Tobramycin was discontinued by
infectious disease on [**4-11**]. On admission, his meropenem was
continued for pseudomonal coverage. We held linezolid given its
potential for marrow suppression and the thought that his coag
negative staph was not the primary organism responsible for his
osteomyelitis. After conferring with his infectious disease
specialist Dr. [**Last Name (STitle) 6137**], Bactrim was contniued for MDR
acenetobacter coverage depsite its risk of causing aplasitic
anemia. He was also restarted on Linezolid on the day of
discharge [**4-25**] given that his anemia was very unlikely to be due
to his linezolid. He had a wound nurse evlauted the patient and
recommended using STEP 1 air mattress as well as doing using
wound vac drsg- especific instructions on the discharge orders.
He will be following with Dr. [**Last Name (STitle) **], ID in [**Month (only) 547**]. He should
cont to have all his antibiotics until then.
- Continue suppresive fluconazole therapy
- Continue meropenem for pseudomonas coverage
- Continue bactrim DS 2 tablets TID for MDR acenetobacter
coverage
- Restarted on linezolid 600mg [**Hospital1 **] for coag negative staph
- He will be following up with DR. [**Last Name (STitle) 6137**] on [**5-23**]
- Please check this labs once per week:
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBCdiff, BUN, CREA, LFTs, Tobra trough, ESR, CRP
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
.
.
# ? h/o PE: The patient has a questionable history of PE and hx
of HIT, so he was on fundaparinux- Although this was on previous
notes, pt denies ever having an PE. This was clarify by records
that pt was placed on fundaparinux for PPX post paraplegia which
has been > 1 year ago. He had + HIT antibody, but neg serotonin
which means that he does not have HIT. At this time given risk
of bleeding, will hold off on restarting on ppx while inpatient.
Bil LE doppler US were negative for DVT. He is also safe to have
heparin. Now given new concern for malignancy will reconsider
restaring on anticoag ppx once stable and while hospitalized.
- Will continue holding fondaparinux for now
.
# Neurogenic bladder. He is using continuous catheterization
at this point. Once his decubitus is improving, ID will
readdress intermittent catheterization to decrease the risk of
infections.
- Continue foley
.
# Depression/anxiety: Pt's symptoms are currently well
controlled. There has been concern that he does not appear to
fully understand his current medical issues.
- Conitinue with paxil 20 mg daily
- Continue ativan 0.5 mg q4h prn
.
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: PPI, fondaparinux held
# Access: single lumen picc, 18G
# Communication: Patient
# Code: Full code
# Disposition: To [**Hospital1 **] in [**Location (un) 701**]- ([**Telephone/Fax (1) 21858**]
Transitional Issues:
====================
- trend HCT make sure he still stable
- would likely need further discussion about anticoagulation, if
biopsy + for malignancy
- Follow-up on bone biopsy, should be available by Friday- Marh
30th or [**Telephone/Fax (1) 766**] [**4-29**]. DR. [**Last Name (STitle) 6137**] will be calling with
further recommendations once results are available if you do not
hear from her by [**Last Name (LF) 766**], [**4-29**] please call [**Telephone/Fax (1) 2756**] and
ask to page her.
- Continue all antibiotics at least until 04/25th when he sees
ID for further recommendations
- Cont wound care
Please feel free to contact either [**Name (NI) 32348**] [**Last Name (NamePattern1) 17157**], [**Name (NI) 4207**] 3 or
Dr. [**Last Name (STitle) **], [**Name6 (MD) **] attending MD with any additional questions
regarding his care- [**Telephone/Fax (1) 2756**]
Medications on Admission:
1. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five (5)
ml PO twice a day.
7. Juven 7-7-1.5 gram Powder in Packet Sig: One (1) packet PO as
directed previously.
8. magnesium oxide Oral
9. gabapentin 250 mg/5 mL Solution Sig: Two Hundred (200) mg PO
BID (2 times a day).
10. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
11. therapeutic multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
12. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours): Continue at least through
[**2164-5-1**] or as otherwise directed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] MD.
13. sulfamethoxazole-trimethoprim 400-80 mg/5 mL Solution Sig:
Two [**Age over 90 11578**]y (280) mg Intravenous every eight (8) hours:
Continue at least through [**2164-5-1**] or as otherwise directed by
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] MD.
14. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): Continue for course as directed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**]
MD.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation Q2H (every 2
hours) as needed for SOB.
16. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours) as needed for SOB.
Discharge Medications:
1. paroxetine HCl 10 mg/5 mL Suspension Sig: Twenty (20) mg PO
DAILY (Daily).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Anxiety: Please hold for sedation and
RR<12.
3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as
needed for SOB/Wheezing.
7. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day): 2 tables TID until he is told by
ID to stop .
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours): Continue at least through
[**2164-5-22**] or as otherwise directed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] MD.
12. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: Continue for course as directed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**]
MD.
.
13. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
mLs Mucous membrane twice a day.
14. Outpatient Lab Work
CBCdiff, BUN, CREA, LFTs, Tobra trough, ESR, CRP
FREQUENCY: Qweekly while on antibiotics
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
- Right gluteal hematoma
- Possible lower GI bleed
- anemia
- Right femur mass
- sacral wound infection
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:
Dear Mr. [**Known lastname 1924**],
You were admitted to [**Hospital1 18**] for low red blood count and concern
for bleeding. You were found to have a large hematoma on your
right gluteal area. you were also found to have darker than
usual stool in your ostomy that was + for blood, even though you
are known to take iron suplements. You had a cat-scan of your
abdomen and pelvic area and you were found to have a mass on
your right femur. There is a concern for metastatic disease and
you had a bone biopsy on [**4-24**]. Your prostate levels were normal
and you had a flex-sigmoidoscopy for evaluation of your rectal
pouch which was also normal. Dr. [**Last Name (STitle) 6137**] will be contacting
you with the results of your bone biopsy and further plans.
We have made the following changes to your medications:
- STOP fundapurinox given that this was given for phrophylaxis
after you became paraplegic and this has been over 1 year and
given your risk of bleeding.
- RESTART ON Linezolid 600mg twice daily
- START on wound vacs for your sacral and ischeal wound
It was a pleasure taking care of you.
Followup Instructions:
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBCdiff, BUN, CREA, LFTs, Tobra trough, ESR, CRP
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Department: [**Hospital3 249**]
When: WEDNESDAY [**2164-5-23**] at 10:00 AM
With: [**Last Name (NamePattern5) 14644**], MD, PHD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: [**Hospital Ward Name **] [**2164-10-8**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"272.4",
"730.15",
"530.10",
"V44.0",
"041.7",
"496",
"707.03",
"707.04",
"V44.3",
"285.1",
"300.00",
"729.92",
"V44.1",
"344.1",
"401.9",
"537.82",
"707.22",
"707.24",
"596.54",
"V45.01",
"311",
"733.90",
"V12.55",
"V15.82",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"45.13",
"77.45",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
20454, 20526
|
9001, 15926
|
320, 336
|
20683, 20683
|
3716, 3721
|
21992, 22832
|
2444, 2533
|
18691, 20431
|
20547, 20662
|
16846, 18668
|
20859, 21649
|
4489, 8978
|
3099, 3697
|
3084, 3084
|
15947, 16820
|
21678, 21969
|
273, 282
|
364, 1817
|
3736, 4472
|
20698, 20835
|
1839, 2235
|
2251, 2428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,472
| 188,190
|
21+55179
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-12-5**] Discharge Date: [**2178-12-21**]
Date of Birth: [**2114-2-8**] Sex: M
Service: MEDICINE
Allergies:
Doxepin / Levofloxacin / Oxycontin
Attending:[**First Name3 (LF) 287**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 year-old gentleman with history of lung cancer s/p right
pneumonectomy in [**2174**], severe COPD, recently discharged from
[**Hospital1 18**] MICU [**2178-12-2**] s/p tracheostomy and [**Month/Day/Year 282**] placement after
admission for respiratory failure due to pneumonia, now
re-admitted to [**Hospital1 18**] with fever, hypotension.
On last admission, patient unabled to be weaned from the
ventilator. After tracheostomy and [**Hospital1 282**] tube placement, he was
discharged to [**Hospital1 **] on [**2178-12-2**] for vent weaning. While there,
was constipated according to wife. On [**2178-12-4**], patient became
agitated and hypotensive to 82/58 and transferred back to [**Hospital1 18**]
ED.
On presentation to the [**Hospital1 18**] ED, he was found to be hypotensive
to 64/56, tachycardic to 120, febrile to 102.8F and agitated.
Patient had several large loose bowel movements in the ED. Also
found to have a drop in hct from 27.8 on arrival to ED to 22.9
on repeat draw one hour later. (Hct 26.9 on discharge.)
Of note, femoral line attempted at [**Hospital1 **] but unsuccessful due
to patient's agitation.
In the [**Last Name (LF) **], [**First Name3 (LF) **] attempt at IJ central line placement was
unsuccessful. A femoral central intravenous catheter was
placed. He was given IVF and started on Neosynephrine for blood
pressure support with good response. He received a total of 4
Liters of normal saline, flagyl 500mg IV x1, vancomycin 1 gram
IV x1, ceftriaxone 1gram IV x1, 2U PRBC.
Past Medical History:
1. Squamous cell lung carcinoma, status post right
pneumonectomy in [**2174**].
2. Prostate cancer, status post radical prostatectomy.
3. Perioperative pulmonary embolus [**2174**].
4. Type 2 diabetes mellitus.
5. Chronic obstructive pulmonary disease.
6. Atrial fibrillation.
7. Transient ischemic attack in [**2165**].
8. Gout.
9. Atypical chest pain since [**2164**].
10. Gastroesophageal reflux disease.
11. Obstructive sleep apnea. unable to tolerate BiPAP.
12. Hypertension.
13. Colonic polyps.
14. Hypercholesterolemia.
15. Basal cell carcinoma on his back.
16. Anxiety.
17. Sciatica.
18. History of herpes zoster.
19. multiple admissions for pneumonia (including pseudomonas)
and bronchitis, last in [**10-31**] resulting in ventilator
dependence, trach and [**Date Range 282**] placement
20. vitamin B12 deficiency.
21. Diastolic heart failure. Echo [**7-31**]: LVEF>55%
21. Cataracts
22. bradycardia on amiodarone
Social History:
Recently discharged to [**Hospital **] rehab s/p trach and [**Hospital 282**].
He has a 3-pack-per-day tobacco history but quit in [**2174**] and an
overall 160-pack-per-year history.
No recent history of alcohol use.
Family History:
Mother with coronary artery disease.
Physical Exam:
Agitated on arrival, kicking leg with femoral line. Sedated on
versed drip.
Vital signs: temp: 99.0F BP: 110/70 on 1.5mcg/kg/min of
Neosynephrine HR: 46
Vent settings: AC 0.40, 18x550, PEEP 5
Gen: sedated on versed drip.
HEENT: pinpoint pupils (fentanyl given in the ED.
Chest: absent breath sounds on right, transmitted upper airway
sounds on left, otherwise clear. Bruising on right upper chest
with guaze taped.
Heart: bradycardic, regular rhythm, exam limited by breath
sounds
Abd: soft, nontender, normoactive bowel sounds, G-tube site
clean, without erythema or induration
Extr: 2+ DP and radial pulses bilaterally, symmetric bilateral
1+ pitting edema in upper extremities, symmetric bilateral trace
pitting edema in lower extremity. Left femoral line site with
some oozing, but no ecchymosis or palpable hematoma or bruits.
2x2cm midline coccyx decubitus ulcer, green exudative material-
exam limited by patient's agitation. ?stage 3 or 4
Neuro: sedated
Pertinent Results:
[**2178-12-5**] 12:52AM HGB-7.6* calcHCT-23
[**2178-12-5**] 12:40AM HCT-22.9*
[**2178-12-5**] 12:18AM COMMENTS-GREEN TOP
[**2178-12-5**] 12:18AM LACTATE-2.2*
[**2178-12-5**] 12:18AM HGB-9.0* calcHCT-27
[**2178-12-4**] 11:50PM GLUCOSE-205* UREA N-23* CREAT-1.1 SODIUM-144
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-40* ANION GAP-11
[**2178-12-4**] 11:50PM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-142*
AMYLASE-16 TOT BILI-0.7
[**2178-12-4**] 11:50PM LIPASE-16
[**2178-12-4**] 11:50PM ALBUMIN-3.4 CALCIUM-8.5
[**2178-12-4**] 11:50PM WBC-19.5*# RBC-2.91* HGB-8.7* HCT-27.8*
MCV-96 MCH-29.8 MCHC-31.2 RDW-14.4
[**2178-12-4**] 11:50PM NEUTS-97.3* BANDS-0 LYMPHS-1.2* MONOS-1.5*
EOS-0 BASOS-0.1
[**2178-12-4**] 11:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2178-12-4**] 11:50PM PLT SMR-NORMAL PLT COUNT-321
[**2178-12-4**] 11:50PM PT-21.3* PTT-54.3* INR(PT)-2.9
CXR: complete white out of the right hemithorax, clear left
hemithorax. no pneumothorax.
EKG: NSR at 78 bpm with first degree AV block, no changes from
baseline.
Brief Hospital Course:
64 year-old male with history of lung cancer post-right
pneumonectomy, severe COPD, recent trach and [**Year/Month/Day 282**] placement and
antibiotic course for pneumonia, now returns from [**Hospital **] rehab
with diarrhea, stage IV sacral decubitus ulcer, and sepsis. No
source of infection had been identified so far. He was C-diff
negative, blood/urine/sputum culture had not yield any organism.
He was treated empirically with ceftazidime, vancomycin and
metronidazole for 7 days. His blood pressure responded to fluid
challenge and he has been normotensive since then. He was
started on stress dose steroid which was weaned off. He was
gradually weaned off ventilation and tolerated trach mask well.
His blood sugar was well controlled with glargine and sliding
scale. He was also noted to have decubitus ulcer. Plastic
surgery was consulted and felt that debridement was not
necessary. Therefore, he was cotinued on wet to dry dressing,
Kinair bed and his nutrition was optimized. He remiained in
normal sinus rhythm and is on coumadin for history of atrial
fibrillation.
He was very agitated in the ICU. He was weaned off fentanyl drip
and put on fentanyl patch. He also was put on standing zyprexa
and prn haldol, morphine. He was also on standing valium and was
actually thought to be in benzo withdrawal as his wife claims
that he was on valium at home.He is full code and his health
care proxy is his wife.
.
Medications on Admission:
1)Paroxetine 20mg QD
2)Ferrous Sulfate
3)Colace 100mg [**Hospital1 **]
4)MVI
5)Atorvastatin 10mg QD
6)vitamin B12 [**2173**] mcg PO QD
7)Combivent neb q2-4 hr
8)Senna 1tab [**Hospital1 **]
9)Coumadin titrate to INR
10)Insulin SS + NPH fixed dose
11)Prednisone taper (starting [**12-3**] as 20,20,10,10,5,5, off)
12)Ambien 10mg qhs prn insomnia
13) Flovent 2 puffs [**Hospital1 **]
14) Fentanyl 75 mcg/hr Patch Q72HR
15) Lactulose
16) Percocet prn
17) Valium PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Paroxetine HCl 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Two
(2) Puff Inhalation Q6H (every 6 hours).
5. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Fentanyl 75 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
10. Warfarin Sodium 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
11. Olanzapine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. Ascorbic Acid 100 mg/mL Drops [**Hospital1 **]: 2.5 ml PO DAILY (Daily).
13. Diazepam 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours).
14. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
15. Haloperidol 3-5 mg IV Q4H:PRN
16. Morphine Sulfate 2 mg/mL Syringe [**Hospital1 **]: [**12-2**] ml [**Month/Day (1) **] Q4H
(every 4 hours) as needed.
17. Insulin Glargine 100 unit/mL Solution [**Month/Day (1) **]: Twenty Eight (28)
unit Subcutaneous at breakfast.
18. Ceftazidime 1 g Recon Soln [**Month/Day (1) **]: One (1) Recon Soln
Intravenous every eight (8) hours for 4 days.
19. Vancocin HCl 1,000 mg Recon Soln [**Month/Day (1) **]: One (1) Recon Soln
Intravenous every twelve (12) hours for 4 days.
20. Flagyl 500 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO three times a
day for 4 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. sepsis
secondary:
1. lung cancer post right pneumonectomy
2. type 2 diabetes
3. COPD
4. atrial afibrillation
5. gout
6. GERD
7. hypertension
8. hypercholesterolemia
Discharge Condition:
stable
Discharge Instructions:
Please return to the hospital if you have shortness of breath,
fever or if there are any cocnerns at all. PLease take all your
prescribed medication
Followup Instructions:
to rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**] MD, [**MD Number(3) 289**]
Completed by:[**2178-12-9**] Name: [**Known lastname 32**],[**Known firstname 33**] F Unit No: [**Numeric Identifier 34**]
Admission Date: [**2178-12-5**] Discharge Date: [**2178-12-21**]
Date of Birth: [**2114-2-8**] Sex: M
Service: MEDICINE
Allergies:
Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan
Attending:[**First Name3 (LF) 35**]
Addendum:
Patient was almost ready for discharge when he developed fever.
His antibiotic has been changed to Vancomycin/zosyn since
[**2178-12-11**]. There has been no source of infection so far. He
remained afebrile throughout the rest of the hospital stay.
Blood/urine/sputum culture has been negative to date. CXR has
also been clear. He was also started on levophed for hypotension
and this was gradually weaned off. He was initally on
tracheostomy mask. However, he developed hypercarbia which
resolved when patient was put back on assist controlled
ventilation. Pressure supposrt trial was tolerated well.
Decubtius ulcer was re-evaluated by the plastic surgery team and
was felt that debridement is not necessary at the moment.
His pain/axiety has been hard to control. He is currently on
standing haldol, ambien, valium and fentanyl patch with PRN
oxycodone & morphine. On discharge, agitation seems to be better
controlled. Of note, he continues to drop his blood pressure at
night (SBP has dipped as low as the 70s), but as he is
completely asymptomatic during these episodes with adequate
mentation/urine output, no treatment is necessary.
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: 4.5 gm
Intravenous Q8H (every 8 hours) for 3 days: last day [**2178-12-24**].
9. Ascorbic Acid 100 mg/mL Drops Sig: Five (5) ml PO BID (2
times a day).
10. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
11. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
12. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QD for 3 days.
14. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
unit Subcutaneous once a day: at breakfast.
15. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours: fentanyl patch 125 mcg/hr q72
hours.
16. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours: fentanyl patch 125mcg/hr q72hrs.
17. Haloperidol 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
18. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Oxycodone HCl 5 mg Tablet Sig: 2-4 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
20. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
1. sepsis
secondary:
1. lung cancer post right pneumonectomy
2. type 2 diabetes
3. COPD
4. atrial afibrillation
5. gout
6. GERD
7. hypertension
8. hypercholesterolemia
9. decub ulcer
Discharge Condition:
stable
Discharge Instructions:
Please return to the hospital if you have shortness of breath,
fever or if there are any concerns at all. Please take all your
prescribed medications
Please have your INR checked once a week.
Followup Instructions:
transfer of care to [**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36**] MD, [**MD Number(3) 37**]
Completed by:[**2179-8-4**]
|
[
"511.8",
"584.9",
"250.00",
"V44.0",
"304.11",
"041.19",
"427.31",
"272.0",
"428.30",
"707.03",
"724.3",
"173.5",
"304.41",
"491.21",
"266.2",
"292.0",
"038.9",
"V10.11",
"518.84",
"V10.46",
"427.89",
"V44.1",
"274.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13177, 13258
|
5217, 6645
|
301, 308
|
13485, 13493
|
4102, 5194
|
13734, 13926
|
3057, 3096
|
11310, 13154
|
13279, 13464
|
6671, 7136
|
13517, 13711
|
3111, 4083
|
255, 263
|
336, 1859
|
1881, 2806
|
2822, 3041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,465
| 185,811
|
19525
|
Discharge summary
|
report
|
Admission Date: [**2136-7-17**] Discharge Date: [**2136-7-19**]
Date of Birth: [**2062-4-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
epigastric pain and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 74-year-old gentleman who was discharged
on [**2136-7-12**] after undergoing R carotid stenting on [**2136-7-11**]. He
has had emesis for the past two days with any PO. Emesis was
first yellow and bilious but has turned brown. Denies any
coffee
ground emesis or blood in vomit. Reports epigastric pain that
was relieved by vomiting. Pain sharp in nature but does not
radiate to back Also reports some associated loose stools.
Decreased appetite. Denies any fever or chills.
Past Medical History:
PMH:
S/P Right Carotid stent [**7-10**]
CAD,
S/P CABG with MVR [**12-5**].
cLDL 105 from [**3-5**],
CRI 1.5,
Ischemic cardiomyopathy,
LV systolic dysfunction,
EF less than 20%,
NYHA class II-III,
Post-op ventricular tachycardia,
Tobacco abuse
Social History:
pos smoker
pos alcohol
Family History:
non contributaary
Physical Exam:
Physical Exam:
Temp-98.7 HR-70 BP-91/40 RR-18 O2-100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: soft crackles B
ABD: soft, nondistended, negative murphys, tender to deep
palpation in RUQ, no rebound, no guarding
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2136-7-16**] 09:15PM WBC-14.8*# RBC-3.50* HGB-10.7* HCT-32.2*
MCV-92 MCH-30.6 MCHC-33.3 RDW-13.8
[**2136-7-16**] 09:15PM NEUTS-92.5* LYMPHS-5.2* MONOS-2.1 EOS-0.1
BASOS-0.2
[**2136-7-16**] 09:15PM PLT COUNT-225
[**2136-7-16**] 09:15PM PT-14.3* PTT-26.8 INR(PT)-1.2*
[**2136-7-16**] 09:15PM GLUCOSE-144* UREA N-38* CREAT-2.0* SODIUM-143
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-27 ANION GAP-13
[**2136-7-16**] 09:15PM ALT(SGPT)-33 AST(SGOT)-67* ALK PHOS-79 TOT
BILI-1.0
[**2136-7-16**] 09:15PM LIPASE-20
[**2136-7-17**] CT Abd : 1. Partial gallbladder distention, with mild
wall thickening and impacted stone in gallbladder neck. Please
correlate clinically for evidence of acute cholecystitis.
2. Left inguinal hernia containing sigmoid colon, without
evidence of
obstruction.
3. Volume overload with small pericardial and pleural effusions,
as well as diffuse mesenteric and subcutaneous edema.
4. Diffuse atherosclerosis involving thoracoabdominal aorta and
coronary
arteries, with infrarenal abdominal aortic, [**Hospital1 **]-iliac, and left
common femoral aneurysms. Multiple intraluminal calcifications
suggestive of focal dissections versus eccentric plaques, cannot
be assessed without intravenous
contrast.
[**2136-7-19**] Cardiac echo : The left atrium is moderately dilated.
The estimated right atrial pressure is 10-15mmHg. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. There is mild
to moderate global left ventricular hypokinesis (LVEF = 40%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild global
hypokinesis. Mild mitral reguritation with normal valve
morphology. Pulmonary artery hypertension. Prominent left
pleural effusion.
Compared with the prior study (images reviewed) of [**2135-1-3**], left
ventricular systolic function is now more depressed and without
regional dysfunction.
Brief Hospital Course:
Mr. [**Known lastname 17204**] was evaluated by the Acute Care Service in the
Emergency Room. His abdominal ultrasound from [**Location (un) 620**] was
reviewed and gallstones were noted without any dilated ducts.
He had an abdominal CT to look for any other pathology however
it noted cholelithiasis and atherosclerosis. His WBC was 14K.
He was admitted to the ICU as he had some hypotension with
systolic BP's 80-90 and he required fluid resuscitation, serial
enzymes due to his EKG which showed some ST depression and
briefly was placed on pressors. His Troponins were mildly
elevated but he had no chest pain or shortness of breath. The
Cardiology service felt he had some demand ischemia due to
possible infection and recommended a cardiac echo which showed
no new wall motion abnormalities.
Following fluid replacement his pressors were weaned quickly and
his BP was 110/50. He was afebrile and his abdominal pain had
resolved. He was transferred to the Surgical floor.
His diet was resumed on day 2 with clear liquids, his LFT's were
normal and he had no abdominal pain. He actually felt hungry.
Over the next 24 hours he was advanced to regular and tolerated
it well without any nausea or vomiting. His femoral line which
was placed in the Emergency Room was removed on [**2136-7-18**] and
after that he was able to get up and ambulate.
Unasyn was started on admission with cholecystitis as a working
diagnosis but it was stopped on [**7-18**] as he had a normal WBC,
normal LFT's and he was pain free. He remained afebrile.
He was discharged to home on [**2136-7-19**] and will follow up with Dr.
[**Last Name (STitle) **] in 3 weeks. Should he have any other abdominal pain
or similar symptoms he was instructed to call the [**Hospital 2536**] Clinic.
Medications on Admission:
atorvastatin 80', plavix 75', lisinopril 20',
ativan 0.5''' prn, asa 325', metoprolol 100', mirtazapine 7.5'
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
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 epigastric pain and
vomiting.
The ultrasound at [**Location (un) 620**] showed some gallstones and the CT
scan here was essentially the same with stones in the
gallbladder but no dilated ducts. Your pain and vomiting
resolved and you are tolerating a regular diet. Your liver
function tests are normal and you do not have any signs of
infection.
* Your cardiac enzymes were a bit elevated but that could have
been due to some low blood pressure which has since resolved.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-8-13**] 1:15
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-8-13**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2137-2-25**]
1:00
Completed by:[**2136-7-19**]
|
[
"V45.81",
"995.91",
"038.9",
"574.00",
"410.71",
"585.9",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6230, 6236
|
3943, 5718
|
342, 349
|
6295, 6295
|
1558, 3920
|
6985, 7470
|
1202, 1221
|
5878, 6207
|
6257, 6274
|
5744, 5855
|
6446, 6962
|
1251, 1539
|
274, 304
|
377, 877
|
6310, 6422
|
899, 1145
|
1161, 1186
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,996
| 105,371
|
1104
|
Discharge summary
|
report
|
Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-17**]
Service: MED
Allergies:
Sulfonamides / Ticlid / Persantine / Aspirin / Benadryl /
Xylocaine / Prevacid
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
respiratory distress and weakness
Major Surgical or Invasive Procedure:
pericardial window
History of Present Illness:
This 86 year old man with h/o Afib(on warfarin), CHF, CAD(s/p
AMI '[**33**]), and PVD, developed a fever 1 wk prior to admission,
and since his primary physician had relocated, he opted to treat
himself with amoxicillin 1000 mg tid, using pills that he kept
for dental procedures. His fever resolved, but he developed
myalgias and arthralgias as well as increasing dyspnea. He
presented to the ED and an echocardiogram on [**6-10**] revealed a
large pericardial effusion, EF-30%, most of fluid in posterior.
region. Tamponade physiology. Pulsus 22-25. Pt. went to OR for
pericardial window, approx. 1 liter of blood tinged fluid was
drained(gram stain neg./prelim. cx neg for malignant cells). Pt
was extubated on [**6-12**], without incident.
Past Medical History:
Afib(on warfarin)
CHF
CAD(s/p AMI '[**33**])
PVD
Pulm. HTN
asthma
gout
CEA('[**36**])
CVA('[**35**])
hypothyroidism
Social History:
no tobacco or EtOH
Lives with wife, a receptionist
Retired pharmacist
Physical Exam:
T: 97.2 HR: 77 (A Fib) RR: 22 BP: 110/47 O2sat: 99 4L NC
Gen: in NAD.
HEENT: PERRL, neck supple
Lungs: diffuse crackles, few wheezes in B middle to lower lobes
Chest: CT in place with dry dressing. Heart irregular rhythm. No
murmurs
Abd: +mass R middle to lower quadrant. Soft, non-tender. +BS
Ext: 1+ edema to mid-calf. Ecchymoses, varicose veins B
Neuro: A&Ox3. Non-focal
Pertinent Results:
Brief Hospital Course:
Prior to going to the Operating Room for the pericardial window
procedure, he was given 2 units of FFP and coumadin(INR-1.8) was
held. His Nitrates and HCTZ were also temporarily held. Mr [**Known lastname **]
was eventually weaned from the ventilator and extubated on
[**2144-6-12**] after a transient episode of tachycardia and O2
desaturation that required lopressor and increase in his O2.
His BP remained stable, his JVD and edema decreased, and a
repeat ECHO on [**2144-6-11**] showed sm. pericardial effusion, RA/[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7151**] dilated, mod-severe TR/MR, severe apical hypokinesis,
mild hypokinesis of rest of LV After extubation in the CCU, pt
stabilized and was returned to floor. Initially, pt was dyspnic,
but denied pain, N/V/HA/fevers. CT remained in place, and was
removed [**6-15**] by cardiac surgery without complications. Pt
started on ethacrinic acid and HCTZ on [**6-15**] to aid in diuresis
(this regimen is one of the only ones he tolerates due to
multiple drug reactions), with close attention paid to
electrolytes. The right lung showed a pleural effusion, but the
patient elected to attempt to reduce the effusion with diuresis
alone and not to perform thoracentesis. Pt had physical therapy
daily, and improved significantly in the few days after being
returned to the floor. When INR came down to patient's baseline
on [**6-16**], pt was restarted on his home dose of coumadin (2 mg po
qd 5 days of the week, 3 mg 2 days of the week). The patient
stated his MD [**First Name (Titles) 7152**] [**Last Name (Titles) 7153**] his INR at 1.3 to avoid
nosebleeds at higher INRs, but it was explained that a range of
[**1-21**] was required for prevention of stroke in patients with
A-fib. Pt understood. On the day of discharge to [**Hospital 38**]
Rehabilitation Center, his INR was 3.1, so coumadin was held,
with plan to have daily INR checks until it stabilizes, then
restart in rehab. Pt conitnued to have good O2 saturations well
and was eating. Pt told medical team that his arthritis and back
pain was well controlled with the Tylenol regimen, therefore, pt
was told he should follow up as an outpt by talking to his PCP
and asking him/her to make a referral for pain management if
patient wants to explore pain management further. During
hospital stay, pt had foley catheter, which was removed. Pt's UA
showed microhematuria, asymptomatic, without any complications
in course. Pt to follow up with PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to see
in interim before re-eatablishing with new geriatrician, Dr.
[**Last Name (STitle) **] to repeat UA in [**2-20**] weeks to look for persistent
hematuria, and subsequent w/u of bladder/renal pathology if
positive. Pt to go to rehab, with close follow up with his
electrolytes, BUN/Cr, and INR.
Medications on Admission:
Lactulose 30 ml PO Q8H:PRN
Metoprolol 50 mg PO BID hold for SBP<100, HR<55
Morphine Sulfate 1-5 mg IV Q4-6H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Multivitamins 1 CAP PO QD
Allopurinol 100 mg PO QOD
Pyridoxine HCl 50 mg PO QD
Albuterol-Ipratropium [**12-20**] PUFF IH Q6H
Senna 1 TAB PO BID
Bisacodyl 10 mg PO QD:PRN
Calcium Carbonate 500 mg PO TID
Docusate Sodium 100 mg PO BID
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for please give until bm.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours).
12. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO qam ().
13. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Three
(3) Capsule, Sustained Release PO qhs ().
14. Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO QD
(once a day).
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
17. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QD EXCEPT
MONDAY AND THURSDAY (): please hold until INR stabilizes.
18. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO MONDAY AND
THURSDAY ONLY (): please hold until INR stabilizes.
19. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Pericardial effusion s/p pericardial window
2. AFib
3. CAD
4. UGI bleed secondary to duodenal ulcers
5. Ashtma
6. Gout
7. Hypothyroidism
8. CVA
9. OSA
10.Pulmonary HTN
11. H/O AMI in [**2133**]
12. PUD
13. CEA in [**2136**]
14. CHF
Discharge Condition:
stable
Discharge Instructions:
1. please take all your medications.
2. If you feel short of breath, or have any problems breathing,
come back to the hospital.
3. If you have fevers, chills, nausea, or vomiting, chest pain,
come back to the hospital immediately.
4. You need to have very strict monitoring of your INR DAILY
since you were re-started on it in the hospital. You are
currently not taking coumadin right now, but once your INR
stabilizes, you should re-start your coumadin. You should also
have daily checks of your electrolytes, BUN/Cr
5. Continue Tylenol for your back pain, and tell your primary
care doctor you would like a referral for a consultation on pain
management. Please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**] to
confirm your appointment.
6. At the rehab center, ask for nebulizers to help you breath
better, and ask to be taught how to use a spacer, so that you
can use the inhalers better
Followup Instructions:
Primary care doctor appointment:
Dr. [**Last Name (STitle) **] [**7-21**]. Mrs. [**Known lastname **] will be called for exact
time.
[**Telephone/Fax (1) 719**] to speak to assistant of Dr. [**Last Name (STitle) **]
Cardiology appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2144-6-25**] 9:00
|
[
"414.01",
"786.09",
"416.8",
"423.8",
"428.0",
"493.90",
"244.9",
"412",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.61",
"96.71",
"38.91",
"99.07",
"93.90",
"96.04",
"37.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6920, 7017
|
1774, 4629
|
315, 335
|
7296, 7304
|
1751, 1751
|
8266, 8705
|
5118, 6897
|
7038, 7275
|
4655, 5095
|
7328, 8243
|
1353, 1731
|
241, 277
|
363, 1111
|
1133, 1250
|
1266, 1338
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,260
| 188,714
|
22334
|
Discharge summary
|
report
|
Admission Date: [**2144-10-14**] Discharge Date: [**2144-10-18**]
Service: [**Hospital Unit Name 196**]
Allergies:
Morphine / Darvocet-N 50
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
SOB, DOE
Major Surgical or Invasive Procedure:
Cardiac catheterization with rotostenting
History of Present Illness:
[**Age over 90 **] y/o woman with CAD IMI [**9-1**], NQWMI [**6-2**], s/p cath [**8-2**] s/p 2
taxus stents to RCA, s/p cath [**2144-9-30**] w/2 cypher stents mid-Lcx
and OM, EF 30-40% ([**9-2**]) w/severe MR, presents to OSH w/SOB,
DOE. Dx CHF. Diuresed, treated for UTI, transfused 1 unit. Trop
there 0.06/0.08, interpreted as due to the severe LAD disease
remaining so sent back to [**Hospital1 18**] for elective cath. Has
orthopnea, pnd, LE edema at baseline, no recent
cp/palpitations/diaphoresis.
During cath, c/o n and groin pain, received dopamine, lasix and
ntg gtt during procedure. Post-cath, sheaths were pulled
immediately and had small ooze to which much pressure was
applied with good effect. But resulted in hypotension to the
60s, relative bradycardia to low 60s. Received IVF bolus with
temporary effect, worsening hypoxia to 90% on 5LNC (from 2L).
Dopamine started peripherally at 5mcg/kg/min with MAPS>60. Lasix
given with productive diuresis >1.5L.
CATH: R dom, LMCA 40% distal, LAD 99% diffuse calcific, complex
rota stenting 0% residual, Lcx with patent stents
HEMODYNAMICS: RA mean 6, RV 72/16, PA mean 53, PCW 38 (with V
waves of 72), CO 3.5, CI 2.32
Past Medical History:
1.CHF
-echo [**2144-7-30**] EF40% with anterior wall, lateral wall and inferior
wall severely HK, mild TR
2.Ischemic cardiomyopathy
-IMI [**2143-9-25**]
-NQWMI [**2144-6-11**]
-Left heart catheterization at [**Hospital3 17921**] Center on
[**2144-7-6**] revealed heavy calcified severe diffuse disease, RCA
100% with faint collateralization, LMCA 40%, LAD 70-80%, D1 90%,
ramus 100%, OM70%
-refused at [**Hospital3 17921**] Center for any further surgery b/c
of high risk.
-Dr. [**Last Name (STitle) **] at [**Hospital1 18**] stented RCA(2 taxus stent)
Hypothyroidism
CRI
S/P appendectomy
S/P oophorectomy
S/P bilateral knee replacement surgery
Anemia (etiology unspecified)
CAD
Detrusor Instability
Hypercholestrolemia
dementia
HTN
severe MR
Social History:
The pt. lives in an assisted care facility([**Location (un) **] home). She
is widowed and had four children (one deceased). She denied use
of tobacco, alcohol, or illicit drugs.
Family History:
The pt. reports a family history of DM, but not cardiac disease.
Physical Exam:
Vitals: 100/70 59 14 99% on 2L
Gen: frail, elderly woman sleeping in bed in mild resp distress
Skin: warm and dry
HEENT: dry MM, EOMI, PERRL
CV: RRR, [**4-4**] holosyst murmur at apex, JVP 10cm
Lungs: bilateral rales in lower [**2-1**]
Abd: soft, nt, nd, +BS
Ext:2+ LE edema
Pulses: 2+DP on R, 1+DP on L, no PT palpable b/l
Neuro: A+O
Pertinent Results:
[**2144-10-14**] 08:59PM BLOOD WBC-7.1 RBC-3.80* Hgb-11.7* Hct-34.4*
MCV-91 MCH-30.9 MCHC-34.1 RDW-16.1* Plt Ct-199
[**2144-10-15**] 05:46AM BLOOD WBC-7.0 RBC-3.67* Hgb-11.3* Hct-33.5*
MCV-91 MCH-30.7 MCHC-33.6 RDW-16.0* Plt Ct-216
[**2144-10-16**] 06:06AM BLOOD WBC-4.9 RBC-2.81* Hgb-8.9* Hct-25.5*
MCV-91 MCH-31.5 MCHC-34.8 RDW-16.0* Plt Ct-157
[**2144-10-16**] 10:50AM BLOOD Hct-26.5*
[**2144-10-17**] 05:30AM BLOOD WBC-5.2 RBC-3.19* Hgb-9.7* Hct-28.7*
MCV-90 MCH-30.5 MCHC-33.9 RDW-16.2* Plt Ct-143*
[**2144-10-18**] 05:40AM BLOOD WBC-5.3 RBC-3.49* Hgb-10.6* Hct-32.3*
MCV-93 MCH-30.5 MCHC-32.9 RDW-16.1* Plt Ct-168
[**2144-10-14**] 08:59PM BLOOD Neuts-81* Bands-5 Lymphs-5* Monos-7 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2144-10-14**] 12:10PM BLOOD INR(PT)-1.0
[**2144-10-14**] 08:59PM BLOOD Plt Ct-199
[**2144-10-18**] 05:40AM BLOOD Plt Ct-168
[**2144-10-17**] 05:30AM BLOOD PT-13.5 PTT-43.9* INR(PT)-1.2
[**2144-10-14**] 08:59PM BLOOD UreaN-39* Creat-1.4* K-4.2
[**2144-10-15**] 05:46AM BLOOD Glucose-134* UreaN-45* Creat-1.8* Na-141
K-4.7 Cl-101 HCO3-26 AnGap-19
[**2144-10-18**] 05:40AM BLOOD Glucose-86 UreaN-36* Creat-1.5* Na-142
K-4.1 Cl-106 HCO3-25 AnGap-15
[**2144-10-14**] 04:38PM BLOOD CK(CPK)-15*
[**2144-10-15**] 05:46AM BLOOD CK(CPK)-37
[**2144-10-16**] 06:06AM BLOOD CK(CPK)-37
[**2144-10-14**] 04:38PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-10-15**] 05:46AM BLOOD CK-MB-NotDone
[**2144-10-16**] 06:06AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2144-10-15**] 05:46AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.1
[**2144-10-17**] 05:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
[**2144-10-14**] 08:59PM BLOOD Cortsol-31.0*
[**2144-10-14**] 05:28PM BLOOD Type-ART O2 Flow-4 pO2-175* pCO2-47*
pH-7.39 calHCO3-30 Base XS-3 Intubat-NOT INTUBA
Brief Hospital Course:
[**Age over 90 **] y/o woman with CAD s/p mult [**Age over 90 **], severe MR, who p/w CHF and
had troponin bump, had rotostent cath to LAD, c/b hypotension to
SBP in 60s and resp distress, transferred to CCU for pressors
and close observation.
1. Cardio:
A. Coronaries: was rotastented in cath lab, then maintained on
asa, statin, plavix; held BB initially given low BP but then
started on low dose and titrated up.
B. Pump: presented in decompensated CHF w/hypoxia and
hypotension; was gentlely diuresed with Lasix; started on
Carvedilol and Lisinopril, [**Male First Name (un) **] stockings to help mobilize fluid
from her LE
C. Rhythm: NSR, no active issues
2. Pulm: was initially hypoxic due to pulmonary edema, but
responded well to gentle diuresis
3. ID: UTI noted on UA, gave 5d course of ampicillin, discharged
on day [**4-3**]
4. GI: gave zantac for gerd; 2g NA, cardiac diet
5. GU: UTI treatment as above
6. Heme: on Day #3 of pt's hospitalization it was noted that her
hct was 25.5 down from 33.5 the day before. No source of
bleeding was found, thought possibly due to fluid shifts. Pt
was transfused 1 unit of PRBCs with good response. (28.7 to
32.3). Will need f/u in the week after her discharge to check
her hct.
7. Endo: hyperglycemia at OSH, SSI here but did not require
insulin
Medications on Admission:
lipitor 10, plavix 75, ranitidine 150 [**Hospital1 **], levoxyl 75, asa 325,
coreg 12.5 [**Hospital1 **], detrol 4, lasox 40, captopril 12.5 qid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
9. Tolterodine Tartrate 2 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
14. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Community [**Hospital1 1501**]
Discharge Diagnosis:
1. Coronary artery disease
2. Congestive heart failure
3. Pulmonary edema
4. Urinary tract infection
5. Anemia
6. Gastroesophageal reflux disease
7. Hypothyroidism
8. Chronic renal insufficiency
9. Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor for increased shortness of breath or
chest pain or pressure.
Followup Instructions:
Please call your primary care doctor (Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**]
[**Telephone/Fax (1) 11254**]) for an appointment this week to check your blood
pressure and electrolytes now that you have been started on new
medications.
|
[
"285.9",
"424.0",
"244.9",
"530.81",
"428.0",
"599.0",
"593.9",
"414.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"99.04",
"37.23",
"36.07",
"88.56",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
7674, 7752
|
4701, 6011
|
263, 307
|
8009, 8017
|
2933, 4678
|
8150, 8432
|
2494, 2560
|
6206, 7651
|
7773, 7988
|
6037, 6183
|
8041, 8127
|
2575, 2914
|
215, 225
|
335, 1516
|
1538, 2283
|
2299, 2478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,202
| 194,067
|
30388
|
Discharge summary
|
report
|
Admission Date: [**2148-2-13**] [**Month/Day/Year **] Date: [**2148-4-9**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / ciprofloxacin / Levofloxacin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
T3-T7 laminectomy and fusion
History of Present Illness:
57 y/o M hx AML s/p MUD allo [**6-22**] in remission with multiple
complications including GVH of liver, skin, lung, most recently
on photopheresis since the end of [**Month (only) 1096**]. Also with DM, AVN of
hips/shoulders, chronic compression fx's, PE's on lifelong
anticoagulation, and b/l achilles tendon rupture after
fluoroquinolone course in [**5-27**]. Multiple recent admissions for
shortness of breath, though infectious (GGO on CT) treated with
abx, as well as norovirus. Recently discharged on O2 and azithro
and pred 20 for SOB and at that time if was unclear from imaging
and exam whether it was due to infectious etiology vs. GVHD.
.
The pt's breathing had improved since d/c up until a couple of
days about when he noticed increasing SOB especially with
exertion. He denies associated CP, fevers/ chills or rash. He
does note worsening productive cough. He also claims that his LE
edema has been increasing b/l as well and this has been going on
for several weeks also. He denies hx of chf. He also has noted
that his RLE in particular has not only become more swollen but
also has become more red and painful as well.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias.All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
.
POST TRANSPLANT COMPLICATIONS:
*GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory
infections (h/o RSV, parainfluenza)
*Chronic lower extremitiy edema, refractory to lasix, suspected
to be GVHD
*Avascular necrosis (bilateral hips and left shoulder)
*Multiple compression fractures of the spine with chronic pain
*Type 2 DM
*Pulmonary embolus in [**11/2144**] and [**5-/2146**], on lifelong
anticoagulation
*s/p L5 vertebroplasty [**3-/2145**]
*Ruptured left calf hematoma ([**9-/2146**]) complicated by MRSA wound
infection
*Influenza A [**1-/2147**]
*bilateral Achilles tendon rupture [**2147-5-23**] ( attributed to
levoflox).
.
OTHER PAST MEDICAL HISTORY (From [**Month/Day/Year **]):
*CKD with baseline Cr 1.1
*Pericardial effusion s/p [**3-23**] drainage.
*Hyperlipidemia, no meds.
*HTN, on metoprolol.
*Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
*Left interpolar renal lesion, followed with MRs
*Basal cell carcinoma, resected.
*Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
*Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical
spine fusion (bone graft, no hardware).
*Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
*Chronic numbness, neuropathic pain in left upper extremity.
*Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
*Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]
Social History:
Lives with his wife, and son. [**Name (NI) **] is retired, worked as a
[**Company 22957**] technician. He smoked for 40 pack years, now quit. He
denies EtOH or drugs.
Family History:
Mother died suddenly in 70s. Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One
sister has [**Name (NI) 5895**].
Physical Exam:
Admission Physical Exam:
Vitals - T:97.7 BP:163/96 HR:77 RR:18 02 sat: 99% 2L
GENERAL: obese male w/ moon facies, prefers to keep his eyes
closed
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, erytematous RLE
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, difficult to assess JVD due to habbitus
CARDIAC: RRR, S1/S2, no mrg
LUNG: crackles present in LL b/l
ABDOMEN: obeses, nondistended, +BS, moderately tender in Lower
quadrants b/l, no rebound/guarding, no hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE medial healed ulcer from prior mrsa infection, LLE
warm, erythematous small puncture wound on posterior distal calf
weeping serous fluid, both LE weeping serous fluid, severe [**1-19**]+
edema present to distal thigh b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
[**Month/Day (3) 894**] EXAM:
afebrile, 122/84, 103, 22, 95% on 0.5L NC
GENERAL: obese male w/ moon facies
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, RLE wrapped in bandages
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obeses, nondistended, +BS, NT, no rebound/guarding, no
hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE ulcer wrapped in clean, dry, dressings, LLE warm,
both LE edematous 1+
NEURO: paralyzed in LE bilaterally. sensation intact but
reduced. incontinent with foley in place. upper extremity motor
and sensation intact, CN 2-12 intact
Pertinent Results:
Pertinent Lab results:
[**2148-2-12**] 08:15AM BLOOD WBC-5.6 RBC-3.10* Hgb-11.6* Hct-35.7*
MCV-115* MCH-37.3* MCHC-32.4 RDW-16.1* Plt Ct-214
[**2148-2-12**] 08:15AM BLOOD Neuts-85* Bands-1 Lymphs-2* Monos-10
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-3*
[**2148-2-12**] 08:15AM BLOOD PT-14.8* INR(PT)-1.4*
[**2148-2-13**] 03:25PM BLOOD UreaN-16 Creat-0.9 Na-141 K-4.3 Cl-102
HCO3-32 AnGap-11
[**2148-2-13**] 03:25PM BLOOD ALT-120* AST-64* LD(LDH)-386*
AlkPhos-135* TotBili-0.1
[**2148-2-13**] 03:25PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0
[**2148-3-5**] 05:26AM BLOOD WBC-5.8 RBC-2.86* Hgb-10.1* Hct-33.6*
MCV-118* MCH-35.2* MCHC-30.0* RDW-16.9* Plt Ct-177
[**2148-3-6**] 01:37PM BLOOD WBC-8.8# RBC-2.16* Hgb-7.6* Hct-26.0*
MCV-121* MCH-35.1* MCHC-29.1* RDW-17.0* Plt Ct-178
[**2148-3-6**] 05:00PM BLOOD WBC-8.0 RBC-1.99* Hgb-6.9* Hct-23.4*
MCV-117* MCH-34.8* MCHC-29.7* RDW-17.3* Plt Ct-171
[**2148-3-6**] 07:00PM BLOOD WBC-6.1 RBC-1.99* Hgb-6.2* Hct-20.2*
MCV-102*# MCH-31.4 MCHC-30.8* RDW-25.1* Plt Ct-102*
[**2148-3-6**] 09:53PM BLOOD WBC-5.9 RBC-2.82*# Hgb-8.3*# Hct-26.2*#
MCV-93# MCH-29.5 MCHC-31.6 RDW-23.1* Plt Ct-72*
[**2148-3-7**] 02:02AM BLOOD WBC-5.6 RBC-3.28* Hgb-9.9* Hct-29.7*
MCV-91 MCH-30.2 MCHC-33.3 RDW-22.1* Plt Ct-78*
[**2148-3-7**] 07:20AM BLOOD WBC-7.1 RBC-3.08* Hgb-9.2* Hct-27.9*
MCV-91 MCH-30.0 MCHC-33.2 RDW-22.5* Plt Ct-85*
[**2148-3-7**] 11:52AM BLOOD WBC-8.1 RBC-3.17* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.4 MCHC-31.9 RDW-23.5* Plt Ct-81*
[**2148-3-6**] 01:37PM BLOOD Hapto-213*
[**2148-2-29**] 11:44AM BLOOD PTH-250*
[**2148-3-6**] 06:28AM BLOOD PTH-64
[**2148-2-29**] 11:44AM BLOOD 25VitD-14*
[**2148-2-18**] 04:00PM BLOOD IgG-236* IgA-36* IgM-7*
[**2148-2-29**] 06:00AM BLOOD IgG-643* IgA-40* IgM-12*
[**2148-2-15**] 06:49AM BLOOD Vanco-12.9
[**2148-2-20**] 04:43AM BLOOD Vanco-17.9
MICRO:
Blood Culture, Routine (Final [**2148-2-19**]): NO GROWTH.
Blood Culture, Routine (Final [**2148-2-20**]): NO GROWTH
URINE CULTURE (Final [**2148-2-15**]): NO GROWTH
**FINAL REPORT [**2148-2-16**]**
GRAM STAIN (Final [**2148-2-14**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2148-2-16**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2148-2-17**] 3:41 pm Rapid Respiratory Viral Screen & Culture
Site: NASOPHARYNX Source: Nasopharyngeal swab.
**FINAL REPORT [**2148-2-20**]**
Respiratory Viral Culture (Final [**2148-2-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2148-2-18**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
Blood Culture, Routine (Final [**2148-3-5**]): NO GROWTH
IMAGAING:
CT CHEST W/O CONTRAST Study Date of [**2148-2-12**] 1:12 PM
IMPRESSION:
1. Near resolution of right lower and middle lobe ground glass
opacities that were new in [**2147-12-17**], consistent with
resolving infectious process.
2. Other bilateral lung and airway findings (including mild
bronchial
dilation and wall thickening) are similar to baseline CT study
in [**2147-4-16**], and are accompanied by moderate expiratory air
trapping. Although
non-specific, they may be related to history of chronic GVHD.
3. Multiple stable compression fractures and rib fractures.
L-SPINE (AP & LAT) Study Date of [**2148-2-12**] 1:53 PM
FINDINGS: There is a previously known sclerotic focus in the
right iliac
crest. There are also several compression fractures identified
along with
severe degenerative changes of the lumbar spine, all previously
identified. Patient is status post kyphoplasty of the L5
vertebral body. No new fractures are seen.
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2148-2-13**] 6:33 PM
FINDINGS: [**Doctor Last Name **]-scale and color son[**Name (NI) 1417**] were acquired of the
right common femoral, superficial femoral, popliteal, posterior
tibial, and peroneal veins. There is normal compressibility,
flow, and augmentation throughout. There is subcutaneous edema
in the calf
2. Subcutaneous edema in the calf
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2148-2-16**] 1:48 PM
Impression:
Mild to moderate restrictive ventilatory defect with a coexsting
obstructive ventilatory defect and a moderate gas exchange
defect. Compared to the prior study of [**2147-3-30**] the FVC has
decreased by 0.74 L (-21%) and the FEV1 has decreased by 0.58 L
(-25%). Compared to the prior study of [**2145-9-9**] the TLC has
decreased by 1.10 L (-19%) and the DLCO has decreased by 2.82
ml/min/mm Hg (-18%).
CT LOW EXT W/O C RIGHT Study Date of [**2148-2-16**] 2:40 PM
IMPRESSION:
1. No CT evidence for osteomyelitis.
2. Large osteochondral fracture with articular collapse
involving the lateral femoral condyle. Subtle changes were seen
in this area on the prior radiograph from [**2146-12-7**];
however, findings have worsened.
3. Prominent amount of subcutaneous soft tissue swelling and
skin thickening compatible with known diagnosis of cellulitis.
There is no air within the soft tissues.
4. Focal 2-mm nodular area of soft tissue attenuation within the
posterior
medial calf, unable to fully characterize.
MR CALF W/O CONTRAST RIGHT Study Date of [**2148-2-18**] 11:30 AM
IMPRESSION:
1. Extensive subcutaneous soft tissue edema throughout the right
lower
extremity consistent with cellulitis in the appropriate clinical
setting.
Lobulated high T2 focus seen in the posteromedial distal right
lower extremity measuring approximately 4.2 x 0.9 cm. could
represent a small focus of fluid, though the ddx includes dense
edema, in the absence of IV contrast.
2. Incompletely characterized ovoid area measuring 1.0 x 1.5 cm
in the distal right lower extremity posteromedial subcutaneous
soft tissues corresponding to an area of soft tissue density on
recent prior CT examination and calf MRI from [**2147-5-25**] may
represent complex fluid or small area of hemorrhage.
3. Fascial fluid and edema between the medial head gastrocnemius
and soleus musculature, slightly more than seen on the most
recent prior MRI. No associated areas of magnetic susceptibility
artifact to suggest foci of gas, nor are any foci of gas seen on
recent prior CT. No other fascial fluid or edema identified
between muscles. Please correlate clinically to exclude the
possibility of necrotizing fasciitis.
4. Muscle edema involving the soleus musculature and medial
aspect of the
lateral head of the gastrocnemius, which could reflect mild
myositis.
5. Incompletely seen osteochondral fracture involving the
lateral tibial
plateau, better assessed on CT examination from [**2148-2-16**].
6. Bone infarcts in the distal tibia and proximal femur.
CT CHEST W/O CONTRAST Study Date of [**2148-2-24**] 3:40 PM
IMPRESSION:
1. Continued resolution of previously seen bilateral
ground-glass and nodular opacities consistent with infection. No
new consolidation.
2. Stable chronic changes including bibasilar scarring and
bronchiectasis. Mild centrilobular emphysema.
3. Hepatic steatosis.
CHEST (PORTABLE AP) Study Date of [**2148-2-27**] 9:27 AM
IMPRESSION: Unchanged exam. No rib fractures evident.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Study Date of [**2148-2-28**] 9:23 AM
IMPRESSION:
1. New T5 inferior endplate fracture with retropulsion of its
dorsal cortex, narrowing the ventral spinal canal, with no
spinal cord signal abnormality. This is new compared to CT
chest done only four days ago, and should be correlated directly
with the symptomatic site.
2. Likely endplate fracture of T7; however, a mild wedge
deformity was present on CT chest four days ago making if
difficult to determine whether there is an acute component.
3. Previously-seen sites of spinal canal stenosis at C3/C4 and
C6 with
indentation and remodeling of the spinal cord have progressed
slightly,
compared to [**2144-10-2**]. The associated focal abnormality
of cord
intrinsic signal from C4/5 to C5, is unchanged compared to
[**2144-10-2**], and likely represents established
myelomalacia.
4. T12 kyphosis with retropulsion and cord compression is
unchanged in degree, compared to [**2146-8-24**].
5. Remaining old lumbar vertebral compression fractures and
multilevel
degenerative changes are unchanged.
HAND (AP, LAT & OBLIQUE) RIGHT Study Date of [**2148-2-28**] 5:18 PM
IMPRESSION:
1. Erosive change with sclerotic margin at the base of the ulnar
aspect
distal ring finger phalanx with adjacent small calcifications
suggestive of tophi, which may represent gout in the appropriate
clinical setting.
Alternatively, this could be post-traumatic in nature and less
likely an
enchondroma.
2. Old ununited right ulnar styloid fracture or accessory
ossicle, grossly
stable.
TTE:
The left ventricle is not well seen. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The aortic valve is not well seen. The mitral valve
leaflets are not well seen. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad. There are no echocardiographic signs of
tamponade.
IMPRESSION: Suboptimal image quality. Overall LV function is
probably normal. However, due to technical difficulties, a focal
wall motion abnormality cannot be fully excluded. Anterior space
likely represents a prominent fat pad (patient on high dose
steroids; recent CT of chest/abdomen also confirms significant
visceral fat around heart and organs). Dr. [**Last Name (STitle) **] was notified
of the limited study and results by telephone today at 4:10 p.m.
CHEST (PA & LAT) Study Date of [**2148-2-29**] 11:22 AM
IMPRESSION: 1. Probable right mid lung atelectasis but followup
is
recommended. 2. Low lung volumes and increased bibasilar
atelectasis. 3. Mild pulmonary vascular congestion.
BILAT LOWER EXT VEINS Study Date of [**2148-3-1**] 8:46 AM
IMPRESSION:
Mildly limited examination secondary to habitus/subcutaneous
edema without
left or right lower extremity DVT.
CHEST (PORTABLE AP) Study Date of [**2148-3-2**] 9:52 PM
FINDINGS: As compared to the previous radiograph, the lung
volumes are
unchanged and relatively low. Borderline size of the cardiac
silhouette
without pulmonary edema or pneumonia. No pleural effusions.
Unchanged
appearance of the mediastinum. Cervical fixation devices.
Unchanged
hemodialysis catheter.
CHEST (PORTABLE AP) Study Date of [**2148-3-6**] 1:58 PM
FINDINGS: In comparison with the study of [**3-2**], there is no
interval change. Low lung volumes may account for the mild
prominence of the cardiac silhouette. No evidence of pulmonary
edema or pleural effusion or acute pneumonia.
Cervical fixation device and hemodialysis catheter are
essentially unchanged.
.
.
[**2148-3-6**] CT ABD & PELVIS W/O CON:
IMPRESSION
1. Left retroperitoneal hematoma in the pararenal spaces, with
extension inferiorly into the pelvis.
2. Multilevel vertebral body compression fractures. Old healing
bilateral rib fractures. Possible bilateral femoral head AVN.
3. Fatty liver. Gallbladder stones or sludge.
4. Bibasilar lung opacities concerning for infection.
.
[**3-7**] MR [**Name13 (STitle) **] W& W/O CONTRAST
IMPRESSION:
Since the previous MRI of [**2148-2-28**] there is slightly increased
compression and signal changes within the T5 vertebra identified
with signal changes in the inferior endplate which could be
related to previous compression and fluid adjacent to the
endplate. The slightly increased retropulsion together with
epidural lipomatosis results in some deformity of the spinal
cord at this level, but the evaluation for increased signal
within the cord is limited secondary to motion but such
possibility cannot be completely excluded. Postoperative
changes are seen in the cervical region as before. The
appearance of lower thoracic spine has remained unchanged
compared to the previous MRI.
.
[**3-11**] CT chest w/o con:
IMPRESSION:
1. Multifocal widespread ground glass opacities with tree-in-[**Male First Name (un) 239**]
opacities along the periphery, most compatible with multifocal
pneumonia. Atypical infections such as mycobacterial can also be
considered.
2. Increased bilateral pleural effusions with worsening adjacent
compressive atelectasis.
3. Incompletely visualized retroperitoneal hematoma, as seen on
the [**2148-3-6**] CT examination.
4. Hepatic steatosis.
5. Unchanged multiple chronic rib fractures and severe
thoracolumbar
vertebral wedge compression deformities.
.
[**3-18**] Head CT:
IMPRESSION:
Bilateral symmetric exophthalmos, new since [**2142**], increased
since [**2143**], and unchanged since [**2148-1-10**]. No evidence of
post-septal mass.
Normal brain CT.
.
[**3-19**] CTA
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Persistent right and left upper lobe opacities, consistent
with pneumonia.
3. Right central bronchial secretions.
.
[**Month/Day (4) 894**] LABS:
[**2148-4-9**] 12:30AM BLOOD WBC-8.4 RBC-3.12* Hgb-10.4* Hct-33.4*
MCV-107* MCH-33.2* MCHC-31.0 RDW-21.3* Plt Ct-251
[**2148-4-9**] 12:30AM BLOOD PT-9.6 PTT-26.6 INR(PT)-0.9
[**2148-4-9**] 12:30AM BLOOD Glucose-219* UreaN-16 Creat-0.8 Na-141
K-4.2 Cl-99 HCO3-35* AnGap-11
[**2148-4-9**] 12:30AM BLOOD ALT-33 AST-30 AlkPhos-221* TotBili-0.2
[**2148-4-9**] 12:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.6
Brief Hospital Course:
Mr. [**Known lastname 47367**] is a 57M h/o GVHD involving liver, skin, lung from
allo transplant for AML, and recent admission for SOB of unclear
etiology initially presenting with worsening SOB and RLE
swelling, pain. He has a h/o thoracic spine compression
fractures, and during this hospitalization received a T3-T7
laminectomy/spinal fusion in [**2-26**] for acute cord compression in
the setting of a code blue and one chest compression. He had a
[**Hospital Unit Name 153**] admission for respiratory depression thought [**1-18**] medication
sedation effect, and was called out to BMT on [**3-21**] after his pain
Rx were adjusted and his sedation had improved. On [**3-28**], he had
several episodes of SBP 70's, and later became unresponsive with
ABG's showing hypoxemia and acidemia, and the pt was transferred
to the [**Hospital Unit Name 153**]. His AMS and hypercarbia improved with CPAP, and he
was called out to the BMT floor again on [**3-30**]. His Abx were
progressively stopped, and he remained afebrile. He was
continued on azithromycin for infection prophylaxis, and plan
was made to continue this at the discretion of the outpatient
physician, [**Name10 (NameIs) 1023**] can decided when or whether or not to stop.
.
ACTIVE ISSUES:
.
# Graft vs Host Disease- Involving his lungs, GI tract, eyes and
skin. On admission, the pt was complaining of persistent SOB. He
had been admitted in mid [**2148-1-17**] with a similar presentation.
He was empirically treated with Vanc/Aztreonam during that
admission for a prolonged course, and his cultures were all
unremarkable. Pulmonary felt that his lung symptoms were the
result of GVHD c/w a bronchiolitis obliterans picture. It was
recommended to start Advair and Albuterol-Ipratropium as well as
pulse dose steroids. IgG level was checked and returned below
500. He was given IVIG once which also improved his symptoms.
PFTs were obtained during this admission and showed a mild to
moderate restrictive ventilatory defect with a coexisting
obstructive ventilatory defect and a moderate gas exchange
defect. He had documented PE's in the past and was continued on
anticoagulation. While he was on stress doses of hydrocortisone
during his ICU stays, these were changed back to his prednisone
10mg in AM and 5mg in PM without incident.
.
# HCAP in setting of pulmonary GVHD: In an effort to elucidate
an etiology for his hypoxia, a repeat chest CT was performed.
It was negative for pulmonary embolism, but showed areas of
consolidation concerning for new PNA. As such, the patient was
restarted on IV vanco & meropenem for planned 8 day course, but
on [**3-27**] pt was found increasingly somnolent with PCO2>100. PT
was transferred back to the [**Hospital Unit Name 153**], was put temporarily on
positive airway pressure with improvement in mental status.
Blood gases showed significant improvement. He was sent to the
floor [**2148-3-30**] on an antimicrobial regimen which included vanc,
[**Last Name (un) 2830**], voriconazole, bactrim, azithromycin. These were
progressively d/c'd, and the pt was weaned down to 0.5L NC and
continued on azithromycin for infection prophylaxis and
discharged to rehab.
.
#Osteopenia, s/p laminectomy - Pt has had multiple fractures in
the past due to chronic steroid use. During this
hospitalization, he fractured his distal ulnar after bumping it
on a table. He fractured his R tibial plateau after bumping into
a door while ambulating to the bathroom. Ortho was consulted and
for each fracture determined that no surgical intervention was
warranted. While bending over to pull up his bed sheets, he
experienced significant pain originating in his thoracic spine
and radiating to his anterior chest. He had no neuro deficits on
exam. An MRI of his spine was obtained which showed new
fractures at T5 and T7. Ortho was again consulted and cleared
him for ambulation they recommended cervicothoracic brace for
comfort. He continued to have significant burning pain
occassionally with movement. Ortho was again consulted and we
were planning on performing a vertebroplasty / kyphoplasty of
both T5 and T7 for pain relief. Pt was then noted to have acute
sensorimotor loss below the level of T5-6 with complete loss of
movement in the lower extremities, loss of rectal tone, fecal
incontinence, and complete loss of sensation to the level of the
T5-T6 dermatome on [**3-7**]. He was sent for STAT MRI which showed a
new epidural compression on T4/T5 with hyperdensity in that
area, and new spinal cord signal change with edema. In the OR a
mass was removed from his cord. It is unclear what caused this
acute cord compression, report from ortho that there may have
been a "fat pad" in the epidural space, or trauma from one chest
compression during his preceding code blue. He was taken
urgently to the OR for urgent T3-T7 laminectomy and fusion by
ortho spine. Endocrine was consulted for assistance with
management of severe osteopenia and recommended that we continue
to give high dose vitamin D and calcium supplementation daily.
He did not have any motor function in his LE, although he did
have some remaining sensation in b/l LE. He was discharged to
rehab.
.
# Retroperitoneal Bleed - In preparation for
vertebroplasty/kyphoplasty, the pt's warfarin was discontinued
and he was started on a Heparin gtt. The morning after
initiation of the drip the pt was noted to be tachycardic on
vitals and pale in appearance. The heparin gtt was turned off
and a stat CBC showed a 7 point Hct drop. He subsequently became
hypotensive to the 70s. He was bolused 2L NS and given a total
of 5 units of blood. He was transfered to the ICU for further
management and hemodynamic stablization. On arrival to the ICU,
patient had an acute episode of LOC with BP drop to 40/doppler.
A code blue was called and abruptly cancelled after patient
awoke following one chest compression. A CT of the Abdomen and
Pelvis was obtained which showed left perinephric
retroperitoneal hematoma. Anticoagulants were discontinued and
patient remined hemodynamically stable. Given that he was no
longer a candidate for anticoagulation, in conjunction with a
h/o multiple pulmonary embolisms, he was taken to IR for
placement of an IVC filter which was placed on [**3-8**].
.
# Chronic Pain - pt has chronic neuropathic pain in LE and also
back pain from old compression fractures and hip / shoulder pain
from avascular necrosis as complication of chronic steroid use.
We initially continued his home doses of PO Dilaudid, Oxycotin
and Gabapentin, but due to oversedation and respiratory
compromise, his Rx were adjusted. Ultimately, the Pain service
was consulted and recommended celebrex, ritalin [**Hospital1 **] for synergy,
APAP, cymbalta, oxycontin, and small PO doses of dilaudid for
breakthrough pain.
.
# Intermittent binocular diplopia: Pt first noticed this while
in the [**Hospital Unit Name 153**] in early [**3-28**]. The pt had anisocoria observed in
[**Hospital Unit Name 153**] in setting of nebulizers, and had head CT which was
negative. Pt had had cataract surgery in 04 and [**4-26**]. Also has
intermittent blurry vision; has no h/o corrective eyewear.
Ophthalmology felt that the pt had significantly dry eyes and a
decompensating exophoria - they recommended aggressive lub with
artificial tear ointment [**Hospital1 **] and preservative free artificial
tears q1h. His blurry vision and diplopia improved thereafter
.
# RLE cellulitis - On presentation, his RLE was significantly
swollen and erythematous. LENi's were obtained and negative for
DVT. He had a puncture wound in his RLE and from hitting his leg
while walking at home. It was felt that he had a cellulitis of
the RLE. ID was consulted and he was placed on Vancomycin and
meropenem for his cellulitis. He completed a two week course of
IV antibiotics with significant improvement in erythema and
swelling. His wounds were dressed daily per wound care
recommendations.
.
Chronic Issues:
.
#DM II- We continued twice per day dosing of NPH which required
frequent titration while on pulse dose steroid. He was also
placed on humalog sliding scale for prandial coverage. On
4/12pm he triggered for FSG 29 (rpt 40) in the setting of no PO
intake for the entire day; was given 1 amp of D50; was tired but
still responsive during that episode.
.
#[**Name (NI) 10952**] Pt was on chronic warfarin for mult PE in past. Please see
above retroperitoneal bleed for adjustments made to this
regimen.
.
# HTN- continued metoprolol.
.
# GVHD [**Name (NI) 2701**] Pt has been suffering from severe GVHD since his
allo transplant in [**2142**]. He is on chronic prednisone at home. He
was then placed on pulse dose steroids and given IVIG which
resulted in improvement in his respiratory symptoms. We
continued Acyclovir, Bactrim and Voriconazole for
immunosuppression prophylaxis.
.
TRANSITIONS OF CARE:
- cont azithromycin for infection prophylaxis
- goal O2 sat 89-92% due to patient's history of OSA and likely
chronic hypoxia at baseline
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Delayed & Ext.Release -
1 (One) Capsule(s) by mouth three times a day PLEASE DISPENSE 3
MONTH SUPPLY
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day please dispense 90 day supply
HYDROMORPHONE - 4 mg Tablet - 0.5 (One half) to 1 Tablet(s) by
mouth once a day as needed for pain
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as per sliding
scale four times a day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
OXYCODONE [OXYCONTIN] - 40 mg Tablet Extended Release 12 hr - 2
Tablet(s) by mouth every eight (8) hours
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day PLEASE DISPENSE 3 MONTH SUPPLY
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
please dispense 3 month supply
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
WARFARIN - 4 mg Tablet - 1 Tablet(s) by mouth once a day or as
directed
Medications - OTC
BLOOD SUGAR DIAGNOSTIC, DISC [BREEZE 2 TEST STRIPS] - Strip -
use as directed 2-4 times a day
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth once a day
INSULIN SYRINGE-NEEDLE U-100 [BD LO-DOSE ULTRA-FINE SHORT] - 31
gauge X [**5-1**]" Syringe - Use as directed for insulin
administration 3 times daily
LANCETS MISC. - Kit - Lancets for Accu check cartridge twice a
day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Dose adjustment - no
new
Rx) - 100 unit/mL Suspension - 10 units subcutaneously twice a
day
PEG 400-PROPYLENE GLYCOL [SYSTANE GEL] - (Not Taking as
Prescribed: pt states the eye drops sting his eyes and is no
onger taking them) - 0.3 %-0.4 % Drops, Gel - 1 ribbon in each
eye at bedtime
PEG 400-PROPYLENE GLYCOL [SYSTANE ULTRA] - (Not Taking as
Prescribed: pt states the eye drops sting his eyes and is no
longer taking them) - 0.3 %-0.4 % Drops - 1 gtt in each eye
every
hour
[**Month/Year (2) **] Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) spray Nasal DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily): hold for loose stool.
13. celecoxib 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Please give in morning and at noon. .
16. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. oxycodone 40 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours): hold for
sedation or RR<10.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
20. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day): hold for loose stool.
21. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: Two
(2) Drop Ophthalmic Q2-3H ().
22. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
23. sodium phosphates 19-7 gram/118 mL Enema Sig: One (1) enema
Rectal DAILY (Daily) as needed for constipation.
24. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours): while awake.
25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours):
while awake.
26. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
27. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)).
28. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain: hold for oversedation, RR< 10.
29. prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
30. prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
31. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
32. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Six (36) units Subcutaneous qAM.
33. Humalog 100 unit/mL Solution Sig: Five (5) units
Subcutaneous three times a day: at breakfast, lunch, and dinner.
34. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous as directed.
35. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
36. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every 6-8 hours as needed for nausea.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital1 700**]
[**Hospital1 **] Diagnosis:
Graft versus host disease
Bronchiolitis [**Hospital **]
Healthcare-associated pneumonia
Vertebral cord compression
Vertebral Compression fractures
Rib fractures
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
[**Hospital **] Instructions:
Dear Mr. [**Known lastname 47367**],
It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you had a
skin infection on your leg and shortness of breath. During your
stay, you required a back surgery to fix the compression on your
back, as well as antibiotics and other therapies for pneumonias
and your GVHD. After you left the ICU, your condition continued
to improve, and you can be discharged to your rehab.
Your new medication list is attached. Please take all of these
medications as directed and no additional medications.
Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: [**Hospital1 **] [**2148-4-15**] at 10:30 AM
Department: HEMATOLOGY/ONCOLOGY
When: [**Year (4 digits) **] [**2148-4-15**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: [**Hospital Ward Name **] [**2148-4-15**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"782.3",
"516.8",
"996.88",
"570",
"507.0",
"255.41",
"338.29",
"733.41",
"355.8",
"486",
"733.12",
"427.5",
"584.5",
"518.84",
"285.1",
"733.42",
"403.90",
"V10.83",
"336.3",
"682.6",
"585.9",
"E932.0",
"327.23",
"733.16",
"279.52",
"253.6",
"378.42",
"205.01",
"733.13",
"278.00",
"344.1",
"276.4",
"588.81",
"V12.55",
"V58.65",
"V58.61",
"733.90",
"733.09",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"81.05",
"99.88",
"38.7",
"03.09",
"81.63",
"99.60",
"33.24",
"99.14",
"03.53",
"77.49"
] |
icd9pcs
|
[
[
[]
]
] |
20173, 21414
|
331, 362
|
6124, 19344
|
35953, 36719
|
4134, 4294
|
29191, 34907
|
4334, 6105
|
1549, 1975
|
272, 293
|
21429, 28106
|
34937, 34983
|
390, 1530
|
19353, 20150
|
35216, 35930
|
29026, 29165
|
35011, 35201
|
28122, 29005
|
1997, 3931
|
3947, 4118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,668
| 165,625
|
35866+58042
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-11-19**] Discharge Date: [**2119-11-22**]
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Left basal ganglia hemmorhage
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
[**Age over 90 **] year old man with history of atrial fibrillation, on
coumadin (INR 2.8), prostate and colon cancer, was found on the
floor in his apartment by a neighbour at 7 pm (? fall at 4 pm).
He does not remember the event. he was taken to another hospital
where he was found to have intracranial bleed; received 10mg
vitamin K, and elevated troponin (14). Patient denies chest
pain.
Patient was transferred here for our evaluation.
Past Medical History:
prostate CA, colon CA, atrial fibrillation, bladder
stimulator for urinary retention
Social History:
widow, lives by himself, he has two daughters,
engineer. [**Name2 (NI) **] denies tobacco use, occasional alcohol use
Family History:
non-contributory
Physical Exam:
Exam on admit:
O: T: BP:204 / 115 HR:82 R 11 98 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: equal and reactive 2-1mm EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: increased pigmentation, signs of peripheral vascular
disease.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**12-15**] 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, to
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 [**4-17**] throughout. No pronator drift
Sensation: Decreased to light touch, propioception, pinprick and
vibration bellow knees bilaterally.
Reflexes: B T Br Pa Ac
Right 3 3 2 2 1
Left 3 3 2 2 1
L upgoing toe
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2119-11-20**] 07:28PM BLOOD WBC-8.8 RBC-4.45* Hgb-11.1* Hct-34.6*
MCV-78* MCH-24.9* MCHC-32.0 RDW-15.4 Plt Ct-197
[**2119-11-20**] 07:28PM BLOOD Plt Ct-197
[**2119-11-20**] 07:28PM BLOOD PT-14.3* PTT-36.0* INR(PT)-1.2*
[**2119-11-21**] 06:00AM BLOOD Glucose-132* UreaN-23* Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
[**2119-11-21**] 06:00AM BLOOD CK(CPK)-155
[**2119-11-21**] 06:00AM BLOOD CK-MB-5 cTropnT-0.54*
Brief Hospital Course:
[**Age over 90 **]yo on coumadin for atrial fibrillation who was admitted after
being found on the floor by his neighbor. [**Name (NI) **] had no recall of
event. Brought to [**Hospital1 18**] where CT imaging of the head revealed
the Left basal ganglia hemorrage with Intra Ventricular
Extension. He was treated with vitamin K and FFP. He has been
followed by Neurosurgery, and neurology. His neurologic exam has
remained stable at time of discharge.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Famotidine 20 mg IV Q12H
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue until [**11-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] health care center at [**Location (un) 38**]
Discharge Diagnosis:
Left basal ganglia hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending. Avoid any straining such as when moving
your bowels, coughing or sneezing. ?????? 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.
??????
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication. You should keep track of the
duration and intensitiy of any headaches you do get.
Followup Instructions:
YOU WILL NEED TO BE SEEN IN THE NEUROSURGERY OFFICE IN 1 MONTH
WITH DR [**First Name (STitle) **] AT [**Telephone/Fax (1) **] / YOU WILL NEED A CAT SCAN OF THE
BRAIN WITH CONTRAST AT THAT TIME.
YOU WILL NEED TO BE OFF OF YOUR COUMADIN UNTIL [**2119-12-20**]
PER DR [**First Name (STitle) **]. PLEASE CONTACT YOUR PRIMARY CARE PHYSICIAN OR
CARDIOLOGIST TO UPDATE HIM / HER OF THIS. THEY WILL BE IN
CHARGE OF RESTARTING THIS MEDICATION.
You have an appointment to see Dr. [**Doctor Last Name 81515**] on [**2119-12-22**] @
10:30am. Please call if you need to reschedule [**Telephone/Fax (1) 2574**].
Completed by:[**2119-11-22**] Name: [**Known lastname **],[**Known firstname 6028**] Unit No: [**Numeric Identifier 13064**]
Admission Date: [**2119-11-19**] Discharge Date: [**2119-11-22**]
Date of Birth: [**2028-3-3**] Sex: M
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 40**]
Addendum:
Pt. med corrected. please see med list
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue until [**11-29**].
6. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4185**] health care center at [**Location (un) **]
Discharge Diagnosis:
Left basal ganglia hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending. Avoid any straining such as when moving
your bowels, coughing or sneezing. ?????? 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.
??????
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication. You should keep track of the
duration and intensitiy of any headaches you do get.
Followup Instructions:
YOU WILL NEED TO BE SEEN IN THE NEUROSURGERY OFFICE IN 1 MONTH
WITH DR [**First Name (STitle) **] AT [**Telephone/Fax (1) **] / YOU WILL NEED A CAT SCAN OF THE
BRAIN WITH CONTRAST AT THAT TIME.
YOU WILL NEED TO BE OFF OF YOUR COUMADIN UNTIL [**2119-12-20**]
PER DR [**First Name (STitle) **]. PLEASE CONTACT YOUR PRIMARY CARE PHYSICIAN OR
CARDIOLOGIST TO UPDATE HIM / HER OF THIS. THEY WILL BE IN
CHARGE OF RESTARTING THIS MEDICATION.
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2119-11-22**]
|
[
"327.23",
"427.31",
"410.71",
"V10.05",
"599.0",
"V58.61",
"V10.46",
"431",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6751, 6840
|
2976, 3429
|
277, 284
|
6914, 6923
|
2533, 2953
|
7984, 8560
|
1016, 1034
|
6221, 6728
|
6861, 6893
|
6947, 7961
|
1049, 1359
|
208, 239
|
312, 755
|
1653, 2514
|
1374, 1637
|
777, 864
|
880, 1000
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,452
| 132,982
|
927+928+55245
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2160-12-17**] Discharge Date:
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 54-year-old gentleman
with past medical history significant for end stage renal
disease, peritoneal dialysis times one year, status post
glomerular nephritis and renal transplant times three and
aortic valve replacement secondary to calcific aorta who
admission, also comes in with a little bit of back pain and
some chills. She denied any localizing symptoms, no cough,
no chest pain, no shortness of breath, no abdominal pain, no
flank pain. He did have some mild nausea earlier the day of
admission which seemed to have resolved. He called his
primary care physician and was told to go to the Emergency
Room. The day prior to admission the patient had an MRA to
and third finger on his right hand.
PAST MEDICAL HISTORY: Included end stage renal disease
status post peritoneal dialysis times one year, post
glomerular nephritis, renal transplant times three, chronic
anemia, hypertension, aortic valve replacement secondary to
calcific aorta, otitis and GI polyps.
MEDICATIONS: Prednisone 3.75 mg q d, Atenolol 25/50,
RenaGel, TUMS, aluminum hydroxide, Prilosec, Coumadin 5 mg
and 3 mg, alternating.
ALLERGIES: Captopril which gave him a rash and talcum
powder.
FAMILY HISTORY: Significant for father having esophageal
carcinoma. Patient denied any alcohol or drug use. No
smoking history. Occupation: Patient is a plastic surgeon
and was practicing doing his surgery two weeks prior to
admission.
PHYSICAL EXAMINATION: In the Emergency Room included a
temperature of 101.7, heart rate 112, blood pressure 153/112.
This is a pleasant white man lying in bed, appeared pretty
sick looking. HEENT: Pupils are equal, round, and reactive
to light and accommodation. Oropharynx was clear. Anicteric
sclera. Neck was supple, no lymphadenopathy. Chest was
clear to auscultation bilaterally. Cardiovascular was tachy,
regular rate and rhythm, grade 3/6 systolic ejection murmur
heard best at the apex. GI was soft, nontender, non
distended, normoactive bowel sounds. GU, no CVA tenderness,
no flank pain. Musculoskeletal: Patient had right second
and third finger ischemic at the fingertips, otherwise no
cyanosis, no clubbing, no edema. Skin with no evidence of
any rashes. Neuro, patient was alert, oriented.
LABORATORY DATA: On admission included a white count of
12.6, hematocrit 29.4, platelet count 91,000, Chem 7 of
138/4.9, 99/25, BUN and creatinine 48/13.4, glucose 91,
calcium 9.1, phosphorus 4.0, magnesium 1.7. Differential on
the white count was 71% polys, 10% bands, 14 lymphs, no eos,
no basos. Peritoneal fluid had two white cells, 19 RBC, 60
PMNs, 30 lymphs, 20 monos. Gram stain with no PMNs, no
organisms. Urinalysis cannot be done because patient did not
make any urine. Chest x-ray was clear on admission.
HOSPITAL COURSE: On [**12-18**] the patient had some respiratory
failure and hypotension. As patient developed fevers,
chills, with no obvious source of infection but developed
some hypoxia, overnight was on nasal cannula, however, in the
morning had increased respiratory rate and decreased O2
saturations with PH of 7.16 and increasing somnolence. The
patient had CT scan to evaluate his questionable abdominal
source, however, the patient was then admitted to the medical
ICU because he became hypotensive in the 70's but responded
to minimal IV fluids. The patient was started on some
Vancomycin, Gentamycin and Flagyl for his ongoing fevers. In
the medical ICU the patient was noted to be hypotensive and
also with an increased metabolic acidosis probably secondary
to sepsis. The patient was started on some Neo-Synephrine
and Levophed for aggressive blood pressure control as well as
some aggressive fluid management. The patient also started
on Levofloxacin for coverage and antibiotics. The patient
was then on Levo, Flagyl, Gent and Vancomycin. The patient
also was found to be in DIC with an elevated PT, PTT. If the
platelets were lower, the patient needed to receive some
fresh, frozen plasma anticoagulation factors as well as some
platelets for this support. The patient had right groin line
placed as well as a left femoral line placed and some
peripheral IVs as well. Later on that evening at 4:30 p.m.
on [**1-18**] the patient became bradycardic with heart rate in the
30's with a low blood pressure. The patient was given
Atropine .5 mg, an amp of Epi with resolving of increased
heart rate, blood pressure and patient was also given Calcium
and some bicarb. Then patient went into VT with the rate at
about 200, was shocked about 200-300 joules and then was back
in sinus rhythm with rate of 140 with a little bit of
hypotension. The patient had his electrolytes repleted. The
patient was found to be over breathing the ventilation with
high respiratory rates despite the sedation with Fentanyl and
Ativan. Therefore, patient was paralyzed to maximize
ventilation. The patient was also changed off the different
pressors with Levophed and Vasopressin. The patient was then
given hemodialysis instead of his peritoneal dialysis for the
next couple of days. The patient was continued on his
antibiotic regimen of Ceftriaxone, Vancomycin, Levofloxacin,
Flagyl as well as Vancomycin for his unknown source. The
patient then had a pulmonary bronchoscopy to evaluate to see
if there is any bacterial pneumonia but the patient had no
evidence of anything on bronchoscopy. Bronchial alveolar
lavage was done which in turn was negative. The patient also
had a TEE for further evaluation with questionable
endocarditis, however, no vegetations were seen on the
patient's aortic valve. The patient was cultured numerous
times in terms of his blood cultures as well as sputum
cultures as well as peritoneal dialysis fluid, however, no
source ended up ever growing out anything.
COMPLICATED MEDICAL ICU COURSE:
1. ID: Septic shock. Etiology of the septic shock was not
entirely clear as chest x-ray, CT scans were just compatible
with ARDS and multifocal pneumonia. However, no bug ever
grew out. The patient was continued on Vancomycin,
Gentamycin, Levofloxacin, Ceftriaxone. TEE was performed to
rule out endocarditis, however, was negative. The patient
was continued on various pressors to support his blood
pressure given the septic picture, such as Levophed and
Vasopressin. As the patient remained in house, the patient
ended up developing some C. diff colitis, probably secondary
to all the antibiotics he was on. The patient was given a 10
day course of po Vancomycin per his NG tube as well as being
continued on the other antibiotics. The patient had his
peritoneal dialysate fluid as well as various sputum cultures
and blood cultures sent for any temperature spike that he had
had. Nothing had ever grown out of any of these cultures.
The patient was continued on Levofloxacin, Flagyl, Vanco,
Gentamycin for 14 day course total. The patient had all his
medications renally dosed as patient has end stage renal
disease. The patient had various tipped catheters of his
central lines changed over wires as well as re-sited and tips
were sent for culture, however, nothing ever grew out as
well. The patient had CT scan of his abdomen times two which
revealed a left iliopsoas abscess which eventually was
drained, however, no bug or any white cells were found in
that abscess. As well, patient had evidence on abdominal CT
scan of an enlarged gallbladder which was drained, however,
just revealed normal biliary substances with no bacteria, no
PMNs. The only thing that ever grew back besides the C. diff
colitis was a sputum culture that was positive for MRSA on
[**1-15**]. The patient had various other negative blood cultures,
sputum cultures as stated before under the ID aspect of this.
2. Renal: The patient was end stage renal disease, was
started on hemodialysis as he first was admitted to the
Medical Intensive Care Unit, however, eventually the patient
went over to peritoneal dialysis as he did at home. The
patient was continued pretty much on his outpatient regimen,
however, while on dialysis the patient developed some glucose
intolerance from the high Dextrose levels found in the
peritoneal dialysis fluid. The patient was started on an
insulin drip and blood sugars were monitored closely while
patient was on peritoneal dialysis requiring different
insulin doses daily. Eventually patient was placed on an NPH
dose as well as insulin being added to his peritoneal
dialysis fluid. Currently patient is pretty much on his own
home dialysate as well as home dialysis schedule.
3. Respiratory: Patient was ventilator dependent on
admission to medical ICU on [**12-18**]. The patient remained on
the ventilator for full support until finally extubated on
[**2161-1-15**]. The patient was very much sedated from all the
medications that we gave him including Fentanyl, Ativan as
well as paralysis. So it took awhile to wean the patient of
the ventilator due to the excessive sedation. However,
patient finally weaned on [**1-15**] while minimal Fentanyl and
Ativan drips which eventually were shut off and was able to
sat well on nasal cannula O2 as well as a face mask. After
patient was admitted to the Medical Intensive Care Unit and
ventilated, the patient developed an ARDS type of picture and
he was vented in a way to keep his total volumes low for
decreased lung injury. The patient remained on the
ventilator as I stated before until [**1-15**] when he was
extubated and patient had some satting.
4. GI: As stated before, the patient had C. diff cultures
which eventually were positive. The patient was started and
completed a 14 day regimen of po Vancomycin and eventually
had a repeat C. diff culture which was negative. The patient
also developed evidence of some lower GI bleed as well as he
has had melenic stools as well as an upper GI bleed with
positive NG lavage. The patient had a colonoscopy done while
in house on [**1-19**] which showed some evidence of some ischemic
colitis as well as a couple of polyps. The patient had some
Epinephrine injected into the part of the colon which was
actively bleeding at the time. The patient's hematocrit
remained stable after that and evidence of the GI bleed
seemed to have decreased. The patient had evidence of some
pancreatitis with rising amylase and lipase levels which
probably was attributed to his septic picture. The patient
also had a minimal elevation in his LFTs but with
normalization of his total bilirubin and his alkaline
phosphatase, therefore it was thought that this was due to
sepsis rather than a primary source of the gallbladder at the
time until patient finally had the gallbladder drained which
revealed that it was indeed just due to his npo status and
having an enlarged gallbladder rather than having infectious
cholangitis or such.
5. Heme: Patient was admitted to the Medical Intensive Care
Unit in sepsis. The patient was in a DIC type of picture.
The patient required excessive platelets as well as blood
transfusions as well as other coagulation factors for support
of his DIC picture. The patient also had to be on Heparin
for an AVR replacement which he had had done previously so
PTT was monitored pretty closely.
6. Cardiovascular: The patient had a history of
hypertension when he came in. He was on Atenolol. The
patient needed aggressive pressor support as well as fluid
boluses to maintain his blood pressure while he was in the
septic picture. The patient was on Neo-Synephrine as well as
Levophed as well as some Vasopressin for support of his blood
pressure control. The patient was weaned off of all pressors
on [**1-11**] and was hemodynamically stable, not requiring anymore
pressor support. Blood pressure at times was maintained with
some fluid boluses as patient sometimes got a little bit
hypotensive while he started peritoneal dialysis. However,
that seemed to have resolved as we changed his peritoneal
dialysate to make his fluid status pretty much even.
7. Fluids, Electrolytes & Nutrition: The patient was
started on TPN while in house and after extubation patient
was on tube feeds. The patient has been tolerating tube
feeds well, started on Neo-Pro for further nutrition while on
tube feeds. He was started on Criticare and tolerated it
well.
8. Endocrine: The patient had evidence of glucose
intolerance secondary to the high Dextrose as well as the
sepsis picture, as well as the chronic Prednisone that
patient was taking at home. The patient was started, as I
said before, on an insulin drip which was titrated to keep
his blood sugars tightly controlled between 90 and 110,
however, eventually patient was weaned off the insulin drip
and was given NPH insulin as well as insulin and his PD fluid
for better blood glucose control. Currently patient was
getting the insulin and the PD fluid as well as sliding scale
for control with fingersticks checked every two hours while
undergoing the peritoneal dialysate. The patient was
continued on stress dose steroids for the chronic Prednisone
he took at home. He was started on 100 mg qid of Hydrocort
and eventually was weaned down to 15 mg tid of Hydrocort and
eventually 10 mg of Prednisone.
9. Musculoskeletal/Neuro: The patient was paralyzed after
the intubation as the patient got hypotensive as well as
patient was given high dose steroids. The patient, after
being taken off the paralysis and being tailored down on the
steroids, the patient continued to be extremely weak and
fairly less spontaneous movements. After extubation the
patient slowly gained a little bit of strength back as the
Fentanyl and Ativan were wearing down as well as stronger as
when he was having some physical therapy. The patient
remained extremely weak, had very little spontaneous
movements and difficulty speaking. The patient will need
aggressive physical therapy to get back to his baseline as
patient is a plastic surgeon and was fully active prior to
coming into the hospital.
I will update any further events that occur after this
dictation on an addendum and will summarize the ID course at
that seems to have been his major issue during this
admission.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-647
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2161-1-22**] 13:09
T: [**2161-1-24**] 09:37
JOB#: [**Job Number 6235**]
Admission Date: [**2160-12-17**] Discharge Date:
Date of Birth: [**2106-1-16**] Sex: M
Service:
ADDENDUM:
Under the neurologic aspect of his care in the Medical
Intensive Care Unit, the patient was on high dose paralytic
as well as some high dose steroids. The patient continued to
be lethargic with decreased movement of his upper extremities
as well as lower extremities.
The patient had a head CT which was unequivocal for any
findings other than slight sinusitis. The patient also had a
magnetic resonance scan of his head and his spine to evaluate
if there was any central process causing his upper and lower
extremity weakness. Both the CT scan as well as the magnetic
resonance scan of the head, as well as the magnetic resonance
scan of the neck, revealed no central process that causes
extensive motor weakness.
Neurology was consulted and attributed this to be a critical
care neuropathy. An EMG was also performed which only
revealed that it was neuropathy, however, the patient was
very sedated at the time and it was not the best time to
perform it because the patient was under high dose sedation.
However, according to neurology, it was very likely to be a
Intensive Care Unit neuropathy and the patient will
eventually regain his strength as high dose paralytics as
well as high dose steroids as well as the stress from being
in sepsis alone will hopefully wear off and the patient will
regain his strength hopefully to his full ability.
The patient's mental status apparently was normalized towards
the end of the admission as the patient was responding
appropriately with head nods as well as minimal spontaneous
movements of his upper and lower extremities. The patient
was also able to attempt to speak and was able to talk with
us although be it extremely difficult for the patient due to
his weakness and was able to talk and let us know exactly
what was bothering him.
We will add more to this dictation summary as his long and
extensive hospital course continues.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2161-1-22**] 13:19
T: [**2161-1-24**] 10:14
JOB#: [**Job Number 6236**]
Name: [**Known lastname **], [**Known firstname 126**] A Unit No: [**Numeric Identifier 766**]
Admission Date: [**2160-12-17**] Discharge Date: [**2161-1-30**]
Date of Birth: [**2106-1-16**] Sex: M
Service: [**Hospital1 767**]
HISTORY OF PRESENT ILLNESS: This is a 55 year old man with
past medical history significant for end stage renal disease,
peritoneal dialysis times one year, status post
glomerulonephritis, renal transplant three times and aortic
valve replacement secondary to calcific aorta who comes in
complaining of temperature of 100.6 on the day of admission
back in [**Month (only) 768**]. He also comes in with a minor complaint
of back pain and some chills. He denied any localizing
symptoms, no cough, no chest pain, no shortness of breath, no
abdominal pain and no flank pain. He did have some mild
nausea earlier on the day of admission which had resolved.
He called his primary care physician and was told to go to
the Emergency Room. The day prior to admission the patient
had an magnetic resonance angiography to evaluate his
brachioplexus because of an ischemic second and third finger
of his right hand.
PAST MEDICAL HISTORY: As mentioned, end stage renal disease
status post peritoneal dialysis times one year, post
glomerulonephritis, renal transplant times three, chronic
anemia, hypertension, aortic valve replacement secondary to
calcific aorta, otitis and gastrointestinal polyps.
HOSPITAL COURSE: Please see the prior discharge summaries to
describe his hospital course.
Once transferred to the floor Dr. [**Known lastname **] improved from a
cardiovascular standpoint. 1. Coronary artery disease, no
issues or medications at this time. 2. Hypertension, his
blood pressures were followed, at times he was hypotensive to
about 108 systolic at which time he was given 500 cc of
normal saline bolus to which he responded well and that is
what was given for his pressor support. There were no other
issues. Electrophysiologically there were no issues, no
telemetry was needed. Congestive heart failure, there were
no issues.
Pulmonary, he was kept on oxygen. He was also given physical
therapy. He remained at 98% on 3 liters of oxygen improving
and he was followed and kept on aspiration precautions to
prevent any subsequent aspiration pneumonias.
Renal, the team followed and recommended daily dialysis
management of his daily peritoneal dialysis which he
continued to do. His electrolytes were followed and replaced
as needed. At the time of discharge on [**2161-1-30**] his
potassium was low so he was being given two days of potassium
resupplementation.
Gastrointestinal, the patient was given his tube feeds via an
nasogastric tube, however, it became plugged secondary most
likely to medications and the patient refused twice to have
his nasogastric tube replaced, so his nutrition was
maintained by his taking medications and feeding p.o. His
swallow study described in the neurological section, but
essentially his ability to eat and drink improved
considerably over the time while he was on the floor. There
were no signs of obstruction and it was recommended that if
he has any worsening abdominal distention, a KUB should be
done. There will be no plan for esophagogastroduodenoscopy
according to the gastrointestinal service following him.
Neurological/psychiatrist, the patient needs extensive
rehabilitation to regain his strength from what was described
as a Medicine Intensive Care Unit neuropathy. He has been
given Ativan prn, aspiration precautions were maintained.
Speech and Swallow has been following him. The most recent
recommendation based on the [**1-29**], evaluation says to
continue thin liquids, he may have ground solids, soft solids
as tolerated, possible for p.o. intake. The patient requires
assistance with self feeding. He should be monitored for
aspiration and acute rehabilitation with dysphagia management
and full cognitive communication assessment was the
recommendation.
Endocrine, he is given NPH insulin as dialysate, regular
insulin sliding scale with fingersticks done. The patient
had chronic steroids at home in a way of suppressing his
rejection of his current kidneys. On the Medicine Intensive
Care Unit he was given stress dose steroids. He has now been
tapered down to 10 mg p.o. of Prednisone and a taper further
can be considered down to perhaps what was at 3.75 mg p.o. q.
day. Hydrochlorothiazide can be used intravenously if there
is no heme access.
Heme, he was mechanical atrial valve so his titered INR was
2.5 to 3.5. He was maintained on heparin GTT, or he started
on Warfarin. His INR most recently was 1.9 and so he should
be continued on the Warfarin and also the heparin drip to
maintain him in an appropriate therapeutic range to protect
him from complications related to his atrial valve.
Infectious disease, he remained afebrile during his time on
the floor. He finished a course of antibiotics. I never
found what the cause of his sepsis was. He did also have
Clostridium difficile which was also treated.
DISPOSITION: The patient remains full code. He will be
discharged to rehabilitation as soon as possible, in other
words, [**2161-1-30**]. Communication has been with his wife,
Dr. [**First Name8 (NamePattern2) 769**] [**First Name8 (NamePattern2) **] [**Known lastname **], phone [**Telephone/Fax (1) 770**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**]
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2161-1-29**] 19:22
T: [**2161-1-29**] 17:23
JOB#: [**Job Number 772**]
|
[
"557.9",
"276.2",
"577.0",
"038.9",
"585",
"518.5",
"286.6",
"427.41",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"88.72",
"96.72",
"96.04",
"51.02",
"38.93",
"96.6",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1336, 1561
|
18259, 22458
|
1584, 2903
|
17074, 17956
|
17979, 18241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,132
| 127,772
|
18494
|
Discharge summary
|
report
|
Admission Date: [**2131-1-10**] Discharge Date: [**2131-2-6**]
Date of Birth: [**2092-12-24**] Sex: F
Service: MEDICINE
Allergies:
Latex / Adhesive Tape
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
DOE - Hodgkin's Lyphoma
Major Surgical or Invasive Procedure:
Chest Tube Placement/VATS
History of Present Illness:
This is a 38 yo female with nodular sclerosing Hodgkin's
lymphoma (diagnosed in [**2123**]) that involves her lungs, who
presents with worsening respiratory function. She notes that
since [**Month (only) 216**] she has had increasing DOE on exertion and is
followed by her oncologist at an OSH for this. Her dyspnea
became worse in [**Month (only) **] and she has been unable to lie flat on
her back since that time. In [**Month (only) 359**] fo [**2129**] she was admitted to
OSH for pneumonia and treated with abx. Her respiratory symptoms
continued. She was noted to have a left pleural effusion by
x-ray and this was tapped in [**2130-10-26**]. At that time only
200cc of dark fluid was removed (per the patient) and this did
not relieve her symptoms at all. More recently in the past two
weeks she has been increasingly SOB with standing and walking.
She notes that she is usually able to breath normally while
lying on her side of sitting up in bed, but this has gotten
worse in the past week. She does have an occasional productive
cough "when I get excited" and produces clear sputum. This cough
has been present since [**2130-6-26**]. She states that
approximately 2 weeks ago she had a low grade temp and was
treated for two weeks with Avelox (this was stopped on [**1-2**]). The
Avelox helped her dyspnea for the first week, but her symptoms
got worse during the second week of treatment. She also notes
that approximately one week ago she developed a gastroenteritis
(which she got from her son), and had two days of
nausea/vomiting and diarrhea that have resolved. She was seen
in clinic today and noted to have DOE with walking short
distances, RR 40 and hypotension with BPs 82/64. Her O2 sat was
95% at rest. She is normally seen at an OSH and per reports PFTs
showed FEV1 of 0.8 (25% of expected). She was also noted to have
a fever, she thinks to 101.0. She was given a 500 cc NS bolus,
blood cultures were drawn, and she was treated with vancomycin
and ceftriaxone. Currently she is SOB with speaking but feels
better since she has been placed on 4 L NC O2.
On ROS: She denies N/V, abdominal pain, diarrhea, constipation,
rashes, sore throat, dysuria, hematuria, abnormal vaginal
discharge.
(+) for daily CP midsternal and under right breast (since [**Month (only) **]
[**2129**])
(+) cough, described above
(+) night sweats when she takes vicodin
(+) pain in her bones (in her back mostly) for which she takes
vcodin
Past Medical History:
1. Hodgkin's lymphoma (stage IIA, diagnosed in [**2123**] -
nodular sclerosing) (see above for details)
2. Splenectomy in [**2126**].
3. h/o herpes zoster.
4. per prior notes has history of Fen-Phen use.
5. Clot in left SVC that resulted in swelling of left breast,
should be taking coumadin for this but stopped taking it last
friday b/c she was upset
6. left pleural effusion
Oncology History: Diagnosed with Hodgkin's lymphoma, nodular
sclerosing) in [**2123**]. The patient initially was treated with
Adriamycin, bleomycin, vinblastine, dacarbazine with subsequent
disease recurrence. Transplant was deferred at that time, and
the patient received four cycles of CEPT. She also received
radiation therapy as part of initial treatment for six weeks.
She had an autologous BMT in 4/[**2128**]. In [**2-/2130**] (about one year
post transplant) a CT evaluation revealed recurrent disease in
her chest and abdomen. Anterior mediastinal adenopathy was in
the field of prior radiation. She underwent a biopsy of her
anterior mediastinal adenopathy that revealed recurrent
Hodgkin's lymphoma. She was then treated with CEPP chemotherapy.
She had a variable response to CEPP and was started most
recently on Rituxan and Vinblastine.
Social History:
The patient is single. She has an 11-year-old son. [**Name (NI) **] tobacco or
ETOH use.
She works occasionally in a convenient store.
Family History:
Mother passed away from a myocardial infarction. Father
diagnosed just recently with pancreatic, liver and colon CA
(primary ca not known)-also states father has cancer from
asbestos
Physical Exam:
VS: Tc 96.5 HR 145 BP 104/70 O2 sat 98% on 2L
Gen: Young female with dyspnea while talking, but able to speak
in full sentances
HEENT: PERRL, EOMI, anicteric sclera, MMM, clear oropharynx
Neck: supple, no LAD
Cardio: tachy with reg rhythm, nl S1 S2, no m/r/g
Pulm: CTA B but with decreased breath sounds on left side about
halfway up lung with dullness to percussion as well, decrease
breath sounds at right lung base
Abd: soft, NT, +BS, mild tenderness in LLQ
Ext: no edema
Neuro: CN 2-12 intact,
Muscle strength 5/5 in b/l upper and lower extremities
Sensation to light touch intact
Pertinent Results:
Imaging:
[**2131-1-10**] CXR - Large amount of left pleural fluid which is worse
in comparison to the previous study. Small amount of right
pleural fluid - unchanged in comparison to the previous film. No
evidence of pulmonary edema. The patient is status post
splenectomy.
[**2131-1-11**] Chest CT - Large left pleural effusion responsible for
near-complete collapse of the left lung. Small right pleural
effusion. Minimal pleural nodularity, but no evidence of
loculation. Extensive prevascular lymphadenopathy extending to
and destroying portions of the sternum, left 1st through 3rd
anterior ribs, and other left anterior chest wall structures.
Superior mediastinal lymphadenopathy with mild narrowing of the
trachea at the thoracic inlet. No other vital structures
compromised.
Right supraclavicular, paratracheal, subcarinal, paraesophageal,
and diaphragmatic lymphadenopathy.
[**2131-1-12**] Echo - The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). 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 a trivial/physiologic
pericardial effusion. An echo dense mass is noted anterior to
the heart/right ventricle outside the pericardial space.
[**2131-1-14**] Unilateral breast U/S - No fluid collections.
[**2131-1-14**] Abd U/S - Gallbladder sludge. Otherwise normal abdominal
ultrasound. Right pleural effusion.
[**2131-1-14**] Unilateral L upper ext U/S - Abnormal finding in the
left internal jugular area likely representing a necrotic lymph
node and adjacent patent diminutive internal jugular vein.
Alternatively, if the patient has had prior procedures or
radiation, this may represent chronic fibrosis with focal
chronic thrombus. If clinically indicated, this may be further
evaluated with a contrast-enhanced neck CT.
[**2131-1-16**] CTA - No pulmonary embolism. Interval improved aeration
of the left lung. No consolidation to suggest pneumonia.
Unchanged bilateral masses and chest wall mass consistent with
known metastatic disease
[**2131-1-17**] CTA - No pulmonary embolism. Interval improved aeration
of the left lung. No consolidation to suggest pneumonia.
Unchanged bilateral masses and chest wall mass consistent with
known metastatic disease.
[**2131-1-20**] CXR - Overall stable appearance of the chest with no
pneumothorax identified. Stable position of the left chest tube.
[**2131-1-21**] CT Abdomen - Marked retroperitoneal and retrocrural
lymphadenopathy. Two soft tissue density nodules within the
mesentery adjacent to the small bowel also likely represent
areas of disease involvement. No bowel obstruction. Stable
appearance of extensive lymphadenopathy within the chest. Two
millimeter hypodensity within the right posterior segment of the
liver, too small to fully characterize.
[**2131-1-25**] CXR - Bilateral small-to-moderate pleural effusions are
again demonstrated with apparent loculation on the left. These
appear unchanged in the interval. Overall, since the recent
radiograph of earlier the same date, there has not been a
significant change in the appearance of the chest.
[**2131-1-28**] CXR - Left subclavian line tip in the superior vena cava
is unchanged. There are bilateral pleural effusions left greater
than right. There are bibasilar patchy areas of volume loss.
Hazy increased opacity in the left mid lung corresponds to known
mediastinal mass with adjacent chest wall invasion. Compared to
the film from 2 days ago, the effusions are slightly smaller.
[**2131-1-29**] ECHO - The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. There is a small, echo dense, organized pericardial
effusion. Compared with the findings of the prior study (images
reviewed) of [**2131-1-14**], the small pericardial effusion is more
evident on this complete study.
[**2131-2-1**] CXR - No interval change in pleural effusions.
[**2131-2-5**] CXR - Mild pulmonary edema improved since [**1-28**] and 9.
Contraction of the left hemithorax is longstanding, and left
lower lobe atelectasis has been stable since [**1-28**]. Small
right and moderate left pleural effusion are unchanged. Cardiac
silhouette is partially obscured by adjacent pleural and
parenchymal abnormality but not grossly changed from mild
cardiomegaly in the interim. Tip of the left subclavian infusion
port projects over the SVC. No pneumothorax.
Brief Hospital Course:
38 yo female with nodular sclerosing Hodgkin's lymphoma
(diagnosed in [**2123**]) and with disease in her lungs, known left
pleural effusion who presented with significant dyspnea on
exertion.
*Hodgkins - The patient has refractery Hodgkins disease. She
was admitted with known disease relapse and progression. Most
of her symptoms (pain, dyspnea on exertion, shortness of breath,
breast swelling) were all thought secondary to disease
infiltration. She was given a cycle of ICE chemotherapy. She
did have neurotoxicity (confusion, hallucinating) that was
thought to be from the ifosfomide so it was held on [**2131-1-25**]; and
she only received 25% of her final dose. Her final dose of the
cycle was on [**2131-1-26**]. She reached her nadir at approximately day
7 and then her counts have slowly started to rise. On discharge
her WBC was 1.2 with an ANC of 840. She will receive a neupogen
shot the day after discharge at the office of Dr. [**Last Name (STitle) 50854**]
(arranged by [**Doctor First Name 8513**]). She will follow up with Dr. [**Last Name (STitle) 50854**] and Dr.
[**First Name (STitle) **] this week. She will likely be readmitted for a second
cycle of ICE next week.
*DOE: Patient has had progressive DOE since [**Month (only) 216**]. Likely [**12-28**]
to underlying Hodgkin's disease (some reports of paralyzed left
diaphragm), pleural effusion and possible overlying PNA. Recent
PFTs done as outpatient showed FEV1 of 0.8, which suggested
obstructive disease. At admission she was tachypneic and febrile
and started on empiric vancomycin and ceftriaxone for possible
pneumonia. Imaging done here with CXR and chest CT showed
diffuse disease in chest and left sided pleural effusion with
almost complete collapse of left lung. IP tried to tap the
effusion without success, likely b/c it was loculated. Pt had
VATS on [**1-12**] with expansion of lung and placement of two chest
tubes and [**Doctor Last Name **] drain. Patient had tachypnea and pain post
procedure. Had O2 sats in low 90s, upper 80s and did not use
much O2 because of history of bleomycin exposure. Several days
after VATs the patient had a desat to 77% on RA and was sent to
the intesive care unit. She was clinically stable in the ICU and
did not require intubation. She had a CTA to evaluate for PE
and was negative. Chest tubes were removed. She was transferred
back to the floor after 4 days. She remained stable and was
treated with morphine PCA and fentanly patch for pain control.
The chest was left in place to drain for approxmiately 10 days.
The patients symptoms were still persistent after the tube was
removed. It was felt that the only way to further improve her
symptoms was to treat the underlying disease. She was then
given a cycle of ICE chemotherapy (see above). During the later
half of her hospital stay she was intermittently treated with
lasix for SOB and put on a steroid taper of dexmethasone (on 2mg
[**Hospital1 **] upon discharge). Repeat X-rays showed improving pulmonary
edema after lasix treatment. She was discharged on lasix 40mg PO
at discharge. (multiple ECHO's showed a normal EF)
*H/o left subclavian vein clot: Patient had a left subclavian
clot several months prior to admission. She took coumadin as an
outpatient. Her coumadin was held during the early part of her
admission because she was scheduled to have a thoracentesis and
then VATS and required an INR of <1.5 for these procedures.
Patient did have some swelling of left breast and left upper
extremity. Ultrasound of left uppper extremity showed: Abnormal
finding in the left internal jugular area likely representing a
necrotic lymph node and adjacent patent diminutive internal
jugular vein. Alternatively, if the patient had prior procedures
or radiation, this could represent chronic fibrosis with focal
chronic thrombus. Breast ultrasound showed no fluid collections.
The hope is that is the chemotherapy shrinks the disease, there
will be improvement in the breast and arm swelling.
*Fevers: Patient had a fever a few weeks prior to admission and
was treated with Avelox at that time. Had fever at admission.
Blood and urine cultures were checked and were negative. CXR
showed large left pleural effusion and she was started on
ceftriaxone and vancomycin for now for broad spectrum abx
coverage to cover for possible PNA hidden behind the effusion.
She was treated with a 14 day course ([**Date range (2) 50855**]) with no
further fevers. The patient remained afebrile off antibiotics.
*Paralyzed vocal cords: Patient was found to have hoarse voice
and paralyzed vocal cords in the ICU. It was unclear if was
secondary to VAT or her Hodgkin's disease affectling the
recurrent laryngeal never. A speech and swallow evaluation was
done and then a video swallow that showed the patient was not
aspirating. Her voice was intermittently improved during her
hospital course.
*Anxiety - The patient had continued anxiety and depression
throughout her hospital course. She responded well to starting
celexa and xanax. She was continued on this regimen at
discharge. Of note, she had an adverse reaction to IV ativan
(hallucinations, confusion).
*Hypotension: Was hypotensive early in admission (SBPs in 90s),
with no improvement with IVF. Had low BPs and nl UPO throughout
her admission, but remained clinically stable.
*Tachycardia: Pt had sinus tachycardia with unclear source.
Thought to be secondary to infection or dyspnea secondary to
collapsed lung. IVFs did not improve tachycardia.
Medications on Admission:
Synthroid, 100 mcg qd
Neurontin 300 mg p.o. qAM and afternoon
Neurontin 600 mg qhs
Vicodin q4-6 hours PRN
Ativan 1 mg p.r.n
Coumadin 2.5 mg p.o. QOD (has not taken since Fri)
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*180 Capsule(s)* Refills:*2*
4. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
Disp:*120 Troche(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QOD ().
Disp:*15 Tablet(s)* Refills:*2*
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
Disp:*30 Tablet(s)* Refills:*3*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
Disp:*90 Tablet(s)* Refills:*0*
10. Vicodin ES 7.5-750 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
11. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Hodgkins Lymphoma
Discharge Condition:
Stable; O2 sats in the mid 90's
Discharge Instructions:
--Please take all medications as prescribed. Use your oxygen as
needed when you have difficulty breathing.
--You will need be closely followed in the outpatient clinic.
Please make sure to go to all of your appointments.
Followup Instructions:
--You have an appointment with Dr. [**Last Name (STitle) 50854**] on Thursday ([**2131-2-8**])
at 1:30 PM. You can call [**Doctor First Name 8513**] ([**Telephone/Fax (1) 50856**]) if you prefer a
morning appointment.
--You have an appointment with Dr. [**First Name (STitle) **] on Friday. Please go
to her office on the [**Location (un) 436**] of the [**Location (un) 8661**] Building at
12:30PM.
--You need to have a Neupogen Shot. I spoke with [**Doctor First Name 8513**] at Dr. [**Name (NI) 50857**] office and she said you can come in anytime on
Wednesday to get the shot.
|
[
"784.7",
"518.0",
"348.30",
"611.1",
"428.0",
"201.50",
"511.8",
"518.82",
"790.4",
"E947.8",
"785.0",
"698.9",
"486",
"458.9",
"300.00",
"V42.81",
"724.5",
"478.33",
"276.1",
"V15.3",
"729.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"33.99",
"31.42",
"34.09",
"34.91",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
17259, 17321
|
9807, 15332
|
307, 335
|
17383, 17417
|
5036, 9784
|
17688, 18274
|
4230, 4415
|
15558, 17236
|
17342, 17362
|
15358, 15535
|
17441, 17665
|
4430, 5017
|
243, 269
|
363, 2805
|
2827, 4061
|
4077, 4214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,180
| 181,092
|
31428
|
Discharge summary
|
report
|
Admission Date: [**2170-11-20**] Discharge Date: [**2170-11-28**]
Date of Birth: [**2116-11-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Pancreatic cancer.
2. Chronic pancreatitis
Major Surgical or Invasive Procedure:
1. Staging laparoscopy.
2. Pylorus-preserving Whipple pancreaticoduodenectomy.
3. Repair of superior mesenteric vein injury.
History of Present Illness:
This 53-year-old lady has a history of pancreas divisum and has
been treated
endoscopically for this at our institution. She has had about a
month-long history of a general uneasiness in her abdomen and
low-lying abdominal pain. This was investigated at an outside
hospital where she was found to have a mass in the head of the
pancreas. She drove from that hospital for admission to our
institution last week. We found her to have a 2.5 cm hypodense
lesion in the head of her pancreas which was separate from the
pancreatic duct and bile duct. It had all of the cardinal
features of an adenocarcinoma. There was
no evidence of any metastatic disease on her CAT scan. It looked
locally contained and totally resectable. An endoscopic
ultrasound examination was performed the week before this
procedure, and this confirmed pancreatic
adenocarcinoma as the diagnosis.
Past Medical History:
PMHx: multiple episodes of acute pancreatitis [**12-17**] pancreatic
divisum (stented [**2168**]), pancreatic cysts, multiple liver
hemangiomas, HTN, hypothyroid, depression
PSHx: CCY [**11/2168**], C-Section x2 (remote)
Social History:
SocHx: married, grown children
Family History:
FHx: non-contributory
Physical Exam:
T 97.6 / HR 107 / BP 130/80 / RR 20 / POx 95% RA
Gen: AA&O x3, NAD
HEENT: MMM, no scleral icterus
CVS: RRR, no m/r/g
Resp: CTA b/l
Abd: Soft, distended, TTP greatest at RUQ and epigastrum. Well
healed vertical midline surgical scar, bowel sounds present
Ext: no C/C/E
Pertinent Results:
[**2170-11-20**] 09:34PM BLOOD WBC-12.1* RBC-3.24* Hgb-9.1* Hct-26.5*
MCV-82 MCH-28.3 MCHC-34.5 RDW-14.3 Plt Ct-285
[**2170-11-24**] 06:40AM BLOOD WBC-11.3* RBC-3.43*# Hgb-10.4*#
Hct-29.2*# MCV-85 MCH-30.2 MCHC-35.4* RDW-14.6 Plt Ct-207
[**2170-11-20**] 09:34PM BLOOD Glucose-264* UreaN-16 Creat-1.3* Na-138
K-4.8 Cl-105 HCO3-24 AnGap-14
[**2170-11-24**] 06:40AM BLOOD Glucose-159* UreaN-5* Creat-0.6 Na-138
K-4.6 Cl-101 HCO3-31 AnGap-11
[**2170-11-22**] 02:27AM BLOOD ALT-156* AST-170* LD(LDH)-263* AlkPhos-89
Amylase-32 TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2170-11-21**] 04:10AM BLOOD Lipase-29
[**2170-11-24**] 06:40AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8
.
SPECIMEN SUBMITTED: Jejunum, Whipple, Pancrease Neck, pancreatic
neck margin.
Procedure date Tissue received Report Date Diagnosed
by
[**2170-11-20**] [**2170-11-21**] [**2170-11-23**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
DIAGNOSIS:
I. Jejunum (V-W):
Small bowel segment, within normal limits.
II. Pancreaticoduodenectomy, partial (A-U):
1. Adenocarcinoma of the pancreas, see synoptic report.
2. Adjacent intraductal papillary mucinous tumor, extending to
the uncinate and posterior margins.
3. Focal fibrosis and atrophy of pancreas, mainly near neck
margin.
4. Common bile duct and duodenal segment, within normal limits.
III. Pancreatic neck (X):
1. Focal area of adenocarcinoma.
2. Marked atrophy of pancreas.
IV. Pancreatic neck margin, final (Y-AA):
1. There is no tumor in the original frozen sections or in the
permanent section of this margin (slide Y).
2. Foci of carcinoma are present in the underlying tissue
(slides Z-AA).
3. Marked atrophy of pancreas.
Pancreas (Exocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Pylorus sparing pancreaticoduodenectomy, partial
pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size
Greatest dimension: 3.5 cm. Additional dimensions: 2.5 cm
x 2.4 cm.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT2: Tumor limited to the pancreas, more than 2
cm in greatest dimension.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 17.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 1-2 mm. Specified
margin: Pancreatic neck.
Margin(s) involved by invasive carcinoma:
Neck margin of this specimen (part II) shows tumor, but
samples of true margin (part IV) show no tumor.
.
Brief Hospital Course:
This is a 54 year old female with a pancreatic mass who went to
the OR on [**2170-11-20**] for:
1. Staging laparoscopy.
2. Pylorus-preserving Whipple pancreaticoduodenectomy.
3. Repair of superior mesenteric vein injury.
She was reintubated in the PACU for respiratory distress and
spent the first night in the SICU. She recovered well and
followed the "Whipple" pathway.
Pain: She had a PCA for pain control. She was transitioned to a
PCA and then oral pain medications once tolerating a diet.
GI/ABD: She was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. Her diet was slowly advanced as
she had return of bowel function. She was tolerating clears
liquids by POD 5. On POD 6, a JP Amylase was measured and was
13. The drain was subsequently removed the next day.
Her abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed.
She was tolerating regular food and reported +flatus and +BM
prior to discharge.
Medications on Admission:
Synthroid 0.137', Zoloft 50', Norvasc 5'
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheeze.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Sertraline 50 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 once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours). Tablet(s)
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ductal adenocarcinoma
Discharge Condition:
Good
Discharge Instructions:
General:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* 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
* Monitor your incision for signs of infection (redness,
drainage).
* It is OK to shower and wash, no tub baths. Keep incision clean
and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-16**] weeks. Call
[**Telephone/Fax (1) 1231**] to schedule an appointment.
Completed by:[**2170-11-28**]
|
[
"228.09",
"311",
"998.2",
"244.9",
"577.1",
"401.9",
"E870.0",
"157.0",
"478.75",
"V64.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.32",
"96.04",
"52.7",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6742, 6748
|
4688, 5709
|
362, 489
|
6813, 6819
|
2026, 4665
|
8006, 8172
|
1698, 1722
|
5800, 6719
|
6769, 6792
|
5735, 5777
|
6843, 7983
|
1737, 2007
|
277, 324
|
517, 1387
|
1409, 1633
|
1649, 1682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,135
| 102,203
|
36329
|
Discharge summary
|
report
|
Admission Date: [**2127-7-23**] Discharge Date: [**2127-8-4**]
Date of Birth: [**2083-9-20**] Sex: M
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
altered mental status, nausea/vomiting, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old man with end-stage liver disease admitted from
clinic with N/V x 3 days and somnolence, thought to be [**2-3**] mild
encephalopathy. Patient was somnolent in Dr.[**Name (NI) 8653**] office
and continues to be somnolent on exam. He is unable to give a
full history and is reluctant to perform physical exam. He has
not taken any lactulose today and it is not certain if he has
missed doses prior to today, in light of recent nausea/vomiting.
No know history of head trauma. Also, c/o "pain all over," but
cannot localize source of pain.
.
Also unclear is whether or not feeding tube is in correct
position (feeds were stopped at 4am by wife). The patient had a
4.2L paracentesis in ultrasound. Cell count negative for SBP. BP
initially 99/59, SBP 89 after tap (93/64 prior to transfer). He
received 25g albumin and has been admitted for altered mental
status and acute renal failure. His creatinine is 2.6 (baseline
is about 1.0). The patient had a recent admission in early [**Month (only) 205**]
for abdominal pain, n/v, and was found to have portal vein
thrombosis, no SBP.
.
On the floor, T=96.9, BP=100/69, HR=84, RR=20, O2sat=100RA
.
Past Medical History:
-Alcoholic cirrhosis diagnosed [**3-9**] c/b portal vein thrombosis,
severe portal htn gastropathy, 3 cords of grade I varices; no
history of variceal bleed; currently gets paracentesis q1-2
weeks.
-Seizures from EtOH withdrawal
-no evidence of HCC on recent CT
-MELD=17; has completed liver [**Month/Year (2) **] work up
Social History:
Lives on cape with wife, no kids, previous heavy etoh(vodka),
sober since [**3-9**], no other drugs or smoking. Worked as a chef.
Family History:
nc
Physical Exam:
GENERAL: Somnolent, cachectic man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTA b/l, decreased breath sounds at b/l bases
ABD: +BS, mild distension, no TTP
EXTREMITIES: dry, warm and well perfused
SKIN: No rashes/lesions, ecchymoses. No jaundice
NEURO: Somnolent but awakens to name. Unwilling to answer
questions regarding orientation. Unwilling to participate with
neuro exam. +asterixis.
Pertinent Results:
[**2127-7-23**] 11:52AM WBC-8.0 RBC-3.52* HGB-11.4* HCT-33.0* MCV-94
MCH-32.5* MCHC-34.6 RDW-14.3
[**2127-7-23**] 11:52AM NEUTS-80.0* LYMPHS-15.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2127-7-23**] 11:52AM PLT COUNT-129*
[**2127-7-23**] 11:52AM PT-15.9* INR(PT)-1.4*
[**2127-7-23**] 11:52AM GLUCOSE-117* UREA N-73* CREAT-2.6*
SODIUM-130* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-18
[**2127-7-23**] 11:52AM ALT(SGPT)-34 AST(SGOT)-59* ALK PHOS-128* TOT
BILI-1.8*
[**2127-7-23**] 11:52AM ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-3.2*
[**2127-7-23**] 11:52AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-7-23**] 02:00PM ASCITES WBC-45* RBC-650* POLYS-0 LYMPHS-32*
MONOS-0 MESOTHELI-1* MACROPHAG-67*
[**2127-7-23**] 02:00PM TOT PROT-1.3* ALBUMIN-LESS THAN
IMAGING:
CT head ([**2127-7-23**]):
IMPRESSION: No acute intracranial process.
CXR ([**2127-7-23**]):
NG tube tip appears to terminate post-pylorically.
Cardiomediastinal contours are normal. The lungs are clear.
There is no pneumothorax or pleural effusion.
ABDOMINAL U/S WITH DOPPLERS ([**2127-7-24**]):
1. Extremely sluggish/slow flow within the portal vein, which
remains
hepatopetal. No thrombus identified.
2. Patent umbilical vein.
3. Findings of cirrhosis including ascites and splenomegaly.
CT HEAD ([**2127-7-29**])
No acute intracranial hemorrhage or obvious abnormality
identified. However, early cerebral edema may be difficult to
identify and
needs clinical correlation for exclusion. If there is a
continued clinical
concern, imaging followup is recommended to assess for any
interval changes.
ABDOMINAL U/S WITH DOPPLERS ([**2127-7-29**])
1. Exceedingly slow flow tending toward no flow in the portal
veins. This
appears to be worse than the ultrasound of [**2127-7-24**].
2. Large amount of ascites.
3. Cirrhotic-appearing liver with no focal liver lesion
identified, and no
biliary dilatation.
DUPLEX ([**2127-7-30**])
IMPRESSION:
1. Extremely slow to no flow within the portal vein, which is
unchanged when compared to the prior examination.
2. Dampened hepatic vein waveforms, consistent with cirrhosis.
3. Sludge within the gallbladder.
CULTURES:
[**2127-8-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-8-3**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture
in Bottles-PENDING INPATIENT
[**2127-8-3**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-negative, PRELIMINARY
INPATIENT
[**2127-8-3**] URINE URINE CULTURE-PENDING INPATIENT
[**2127-8-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-8-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
FINAL INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-29**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-negative; Cryptosporidium/Giardia (DFA)-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative FINAL INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-29**] URINE URINE CULTURE-negative FINAL INPATIENT
[**2127-7-29**] MRSA SCREEN MRSA SCREEN-positive FINAL {STAPH AUREUS
COAG +} INPATIENT
[**2127-7-29**] PERITONEAL FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-PRELIMINARY INPATIENT
[**2127-7-29**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2127-7-23**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-negative FINAL; ANAEROBIC CULTURE-negative FINAL
[**2127-7-23**] BLOOD CULTURE Blood Culture, Routine-negative FINAL
Brief Hospital Course:
43 year old man with a history of EtOH cirrhosis since [**3-9**] c/b
diuretic refractory ascites, portal hypertensive gastropathy,
and portal vein thrombosis on the liver [**Month/Year (2) **] list admitted
with 3 days of nausea/vomiting and somnolence thought to be due
to mild encephalopathy.
1. ALTERED MENTAL STATUS: His neurological exam on admission
showed the patient was somnolent, but would awaken to name,
unwilling to answer questions but said he was in the hospital,
+asterixis. His altered mental status was thought to be due to
hepatic encephalopathy vs. toxic-metabolic in the setting of
possibly not tolerating lactulose (given his n/v prior to
admission). Tox screen was negative. CT scan was negative for
acute intracranial process. He had a paracentesis for 4.2 L
removed which was not consistent with SBP. Encephalopathy
improved with lactulose and rifaximin and the patient was AAOx3
until the morning of [**2127-7-29**]. He was then transferred to the
MICU for acute change in mental status with decreased
responsiveness to sternal rub. Non contrast Head CT and CXR were
negative for acute process. EEG showed no seizure. Reglan,
megase, and H2 blocker were held. Lactulose was continued.
Mental status improved the next AM, at which point he was again
AAOx3. The acute change in mental status was likely secondary to
either changes in portal vein flow or decreased clearance of
reglan [**2-3**] renal failure.
On discharge, the patient was AAOx3.
2. ACUTE RENAL INSUFFICIENCY: Patient's Cr was 2.6 on admission
from a recent baseline of 1.0-1.5. Creatinine improved to 2.2
overnight with IVF and albumin, but remained in the 2.1-2.3
range in the days thereafter. Urine lytes were consistent with
prerenal vs. hepatorenal etiology. He was started on octreotide
and midodrine, but creatinine remained persistently elevated.
Creatinine gradually improved on this regimen and was 1.7 on
discharge.
3. ABDOMINAL PAIN: Pain was consistent with "bloating" sensation
and [**2-3**] discomfort associated with nausea. He was given reglan
and tube feeds were slowed (from goal of 45cc/hr) as needed.
This improved his pain and emesis. Paracentesis was negative for
SBP and ultrasound showed slowed portal vein flow, consistent
with past ultrasounds. After MICU transfer, reglan was switched
to zofran.
Abdominal pain subsided with alterations in tube feeds. At
discharge he was tolerating tube feeds at 45cc/hr.
4.ETOH cirrhosis-Patient has history of withdrawal seizures,
though he states that his last drink was in [**2126-3-2**]. He
paracentesis twice during this hospitalization having 4.2 L and
3.25 L which did not show SBP. He has diuretic refractory
ascites, portal hypertensive gastropathy, and portal vein
thrombosis on the liver [**Year (4 digits) **] list. His discharge Meld
score was 18. He has grade I varices. Currently on lactulose to
titrate to [**3-6**] BMs per day and on rifaximin as above.
5.FAILURE TO THRIVE: Patient extremely cachectic on admission.
When at goal tube feeds of 45cc/hr, patient complained of
bloating and nausea. Tube feeds reduced accordingly. Patient
with poor appetite; megace and ensure TID were added. After MICU
transfer, megace was stopped. Patient gained weight with
continuous tube feeds and was supplementing with an oral diet as
well upon discharge.
Medications on Admission:
1. Ranitidine HCl 150 mg
2. Folic Acid 1 mg
3. Thiamine HCl 100 mg
4. Multivitamin
5. Lactulose 30mL TID
6. Senna 8.6 mg Capsule
7. Docusate Sodium 100 mg [**Hospital1 **] PRN
8. Simethicone 60 mg
9. Clotrimazole 10 mg Troche Sig: One (1) tablet Mucous membrane
five times a day: dissove one in mouth five times a day
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5 TIMES A DAY ().
Disp:*150 Troche(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO [**3-5**]
times per day: You should have [**3-6**] bowel movements daily.
Disp:*1 Month supply* Refills:*2*
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO as needed as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
11. Outpatient Lab Work
Please check a CBC,Na,K,Cl,HCO3,BUN,creatinine on Thursday
[**2127-8-7**] and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at [**Telephone/Fax (1) 82304**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hepatic Encephalopathy
2. Acute renal failure
3. Malnutrition
Discharge Condition:
Afebrile, stable vital signs. AAOx3.
Discharge Instructions:
You were admitted to the hospital with confusion,
nausea/vomiting, and kidney failure. Your confusion improved
with lactulose and rifaximin, and you had normal mental status
on discharge.
We gave you reglan for nausea which made you very drowsy and you
should avoid taking this medication in the future. Your nausea
improved, we slowed your tube feeds. You should also supplement
your meals with a nutritional supplement drink called Ensure.
Your kidney failure improved with hydration. You will have
outpatient labs to follow your kidney function and these will be
sent to your doctor.
We have made the following changes to your medications:
-Started on Rifaximin to prevent confusion
Please return to the ER or call your doctor if you experience
worsening confusion, chest pain, shortness of breath,
fevers/chills, abdominal pain, bloody stools, or any other
symptoms concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **],ORIENTATION [**Name10 (NameIs) **] CENTER -
Date/Time:[**2127-8-14**] 3:00
PROVIDER: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 497**], Gastroenterology, on [**2127-8-13**] at
2:00PM at [**Hospital 1326**] Clinic, [**Hospital Unit Name **] [**Location (un) 436**]. [**Hospital1 18**]
Office Phone: ([**Telephone/Fax (1) 3618**] Office Fax: ([**Telephone/Fax (1) 4409**]
BLOOD DRAW: Please come to the lab to have your blood draw on
[**Last Name (un) **], [**2127-8-7**]
|
[
"261",
"571.2",
"789.59",
"572.2",
"V49.83",
"537.89",
"584.9",
"276.3",
"572.4",
"276.2",
"303.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11530, 11536
|
6427, 6734
|
325, 332
|
11645, 11684
|
2682, 6404
|
12626, 13245
|
2023, 2027
|
10123, 11507
|
11557, 11624
|
9779, 10100
|
11708, 12326
|
2042, 2663
|
12355, 12603
|
228, 287
|
360, 1513
|
6749, 9753
|
1535, 1859
|
1875, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,557
| 179,279
|
3456
|
Discharge summary
|
report
|
Admission Date: [**2132-9-26**] Discharge Date: [**2132-9-29**]
Date of Birth: [**2048-8-10**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Neurontin / Codeine / Lyrica / Sulfa (Sulfonamide
Antibiotics) / Trimethoprim / Lactose
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 yo presenting with AFIB, HTN, CHF who presented with SOB
since yesterday. Pt resides at [**Doctor First Name 391**] Bay NH, and on morning
pill administration (0530) pt was found to have room air oxygen
sats in 70s, as well as SOB and congestion. Facemask 5L O2 was
placed at NH and sats improved to 93%. BP at NH was 148/82.
.
In the ED, initial vs were: T 98 P 87 BP 195/76 RR 40 O2sat 93%
on NRB. The pt did not require bipap, and was found to have
crackles and edema on exam. Pt had UA concerning for UTI,
lactate was 2.2, WBC 20, Creatinine was 1.4, which may be
baseline or slightly elevated from baseline. Troponin was 0.02,
and on recent admission in [**8-31**] Trop was 0.03. Patient was given
nitro gtt, lasix 40 IV x1, zosyn and tylenol. Vanco was written
for, but pt did not receive it before transfer to the ICU.
Reason for ICU admission was that pt still requiring nitro gtt.
Transfer vitals 70 164/90 26 99% NRB. Pt is DNR [**Name (NI) 835**], transfered
from NH with signed order.
.
On the floor, the pt appears comfortable on NRB, with lips
becoming cyanotic on 6L NC O2. Pt endorses new shortness of
breath since last night, mild dysuria for several days, stable
two pillow orthopnea, no PND, increased lower extremity edema
and increased urination.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
Denied arthralgias or myalgias.
Past Medical History:
1. DM c/b L femoral neuropathy, prior hypoglycemic episodes. Was
instructed to cut her metformin dose, but hasn't.
2. HTN with orthostatic changes
3. Spinal stenosis s/p laminectomy
4. Recurrent falls - suspected [**2-25**] numbers 1,2,3 above, as well
as poor center of gravity from kyphoscoliosis
5. Depression
6. Hyperlipidemia
7. Chronic anemia - negative EGD [**7-30**]. Colon polyp removed
[**10-29**].
8. CRF
9. OA
10. CCY 23 y ago
11. s/p C-section
12. Stress incontinence
13. Bilateral carpal tunnel syndrome
14. R cataract removal
15. Lactose intolerance
16. h/o H pylori gastritis [**10-29**] - treated.
Social History:
Lives in [**Location **]. Uses wheelchair, can ambulate with [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15935**]
steps in PT at NH. Denies t/e/d.
Family History:
DM in many family members
Physical Exam:
Vitals: T: 97.8 BP: 177/68 P: 73 R: 22 18 O2: 96% on NRB, 90% on
6L NC O2
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, lips cyanotic on
NC O2
Neck: supple, +JVD ~10, no LAD
Lungs: Bilateral crackles, R>L half way up, no wheezes, no
dullness to percussion
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +foley, no suprapubic ttp, no CVA ttp
Ext: warm, well perfused, 1+ pulses, 2+ pitting edema bilat LE,
L>R
Neuro: A+Ox3, hard of hearing, speech fluent, answers questions
appropriately
CN II-XII intact
Motor: 5/5 strength UE and LE bilat
Coordination: No dysmetria, gait assessment deferred
Pertinent Results:
[**2132-9-26**] 06:50a
.
140 108 37 AGap=18
------------- 228
4.7 19 1.4
.
estGFR: 36/43 (click for details)
.
CK: 46 MB: Notdone Trop-T: 0.02
proBNP: 3288
.
Ca: 9.8 Mg: 1.7 P: 4.9
.
9.4
20.0 ------- 430
29.9
N:83.4 L:11.0 M:2.6 E:2.6 Bas:0.3
.
PT: 12.3 PTT: 27.4 INR: 1.0
.
Echo. [**2132-9-26**].
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 and free wall motion are normal. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2131-9-25**],
pulmonary pressures are lower. The other findings are similar.
.
CXR. [**2132-9-26**].
IMPRESSION: Findings consistent with interval development of
pulmonary edema
and mild congestive heart failure.
Brief Hospital Course:
84 year old woman with history of DM, HL, diastolic CHF,
admitted with respiratory distress and likely flash pulmonary
edema [**2-25**] hypertensive urgency, perhaps provoked by underlying
UTI.
.
# Acute Pulmonary Edema - Initially was treated in MICU with
lasix IV and nitro gtt. SOB improved. CXR consistent with
pulmonary edema. Thought to have flashed in setting of elevated
BP with hx of diastolic HF. Oxygen requirements decreased with
diuresis. Echo ruled out systolic dysfunction with EF>55%. On
the floor, continued diuresis with IV Lasix with significant
improvement of her breathing.
.
# Acute on chronic diastolic CHF: Echo with unchanged from prior
with EF>55%. Tx with lasix for fluid overload. Continued ACE-I
and atenolol. Initiated salt restriction and 2L fluid
restriction. She was discharged on her home doses of the
atenolol and lisinopril.
.
# Urinary tract infection: Pt reports urinary frequency leading
up to her admission. Received zosyn x 1 in Ed, cefepime x 1 in
MICU. Was then changed to cipro. Initial UA positive for UTI and
culture showed GNR. She was treated with Cirpo IV and discharged
on a 14 day po course, as pt had a foley throughout her
hospitalization.
.
# Hypertension: BP initially controlled with nitro gtt
initially. Pt continued on amlodpine, atenolol and lisinopril
throughout her stay to manage high BP with adequate control.
.
# Chronic renal insufficiency: At baseline Cr 1.4 with slight
increase to Cr 1.8 in the setting of Lasix diuresis.
.
# Anemia: Pt is at recent baseline hct (29). Pt was seen in [**Month (only) **]
by hematology, and was diagnosed with anemia of chronic disease
secondary to chronic renal failure.
Medications on Admission:
Tylenol 1000 tid
Alendronate 70 weekly
Omeprazole 20mg daily
MVI daily
Vit B12 1000mcg daily
Vit D 800u daily
Aspirin 1 tab daily
Glipizide 10mg daily
Lisinopril 20mg daily
Oxybutynin ER 10mg daily
Sertraline 25 mg 3 tabs daily
Atenolol 50 daily
Amlodipine 10 daily
Levothy 75 daily
Calcarb 600 [**Hospital1 **]
Cranberry tabs [**Hospital1 **]
Simvastatin 80 daily
Ipratrop-Alb q6 prn
Loperamide 2mg prn diarrhea
Milk of Mag 30 prn constip
Compazine 1 tab q8 prn nausea
Tramadol 50 q8 prn pain
Tums prn
Insulin humalog 3 u pre-breakfast, 2 u pre-dinner
Insulin lispro ss
Insulin glargine 11u qam
Bengay
Bilat hand splints
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Sertraline 25 mg Tablet Sig: Three (3) Tablet PO once a day:
Total dose of 75mg daily.
16. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr
Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
17. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Cranberry 405 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. Loperamide 2 mg Tablet Sig: One (1) Tablet PO as needed as
needed for diarrhea.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: [**1-25**] PO as
needed as needed for constipation.
21. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
22. Humalog 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous before breakfast daily: As directed per sliding
scale.
23. Humalog 100 unit/mL Cartridge Sig: Two (2) units
Subcutaneous before dinner daily: As directed per sliding scale.
.
24. Insulin Glargine 100 unit/mL Solution Sig: Eleven (11) units
Subcutaneous qAM: As directed.
25. BenGay Arthritis Formula Cream Topical
26. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous per sliding scale.
27. Tramadol 50 mg Tablet Sig: One (1) Tablet PO q8h prn as
needed for pain.
28. Compazine 10 mg Tablet Sig: One (1) Tablet PO q8h prn as
needed for nausea.
29. [**Male First Name (un) **]-Tussin Original 13-4-83-25 mg/5 mL Solution Sig: Thirty
(30) ml PO every twelve (12) hours as needed for cough.
30. Calcarb 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
31. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary diagnosis:
1. Pulmonary Edema
2. Urinary Tract Infection
Secondary diagnosis:
1. Congestive Heart Failure
2. Hypertension
Discharge Condition:
stable
Discharge Instructions:
You were seen at [**Hospital1 18**] for an episode of shortness of breath.
You had your heart function checked with an Echocardiogram,
which showed no change from your previous study echocardiogram.
You also had a chest x-ray that showed fluid in your lungs and
you were given medication to help you get rid of this fluid. You
were also found to have a urinary tract infection and you were
treated with antibiotics to resolve this problem.
Medication changes:
- Ciprofloxacin 500mg daily was added to be taken for 12
additional days (for a full course of 14 days).
If you experience fever, shortness of breath, chest pain, or
other concerning symptoms, please return to the hospital.
Followup Instructions:
Please follow up with your primary care provider at the nursing
home within 1 week of being discharged.
|
[
"428.33",
"272.4",
"427.31",
"585.9",
"403.90",
"599.0",
"357.2",
"428.0",
"715.90",
"285.9",
"244.9",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10190, 10270
|
5093, 6766
|
368, 374
|
10445, 10454
|
3757, 5070
|
11188, 11295
|
2912, 2939
|
7439, 10167
|
10291, 10291
|
6792, 7416
|
10478, 10919
|
2954, 3738
|
10939, 11165
|
321, 330
|
1694, 2041
|
403, 1676
|
10378, 10424
|
10310, 10357
|
2063, 2682
|
2698, 2896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,300
| 172,854
|
47201
|
Discharge summary
|
report
|
Admission Date: [**2102-1-9**] Discharge Date: [**2102-1-25**]
Service: MEDICINE
Allergies:
Sulfonamides / Tetanus Antitoxin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
Cardiac catheterization
Thoracentesis
Esophagogastroduodenoscopy
History of Present Illness:
84F with history of coronary artery disease, status post PTCA of
LCx ([**2093**]) who presented to [**Hospital1 18**] ED this morning with nausea
and lethargy. Pt was recently seen in [**Hospital 191**] clinic with fevers and
increased cough and CXR showed Right middle and lower lobe
infiltrate and small surrounding effusion consistent with
pneumonia. EKG in ED notable for 2 mm STE in III and F. MB index
17 and troponin I 0.73. Pt started on heparin gtt and
integrillin gtt, given ASA 325 mg PO and metoprolol 5 mg IV and
transferred to cath lab.
.
In cath lab, found to have elevated filling pressures: RA 17, RV
42/2, PA 39/17, W 17. Pt has 3VD with LMCA 30%, LAD 70% prox,
70% dist, LCx 70% OM1, RCA 70% dist with cut off at RPL after
spontaneous reperfusion at dist RCA stenosis. 40% after stenosis
patent. distal RCA stented with Vision stent, unable to deliver
DES.
.
Post cath, pt denies any chest pain, SOB, orthopnea, PND or leg
swelling. She does report moderate rRight groin discomfort and
back pain related to her spinal stenosis and laying flat on the
stretcher. Pt usually sleeps in a recliner secondary to back
pain from spinal stenosis.
Social History:
Patient lives at [**Hospital1 756**] house. She denies smoking, alcohol, or
illicit drug use. Children live in the area. Retired fashion
consultant/dressmaker. Currently enjoys painting watercolors and
acrylics.
Family History:
Mother and sister with Type 2 DM. Mother died of MI. Father died
of "heart trouble"
Physical Exam:
PE: VS 97.2 BP 100/61 HR 65 R 15 100% RA
Gen: NAD, laying flat on stretcher, pale appearing
HEENT: EOMI, PERRL, O/O clear
Neck: unable to assess neck veins laying flat, no LAD
Chest: clear anteriorly
CV: RRR Nl s1 s2 no mrg appreciated
Abd: soft, NT, ND + BS
Ext: Pt has clamp on R groin so pulses not palp on R side, but
full on L at DP and PT. R groin without hematoma or bruit.
Pertinent Results:
[**2102-1-22**] 07:10AM BLOOD WBC-15.7* RBC-2.87* Hgb-8.6* Hct-26.3*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.3* Plt Ct-224
[**2102-1-21**] 07:20AM BLOOD WBC-16.7* RBC-3.06* Hgb-9.3* Hct-27.6*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.3* Plt Ct-291
[**2102-1-20**] 12:50PM BLOOD WBC-20.5* RBC-3.32* Hgb-10.0* Hct-29.8*
MCV-90 MCH-30.0 MCHC-33.4 RDW-16.2* Plt Ct-348
[**2102-1-19**] 03:57AM BLOOD WBC-22.8* RBC-3.60* Hgb-10.6* Hct-32.1*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.6* Plt Ct-380
[**2102-1-18**] 08:00AM BLOOD WBC-17.1* RBC-3.31* Hgb-9.9* Hct-29.7*
MCV-90 MCH-29.9 MCHC-33.3 RDW-16.2* Plt Ct-328
[**2102-1-17**] 02:22PM BLOOD WBC-18.5* RBC-3.11* Hgb-9.1* Hct-27.8*
MCV-90 MCH-29.2 MCHC-32.7 RDW-15.9* Plt Ct-282
[**2102-1-20**] 12:50PM BLOOD Neuts-91.7* Bands-0 Lymphs-4.2* Monos-3.8
Eos-0.1 Baso-0.2
[**2102-1-20**] 12:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
[**2102-1-21**] 07:20AM BLOOD PT-14.1* PTT-27.7 INR(PT)-1.3
[**2102-1-21**] 07:20AM BLOOD Plt Ct-291
[**2102-1-22**] 07:10AM BLOOD Plt Ct-224
[**2102-1-22**] 07:10AM BLOOD Glucose-129* UreaN-125* Creat-3.8*
Na-132* K-4.5 Cl-101 HCO3-18* AnGap-18
[**2102-1-19**] 03:57AM BLOOD LD(LDH)-638*
[**2102-1-10**] 07:10AM BLOOD CK(CPK)-331*
[**2102-1-9**] 09:21PM BLOOD CK(CPK)-434*
[**2102-1-9**] 12:05PM BLOOD CK(CPK)-298*
[**2102-1-10**] 07:10AM BLOOD CK-MB-45* MB Indx-13.6* cTropnT-2.66*
[**2102-1-9**] 09:21PM BLOOD CK-MB-61* MB Indx-14.1* cTropnT-2.54*
[**2102-1-9**] 12:05PM BLOOD CK-MB-52* MB Indx-17.4* cTropnT-0.73*
[**2102-1-22**] 07:10AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.2
[**2102-1-21**] 07:20AM BLOOD Hapto-281*
[**2102-1-11**] 07:00AM BLOOD calTIBC-143* Ferritn-379* TRF-110*
[**2102-1-16**] 04:58PM BLOOD freeCa-1.12
CXR:[**2102-1-20**]
reduction in the size of the right pleural effusion since the
prior film of the same date. No pneumothorax. There is
persistent small right pleural effusion and atelectases are
present at both lung bases.
.
EGD:[**2102-1-18**]:
-Small hiatal hernia
-Grade II esophagitis in the middle third of the esophagus and
lower third of the esophagus
-Erythema and congestion and mild atrophy in the stomach body
and antrum compatible with gastropathy
-Otherwise normal egd to fourth part of the duodenum
**
Recommendations: Followup biopsies
Continue current medications
Additional notes: The esophagitis is a possible source of GI
bleeding, although there is no blood or stigmata of bleeding at
present. The etiology is likely reflux, but biopsies were done
to rule out [**Female First Name (un) **] or other infectious causes
*
CXR [**2102-1-15**]:
-interval increase in opacity overlying the R lung c/w effusion
layering posteriorly. Likely element of volume loss and
infiltrate in the right lower lung as well. There is an
increased left effusion with retrocardiac opacity consistent
with volume loss/infiltrate/
effusion.
Impression:worsening pulmonary edema. Underlying infectious
etiology cannot be totally excluded.
.
CXR [**2102-1-7**]: IMPRESSION: New right effusion and associated air
space consolidation affecting right middle and lower lobes.
Findings consistent with pneumonia in the appropriate clinical
setting.
.
[**2099**] echo: EF > 55%, 1+ AR
.
EKG [**2102-1-9**] (pre cath): NSR at 70 bpm with 2 mm STE in III and
F. QTc 440.
.
EKG [**2102-1-9**] (post cath): 65 bpm, L axis, bad baseline, QTc 458,
0.5 mm STE in III and F. LVH by aVL criteria.
.
Studies:
ECHO [**2102-1-11**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). WMA cannot be fully excluded. RV chamber size and
free wall motion are normal. The AV leaflets are mildly
thickened. Mild (1+) AR. MV leaflets are mildly thickened.
([**2-6**]+) MR. There is mild PA systolic HTN.
.
CARDIAC CATH [**2102-1-11**]:
L main coronary art: 30% stenosis
LAD 70% prox stenosis; 70% stenosis of diag branch
OM1 w/ 70% lesion
40% prox RCA lesion
70% distal RCA lesion w/ cut-off in distal RCA branch
distal RCA w/ minivision stent
RVEDP: 16mmHg, PCWP: 15mmHg
Brief Hospital Course:
84 female with recent pneumonia who presented with malaise and
nausea and was found to have an inferior STEMI. Pt underwent a
cardiac catheterization, found to have thrombosed RCA with
distal embolization which was stented with a Vision stent. After
the catheterization the [**Hospital 228**] hospital course has been
complicated by pleural effusions, gastrointestinal bleeding and
acute renal failure. Ms. [**Known lastname 99961**] [**Last Name (Titles) **] at 1300 on [**2102-1-25**].
.
CARDIAC: Ischemia
Ms. [**Known lastname 99961**] has a history of coronary artery disease and is status
post myocardial infarction (CK peak: 434, Trop-T peak: 2.66).
She presented with EKG changes suggestive of a right ventricular
coronary artery disease. She likely had a right ventricular
infarction. The pt underwent a cardiac catheterization showed
three vessel coronary artery disease, the left main coronary
artery had a 30% stenosis, the left anterior descending artery
had a 70% proximal stenosis. There was no angiographic evidence
of obstructive coronary artery disease in the mid and distal
LAD. There was a 70% stenosis of the a diagonal branch. The
left circumflex artery had no angiographic evidence of
obstructive coronary artery disease. The OM1 had a 70% lesion.
There was angiographic evidence of a 40% proximal RCA lesion and
a 70% distal RCA lesion and there was a cut off in the PL
branch, likely after spontaneous reperfusion at the distal RCA
stenosis. The pt underwent successful stenting of the distal
RCA with a 2.5 mm MiniVision stent. The pt was recommended
medical therapy as initial treatment, she was determine to not
be a surgical candidate. After cardiac catheterization, the pt
was noted to have a dropping hematocrit for which she was
transfused 1 unit of PRBC. During the transfusion, the patient
became acutely short of breath and was noted to have flash
pulmonary edema. She was transferred to the Cardiac Care Unit
(CCU) where she responded to aggressive lasix diuresis. She was
transferred back to the [**Hospital1 **] the following day. She was
continued on aspirin, plavix, statins and beta-blockers (which
were titrated down in the setting of low blood pressure).
.
CARDIAC: Pump
The patient was noted tohave a left ventricular ejection
fraction of >50% on ECHO. She was continued on an ACE inhibitor
for remodeling benefit. The patient's hemodynamics during the
cathterization were notable for elevated right sided pressures.
The patient was managed with diuresis.
.
CARDIAC: Rhythm
The patient has a pacemaker and has been A sensed V paced. She
was noted to have no significant events on telemetry.
.
RENAL FAILURE: Acute on Chronic
Ms. [**Known lastname 99961**] has a history of chronic renal failure with a baseline
creatinine of 1.4. During her hospital stay Ms. [**Known lastname 99962**]
creatinine was monitored daily. In the post-catheterization
setting her creatinine was noted to rise as high as 3.9 with a
corresponding rise in phosphate to a maximum of 6.0. Ms. [**Known lastname 99961**]
was also noted to have aninitial pre-renal failure and had poor
presponse to IV fluids in teh setting of decreased PO intake.
She was seen by the nephrology team and was offered dialysis,
which she refused. A renal ultrasound to assess her kidneys
showed atrophic changes but not evidence of hydronephrosis.
During the hospital stay, Ms. [**Known lastname 99961**] was also noted to have a
yeast urinary tract infection which was treated with
Fluconazole.
.
ANEMIA:
Ms. [**Known lastname **] has a history of normocytic anemia )with a negative
bone marrow biopsy in the past) for whihc she was treated with
Procrit in the past. She underwent several transfusions for
gastrointestinal bleeding (in the setting of guaiac stools). Ms.
[**Known lastname **] an EGD on [**1-18**]. Esophageal biopsies taken during the EGD
showed fragments of granulation tissue and exudate with acute
and chronic inflammation consistent with ulceration. The pt was
offered a colonoscopy but declined to undergo the procedure
after weighing the risks and benefits. She was medically managed
with a [**Hospital1 **] dose of pantoprazole.
.
DIABETES MELLITUS:
Ms. [**Known lastname 99961**] was on NPH (qAM) and regular insulin sliding scale at
home. She was maintained on teh sliding scale with QID
fingersticks.
.
POLYMYALGIA RHEUMATICA:
Ms. [**Known lastname 99961**] has a history of discoid lupus and polymyalgia
rheumatica for which she was on 7.5 mg PO prednisone daily.
Given the risk of wall rupture, Ms. [**Known lastname 99961**] was not given a stress
dose of steroids. She was maintained on her home dose of
prednisone.
.
PNEUMONIA:
Ms. [**Known lastname 99961**] presented to the hospital with a recent diagosis of
pneumonia. She was treated with a 5 day course of azithromycin
and IV Ceftriaxone (for total 14 day course). She remained
afebrile during the hospital stay. She was noted to have
progressive bilateral (right more than left) pleural effusions.
She underwent two thoracocentesis (with removal of 1 liter each
time). The effusions were noted to be inflammatory in nature (no
empyema). A post-procedure chest x-ray did not show any evidence
of pneumothorax.
.
HYPERTENSION:
Ms. [**Known lastname 99961**] was continued on lopressor and lisinopril. Her HCTZ
was held while in hospital because she was not hypertensive.
.
SPINAL STENOSIS:
Ms. [**Known lastname **] was maintained on tylenol, oxycodone and morphine
(once she was CMO status) for pain control.
.
MACULAR DEGENERATION:
Ms. [**Known lastname 99961**] was continued on her vitamins.
.
FLUIDS/ELECTROLYTES/NUTRITION:
Ms. [**Known lastname **] was maintained on a diabetic, heart healthy diet. Her
electrolytes were monitored and relpeted as needed.
.
Access:
peripheral IV
.
CODE STATUS:
DNR/DNI with Comfort Measures Only. During a family meeting with
the pt and her daughters on [**2102-1-21**] the goals of continued care
were discussed. The patient and her family were reluctant to
pursue further medical intervention and they decided (with the
patient in agreement) that she would be comfort measures only.
It was decided that the patient would be offered medications
(aspirin, plavix) that would prevent instent
thrombosis/stenosis. She will be maintained on medications that
would make her comfortable.
.
Prophylaxis:
Subcutaneous heparin
Pantoprazole [**Hospital1 **] for Gi protection
Medications on Admission:
Metoprolol Tartrate 50 mg PO BID
Hydrochlorothiazide 25 mg PO DAILY
Acetaminophen 325 mg PO q 4-6 h prn
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Ferrous Gluconate 300 mg PO DAILY
Aspirin 325 mg PO DAILY
Prednisone 7.5 mg PO DAILY
B-Complex with Vitamin C Tablet PO qD
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 200 unit Tablet PO DAILY
Clopidogrel 75 mg PO DAILY
Lisinopril 20 mg PO DAILY
Insulin NPH (18) units Subcutaneous QAM.
Procrit Injection
Borrage oil Sig: 1000 (1000) mg once a day.
Pantoprazole 40 mg PO once a day.
Azithromycin 500 mg PO qd (D3)
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Community Acquired Pneumonia
Congestive heart failure
Acute Renal Failure
Blood loss anemia
Polymyalgia rheumatica
Restless Legs
Transudative Pleural Effusions
GI Bleed
Grade II Esophagitis
Yeast Urinary Tract Infection
Discharge Condition:
Fair - Comfort management only
Discharge Instructions:
COMFORT MANAGEMENT ONLY- patient [**Hospital1 **] at 1300 on [**2102-1-25**]
Symptom management and support.
Followup Instructions:
none
Completed by:[**2102-1-25**]
|
[
"280.0",
"530.10",
"357.2",
"584.9",
"486",
"412",
"112.9",
"250.60",
"V45.01",
"578.9",
"362.50",
"403.91",
"695.4",
"041.89",
"V12.59",
"410.41",
"398.91",
"333.99",
"724.02",
"511.8",
"725",
"398.90",
"414.01",
"599.0",
"V45.82",
"V66.7",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"37.23",
"00.45",
"00.66",
"88.56",
"00.40",
"45.16",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
13371, 13386
|
6327, 12723
|
254, 321
|
13689, 13722
|
2256, 6304
|
13879, 13914
|
1754, 1839
|
13407, 13668
|
12749, 13348
|
13746, 13856
|
1854, 2237
|
208, 216
|
349, 1508
|
1524, 1738
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,391
| 129,058
|
54424
|
Discharge summary
|
report
|
Admission Date: [**2186-11-26**] Discharge Date: [**2186-12-4**]
Date of Birth: [**2104-12-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hypotension, acute cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mrs.[**Known lastname **] is an 81 year old female with a history of
hypertension, diabetes and dementia who presents from her
nursing home with fevers, nausea and vomiting. Per records the
patient was in her usual state of health until the evening prior
to presentation. She resids at [**Hospital **] nursing home in [**Location (un) **].
She was noted to be vomiting the evening prior to presentation
and was unable to keep down fluids. She has a significant
dementia at baseline so it was unclear if she was more confused.
She is total care for all of her activities of daily living at
baseline. She was reported febrile to 102.6 degrees and was
noted to be rigoring. She was also noted per nursing records to
be mildly jaundiced. She was taken to [**Hospital 111406**] hospital for
evaluation.
.
On arrival to [**Location (un) **] she was febrile to 100.7, pulse 70s, blood
pressure 78/54. Labs were notable for a leukocytosis of 14.6
with 73% neutrophils and 21% bads. Her transaminases were
elevated with an AST of 372, ALT 383, Lipase 11, total bilirubin
4.4/direct bilirubin 3.1, alkaline phophatase 221. Creatinine
was elevated at 1.9 (baseline unknown). UA was positive. She had
a right upper quadrant ultrasound which per report showed
cholelithiasis with a dilated CBD to 1.1 cm with intrahepatic
bile duct dilitation. She received 3L normal saline and was
started on levofloxacin and flagyl. She was transferred to [**Hospital1 18**]
for further management.
.
On arrival to our emergency room her vitals were T: 97.3 HR: 90
BP: 94/54 RR: 22 O2: 97% on RA. EKG showed no ischemic changes.
She received an additional 2L of normal saline and zosyn 4.5
grams IV x 1. She was transferred immediately to the ERCP suite
where she was found to have a stone in the common bile duct.
Sphincterotomy was performed and a plastic stent was placed. She
tolerated the procedure well and was transferred to the [**Hospital Unit Name 153**].
.
[**Hospital Unit Name 153**] Course: The patient improved post-procedure, did not
require pressors. The patient now had GNR growing from blood
cultures from blood cultures from [**2186-11-26**] as well as [**2186-11-27**],
not yet speciated. The patient has not required additional fluid
boluses for blood pressure control and is now transferred to the
floor for ongoing management. On arrival to the floor the
patient is noted to be oriented x1. Review of systems positive
for abdominal discomfort and nausea, all other negative
Review of systems: Currently endorses mild abdominal pain, no
nausea or vomiting. No chest pain, shortness of breath.
Otherwise difficult to obtain review of systems secondary to
dementia
Past Medical History:
Osteochondroma of L knee as a child
Mitral Valve Prolapse
Type II Diabetes
Hypertension
Alzheimer's disease
Right ORIF of hip fracture at age 75
Social History:
Not currently smoking, alcohol or illicit drug use. Lives in a
nursing home. Full care for all of her activities of daily
living. Daughter [**Name (NI) 111407**], ph: [**Telephone/Fax (1) 111408**]
Family History:
Daughter with arthritis, father died of hepatitis C from a blood
transfusion. Mother died at age 86 of a myocardial infarction.
Son with hypertension.
Physical Exam:
Vitals: T: 95 HR: 96 BP: 116/60 RR: 19 O2: 95% on 4L
General: Alert, oriented to person only, no distress
HEENT: Pupils pinpoint periprocedure, sclera mildly icteric, MM
moist, oropharynx clear
Neck: supple, no LAD, JVP not elevated
CV: RRR, s1+ s2, faint HSM at apex
Resp: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
GI: soft, mildly tender in RUQ, +BS, no rebound tenderness or
guarding, no organomegaly
GU: foley with clear yellow urine
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Skin: faint janudice
Pertinent Results:
Admission labs:
[**2186-11-26**] 05:00PM
URINE RBC-[**5-23**]* WBC-[**11-2**]* BACTERIA-MANY YEAST-NONE EPI-0-2
BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-MOD UROBILNGN-1 PH-6.0 LEUK-LG
COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2186-11-26**] 05:07PM
LACTATE-3.0* FIBRINOGE-527*
PT-17.8* PTT-34.6 INR(PT)-1.6*
PLT SMR-NORMAL PLT COUNT-143*
HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
NEUTS-82* BANDS-6* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-4*
WBC-26.8*# RBC-3.96* HGB-12.6# HCT-37.2 MCV-94 MCH-31.8
MCHC-33.8 RDW-14.1
HAPTOGLOB-150 ALBUMIN-3.4 LIPASE-10 ALT(SGPT)-404*
AST(SGOT)-371* LD(LDH)-447* ALK PHOS-202* TOT BILI-4.3*
GLUCOSE-144* UREA N-37* CREAT-1.5* SODIUM-145 POTASSIUM-3.6
CHLORIDE-112* TOTAL CO2-19* ANION GAP-18
[**2186-11-26**] 10:00PM
LACTATE-1.6
[**2186-11-27**] CXR: PND
[**2186-11-26**] 5:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2186-11-27**]): GRAM NEGATIVE
ROD(S).
[**2186-11-26**] 5:00 pm URINE Site: CATHETER
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
Brief Hospital Course:
Patient is an 81 year old female with advanced dementia,
presents with biliary obstruction secondary to
choledocholithiasis complicated by cholangitis and sepsis.
1. Septic Shock due to Cholangitis, choledocolithiasis:
- Patient s/p ERCP with removal of stone and stent placement.
- Patient clinically improved with Zosyn, continue Antibiotics
for 14 day course, was initially on Zosyn but tailored on
ceftriaxone on [**11-30**] based on sensitivities
- Bilirubinemia resolved
- Patient will require repeat ERCP in [**5-21**] weeks for stent
removal and stone extraction, to be scheduled by ERCP team
- Pt already evaluated by surgery for possible cholecystectomy,
they want pt to follow up with Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] in clinic
after the repeat ERCP.
2. Bacteremia:
- As above, related to cholangitis vs UTI
- Had 3 days of + blood cx, one at OSH, 2 days here but after
ERCP and with Zosyn, bactermia cleared. Repeat Blood cx from
[**11-28**], [**11-29**] and [**11-20**] are negative. Final culture showed 2
colonies of E coli and based on sensitivities, antibiotics were
narrowed to ceftriaxone. PICC requested in anticipation of long
Abx course, PICC placed by IV team at bedside but is being
repositioned by IR today
3. Bacterial UTI:
- Patient with evidence of UTI by UA and culture, E. coli,
senistive to ceftriaxone
4. Diarrhea
- noted on floor, C diff neg. Diarrhea now resolved
5. Non-gap acidosis
- likely [**1-14**] diarrhea, resolved w resolution of diarrhea.
6. Acute Renal Failure:
Patient presented with Cr of 1.9 at OSH, per ICU signout, likely
[**1-14**] sepsis, resolved with hydration.
7. Hypernatremia:
- Na 149 with fluid deficit of 2.8 liters when came to floor
from ICU but resolved with IVFs.
8. Diabetes II, uncontrolled with complication:
At home on NPH 34 units qam. Initially was hyperglycemic [**1-14**]
sepsis, then as getting D5 for hypernatremia. D5 stopped today,
cont SSI for now but if bs continue to remain elevated would
increase insulin. It may be easier to have pt on lantus and may
consider switching to that in AM, but this can be done post
discharge
9. Alzheimers Dementia:
By description patient appears to be at baseline
- continue aricept, trazodone
# Pressure ulcer (Heel, Sacral)
- wound care in POE for R gluteal and L heel pressure ulcers
#. Code: Full
#. Communication: Daughter [**Known firstname **] [**Last Name (NamePattern1) 111409**] [**Telephone/Fax (1) 111410**], Son
[**Name (NI) **] [**Name (NI) 4027**] [**Telephone/Fax (1) 111411**]
#. Dispo - to [**Hospital1 1501**] for now as needing IV abx and more
deconditioned due to recent illness. Despite pt having advanced
dementia and not able to use L leg due to knee problems,
daughter has been able to manage to keep mother at [**Name2 (NI) **] with
services to help...including having someone twice a day to
check/give insulin, having help to get her on commode every few
hours for toileting etc... and it is her goal to get her mother
back to [**Name2 (NI) **] if possible
Medications on Admission:
Propoxyphene N-100 daily
Multivitamin daily
Insulin NPH 34 units QAM
Insulin sliding scale
Aricept 5 mg daily
Iron 325 mg daily
Senna
Colace
tylenol PRN
Trazodone 25 mg [**Hospital1 **]
Calcium Carbonate 500 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Discharge Medications:
1. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Donepezil 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
7. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day).
8. Insulin NPH Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Thirty
Four (34) Units Subcutaneous QAM.
9. Insulin Sliding Scale
Per Usual ISS Protocol
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily) as needed for pt
unable to swallow whole pills.
11. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) dose PO BID
(2 times a day).
12. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback [**Last Name (STitle) **]:
One (1) gram Intravenous Q24H (every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Septic Shock
Cholangitis
Choledocolithiasis
Bacterial UTI
Alzheimers Dementia
Type 2 Diabetes Uncontrolled with Complications
Benign Hypertension
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with Jaundice, Fever, Abdominal Pain,
nausea/vomitting, increased confusion, black/tarry stools
Followup Instructions:
Repeat ERCP in 8 weeks for stent removal and stones extraction.
Please contact Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 31331**] to arrange
this
|
[
"584.9",
"707.07",
"574.90",
"707.05",
"707.22",
"294.10",
"424.1",
"799.02",
"294.8",
"995.92",
"576.1",
"276.2",
"250.02",
"785.52",
"401.9",
"599.0",
"038.42",
"276.0",
"331.0",
"E938.4",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10017, 10131
|
5404, 8455
|
348, 354
|
10320, 10326
|
4160, 4160
|
10493, 10673
|
3442, 3595
|
8768, 9994
|
10152, 10299
|
8481, 8745
|
10350, 10470
|
3610, 4141
|
5150, 5301
|
2871, 3042
|
278, 310
|
5330, 5381
|
382, 2852
|
4176, 5112
|
3064, 3210
|
3226, 3426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,948
| 160,510
|
55174
|
Discharge summary
|
report
|
Admission Date: [**2185-9-8**] Discharge Date: [**2185-9-13**]
Date of Birth: [**2098-9-9**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
"confusion"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 86 y/o Right handed priest with a history of
HTN, [**Name (NI) 17584**] on coumadin, CAD, s/p stents, presented to the [**Hospital1 **] by
way of air
transport from [**Hospital3 26615**] hospital for IPH.
He states that 2 days prior he had a fall secondary to light
headed feeling resulting in a fall without head strike. He is a
little sparse in regards to details of the fall, states there
were no witnesses, and states that there may have been brief
loss
of consciousness. After his fall he believes he was able to get
up on his own without trouble. Today he says he went to a
funeral
home to give service and was noted there to be "confused" and
not
looking right. His only complaints were that he had trouble
going
up stairs but when asked about details of this (what he meant by
this) he was not quite sure. Because of his "confusion" he was
sent to OSH where the chain of events as described above
unfolded.
Here he had no acute complaints, specifically denies headache,
changes to vision, weakness, numbness, tingling, trouble
understanding people, or producing speech. He says he had some
sort of GI bleed about 20 yrs ago, that may have related to a
colonoscopy.
At OSH he was given 10mg Vit K, Factor IX and placed on
Nicardipine gtt for air transport.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, paraesthesia. No bowel or bladder
incontinence or retention. On general review of systems, the pt
denies recent fever or chills. No night sweats or recent weight
loss or gain. Denies cough, shortness of breath. Denies chest
pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea or abdominal pain. No recent change in bowel or
bladder
habits. No dysuria.
Past Medical History:
A-fib on Coumadin
CAD s/p stent x3
Pacer/ AICD
DM
Social History:
Priest. + tobacco (1 pack every 3 days), -etoh, no other drug
use noted
Family History:
MOM with DM and dad passed away from MI
Physical Exam:
Physical Exam on Admission:
Vitals: 98.3 69 182/72 18 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, Dry MM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR.
Abdomen: soft, NT/ND.
Extremities: 1+ edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
DOW
backward without difficulty. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Pt. was able to name fingers. [**Location (un) 1131**] not tested. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**2-19**] at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. limited up gaze.
V: Facial sensation intact to light touch.
VII: left facial droop.
VIII: Hearing NOT-intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone with cogwheeling with contralateral
activation. Resting tremor b/l.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 4 5 4 4 5 4 - 4+ 5 5 5 5 5
R 5 5 5 5 5 5 - 5 5 5 5 5 4
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 1 2 0
R 2 2 1 2 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF bilaterally.
Physical Exam on Discharge:
Vitals T 98.2 BP 157/69 HR 59 RR 18 O2 97 RA
awake, alert, oriented to self, [**Hospital1 18**], [**2185-8-20**]
The rest of exam unchanged from admission
Pertinent Results:
Labs on Admission:
[**2185-9-8**] 01:30PM WBC-7.6 RBC-4.38* HGB-13.9* HCT-39.3* MCV-90
MCH-31.6 MCHC-35.2* RDW-12.8
[**2185-9-8**] 01:30PM NEUTS-80.7* LYMPHS-14.0* MONOS-3.8 EOS-1.0
BASOS-0.6
[**2185-9-8**] 01:30PM GLUCOSE-254* UREA N-13 CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-31 ANION GAP-8
[**2185-9-8**] 03:02PM PT-15.6* PTT-28.4 INR(PT)-1.5*
[**2185-9-8**] 01:50PM LACTATE-1.6
[**2185-9-8**] 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2185-9-8**] 01:30PM URINE RBC-12* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2185-9-8**] 01:30PM URINE HYALINE-4*\
Relevant Labs:
[**2185-9-9**] 02:15AM BLOOD %HbA1c-10.1* eAG-243*
[**2185-9-9**] 02:15AM BLOOD Triglyc-134 HDL-46 CHOL/HD-3.8
LDLcalc-102
[**2185-9-9**] 02:15AM BLOOD Digoxin-0.9
Imaging:
CT head w/o contrast [**9-8**]
Stable appearance of right basal ganglia intraparenchymal
hemorrhage with probable extension into the right lateral
ventricle and trace left occipital [**Doctor Last Name 534**] intraventricular
hemorrhage.
CT head w/o contrast [**9-9**]
Stable right basal ganglia intraparenchymal hemorrhage, with
slightly increased hemorrhagic component in the occipital [**Doctor Last Name 534**]
of the
bilateral lateral ventricles. Unchanged mass effect on the
right lateral
ventricle.
CT head w/o contrast [**9-12**]
Stable right basal ganglia intraparenchymal hemorrhage. No
evidence of new hemorrhage or acute infarction.
Brief Hospital Course:
Mr. [**Known lastname 16807**] is a 86 y/o man with history of CAD, A-fib on
Coumadin and HTN who
comes in from OSH with IPH located in the deep white matter of
the right hemisphere.
# Neuro: On admission, exam significant for left sided weakness
in an upper motor neuron pattern consistent with his stroke
location in right basal ganglia. The etiology is likely
secondary to high blood pressure and being on
Coumadin/ASA/Plavix. INR at OSH was 1.6. Prior to transfer, he
received Vit K and factor IX. Here, INR was 1.5. Received 2
units of FFP. On arrival at [**Hospital1 18**], repeat CT head demonstrated a
stable bleed and his. INR is at 1.5 on arrival. He was
transiently in the isue for SBP control on a nicardipine drip.
Had repeat head CT 24 hours after admission which showed stable
right basal ganglia intraparenchymal hemorrhage, with slightly
increased hemorrhagic component in the occipital [**Doctor Last Name 534**] of the
bilateral lateral ventricles. Unchanged mass effect on the
right lateral ventricle. Could not obtain MRI given pacemaker.
Patient was disoriented in the afternoon on [**9-12**], so repeated
head CT which was again stable. Attributed disorientation to
sundowning. During admission, talked to his cardiologist, who
agreed with holding Coumadin and Plavix and aspirin for now.
Will re-assess when aspirin can be re-started when patient
follows up in stroke clinic. Notably, counseled about stroke
risk factors and importance of quitting smoking, HTN, HLD and
diabetes control.
# Cards: Telemetry monitoring, no aberrant rhythms. Continued
digoxin and
amiodarone. Currently rate controlled. Did increase lisinopril
from 5mg to 10mg qd as he was hypertensive with SBPs up to 170s.
# Endo: HbA1c 10.1, started metformin 1000mg [**Hospital1 **]. Will follow up
with PCP regarding DM [**Name9 (PRE) **] control and likely insulin initiation.
TRANSITIONS OF CARE:
- will follow up in stroke clinic with Dr. [**First Name (STitle) **]
Medications on Admission:
atenolol 25 daily
Amiodarone 200 mg PO/NG DAILY
Digoxin 0.25 mg PO/NG DAILY
Lisinopril 2.5 mg PO/NG DAILY
Pantoprazole 40 mg PO Q24H
Pravastatin 40 mg PO DAILY
ASA 81, Plavix 75, Coumadin 2.5 daily.
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
Hold for sbp <100
RX *lisinopril 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*2
4. Pantoprazole 40 mg PO Q24H
5. Pravastatin 40 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
8. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Apply 1 patch Daily Disp #*30
Transdermal Patch Refills:*2
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
hemorrhagic stroke of right basal ganglia
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 16807**],
You were brought in to the hospital because you were confused at
work. Also, you had some weakness in your left arm and leg. A
CAT scan of your head showed some bleeding in your brain. Most
likely, the bleeding occurred because of your very high blood
pressure. We monitored you very carefully and repeated two CAT
scans which did NOT show progression of the bleeding, which was
reassuring. Your aspirin/plavix/coumadin were discontinued
since they thins your blood and increase the risk of bleeds.
Please do not take it at home until you see Dr. [**First Name (STitle) **] in stroke
clinic.
For you high blood pressure, we changed some of your medications
as below. Also, you have new diabetes which we started treating
as well. Please avoid foods high in simple carbohydrates such
as white bread, sweets, pasta. You can substitute wheat bread
for white bread.
Please DO NOT DRIVE after you are discharged until you see Dr.
[**First Name (STitle) **] in stroke clinic to avoid putting your safety and that of
others at risk.
Also, as we discussed PLEASE STOP SMOKING. Tobacco increases
your risk of stroke, heart disease, lung cancer and many others
and also death. To help you, a prescription for a nicotine patch
is included. We commend you in advance for your dedication to
your health.
We have made the following changes to your medications:
STOP
Aspirin
Plavix
Coumadin
INCREASE
Lisinopril to 10mg daily
START
Metformin 1000mg twice per day
Nicotine patch daily (DO NOT SMOKE while wearing the patch)
On discharge, please follow up with Dr. [**First Name (STitle) **] in stroke clinic
and your primary care doctor.
It was pleasure taking care of you, we wish you all the best!
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: FAMILY CARE ASSOCIATES, LLC
Address: [**Street Address(2) 112540**], [**Location **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 75712**]
Department: NEUROLOGY
When: MONDAY [**2185-11-7**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2185-9-14**]
|
[
"414.01",
"427.31",
"401.9",
"V45.02",
"250.00",
"431",
"V58.61",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8723, 8793
|
5947, 7831
|
315, 322
|
8892, 8892
|
4418, 4423
|
10806, 11580
|
2386, 2428
|
8173, 8700
|
8814, 8871
|
7949, 8150
|
9043, 10412
|
3204, 4215
|
2443, 2457
|
4243, 4399
|
10441, 10783
|
264, 277
|
350, 2206
|
4438, 5924
|
8907, 9019
|
7852, 7923
|
2228, 2280
|
2296, 2370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,975
| 143,483
|
42074
|
Discharge summary
|
report
|
Admission Date: [**2108-10-11**] Discharge Date: [**2108-10-17**]
Date of Birth: [**2049-4-15**] Sex: M
Service: NEUROLOGY
Allergies:
aspirin / Codeine / NSAIDS
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
intubation (done at OSH)
History of Present Illness:
The pt is a 59 year-old man with a history of asthma and
chronic back pain for which he is on methadone, who presents
following 3 seizures. Patient was intubated on arrival, so
history obtained from records as well as conversation with Dr.
[**Last Name (STitle) 91302**] who was caring from him initially in the [**Hospital3 6592**]
emergency department. The patient reportedly attends a
methadone
clinic daily, either for chronic lower back pain, or for a
remote
history of substance abuse, reports vary. He has a friend who
picks him up every day, who came to his house this morning and
noted that he had to pound on the door to wake him up this
morning, and felt he was 'just not quite right' though we have
no
further details of precisely what this involved. His friend
placed him in the taxi cab, but enroute to the methadone clinic
he became unresponsive and was 'jerking all over'. They stopped
at the nearest fire station, and on arrival he was reportedly
lethargic, and thought to be post-ictal by the firemen. He then
became combative. FSG at that time was reported to be 131. He
was
brought to [**Hospital3 6592**], where on arrival Dr. [**Last Name (STitle) 91302**] made it
as far as asking him his name, when he became unresponsive,
staring off into space, with his jaw clenched, and then
proceeded
to have rhythmic jerking movements of all his extremities,
lasting 2-3 minutes. He was given 2mg of Ativan, repeated once,
right at the end of this episode. At this time he was noted to
have dilated pupils and snoring respirations, and was initially
lethargic, but then began to come around again, and was
reportedly combative. The decision was made at that time to
load
him with fosphenytoin and intubate him for airway protection.
As
they were preparing to intubate him he again developed a blank
stare, followed by jaw clenching and rhythmic jerking of his
extremities. He was then paralyzed and sedated with propofol,
with no further seizure activity noted prior to transfer.
Per discussion with the [**Hospital3 6592**] emergency department, he
was last seen in their hospital in [**2104**], at which time he was
admitted for cellulitis. His only other medical history
documented at that time was of asthma, as well as a report of a
lung/chest tumor removal, though it is unclear what that was.
According to the methadone clinic, he has no other documented
medications. He does have a son, who so far has not been
available by phone, and the friend who brought him in the taxi
refused to leave his name and phone number for any further
questions.
Patient intubated, unable to answer ROS.
Past Medical History:
(per [**Hospital3 6592**] records):
- Asthma
- s/p resection of a lung mass (no further details available)
- Chronic lower back pain
- Hospitalized for cellulitis in [**2104**]
Social History:
Reportedly lives with his son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 91303**] though
he is not answering his phone.
Family History:
unknown
Physical Exam:
Discharge Physical Exam
General: Awake, comfortable, in NAD. Long shaggy beard, mild
disheveled appearance.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W. Median scar
noted over sternum
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Clubbing on all fingernails.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Speech was not dysarthric. No evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2 mm and brisk. VFF to confrontation. No ptosis.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift. Mild
essential tremor, asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 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 5 5
-Sensory: No deficits to light touch, temperature,
proprioception throughout.
-DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysmetria on FNF
bilaterally.
-Gait: Normal stride without ataxia. Romberg absent.
Pertinent Results:
ADMISSION LABS:
[**2108-10-11**] 10:20AM BLOOD WBC-17.6* RBC-4.88 Hgb-15.8 Hct-47.5
MCV-97 MCH-32.4* MCHC-33.2 RDW-12.9 Plt Ct-283
[**2108-10-11**] 10:20AM BLOOD Neuts-80.8* Lymphs-13.7* Monos-4.7
Eos-0.4 Baso-0.4
[**2108-10-11**] 10:20AM BLOOD PT-11.7 PTT-20.1* INR(PT)-1.0
[**2108-10-11**] 10:20AM BLOOD Glucose-223* UreaN-8 Creat-1.0 Na-133
K-5.1 Cl-99 HCO3-17* AnGap-22*
[**2108-10-11**] 10:20AM BLOOD ALT-55* AST-60* AlkPhos-74 TotBili-0.3
[**2108-10-11**] 10:20AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.5
[**2108-10-12**] 02:51AM BLOOD %HbA1c-5.4 eAG-108
[**2108-10-12**] 02:51AM BLOOD Triglyc-99 HDL-45 CHOL/HD-3.2 LDLcalc-79
[**2108-10-11**] 10:20AM BLOOD TSH-1.4
[**2108-10-11**] 10:20AM BLOOD Phenyto-14.7
[**2108-10-11**] 10:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2108-10-11**] 11:14AM BLOOD Type-ART Rates-/12 Tidal V-450 FiO2-50
pO2-161* pCO2-46* pH-7.32* calTCO2-25 Base XS--2 -ASSIST/CON
Intubat-INTUBATED
[**2108-10-11**] 10:36AM BLOOD Lactate-3.8*
IMAGING:
MRI [**2108-10-11**]: IMPRESSION: Small subcortical acute infarct in the
right cerebral hemisphere identified. No enhancing brain
lesions, mass effect or hydrocephalus. No intrinsic
abnormalities within the hippocampi on coronal T2 images.
ECHO [**2108-10-11**]: Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest (patient intubated). Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CTA HEAD/NECK [**2108-10-12**]: IMPRESSION:
HEAD CT: No acute intracranial process.
HEAD AND NECK CTA: Limited study secondary to motion in the
neck, atherosclerotic disease is difficult to quantify on this
exam
Brief Hospital Course:
The pt is a 59 year-old man with a history of asthma and chronic
back pain for which he is on methadone, who presented following
3 seizures found to have a small stroke in his R cerebral
hemisphere.
Mr. [**Known lastname **] was admitted to the ICU intubated and sedated. He was
initially on dilantin (goal level of 15-20). His exam showed
some decreased movement on the R-side, prompting an MRI which
revealed a very small R-sided infarct that did not seem to
explain his seizures or weakness. He was started on ASA 325mg QD
and CTA of the head and neck was unremarkable. An LP showed 5
WBCs and 4,000 RBCs. He was started on vancomycin, ceftriaxone,
ampicillin and acyclovir until his HSV and cultures returned
negative at 48hrs.
The patient was monitored on bed side EEG in ICU and on
transition to the floor. No seizures seen while the patient was
admitted. Diffuse slowing seen initially, however that improved
as the patient's mental status did. He was extubated and weaned
easily to room air and transferred to the floor without events.
While on the floor his mental status improved. Dilantin was
switched to Keppra 100 mg [**Hospital1 **] and he remained seizure free. He
was continued on his home dose of methadone.
While on the floor his strength improved and his neurologic exam
was full and symmetric. The Epilepsy team remained uncertain
what the etiology of his seizures were - with the differential
including the small right infarct, overdose or withdrawal from
medication/drugs of abuse, newly developing epilepsy or some
combination of the above.
Regardless the patient was discharged on Keppra 1000 mg [**Hospital1 **] and
instructed not to drive for 6 months. The patient was discharged
home in good condition with follow-up scheduled with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2442**].
Medications on Admission:
Same as discharge medications with the addition of Keppra 1000
mg [**Hospital1 **].
Discharge Medications:
1. methadone 10 mg/mL Concentrate Sig: One (1) PO DAILY
(Daily).
2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*
3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for peripheral arterial disease.
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Exam: No focal deficits.
Discharge Instructions:
Mr [**Known lastname **],
You were admitted to the the hospital for seizures. These
seizures may be due to a small stroke. We are not sure whether
you have had seizures prior to this which may indicate that you
have epilepsy. We started you on a seizure medication
(levetiracetam 1000 mg twice daily) that you should continue
taking until told otherwise by your neurologist.
You cannot drive until you are 6 months seizure free.
Followup Instructions:
You have a follow-up appointment scheduled with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2442**] at [**Hospital3 **] Medical Center on [**11-7**] at 4:30
PM (Drs. [**Last Name (STitle) 2442**] and [**Name5 (PTitle) 1968**]). Please call them with any
questions or concerns: [**Telephone/Fax (1) 3506**].
Please call your PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 70948**]) to schedule a
follow-up appointment in the next 2 weeks.
|
[
"434.91",
"V58.69",
"724.2",
"338.29",
"493.90",
"345.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9798, 9804
|
7511, 9352
|
299, 325
|
9857, 9857
|
5308, 5308
|
10525, 11035
|
3341, 3350
|
9486, 9775
|
9825, 9836
|
9378, 9463
|
10071, 10502
|
4171, 5289
|
3365, 3903
|
251, 261
|
353, 2975
|
7327, 7488
|
5325, 7318
|
9872, 10047
|
2997, 3176
|
3192, 3325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,350
| 166,834
|
11413
|
Discharge summary
|
report
|
Admission Date: [**2159-9-24**] Discharge Date: [**2159-9-29**]
Date of Birth: [**2114-3-15**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
dysgerminoma of the right ovary
Major Surgical or Invasive Procedure:
diagnostic laparoscopy
total abdominal hysterectomy
left salpingoopherectomy
pelvic and para-aortic lymph node dissection
omentectomy
cystoscopy
History of Present Illness:
This is a 45 yo P0 who presented following discovery of
disgerminoma of the right ovary. Dr. [**Known lastname **] was in
her usual state of good health until [**2159-6-12**]. She
presented at that time to [**Hospital 1559**] Medical Center with acute
severe abdominopelvic pain. She was found to have a torsion of
the right ovary and underwent an emergent exploratory
laparotomy,
right salpingo-oophorectomy. Final pathology revealed a 15 cm
serous cystadenoma of the ovary with a 1 cm disgerminoma of the
ovary focussed within the center. She had this surgery through
[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 22790**] incision and has healed well from that surgery.
Pathology has been read here at [**Hospital1 188**]. The disgerminoma is identified as well as the serous
cyst. The report was that the ovary was intact without surface
involvement. The serous cyst was separate. The patient has had
laboratory evaluations performed postoperatively and these
include an LDH level which is normal, an inhibin level which
evidently was normal, hCG level normal. She had normal liver
function tests and blood counts as well. She has been advised
after an evaluation at the [**Hospital 1559**] Medical Center to undergo a
staging laparotomy including hysterectomy, left
Past Medical History:
PAST MEDICAL HISTORY: She is relatively healthy. She denies
any
history of asthma, hypertension, mitral valve prolapse, or
thromboembolic disorder. With respect to screening evaluations,
she reports being up-to-date with respect to colonoscopy and
mammography. She does suffer from GERD, for which she uses
Prilosec.
PAST SURGICAL HISTORY: As above. She also underwent an
appendectomy at the age of 13.
OB/GYN HISTORY: She is a gravida 0. She has two adopted
children. She reports irregular menstrual cycles, which are
moderate to heavy in flow. They last five days. Her last was
on
[**7-27**]. She denies any history of pelvic infections or abnormal
Pap
smears and her last was obtained in 12/[**2156**]. She denies any
history of gynecological problems.
Social History:
Neurologist in [**Location (un) **] within the [**Hospital3 **] system. Denies
tobacco or illict drug use. Occasional alcohol use. She lives
with her
husband and two adopted children. She denies any history of
verbal, physical, or sexual abuse.
Family History:
She reports her father had [**Name2 (NI) 499**] cancer at the
age of 59. There is no other family history of cancer.
Physical Exam:
At the time of preoperative visit:
GENERAL: She appears her stated age, in no apparent distress.
HEENT: Normocephalic, atraumatic. Oral mucosa without evidence
of thrush or mucositis. Eyes, sclerae are anicteric.
NECK: Supple. There are no masses.
LYMPHATICS: Lymph node survey, negative cervical,
supraclavicular, axillary, or inguinal adenopathy.
CHEST: Lungs clear.
HEART: Regular rate and rhythm.
BACK: No spinal or CVA tenderness.
ABDOMEN: Soft, nontender, nondistended. There are no palpable
masses. There is no hepato or splenomegaly. There is no fluid
wave. A well-healed incision is noted.
EXTREMITIES: There is no clubbing, cyanosis, or edema.
PELVIC: Normal external genitalia. Inner labia minora are
normal. Urethral meatus normal. Speculum is placed. The walls
of the vagina are normal. Apex is normal. Cervix is normal.
Bimanual exam reveals no mass or lesion.
At the time of [**Hospital Unit Name 153**] transfer:
General Appearance: Well nourished, Overweight / Obese, full
neck
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, orbital edema
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Abdominal: Midline incision, dressing in place, clean, dry,
intact with mild serosanguinous drainage
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Not assessed, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person, place, time, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
[**2159-9-24**] 02:20PM BLOOD WBC-9.3 RBC-3.93* Hgb-8.3*# Hct-27.5*
MCV-70*# MCH-21.1*# MCHC-30.1*# RDW-17.5* Plt Ct-366
[**2159-9-26**] 07:15AM BLOOD WBC-10.1 RBC-3.53* Hgb-8.1* Hct-25.2*
MCV-71* MCH-23.0* MCHC-32.2 RDW-19.4* Plt Ct-243
[**2159-9-24**] 07:49PM BLOOD Neuts-85.2* Lymphs-9.1* Monos-5.2 Eos-0.3
Baso-0.2
[**2159-9-25**] 05:10PM BLOOD Neuts-77.8* Lymphs-14.5* Monos-7.2
Eos-0.5 Baso-0.1
[**2159-9-24**] 02:20PM BLOOD PT-13.0 PTT-21.5* INR(PT)-1.1
[**2159-9-26**] 07:15AM BLOOD PT-13.2 PTT-25.1 INR(PT)-1.1
[**2159-9-24**] 02:20PM BLOOD Glucose-168* UreaN-7 Creat-0.7 Na-138
K-4.6 Cl-104 HCO3-28 AnGap-11
[**2159-9-26**] 07:15AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-133
K-4.4 Cl-97 HCO3-27 AnGap-13
[**2159-9-24**] 02:20PM BLOOD Calcium-7.8* Phos-4.5# Mg-2.1
[**2159-9-25**] 06:00AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.2
[**2159-9-24**] 03:07PM BLOOD Type-ART pO2-163* pCO2-59* pH-7.27*
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
CT-A
IMPRESSION:
1. Slightly limited exam secondary to motion and body habitus
however no
pulmonary embolus in the central or segmental pulmonary
arteries.
2. Scattered upper lobe predominent bilateral peribronchiolar
nodular
opacities which may be due to an infectious/inflammatory
etiology or
aspiration. Bilateral lower lobes and lingular atelectasis.
3. Diffuse low attenuation of the liver compatible with fatty
infiltration.
Brief Hospital Course:
On [**9-24**], she underwent diagnostic laparoscoy, converted
to open total abdominal hysterectomy, left salpingoopherectomy,
pelvic and para-aortic lymph node dissection, omentectomy, and
cystoscopy. Procedure was converted due to difficulty accessing
the lymph nodes. Please see Dr.[**Name (NI) 27357**] operative note for
full details.
Postoperatively, the patient received a TAP block for pain in
the PACU. She developed tachycardia to 130s. Preoperatively,
the patient had been tachycardic to 110s. The patient had
received 6L IV fluids and maintained good UOP. She also
received 13mg IV morphine and RR went down to 8. Arterial
blood gas demonstrated hypercarbia with pCO2 to 59. No
pre-operative Hct was drawn, but the post-op HCT was 27.5. Her
02 sat was 82% on RA and up to mid 90s on CPAP. The decision
was made to transfer the patient to the [**Hospital Ward Name 332**] ICU for further
management. On arrival to the ICU the patient's 02 sat 99% on
2L, she was alert, oriented and RR 15, not complaining of any
pain. She had a one-night [**Hospital Unit Name 153**] stay.
The following were addressed during the [**Hospital Unit Name 153**] stay:
1) Hypoxia:
Her hypoxia was likely multifactorial, associated with
atelectasis and low RR in the setting of a high morphine dose.
The CXR was consistent with atelectasis. Patient also noted to
have some snoring and full neck likely associated with some
degree of sleep apnea. She was ruled out for pulmonary embolism
with CT-A. The CT did suggest possible aspiration versus
infectious etiology with "scattered bilateral
peribronchovascular opacities." At the time of [**Hospital Unit Name 153**] call-out,
the patient was saturating 98% on 2L oxygen by nasal canula,
which was stable from her presentation to the ICU, mildly
improved.
2) Sinus Tachycardia:
Her sinus tachycardia was of unclear etiology, though clearly
documented prior to going to the OR. The patient clearly denied
pain, anxiety; her post-op pain was controlled with dilaudid
PCA. She did describe some difficulty with bowel prep that
could have caused dehydration, but the tachycardia did not
resolve with 6L IVFs despite orbital edema. Her post-operative
fever could have been contributing to the tachycardia as well.
Telemetry was discontinued upon transfer to the GYN oncology
service.
3) Fever:
The patient spiked a fever to 102.5 the evening of POD#0. CTA
was suggestive of possible aspiration pneumonia as an etiology.
4) Anemia:
Hematocrit at time of transfer to the [**Hospital Unit Name 153**] was 24. She was
transfused 1 unit of pRBCs in the ICU in addition to 2 units of
pRBCs she had received intraoperatively in the PACU.
The patient was transferred to the gyn oncology service on
POD#1. The remainder of her hospital stay was notable for the
following:
1) Apiration pneumonia:
The patient was successfully weaned to room air on gyn oncology
service. Given that her temperature was still elevated to 101.2
at the time of transfer, she was started on IV clindamycin
empirically for treatment of aspiration pneumonia. Urine
culture was negative, and blood cultures were still pending at
the time of hospital discharge. Following initiation of
clindamycin, she remained afebrile for over 24 hours. She then
respiked to a low grade temperature of 100.6. Urinalysis was
negative. CXR was repeated, demonstrating bibasilar opacities
concerning for ongoing aspiration pneumonia. The patient
spontaneously defervesced, and remained afebrile for the
remainder of her hospital stay. Clindamycin was discontinued
and levofloxacin initiated. The patient received 24 hours of IV
levofloxacin and was discharged home on po levofloxacin. Within
24 hours of discharge, the patient called informing that
insurance would not cover po levofloxacin. She was switched to
a 10 day course of augmentin and azithromycin.
2) Nausea/emesis
The patient experienced an episode of nausea with small amount
of bilious emesis on POD#3. Diet was retracted from full
liquids back to NPO with resolution of symptoms. Diet was
successfully advanced the following day.
She was discharged home on POD#5 in good condition: tolerating a
regular diet, ambulating and voiding without difficulty,
afebrile, saturating well on room air.
Medications on Admission:
prilosec
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not exceed 12 pills
in any 24 hour period.
Disp:*40 Tablet(s)* Refills:*0*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
dysgerminoma of the ovary
Discharge Condition:
good
Discharge Instructions:
- Please call your doctor if you experience fever > 100.4,
chills, nausea and vomiting, worsening or severe abdominal pain,
heavy vaginal bleeding, chest pain, trouble breathing, or if you
have any other questions or concerns.
- Please call if you have
redness and warmth around the incision, if your incision is
draining pus-like or foul smelling discharge, or if your
incision reopens.
- No driving for two weeks and while taking narcotic pain
medication as it can make you drowsy.
- No heavy lifting or strenuous exercise for 6 weeks to allow
your incision to heal adequately.
- Nothing per vagina (no tampons, intercourse, douching for 6
weeks.
- Please keep your follow-up appointments as outlined below.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33326**] Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2159-10-4**] 10:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2159-10-31**] 1:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2159-10-4**]
|
[
"276.51",
"507.0",
"530.81",
"427.89",
"997.1",
"285.9",
"568.0",
"V64.41",
"E935.2",
"183.0",
"997.39",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"65.49",
"57.32",
"68.49",
"54.4",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
11196, 11202
|
6166, 10448
|
360, 507
|
11272, 11279
|
4769, 6143
|
12040, 12488
|
2909, 3029
|
10507, 11173
|
11223, 11251
|
10474, 10484
|
11303, 12017
|
2200, 2627
|
3044, 4750
|
289, 322
|
535, 1832
|
1877, 2176
|
2643, 2893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,735
| 155,044
|
30248
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 72027**]
Admission Date: [**2147-4-14**]
Discharge Date: [**2147-5-7**]
Date of Birth: [**2067-2-11**]
Sex: M
Service:
CHIEF COMPLAINT: Colocutaneous fistula.
PROCEDURE:
1. Exploratory laparotomy, splenic flexure take down,
sigmoid colectomy, coloproctostomy.
2. Percutaneous abscess drainage.
3. Tracheostomy.
CHIEF COMPLAINT: Patient was admitted earlier in the year
with severe complicating diverticulitis. A percutaneous
drain was placed and that subsequently turned into a
colocutaneous fistula. He was sent to rehab for nutritional
improvement and brought back for definitive surgical excision
of the fistula and re-establishment of bowel continuity.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
coronary artery disease, pacemaker, and gastritis.
MEDICATIONS: Included Metoprolol, Protonix, Isosorbide
dinitrate, Plavix, enalapril, aspirin, gabapentin,
acetaminophen, and parenteral nutrition.
DISCHARGE SUMMARY OF HOSPITAL COURSE: The patient was
admitted on [**2147-4-14**]. He underwent his exploratory
laparotomy and bowel resection on [**2147-4-21**]. Prior to his
surgery, he underwent an IVC filter placement. There was a
clot in his iliac vessels which was likely chronic that we
did not want to propagate and give him a pulmonary embolus.
His subsequent course was complicated by anastomotic leak
requiring percutaneous drainage. He did not significantly
improve with this and surgical re-exploration was not
requested by the family. Due to deterioration, he was made
comfortable and he subsequently expired on [**2147-5-7**]. A
post mortem exam was declined by the family.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern4) 9859**]
MEDQUIST36
D: [**2148-10-27**] 14:10:53
T: [**2148-10-27**] 14:48:57
Job#: [**Job Number 72028**]
|
[
"410.71",
"997.4",
"569.81",
"599.7",
"998.32",
"707.03",
"578.1",
"569.5",
"255.4",
"996.61",
"482.41",
"V45.82",
"V45.81",
"562.11",
"280.0",
"038.11",
"E879.8",
"996.01",
"276.2",
"995.92",
"428.0",
"401.9",
"453.41",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"46.39",
"45.76",
"38.7",
"31.1",
"96.6",
"99.15",
"89.64",
"38.93",
"00.14",
"96.04",
"88.72",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1001, 1907
|
370, 702
|
725, 972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,317
| 117,661
|
2963
|
Discharge summary
|
report
|
Admission Date: [**2164-2-20**] Discharge Date: [**2164-2-26**]
Date of Birth: [**2082-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 5552**]
Chief Complaint:
Shortness of breath, abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Patient is an 81 y/o M with metastatic NSCLC on Alimta, HTN,
CAD, COPD on home O2 and afib who presents with abdominal pain
and SOB. Per the patient's wife, over the last week he has
developed progressive abdominal distention and discomfort. The
pain is diffuse across his abdomen. He denies nausea or
vomiting. He has also had progressive SOB over the same period
of time. He has been using his nebulizer up to every 2 hours
with minimal relief. His wife reports that his appetite was
intially ok, however over the last few days his PO intake has
decreased and he did not eat anything for dinner last night. He
denies fever, chills, or cough. He also denies dysuria. He has
had constipation fo rwhich he took Milk of Magnesia tablets last
evening and today with his last BM this morning.
.
Of note the patient was recently admitted to [**Hospital1 18**] from
[**Date range (1) 14195**] for dyspnea. He was admitted to the MICU for tachypnea
to 50s and oxygen requirement. In the ICU, he required bipap
which was gradually weaned off to his home 2.5L NC with sats in
the 89-91 range. Patient
symptomatically felt better. A chest X-ray showed RUL infiltrate
consistent with pneumonia. He continued solumedrol and Abx were
tapered to levaquin alone. He developed new onset a fib and was
started on diltiazem for rate control. He was discharged home on
prednisone taper and completed 7 day course of levofloxacin.
.
In the emergency department initial VS were BP 114/54 HR 108 RR
36 O2 sat 99% 4L. CT abdomen was performed and showed new
ascites and worsening of his liver and omental mets. Surgery
evaluated him for ? SBO. They did not see signs of obstruction,
felt that he had likely ileus from progressive metastatic
disease and is not a surgical candidate. NGT was placed for
comfort. Labs were notable for K 6.0 without EKG changes. He was
given D50 and insulin. He also received solumedrol 125mg IV,
vanco 1gm, zosyn 4.5gm, combivent nebs x2 and 2L NS.
.
Currently the patient states his breathing feels much better. He
continues to have some abdominal discomfort with exam. He denies
chest pain, fever, cough, nausea or vomiting. He reports that
the NGT is uncomfortable when he swallows.
Past Medical History:
1) CAD s/p MI in [**2140**] by EKG diagnosis, no admission, no
symptoms, ETT/MIBI [**2159**] showing partially reversible defect in
RCA distribution. No interventions performed.
2) HTN
3) Hyperlipidemia
4) COPD
5) DJD
6) Thoracic artery aneursym, stable
7) Nonsmall cell lung cancer (see below)
ONCOLOGIC HISTORY:
Mr. [**Known lastname 14194**] was in his USOH until [**2163-7-25**] when he
presented with hemoptysis and weight loss of 10 pounds over
previous 1-2 months. He had a CT scan of the chest on [**8-21**] and
it showed a 4.1 x 4.0 right hilar mass with subcarinal
lymphadenopathy, 19 mm right axillary lymph node as well as
multiple right lower lobe and left lower lobe nodules concerning
for lung cancer. On [**2163-8-28**], he was admitted to [**Hospital1 771**] with chest pain and ruled out for a
non-ST elevation MI. He was seen by the hematology-oncology
consult service while in the hospital and underwent FNA of the
right axillary lymph node, the pathology of which showed
nonsmall cell cancer, squamous cell type. He was discharged on
the third of [**Month (only) 359**] and then on [**2163-8-30**], he had a
bronchoscopy done for evaluation of his hemoptysis as well as
bronchial biopsy and the cytology confirmed metastatic nonsmall
cell lung cancer. He has subsequently completed 2 cycles of
Navelbine.
Social History:
He lives in [**Location 3146**]. He is married and has a daughter and a son.
[**Name (NI) **] has two grandchildren. He is here today with his wife & son.
[**Name (NI) **] smoked for at least 50 years, stopped smoking 3-4 years ago.
He drinks occasional alcohol. He used to work as a carpenter, it
is unclear if he has had asbestos exposure.
Family History:
Father died at age 43 of unknown causes.
Mother died of breast cancer complications at age 53.
Sister had breast cancer and lung cancer and died at age 80
Physical Exam:
VS: T 97.2, BP 122/70, HR 97, RR 24, O2sat 93% on 4LNC, Wt 140
lbs,
Height 62"
GEN: Wearing NC, breathing with pursed lips on expiration.
HEENT: NC/AT.
NECK: Thin, suppple, no lymphadenopathy
PULM: Diffusely decreased breath sounds and air movement. No
crackles or wheezes.
CARD: RR, nl S1, Sl S2, II/VI systolic murmur RUSB
ABD: BS+, soft, NT, ND
EXT: Clubbing of fingernails on hands bilaterally, no LE edema
SKIN: No rashes
NEURO: Oriented x 3, non-focal exam
PSYCH: Patient upbeat with joking manner
Pertinent Results:
[**2164-2-19**] CT abdomen
Worsened metastatic disease with innumerable hepatic metastases,
enlarging and new implants adjacent to the stomach and spleen in
the omentum
and new ascites and omental deposits.
[**2164-2-20**] CTA chest
1. Progression of abdominal metastatic disease, partly
visualized and better
characterized on a CT from the prior day.
2. Right hilar mass with a similar degree of narrowing of
segmental pulmonary
arteries, but exerting greater mass effect on descending airways
serving the
right lower lobe, some of which are now occluded.
3. Patchy new peribronchovascular consolidation in the right
lower lobe, most
suspicious for post-obstructive pneumonia.
4. Interlobular septal thickening in each lower lobe, more
prominent on the
right than left. The appearance may reflect fluid overload or
lymphatic
congestion, but the possibility of lymphangitic carcinomatosis
on the
right should also be considered.
5. NG tube terminating in the stomach, but with the sidehole
near the GE
junction. If clinically indicated, it could be advanced to gain
better
purchase in the stomach.
[**2164-2-20**]
Successful paracentesis yielding two liters of clear amber
fluid.
Samples were sent to microbiology and cytology.
Brief Hospital Course:
81y/o M with metastatic non-small cell lung cancer on
chemotherapy with Alimta last given on [**1-31**] who presents with
abdominal pain and SOB.
.
#. Shortness of breath: This was likely multifactorial, with
contributions from COPD, extensive lung cancer disease burden,
possible post-obstructive pneumonia, and increased abdominal
girth. CTA chest negative for PE but showed tumor invasion of
bronchi and pulmonary artery. NG tube for decompression was
placed, vancomycin and zosyn were started, and he was given
standing nebulizer treatments and supplemental O2. He underwent
two 2-L paracenteses with some improvement in shortness of
breath. Several days into his hospital course he developed
episodes of chest pain and increased shortness of breath without
EKG changes, responsive to nitroglycerin and morphine. These
were thought to represent unstable angina with a possible
contribution from aspiration events. Goals of care were
discussed with the palliative care team and eventually revised
to include comfort measures only. Antibiotics were stopped.
Morphine was given to help with shortness of breath and
nitroglycerin as needed for comfort.
.
#. Abdominal distention: Found to have new ascites in setting of
worsening metastatic disease to liver and omentum. Also found to
have ileus in setting of this and combination of these is likely
contributing to his worsening discomfort. Surgery evaluated pt.
in ED and were not concerned for SBO. NGT was placed for
comfort. He was found to have c diff, which was treated with PO
vanc and zosyn. He underwent two 2-L paracenteses under
ultrasound guidance. Antibiotics were stopped when goals of
care were revised to CMO.
.
#. Leukocytosis: WBC on admission 88K rose to >100k during this
admission, increased from 68K on [**2-10**]. This had been discussed
with heme/onc in the past and previously attributed to his
cancer. The acute rise may have been related to infections (c
diff, possible pneumonia). After goals of care were revised,
labs were no longer checked.
.
#. Non-small cell lung cancer: Widely metastatic with worsening
disease despite Alimta. Followed by Dr. [**Last Name (STitle) **]. Palliative
care assisted in discussions with the family and the goals of
care were revised to comfort when it became clear that no
further reasonable therapeutic options were available. He
expired several days later.
.
Medications on Admission:
1. Albuterol MDI prn
2. Citalopram 20 daily
3. Fluticasone-Salmeterol 250-50 [**Hospital1 **]
4. Folic Acid 1 mg daily
5. Combivent MDI, every four (4) hours as needed for shortness
of
breath or wheezing.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
7. Nitroglycerin SL as needed as needed for chest pain.
8. Prochlorperazine 10 mg every eight hours as needed for
nausea.
9. Ambien 5 mg prn insomnia.
10. Calcium Carbonate 500 mg [**Hospital1 **]
11. Multivitamin Daily
12. Omeprazole 20 mg [**Hospital1 **]
13. Diltia XT 120 mg daily
14. Aspirin 325 mg daily
15. Prednisone taper completed on [**2-17**]
16. Insulin Aspart SS qid
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2164-2-26**]
|
[
"008.45",
"715.90",
"272.4",
"496",
"276.52",
"789.59",
"401.9",
"486",
"276.2",
"V58.65",
"412",
"V66.7",
"427.31",
"276.7",
"162.8",
"V87.41",
"197.6",
"197.7",
"414.01",
"411.1",
"V46.2",
"441.2",
"560.1",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9395, 9404
|
6277, 8665
|
355, 369
|
9456, 9466
|
5017, 6254
|
9523, 9562
|
4321, 4477
|
9363, 9372
|
9425, 9435
|
8691, 9340
|
9490, 9500
|
4492, 4998
|
274, 317
|
397, 2595
|
2617, 3945
|
3961, 4305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,653
| 167,757
|
38180
|
Discharge summary
|
report
|
Admission Date: [**2180-5-16**] Discharge Date: [**2180-5-30**]
Service: SURGERY
Allergies:
Amoxicillin / Pork Derived (Porcine)
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F unrestrained passenger s/p motor vehicle crash with
possible LOC who presented to [**Hospital1 18**] ED confused, found to have
sternal fracture, pneumomediastinum and anterior mediastinal
hematoma, left rib fractures, and bilateral pelvic fractures.
Past Medical History:
LBBB, HTN? ,sciatica, anxiety, ? hypothyroid
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Constitutional: Pale
HEENT: No head laceration
C-spine immobilized
Chest: Subcutaneous air palpable, chest wall hematoma,
bilateral breath sounds
Cardiovascular: Regular rate rhythm one out of 6 systolic
ejection murmur
Abdominal: Soft, Nontender, Nondistended
Pelvic: Tender to palpation and rocking
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Moving all 4 extremities
ECG
Heart Rate: 90
Note(s): Left bundle branch block-old
Rhythm: Sinus
ECG Axis: Left
Intervals: Normal
Pertinent Results:
[**2180-5-16**] 08:35PM WBC-9.6 RBC-2.71* HGB-8.5* HCT-26.7* MCV-98
MCH-31.4 MCHC-31.9 RDW-15.7*
[**2180-5-16**] 08:35PM NEUTS-86.6* LYMPHS-7.7* MONOS-5.5 EOS-0.2
BASOS-0.1
[**2180-5-16**] 08:35PM PLT COUNT-216
[**2180-5-16**] 08:35PM PT-12.2 PTT-25.6 INR(PT)-1.0
[**2180-5-16**] 05:32PM GLUCOSE-141* LACTATE-2.1* NA+-144 K+-4.6
CL--106 TCO2-24
[**2180-5-16**] 05:20PM UREA N-22* CREAT-1.1
[**2180-5-16**] 05:20PM CK(CPK)-176
[**2180-5-16**] 05:20PM LIPASE-50
[**2180-5-16**] 05:20PM cTropnT-<0.01
[**2180-5-16**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.6*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2180-5-27**] Urine Culture negative
[**2180-5-26**] Cystogram Persistent extraperitoneal bladder leak
[**2180-5-25**] MRI spine T1-2 comp fxs, I anterolisthesis L3-4,
multilevel DJD
[**2180-5-18**] echo small LV, EF>75%; mod TR, mod pHTN
[**2180-5-18**] UCx 10-100K enterococcus
[**2180-5-17**] Renal US Right kidney no hydro/nl blood flow
[**2180-5-16**] CT spine No fracture; degenerative changes
[**2180-5-16**] CT head No acute intracranial processes
Brief Hospital Course:
She was admitted to the trauma service. Neurosurgery,
Orthopedics and Urology were consulted due to her multiple
injuries.
Her spine fractures were managed by Neurosurgery. Initially an
MRI and TLSO brace were recommended but patient refused both.
Patient's refusal was noted in Neurosurgery documentation. She
is currently without any brace. Neurologically she is moving all
four extremities. She will require repeat imaging of her spine
in 4 weeks with Dr. [**Last Name (STitle) 739**].
She had multiple orthopedic injuries which were evaluated by
Orthopedics and also managed non operatively. She is to remain
non weight bearing on her left leg and weight bearing as
tolerated on her right leg. She will follow up in 4 weeks for
repeat imaging.
Urology was consulted for the bladder perforation. A cystogram
was performed on [**5-17**] which demonstrated an extraperitoneal
bladder leak; repeat cystogram on [**5-26**] showed persistent leak. it
is being recommended that the Foley remain in place and that
patient should follow up in [**Hospital 159**] clinic in 2 weeks.
For management of her rib fractures pain control and pulmonary
toilet have been the primary goal. Narcotics have shown to make
her sleepy and she was changed to standing Tylenol and Ultram
with better effect. Oxycodone is used only for prn. She is
receiving standing nebulizers as well. She also required a small
dose of IV Lasix for failure upon examination; she had an
adequate response from this. She may require further diuresis
while at rehab.
Of note a calcified right thyroid nodule was found on CT scan
upon intial imaging. It is being recommended that she follow up
with her PCP [**Last Name (NamePattern4) **]: scheduling a non urgent ultrasound.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
Paroxetin 20mg, Fluzone 45mg, Colace 100'', Prednisone 1% Optic
gtt
diazepam 5mg qd, neurontin, trazodone, paxil, centrum, vit c,
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation every six (6) hours.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation every six (6) hours.
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): HOLD for SBP <110/HR <60.
11. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
s/p Motor vehicle crash
Sternal fracture
Superior & inferior right pubic rami fractures
Left anterior acetabular fracture
Bilateral sacral fractures
Pelvic hematoma
Multiple rib fractures bilaterally.
Displaced fracture of the left proximal humerus & distal
clavicle
Extensive compression deformities lower thoracic & lumbar spine
w/ a retropulsed fragment @ T12
Bladder perforation
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 hospitlaized following an auto crash where you
sustained multiple orthopedic injuries, rib fractures and a
bladder injury requiring that you keep a catheter in place until
the injury resolves. Your orthopedic injuries did not require
any operations. It is important that you DO NOT put any weight
on your left leg.
Followup Instructions:
**Follow up with your PCP [**Last Name (NamePattern4) **]: scheduling a non urgent ultrasound
of a calcified right thyroid nodule found on CT scan when you
were admitted to hopsital. You or your family will need to call
to schedule the appointment after you are discahrged from rehab.
Follow-up with Dr [**Last Name (STitle) 739**] AP/lateral xrays for thoracic
and lumbar spine in 4 weeks. Please call [**Telephone/Fax (1) 1669**] for an
appointment.
Follow up in 4 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 85162**] Trauma for
your multiple orthopedic fractures. Call [**Telephone/Fax (1) 1228**] for an
appointment.
Follow up in 2 weeks in [**Hospital 159**] clinic, call ([**Telephone/Fax (1) 772**] for
an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma for your rib
fractures; you will need an end expiratory chest xray for this
appointment. Call [**Telephone/Fax (1) 600**] fo an appointment.
Completed by:[**2180-5-30**]
|
[
"867.1",
"807.05",
"285.9",
"806.60",
"E812.1",
"808.0",
"958.7",
"241.0",
"810.01",
"807.2",
"E849.5",
"812.09",
"808.2",
"584.9",
"806.20",
"041.04",
"599.0",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.77"
] |
icd9pcs
|
[
[
[]
]
] |
5777, 5854
|
2474, 4318
|
267, 273
|
6281, 6281
|
1373, 2451
|
6804, 7820
|
664, 681
|
4499, 5754
|
5875, 6260
|
4344, 4476
|
6456, 6781
|
696, 1354
|
204, 229
|
302, 580
|
6296, 6432
|
602, 648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,235
| 127,367
|
43902
|
Discharge summary
|
report
|
Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-25**]
Date of Birth: [**2060-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right sided thoracentesis
Insertion of Pleurex catheter
History of Present Illness:
60 yo male with widely metastatic RCC s/p recent hospitalization
for dyspnea and worsening likely malignant pleural effusion s/p
chest tube placement/removal and pleurodesis who now presents
with progressive dyspnea x 3 days. The patient had been on
approximately 4L NC at home since discharge, and about 3 days
ago, started to feel more dyspneic. He increased his O2 to
about 8L in the last 1.5 days, with mild improvement, but in the
last 12-24 hours, he became more acutely dyspneic. He also has
been c/o chest pain that started mostly today, in the anterior
left chest just lateral to his sternum. He reports the pain as
sharp, and approximately [**2122-4-16**]. He has taken dilaudid,
morphine, and nitro SL without much benefit for the CP. His
narcotics have been helping with his chronic back pain. He
denies nausea, vomiting, fevers. He does report having some
night sweats. His last BM was yesterday.
In the ED, his vitals were 98.2, 102/59, 102, 15, 82% on 8LNC.
Patient improved to mid 90s on 3-4L, but had occasional
desaturations which improved with intermittent NRB. Can feel
"spells" prior to desat, and NRB at this time seems to prevent
desaturations. CTA was done in the ED which was negative for
PE. Given levofloxacin 750 mg IV x 1; ASA 325 mg x 1, morphine
2 mg IV x 2. Patient admitted to MICU for further eval and tx
for dyspnea. CP with mild improvement with dilaudid; nitro SL
without any benefit. Cardiology contact[**Name (NI) **] but did not feel
there was any acute issue for them to resolve at this time,
especially given poor long term prognosis.
Of note, during this patient's previous hospitalization
(Discharge [**2120-6-1**]), the patient was discharged home DNR/DNI
with hospice services. He was continued on 7 more days of
Enoxaparin for a LUE DVT. The patient was requiring home O2,
approximately 4-5L NC to maintain comfort.
Past Medical History:
1. Metastatic papillary renal cell carcinoma.
Mr. [**Known lastname 94255**] was in his usual state of health until [**2119-8-12**]
when he developed back pain. An MRI of the lumbar spine on
[**2119-10-20**] was notable for a massive retroperitoneal
lymphadenopathy. A CT torso on [**2119-10-23**] confirmed these
findings along with supraclavicular
lymphadenopathy and a large conglomerate lymph node mass in the
periaortic location 10 x 5 cm. MRI of the head on [**2119-11-1**] was
negative for disease. On [**2119-11-7**], an excisional biopsy of the
left supraclavicular node was consistent with metastatic
papillary adenocarcinoma - positive for CD10 and PAX2, negative
for CK7, CK 20, thyroglobulin, and TTF-1; it was felt most
likely to be renal in origin. PET-CT on [**2119-11-27**] showed multiple
FDG avid lymph nodes in the left cervical, mediastinal, hilar
and retroperitoneal regions. MRI abdomen on [**2119-11-30**] was notable
for a 3.0 x 2.5 cm mass in the lower pole of the left kidney. He
started sunitinib on [**2120-1-2**]. He had increasing pain, developed
pleural effusions and had significant side effect from the
sunitinib including nausea, vomiting, poor appetite and diarrhea
so it was stopped on [**2120-4-24**].
2. Seizure disorder
Social History:
He works as a manager for [**Company **] Kinko's. He is currently on a
leave of absence due to his back pain and malignancy. He smoked
half pack per day and has done so for approximately 40-45 years.
He rarely drinks alcohol. He is single and lives with his aunt
in [**Name (NI) 86**].
Family History:
Non-contributory.
Physical Exam:
VS: 95.3 117/76 97 27 97% on 4L NC and NRB
GEN: thin, cachectic male, in moderate respiratory distress,
unable to speak in complete sentences
HEENT: trachea midline; PERRL. JVP flat at 60 degrees
CV: tachycardic, regular. mild 1/6 systolic murmur at base
LUNGS: decreased BS bilateral bases, R posterior decreased [**12-13**]
up lung fields. Coarse BS throughout lung fields with few
inspiratory crackles diffusely. + dullness to percussion
bilateral posterior lung fields
ABDOMEN: soft, NT, normal BS
EXT: no edema
NEURO: A/O x 3; moves all extremities.
Pertinent Results:
[**2120-6-10**] 07:00PM BLOOD WBC-4.7 RBC-2.94* Hgb-9.4* Hct-28.8*
MCV-98 MCH-31.8 MCHC-32.5 RDW-16.2* Plt Ct-813*
[**2120-6-19**] 06:45AM BLOOD WBC-4.9 RBC-3.13* Hgb-9.5* Hct-30.1*
MCV-96 MCH-30.3 MCHC-31.4 RDW-15.2 Plt Ct-512*
[**2120-6-10**] 07:00PM BLOOD PT-13.5* PTT-29.4 INR(PT)-1.2*
[**2120-6-10**] 07:00PM BLOOD Glucose-95 UreaN-7 Creat-0.7 Na-138 K-4.6
Cl-102 HCO3-27 AnGap-14
[**2120-6-19**] 06:45AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-137 K-4.3
Cl-100 HCO3-28 AnGap-13
[**2120-6-11**] 04:42AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.9
[**2120-6-19**] 06:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
Brief Hospital Course:
A/P 60 yo male with widely metastatic RCC with known pleural
effusions s/p chest tube placement/removal, pleurodesis, now
admitted with progressive dyspnea
.
#. Dypsnea: Likely in the setting of worsening malignant pleural
effusion ([**2120-5-22**] pleural fluid cytology with malignant cells).
Given pleural nodularity and lobulation, most likely c/w
malignant pleural effusion. Patient was given furosemide 20 mg
IV to see if there is any improvement with mild diuresis even
though no evidence of overt heart failure and no documented ECHO
previously. Interventional pulmonary was consulted for placement
of pleurex catheter on right side for symptomatic relief.
Pleurex catheter was originally placed with >1L output with
relief of dyspnea. Catheter was drained on subsequent days with
1L, 850cc and 800cc respectively. His breathing status
stabilized and catheter was subsequently drained every 3 days
with 800-1000cc output.
#. Chest Pain: Patient has had chest pain similar to this during
previous hospitalization, though per patient, this time seems
worse. He has received dilaudid, nitro, and morphine without
much relief. Although cardiac cause is possible, there is no
evidence of acute ECG changes at this time. First set of CEs
normal. Cardiology was called in ED, and felt that since
patient is end stage from heme-onc standpoint, there wouldn't be
much to do in the way of coronary evaluation. Likely, chest
pain secondary to lung disease, mets, and/or pleural effusions.
Pain was eventually determined to be non-cardiac and was managed
with Dilaudid.
#Pain: Patient had previously been started on low-dose methadone
with dilaudid po for breakthrough pain, however he chose not to
continue the methadone. He was started on oxycontin for
long-acting pain relief with dilaudid for pain relief.
Adjustments were made for pain relief and mental
alertness/oversedation. Patient was stabilized on current
regimen(oxycontin 60mg qam and noon, 80mg qpm with 4-12mg Po
dilaudid q2h for breakthrough pain) several days prior to
discharge and should remain on this regimen. He was also started
on ritalin 2.5mg qam and noon for increased mental alertness
given sedating effects of narcotics.
.
#. Metastatic RCC: no further therapy at this time. Outpatient
oncologist is Dr. [**Last Name (STitle) **]; has failed suminitib therapy in the
past.
.
#. LUE DVT: Received day [**6-17**] of enoxaparin on admission.
However, due to increased swelling he was started on coumadin
with a Lovenox bridge. He will remain on Lovenox until 2 days
after his INR>2.0 at which time he will continue coumadin
indefinitely at a dose necessary to [**Last Name (un) **] INR 2.0-3.0
#. Seizure D/o - Keppra, primidone, and gabapentin were
continued at outpatient dose. No evidence of seizure activity
during hospitalization.
.
#. PPX: Patient was continued on subcutaneous heparin for DVT
prophylaxis, and a bowel regimen.
.
#. CODE: DNR/DNI. [**Hospital 1739**] hospice
.
#. Contact: niece [**Name (NI) **] [**Name (NI) 1557**] [**Telephone/Fax (1) 94256**]
Medications on Admission:
Prochlorperazine Maleate 10 mg PO Q6H PRN
Zolpidem 10 mg Tablet PO QHS
Docusate Sodium 100 mg PO BID
Senna 8.6 mg Tablet PO BID PRN constipation.
Primidone 250 mg Tablet PO BID
Clonidine 0.1 mg/24 hr Patch Weekly QFRI (every Friday)
Gabapentin 400 mg PO TID
Levetiracetam 1000 mg Tablet PO BID
Lidocaine 5 %(700 mg/patch) Patch DAILY
Lorazepam 0.5 mg 1-2 Tablets PO Q4H PRN
Methadone 10 mg Tablet PO Q8H
Hydromorphone 4 mg Tablet 5-8 Tablets PO Q3H PRN PAIN
Acetaminophen 650 mg PO Q6H PRN
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Primidone 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*1 Patch Weekly(s)* Refills:*0*
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/nausea.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day): Please give first dose in am and second dose at noon. Do
not give after noon.
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO QAM (once a day (in the
morning)) as needed for pain.
14. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO NOON (At Noon) as needed
for pain.
15. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO QPM (once a day (in the
evening)) as needed for pain.
16. Hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q2H (every 2
hours) as needed for pain.
17. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM as needed for Left arm DVT.
20. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Give 70 mg sc q12h until 2
days after INR >2.0.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted for difficulty breathing. It was found that
the difficulty breathing was due to fluid in your right lung. A
catheter was inserted in your right lung to drain the fluid that
collects. This catheter will remain in place and should be
drained twice a week to remove any fluid that has accumulated.
In addition, if you feel short of breath, or feel like you need
to increase your oxygen because of difficulty breathing, you
should ask that the catheter be drained. It can be drained as
often as once a day if needed to help you breathe more
comfortably.
Per IP, he can drain the catheter as frequently as he becomes
symptomatic. He will likely need draining every 3rd day. If he
becomes short of breath, he should drain the catheter rather
than increasing his oxygen requirement to relieve his symptoms.
Can drain as often as once daily, but will need to monitor
closely for hypovolemia if he is requiring daily drainage.
Drainage should be stopped is patient experiences chest pain.
Will need VNA at home or at inpatient hospice to care for right
sided drain, monitor output, and care for the wound.
Followup Instructions:
None
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
Completed by:[**2120-6-25**]
|
[
"338.3",
"198.5",
"196.1",
"453.8",
"197.2",
"189.0",
"345.90",
"196.0",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11046, 11146
|
5138, 8190
|
323, 381
|
11221, 11260
|
4515, 5115
|
12424, 12582
|
3898, 3917
|
8730, 11023
|
11167, 11200
|
8216, 8707
|
11284, 12401
|
3932, 4496
|
276, 285
|
409, 2292
|
2314, 3579
|
3595, 3882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 163,541
|
5062+55634
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-10-31**] Discharge Date: [**2126-11-13**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 55 year old male with a history of type 1
diabetes complicated by chronic kidney disease, multiple
episodes of hypoglycemia attributed to insulin receptor
autoantibody syndrome now on immunosuppression who is admitted
to the MICU for altered mental status. On the morning of
admission, patient was found in his bed unresponsive by his
family. EMS was called and upon arrival FSBG was 20. He
received 1 amp of D50 and according to EMS reports, he was
briefly responsive but again became upresponsive and was brought
to [**Hospital1 18**] ED.
.
Of note, he has been admitted to the hospital multiple times for
altered mental status which has required intubation in the past.
Many times this is due to hypoglycemia and mental status
typically improves with correction of his hypoglycemia. He was
most recently admitted [**Date range (1) 20873**] to the general medical
service for hypoglycemia and mental status improved rapidly.
Prior to this admission he was admitted at the end of [**8-/2126**]
where he was followed by endocrinology and rheumatology and he
was initiated on azathioprine for his insulin receptor
autoantibody syndrome and received a course of prednisone. On
his most recent admission he was continued on his azathioprine
and prednisone without change.
.
In the ED, T<96 rectal, 193/91, 78, 14, 100% NRB. Exam showed
PERRL, clenched jaw so gag could not be performed, and he was
not withdrawing to painful stimuli. FSBG in ED was normal at
139. Subsequent checks remained normal at 96 and 104. Despite
normal FSBGs he remained unresponsive. He received a dose of
narcan without improvement. He had abnormal movements in the ED,
seizures vs shivering and he received 2 mg of ativan without
significant change. On a recent trip to the ED, he required
intubation by anesthesia for a difficult airway and anesthesia
was called today. However, once anesthesia arrived, patient sat
up in bed and was conversant, A+Ox3. ROS was negative at that
time. He remained somnolent in the ED but was easily arousable
so he was not intubated as it was felt he was protecting his
airway. ABG 7.38/49/248 on 3LNC. Labs remarkable for Hct of
23(within recent baseline), electrolytes normal with the
exception of BUN/Cr of 117/6.5 (baseline Cr 5.5-6), lipase of
204, CK 367 with normal MBI (MB 11). Serum tox screen was
negative. ECG, CXR, and CT head were unremarkable. He was
initially started on D5NS @ 100 cc/hr which was changed to D5W
prior to transfer given h/o chronic kidney disease.
.
On arrival to the ICU, patient is obtunded. Unresponsive to pain
and sternal rub. Cannot be aroused. ROS cannot be obtained.
Past Medical History:
# Diabetes type 1 (since age 16 on insulin, followed by Dr.
[**Last Name (STitle) 10088**]
-frequent hypoglycemic episodes, has required intubation for
altered MS in the past
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-3**])
# Anti-Insulin receptor antibodies, on immunosuppression
# Chronic diastolic heart failure with LVH
# Peripheral vascular disease
# Chronic renal insufficiency (most recent baseline Cr 5.5-6,
followed by Dr.[**Name (NI) 4849**] at [**Last Name (un) **])
# Hypertension
# Hyperlipidemia
# Anemia, most recent baseline low to mid 20s, highest low 30s
# Hypothyroidism with h/o [**Doctor Last Name 933**] Disease
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco.
Family History:
Mother has DM2 and RA. Maternal Aunt also c DM2. Nephew c DM1
Physical Exam:
T: 97.8 BP: 157/67 HR: 67 RR: 18 O2 100% 3LNC
somnolent. Prominent snoring with periods of apnea
plethoric with periorbital and lip edema
poor dentition. Tongue appears enlarged but cannot fully assess
due to jaw clenching
+ JVD
RRR, no appreciable MRG
Clear bilaterally with referred upper airway sounds. Decreased
at bases
Obese. NABS. S/NT/ND
Trace-1+ UE and LE edema. Full DP pulses
Small erythematous nonblanching macule on LL abdomen. Otherwise
no rashes, lesions.
Pertinent Results:
[**2126-11-2**] 06:45AM BLOOD WBC-6.4 RBC-2.45* Hgb-7.0* Hct-19.8*
MCV-81* MCH-28.6 MCHC-35.5* RDW-15.7* Plt Ct-141*
[**2126-11-1**] 04:13AM BLOOD WBC-4.8 RBC-2.32* Hgb-6.7* Hct-18.4*
MCV-79* MCH-28.9 MCHC-36.4* RDW-15.7* Plt Ct-139*
[**2126-10-31**] 07:30AM BLOOD WBC-6.9 RBC-2.91* Hgb-8.4* Hct-23.6*
MCV-81* MCH-28.9 MCHC-35.5* RDW-16.1* Plt Ct-207
[**2126-11-2**] 06:45AM BLOOD Glucose-135* UreaN-99* Creat-6.3* Na-139
K-4.3 Cl-101 HCO3-26 AnGap-16
[**2126-11-1**] 04:07PM BLOOD Glucose-310* UreaN-101* Creat-6.2* Na-139
K-4.1 Cl-101 HCO3-28 AnGap-14
[**2126-11-1**] 04:13AM BLOOD Glucose-137* UreaN-104* Creat-6.2* Na-139
K-3.9 Cl-103 HCO3-27 AnGap-13
[**2126-10-31**] 04:43PM BLOOD Glucose-111* UreaN-110* Creat-6.4* Na-141
K-3.9 Cl-102 HCO3-29 AnGap-14
[**2126-10-31**] 07:30AM BLOOD Glucose-99 UreaN-117* Creat-6.5*# Na-144
K-4.3 Cl-103 HCO3-28 AnGap-17
[**2126-10-31**] 07:30AM BLOOD ALT-36 AST-41* CK(CPK)-367* AlkPhos-49
TotBili-0.3
[**2126-10-31**] 07:30AM BLOOD Lipase-208*
[**2126-10-31**] 07:30AM BLOOD cTropnT-0.18*
[**2126-10-31**] 07:30AM BLOOD CK-MB-11* MB Indx-3.0
[**2126-11-2**] 06:45AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.4 Iron-PND
[**2126-11-1**] 04:07PM BLOOD Calcium-8.1* Phos-5.2* Mg-2.4 Iron-40*
[**2126-11-1**] 04:07PM BLOOD calTIBC-298 Ferritn-43 TRF-229
[**2126-10-31**] 07:30AM BLOOD TSH-4.7*
[**2126-11-1**] 04:13AM BLOOD T4-5.7 Free T4-1.1
[**2126-10-31**] 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-10-31**] 09:45AM BLOOD Type-ART pO2-248* pCO2-49* pH-7.38
calTCO2-30 Base XS-3
[**2126-10-31**] 09:45AM BLOOD Glucose-75 Lactate-0.5 K-4.0
ECG [**10-31**]: NSR @ 67. LAD. LAFB. Nl intervals. Poor baseline.
Asymmetric TWI in lateral leads c/w strain pattern. Compared to
previous tracing [**2126-10-19**], no significant change.
.
CT head [**10-31**]: No evidence of hemorrhage.
.
CXR [**10-31**]: Patchy opacity at the right lung base with associated
pleural effusion, which could represent atelectasis, but early
pneumonia cannot be excluded.
CXR [**11-5**]: Cardiomediastinal silhouette is stable. There is poor
inspiratory effort that
might explain lower lung volumes. Small pleural effusion is seen
on the left
and potentially minimal effusion on the right. No evidence of
new opacities
consistent with aspirations were demonstrated.
[**2126-11-6**] 07:15AM BLOOD WBC-6.3 RBC-2.13* Hgb-6.2* Hct-17.0*
MCV-80* MCH-28.9 MCHC-36.3* RDW-16.2* Plt Ct-125*
[**2126-11-6**] 07:15AM BLOOD Plt Ct-125*
[**2126-11-6**] 07:15AM BLOOD Glucose-249* UreaN-130* Creat-7.0* Na-133
K-4.6 Cl-95* HCO3-26 AnGap-17
[**11-1**], [**11-3**] UCx negative
[**10-31**] BCx x2 negative
Brief Hospital Course:
55 year old male with a history of type 1 diabetes due to
insulin receptor autoantibody syndrome on immunosupression,
chronic kidney disease who is admitted for hypoglycemia and
altered mental status. He was initially admitted to the ICU for
monitoring.
.
1. Altered mental status: Thought to be due to hypoglycemia
given prior history of similar events. In the past, has taken
time for mental status to recover despite normal blood sugars.
Head CT negative. He was continued on D5W drip in the ICU and
his mental status improved back to his baseline. He did not
require intubation.
.
2. Hypoglycemia: secondary to insulin receptor autoantibody
syndrome. He was continued on D5W drip until hospital day #2
when it was stopped due to rising blood sugars. Rheumatology
was consulted who recommended continuing steroids and holding
azothiaprine. His fingersticks were checked q2 until his sugars
stabilized. The night prior to leaving the ICU, Mr.[**Known lastname 20874**]
fingersticks were elevated to 400 at which point he required
several insulin doses to return to normoglycemia (he was
asymptomatic). [**Last Name (un) **] service was consulted and recommended
restarting his home glargine regimen and using a conservative
sliding scale to supplement. He was transferred to the floor
once sugars were consistently in the 200s-300s. However, on the
following morning, his sugars continued to rise, into the 500s,
despite insulin therapy. He was transferred back to the ICU for
an insulin gtt. Once sugars were again consistently in the
200-300s range, he was transferred back to the floor. [**Last Name (un) **] saw
him daily, and adjusted his insulin regimen appropriately.
.
# Facial edema: unclear cause. According to ED physicians and
respiratory therapists who know patient well, these are not new
findings. Lip and facial swelling raising risk of airway
compromise and cannot evaluate airway currently. Swelling
improved with diuresis suggesting most likely due to uremia and
volume overload. Aspirin was initially held with question of
angioedema but was restarted on hospital day # 2 without
complication. TSH was slightly elevated but free T4 was normal.
He was maintained on 120mg po lasix [**Hospital1 **].
.
# Hypothermia: most likely due to hypoglycemia. No evidence of
infection currently. No h/o drug or EtOH abuse. H/o hypothyroid
but has been compliant with meds. Now corrected. Resolved prior
to transfer to ICU.
.
# Diabetes Mellitus: type 1, since age 16 on insulin. As above,
frequent hypoglycemic episodes attributed to anti-insulin Ab.
Lantus was initially held. After D5W drip stopped he was
covered with standard humalog sliding scale. [**Last Name (un) **] service was
consulted and followed the patient during hospital stay. They
titrated his insulin regimen appropriately.
.
# Hypertension: hypertensive on arrival and h/o more significant
hypertension in past. He was continued on his home dose
clonidine, minoxidil, diltiazem, toprol XL, doxazosin.
Metoprolol dose was increased, and he was started on 120mg lasix
po bid.
.
# Chronic diastolic heart failure with LVH. Slightly volume
overloaded on exam. No evidence of decompensated CHF. No current
evidence of ischemia. He was continued on diltiazem and toprol.
He received 120mg po lasix [**Hospital1 **] and diuresed well.
.
# Chronic kidney disease: Cr close to most recent baseline.
Renal was consulted given ESRD but patient continues to refuse
fistula placement and HD. They will continue to follow. Given
the patients anemia (see below) he was given a dose of EPO
during admission.
.
# Anemia: attributed to chronic kidney disease. Most recent
baseline low to mid 20s, highest low 30s. Currently within most
recent baseline. No evidence of bleeding currently. His Hct
dropped to less than 20. Iron studies were sent and renal was
asked about EPO. Given his hct dropped to 17 transfusion was
discussed but the patient refused, on multiple occasions. He
agreed to treatment with EPO.
.
# Hypothyroidism: h/o [**Doctor Last Name 933**] Disease per prior reports. TSH was
slightly elevated but free T4 was normal. He was continued on
his home dose levothyroxine.
.
# Disposition: A family meeting was held with the patient's
parents, 2 sisters, social work, palliative care, and the
primary team. The patient's family decided that they could not
take him home anymore. The patient was reluctant to go to a
rehab facility or hospice. However, 3 days later seemed amenable
to such placement. Case management screened the patient and he
was discharged to a rehab facility. Goals of care: Patient
amenable to insulin or glucagon if sugars uncontrolled. Okay to
rehospitalize, though DNR/DNI, refuses transfusions and
dialysis.
Medications on Admission:
B Complex Vitamins One Cap PO DAILY
Folic Acid 1 mg DAILY
Doxazosin 4 mg PO HS
Diltiazem SR 180 mg [**Hospital1 **]
Clonidine 0.3 mg/24 hr Patch One Patch QFri
Calcitriol 0.25 mcg DAILY
Levothyroxine 75 mcg DAILY
Minoxidil 5 mg [**Hospital1 **]
Ferrous Sulfate 325 mg DAILY
Ascorbic Acid 500 mg DAILY
Calcium Carbonate 500 mg [**Hospital1 **]
Rosuvastatin 20 mg DAILY
Furosemide 80 mg [**Hospital1 **]
Toprol XL 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Bisacodyl 5 mg [**Hospital1 **] prn
Aspirin 81 mg once a day.
Pantoprazole 40 mg Q24H
Trimethoprim-Sulfamethoxazole 80-400 mg DAILY
Sevelamer Carbonate 1600 mg TID W/MEALS
Allopurinol 50 mg QOD
Prednisone 15 mg [**Hospital1 **]
Azathioprine 25 mg DAILY
Insulin Glargine 3 units [**Hospital1 **]
Humalog insulin sliding scale
Discharge Medications:
1. Influen Tr-Split [**2125**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: [**11-28**]
MLs Intramuscular ASDIR (AS DIRECTED).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
15. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
16. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
19. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
20. 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*
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
23. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
24. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily) as needed.
25. Lasix 40 mg Tablet Sig: Four (4) Tablet PO twice a day.
26. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous twice a day.
27. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous qachs: See attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Primary diagnosis:
1. Labile blood sugars secondary to type 1 Diabetes
2. Altered mental status
3. Anemia
4. Hypertension
5. Chronic kidney disease
6. Chronic diastolic heart failure
Secondary diagnosis:
Hypothyroidism
Hyperlipidemia
Discharge Condition:
Blood sugars in 200-400s
Discharge Instructions:
You were admitted after finding you at home, unresponsive, with
a blood sugar of 20. You were admitted to the ICU, and were
given sugar, until your blood pressures came up to normal
levels. Once you were transferred to the general medicine floor,
your blood sugars were too high, in the 400s and 500s, and you
transferred back to the ICU for an insulin drip. On discharge,
your sugars were in the 200s and 300s, and were closely
monitored by doctors from the [**Name5 (PTitle) **] clinic.
Your blood count was low, but you refused to be transfused.
Dialysis was discussed, but you did not want this. After
discussing your goals, it became clear that you did not want any
transfusions, dialysis, peripheral IVs, and your code status
changed to DNR/DNI.
Please do not operate any machinery, including a car, given that
you have episodes of low sugars and pass out. This could put you
and others in danger.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: Do not drink more than 1.5L of liquids a day.
If you have sugars that are uncontrolled, difficulty thinking,
weakness, fevers, chest pain, or shortness of breath, please
call your primary doctor or go to the emergency room.
Followup Instructions:
Goals of care:
no return to hospital, no iv meds, no intensive level of care
but oral glucagon to reverse hypoglycemia, insulin to reverse
hyperglycemia and continue his meds.
Completed by:[**2126-11-13**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 3475**]
Admission Date: [**2126-10-31**] Discharge Date: [**2126-11-13**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 128**]
Addendum:
Please make an appointment to see Dr. [**Last Name (STitle) **] in [**1-29**] weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3477**] Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]
Completed by:[**2126-11-13**]
|
[
"250.43",
"428.32",
"403.91",
"780.65",
"V58.67",
"585.5",
"784.2",
"428.0",
"285.21",
"250.83",
"244.9",
"V58.65",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17515, 17727
|
7075, 7342
|
293, 299
|
15535, 15562
|
4405, 7052
|
16861, 17492
|
3834, 3899
|
12664, 15180
|
15278, 15278
|
11816, 12641
|
15586, 16838
|
3914, 4386
|
232, 255
|
327, 2980
|
15482, 15514
|
15297, 15461
|
7357, 11790
|
3002, 3726
|
3742, 3818
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,716
| 164,747
|
36740
|
Discharge summary
|
report
|
Admission Date: [**2186-7-18**] Discharge Date: [**2186-7-31**]
Date of Birth: [**2162-10-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left proptosis, chemosis.
Major Surgical or Invasive Procedure:
[**7-19**] Left frontal Craniotomy for orbital/ retro-orbital
exploration and mass resection/decompression
History of Present Illness:
23M in good health, s/p MVA in [**5-4**], w/ left frontal
laceration, left black eye; noticed a few weeks afterwards to
have left periorbital swelling; treated with erythromycin drops,
which made it better; swelling recurred, w/proptosis and left
retroorbital pain.
Denies any fever, n/v, loss of vision, blurry or double vision.
Past Medical History:
none
Social History:
born/raised [**State **], moved to [**State 350**] 2 years ago, works
as photo lab supervisor, lives in [**Location 39908**] with parents and son
(22 months old)
no smoking, rare etoh, no ivdu
Family History:
Non-contributory
Physical Exam:
On admission:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Speech intact.
Left periorbital swelling and erythema; mild proptosis,
chemosis;
no audible bruit; no pulsation;
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact except for discreete
limitation in extreme upward gaze on left.
V, VII: Facial strength and sensation intact and symmetric.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-30**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
On discharge:
PERRL 4-3mm bilaterally
EOMs intact
face symmetrical, tongue midline
negative pronator drift
Motor: B T D IP QUAD HAM AT [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5
Wound- clean, dry and intact.
Negative clonus
Pertinent Results:
Labs on Admission:
[**2186-7-17**] 10:00PM PT-13.0 PTT-25.5 INR(PT)-1.1
[**2186-7-17**] 10:00PM PLT COUNT-309
[**2186-7-17**] 10:00PM NEUTS-63.5 LYMPHS-30.7 MONOS-3.6 EOS-1.4
BASOS-0.7
[**2186-7-17**] 10:00PM WBC-7.7 RBC-5.11 HGB-14.9 HCT-41.3 MCV-81*
MCH-29.1 MCHC-36.0* RDW-13.0
[**2186-7-17**] 10:00PM estGFR-Using this
[**2186-7-17**] 10:00PM GLUCOSE-95 UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2186-7-17**] 10:12PM LACTATE-1.0
[**2186-7-18**] 02:25AM SED RATE-6
[**2186-7-18**] 02:25AM PT-13.6* PTT-22.4 INR(PT)-1.2*
[**2186-7-18**] 02:25AM PLT COUNT-293
[**2186-7-18**] 02:25AM NEUTS-72.3* LYMPHS-23.4 MONOS-3.0 EOS-0.7
BASOS-0.6
[**2186-7-18**] 02:25AM WBC-7.6 RBC-4.81 HGB-14.0 HCT-38.9* MCV-81*
MCH-29.2 MCHC-36.0* RDW-12.9
[**2186-7-18**] 02:25AM PHENYTOIN-LESS THAN
[**2186-7-18**] 02:25AM CRP-14.4*
[**2186-7-18**] 02:25AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.8
[**2186-7-18**] 02:25AM GLUCOSE-135* UREA N-14 CREAT-1.0 SODIUM-139
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2186-7-30**] 06:45AM 5.4 3.58* 10.5* 29.1* 81* 29.2 36.0* 13.5
271
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2186-7-18**] 02:25AM 72.3* 23.4 3.0 0.7 0.6
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT INR(PT)
[**2186-7-31**] 06:00AM 21.0* 42.3* 2.0*
MISCELLANEOUS HEMATOLOGY ESR
[**2186-7-28**] 06:05AM 10
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2186-7-31**] 06:00AM 3.5
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2186-7-25**] 05:30AM Using this1
Source: Line-R PICC
Imaging:
MR HEAD [**2186-7-18**]
2.8 x 2.7 x 2.1-cm lesion within the left retroorbital space and
middle
cranial fossa, adjacent soft tissues, laterally and into
infratemporal
fossa, and preseptal soft tissues, with osseous destruction
invovling sphenoid [**Doctor First Name 362**] and intraorbital extension causing mass
effect upon the rectus muscles, optic nerve and globe. There is
no intraconal or intraaxial cerebral extension. Given the
clinical history obtained from the online medical record of
prior facial laceration and infectious symptoms, as well as the
rapid development of symptomatology, this most likely represents
chronic aggressive infection- fungal or indolent bacterial, with
or without a foreign body reaction. The differential diagnosis
includes Langerhans cell hisitiocytosis or round cell tumor or
rhabdomyosarcoma. Evaluation of the opthamic veins is limited on
the present study. This can be performed with CT Venogram.
CT HEAD W/O CONTRAST [**2186-7-19**]
NON-CONTRAST HEAD CT: There has been interval left frontal
craniotomy. Post-surgical changes underlying the left
retro-orbital region, with pneumocephalus and a thin rim of
hyperdense material consistent with blood products.
Heterogeneous attenuation material with mottled lucencies (
series 2, im 8 and 9) within the region of the prior retro-
orbital lesion is possibly consistent with packing material or
foci of air in the soft tissues, though correlation with
operative note and close interval follow-up is advised to
exclude retained material. Small subdural hemorrhage is noted in
the elft frontal and parietal regions. There is no significant
intraparenchymal hemorrhage, edema, or mass effect. Ventricles,
sulci, and cisterns are unchanged in size and appearance. There
is no shift of normally midline structures. Residual osseous
destruction is again seen involving the left lateral orbit and
left frontal bone. This appears unchanged compared to [**2186-7-17**]. Orbits are incompletely assessed on this study, though the
degree of mass effect upon the left extraocular muscles and
globe appears reduced compared to MRI performed one day prior.
The visualized paranasal sinuses and mastoid air cells are
normally
pneumatized and clear.
IMPRESSION:
1. Status post craniotomy and wash out of left retro-orbital
lesion. Expected postoperative changes, with pneumocephalus and
small peripheral blood products. Heterogeneous material within
the surgical bed likely represents packing material or air in
the soft tissues related to the procedure. Correlation with
operative note and close interval follow- up is recommneded to
exlcude retained material.
2. Persistent osseous destruction involving the left lateral
orbital wall and frontal bone. There is apparent decreased mass
effect upon the left orbital contents.
3. Small subdural hemorrhage along the left vertex.
Brief Hospital Course:
Mr. [**Known lastname **] is a 23M in good health, s/p MVA in [**5-4**], w/ left
frontal laceration, left black eye; noticed a few weeks
afterwards to have left periorbital swelling; treated with
erythromycin drops, which made it better; swelling recurred,
w/proptosis and left retroorbital pain. After initial
evaluation in the Emergency room he was admitted to the
neurosurgical service for further workup and treatment.
An MRI of the brain and orbits revealed a 2.8 x 2.7 x 2.1-cm
lesion within the left retroorbital space and middle cranial
fossa, adjacent soft tissues, laterally and into infratemporal
fossa, and preseptal soft tissues, with osseous destruction
invovling sphenoid [**Doctor First Name 362**] and intraorbital extension causing mass
effect upon the rectus muscles, optic nerve and globe.
Pt. was taken to the operating room on [**2186-7-19**] for a left
frontal craniotomy and orbital cavity exploration. Interop
cultures and tissue pathology suspicious for old abscess; final
microbiology cultures and tissue pathology is pending at this
time.
Infectious disease has been consulted for help with broad
spectrum antibiotic selection and treatment. The patient will
likely need a long course of antibiotics and had a Picc line
placed for continued therapy and will be discharged with this
line.
Pathology prelim reports Langerhans cell histiocytosis.
Hemotology oncolocy was consulted and waiting to determine if
antibiotics can be discontinued. Patient was also diagnosed with
a right upper extremity DVT =, aspirin and heparin started. PICC
line was discontinued.
On [**7-28**] sutures were removed and skeletal survery showed no
additional tumor sites. Patient's PPT bacame theraputic and he
was started on coumadin 7.5mg. On [**7-31**] Heme/onc has decided to
follow up as an outpatient in a month to discuss chemotherapy
treatments. His DVT is being controlled with coumadin, upper
extremity doppler scan showed improvement of clot in SVC and
stable right basilic clot. He will follow up with his primary
care physician for blood work to maintain theraputic level of
coumadin. He will also follow up with neurosurgery in 4 weeks
with a CT scan.
Medications on Admission:
antibiotics (?cipro)
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache.
Disp:*40 Tablet(s)* Refills:*0*
3. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Left retroorbital mass, ethmoid fracture
Langerhans Cell Histiocytosis
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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.
***PLEASE TAKE OVER THE COUNTER GASTRIC ACID CONTROL (ex pepcid
or zantac)WHILE TAKING ASPIRIN***
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain with contrast prior to
your follow up appointment.
. Hemotology/Oncology will call within one month to schedule an
appointment for you to be seen to manage your Langerhans Cell
Histiocytosis.
FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN [**Last Name (NamePattern4) **] [**1-27**] DAYS TO HAVE
BLOOD DRAWN for your anticoagulation therapy for your upper
extremity blood clot. The goal INR is INR [**2-28**].
Completed by:[**2186-7-31**]
|
[
"E929.0",
"470",
"733.90",
"376.30",
"376.01",
"453.8",
"202.52",
"432.1",
"324.0",
"997.02",
"997.2",
"372.73",
"733.19",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.91",
"01.39",
"16.09",
"38.93",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
9497, 9503
|
6779, 8959
|
347, 456
|
9618, 9642
|
2138, 2143
|
11233, 11883
|
1070, 1088
|
9031, 9474
|
9524, 9597
|
8985, 9008
|
9666, 11210
|
1103, 1103
|
1864, 2119
|
281, 309
|
3234, 4892
|
484, 816
|
4901, 6756
|
2157, 3213
|
1132, 1850
|
838, 844
|
860, 1054
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,134
| 199,200
|
10989
|
Discharge summary
|
report
|
Admission Date: [**2204-9-16**] Discharge Date: [**2204-10-4**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / ORENCIA / Remicade
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of breath, palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 17385**] is a 40 year old Caucasian male with a past
medical history of morbid obesity, steroid dependent psoriatic
arthritis, insulin dependent type II diabetes mellitus,
obstructive sleep apnea on CPAP and multiple recent admissions
for a left lower extremity wound/cellulitis s/p wound VAC
presenting from a rehabilitation facility with episodes of
shortness of breath, hypoxemia and palpitations. At the
rehabilitation facility he was receiving vancomycin and Zosyn
for a left lower extremity cellulitis. The patient was evaluated
in the ED on [**2204-9-12**] (4 days prior to this presentation) for a
question of cellulitis and an elevated INR. General surgery was
consulted and recommended conservative management and no
antibiotics. The physicians at the rehab disagreed with the
decision to withhold antibiotics and started vancomycin and
Zosyn upon his return to the facility. The cellulitis stems from
an open wound which is the result of multiple surgeries
performed on his left lower extremity. He initially presented in
[**2201-12-28**] with an idiopathic fluid collection in his left
lower extremity seen on CT performed for calf pain and erythema.
He has undergone at least 6 separate operations including I&Ds,
debridements and fasciotomies. His recovery has been complicated
by wound healing difficulties, thought to be secondary to
immunotherapies for psoriatic arthritis.
Briefly, concerning his LLE wound:
-[**Date range (2) 35634**]: Admitted to medicine for cellulitis, treated
with Vanc/Zosyn
-[**Date range (3) 35635**]: Patient presented with fever, worsening LLE
erythema, and pain while on Vancomycin and Zosyn. In the ED,
left tib/fib XR demonstrated subcutaneous gas concerning for
necrotizing fasciitis in the medial left proximal to mid calf.
He was taken emergently to the OR for LLE incision and
debridement. Some tissue and gas released medially, but no
extensive tissue necrosis was noted. Intraoperative wound
cultures were negative. Washout and dressing changes were
performed on [**2204-8-3**], followed by wound VAC placement on [**2204-8-5**].
Patient taken to the OR again on [**2204-8-6**]. He was treated with
vancomycin and Zosyn until [**2204-8-13**].
-[**Date range (1) 35636**]: Patient with low grade temperature and
increasing redness and drainage from the left leg wound. Wound
vac was removed, and there was a concern for pus in the wound.
Patient was admitted to general surgery for IV antibiotics, no
procedural interventions performed at that time.
-[**2204-9-12**]: Patient presented to the ED for erythema around the
wound vac. General surgery consulted and felt this was normal
healing and did not recommend further antibiotics. The
rehabilitation facility felt antibiotics were warranted;
initiated vancomycin/Zosyn.
Mr. [**Known lastname 35620**] recovery has also been complicated by pulmonary
emboli discovered on a CTA chest at an outside hospital on
[**2204-8-19**]. The CTA was performed for tachycardia, lightheadedness
and an O2 saturation of 81%. The CTA was 'suboptimal' due to
incorrect contrast bolus IV timing. The CTA was repeated upon
transfer to [**Hospital1 18**] and demonstrated: scattered non-occlusive
emboli in the left lower lobe segmental arteries, without
evidence of right heart strain or pulmonary infarction. He was
treated with a heparin drip at the time and discharged to a
rehab facility with a heparin drip and escalating doses of
warfarin. He need a prolonged course of IV heparin due to his
apparent warfarin resistance. Per the patient and his wife, on
[**Name (NI) 766**] of this week (6 days PTA) while at rehab the patient had
a recurrent episode of tachycardia, pulsatile tinnitus,
shortness of breath, and hypoxia to 93% on RA. He required 6L
NC to get to 95% on RA. He was brought to [**Hospital6 5016**]
and had a repeat CTA showing no new PEs; his tachycardia and
hypoxia resolved over several hours. Saturday at 5pm (1 day PTA)
he again experienced pulsatile tinnitus, tachycardia and an O2
saturation of 85%; he required 8L of O2 to get his saturation to
the mid 90s. This resolved but then similar episodes occurred
Saturday night and Sunday morning, finally dropping to 74% on RA
Sunday morning. At that point he was placed on a NRB at rehab
and was transferred to HFH and then to [**Hospital1 18**] for further
management.
In the ED, initial VS were T 98.3 HR 82 BP 121/72 RR 16 Sat 96%
3L Nasal Cannula. The patient had an ECG which was normal sinus
rhythm with frequent PVCs. His INR was 1.9. CTA from HFH
reviewed w/ radiologist: no evidence of new PE to subsegmental
level. B/l small pleural effusions. Blood cx were sent and he
received a dose of Zofran 4mg IV x1 and Dilaudid 2mg IV x1.
On arrival to the floor, VS T 98 BP 159/72 HR 98 RR 22 O2sat
97%RA. The patient reports improved breathing; he denies current
cough, shortness of breath, fevers and chills. He notes
significant weight gain and abdominal distension over the past
week. He estimates that he has put on approximately 28 lbs since
restarting IV antibiotics. He states he has been using his CPAP
at rehab and has no prior history of these episodes of shortness
of breath.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Psoriatic arthritis
- Dx [**2198**] when pt presented with a few skin lesions of psoriasis
and symmetric polyarticular swelling of MCPs, PIPs, MTPs, and
dactylitis.
- Previously on multiple immunosuppressive medications (MTX,
Entanercept, Remicade, Arava, Orenica, Simponi, Stelara)
- Received 2 doses of Rituximab on [**2204-5-3**] and [**2204-5-24**] and
Azathioprine (held since [**Date range (2) 35637**] admission per outpatient
rheumatologist)
2. Secondary adrenal insufficiency due to chronic steroid use
- Multiple admissions in [**Last Name (un) **], N/V, Leukocytosis, most recently
admitted for hypotension
3. L gastrocnemius sterile fluid collection since [**12/2201**], s/p
multiple evacuations with no significant growth, wound
superinfection with MSSA
4. MSSA Bacteremia [**12/2201**] s/p 14 days of antiobiotic therapy
5. Morbid obesity
6. OSA on CPAP
7. IBD vs IBS: never diagnosed as UC or Crohn's
8. Hypertension
9. DMII
10. Hyperlipidemia
11. Peripheral neuropathy
12. Nonalcoholic fatty liver disease
13. Cervicogenic migraine/dystonic muscle spasm/occipital
neuralgia, followed by pain clinic.
14. Keratoconus s/p bilateral corneal transplants: [**2186**], [**2190**]
15. s/p 4 anal fistulotomies
16. s/p tonsillectomy x2 and adenoidectomy
17. DJD s/p L4/L5 diskectomy
18. Patello-femoral syndrome s/p arthroscopic surgery for both
knees x 3 each
19. MRSA infection [**2196**] - ?abdominal cyst
Social History:
Married with 4 children. Wife is RN at [**Hospital1 18**]. Never smoked. Rare
EtOH. No drugs. Currently on disability.
Family History:
Grandmother: Hypokalemia.
Mother: UC, HTN, HL, and bipolar disorder.
Father: [**Name (NI) 35631**] COPD and HTN.
Brother: Dermatologic psoriasis and UC.
Sister: HTN/HL.
Paternal aunt: [**Name (NI) 4522**] disease and sarcoidosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 97.5 BP 135/80 HR 80 RR 24 O2sat 95% on RA
GEN Obese male, sitting in bed, nad, A&Ox3
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, unable to assess jvd given habitus
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT RLE 3+ edema to the knee, LLE with woundvac in place
NEURO CNs2-12 intact, motor function grossly normal
SKIN chronic psoriatic lesions, some dactylitis
DISCHARGE PHYSICAL EXAM:
VS T 98.1 BP 125/69 HR 59 RR 18 O2sat 99% RA I/O 1440/3150
GEN Alert, oriented x 3, obese, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB, no wheezes, rales, ronchi
CV irregular rhythm, regular rate, normal S1/S2, no mrg
ABD obese, striae, soft NT ND normoactive bowel sounds, no r/g
EXT symmetric hand swelling, WWP 2+ pulses palpable bilaterally,
no c/c, trace b/l lower extremity edema
WOUND well appearing wound with granulation tissue, wound edges
with physiologic erythema, no drainage/purulence
Pertinent Results:
Admission labs:
[**2204-9-16**] 05:55PM BLOOD WBC-6.2 RBC-3.84* Hgb-11.0* Hct-33.9*
MCV-88 MCH-28.7 MCHC-32.5 RDW-16.1* Plt Ct-128*
[**2204-9-16**] 05:55PM BLOOD Neuts-85.0* Lymphs-8.1* Monos-5.7 Eos-1.0
Baso-0.3
[**2204-9-16**] 05:55PM BLOOD PT-20.3* PTT-23.5* INR(PT)-1.9*
[**2204-9-16**] 05:55PM BLOOD Glucose-236* UreaN-22* Creat-0.9 Na-136
K-3.9 Cl-99 HCO3-27 AnGap-14
[**2204-9-17**] 04:56PM BLOOD CK(CPK)-31*
[**2204-9-17**] 04:56PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-170*
[**2204-9-17**] 07:28PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-157*
[**2204-9-17**] 06:03AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
[**2204-9-17**] 06:03AM BLOOD Vanco-12.2
[**2204-9-16**] 05:57PM BLOOD Lactate-2.3*
Discharge labs:
[**2204-10-4**] 08:15AM BLOOD WBC-7.3 RBC-4.32* Hgb-12.2* Hct-38.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.2* Plt Ct-338
[**2204-10-4**] 08:15AM BLOOD UreaN-31* Creat-1.0 Na-137 K-3.9 Cl-98
HCO3-30 AG-13
[**2204-10-4**] 08:15AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2
Other pertinent labs:
[**2204-9-19**] 09:33AM BLOOD Type-ART pO2-82* pCO2-39 pH-7.44
calTCO2-27 Base XS-1 (performed during episode of
unresponsiveness)
[**2204-9-21**] 08:32PM BLOOD Fact II-39* Fact X-21* (performed while
on warfarin)
[**2204-10-1**] 07:15AM BLOOD ESR-19*
[**2204-10-1**] 07:15AM BLOOD CRP-3.0 (performed in the setting of
'severe' arthritic pain)
Blood Culture, Routine (Final [**2204-9-22**]): (drawn off PICC line)
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13214**] @ 14:48 ON
[**2204-9-18**].
VIRIDANS STREPTOCOCCI. OF TWO COLONIAL MORPHOLOGIES.
Isolated from only one set in the previous five days.
ENTEROBACTER SPECIES. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE
IDENTIFICATION.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER SPECIES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2204-9-17**]):
GRAM POSITIVE COCCI IN CHAINS.
GRAM NEGATIVE ROD(S).
CXR
[**2204-9-18**]
IMPRESSION: AP chest compared to [**9-16**] and 22: There is no
pulmonary edema. Mild cardiac enlargement is exaggerated by
severe mediastinal fat deposition. There is no pleural effusion
or pneumothorax and the lungs are clear. Left PIC line ends in
the low SVC.
LENI
[**2204-9-18**]
FINDINGS: Duplex Doppler examination was performed on the right
and left
lower extremity. On the right, there is normal compression and
augmentation of the common femoral, superficial femoral and
popliteal veins. There is normal compression and flow seen
within the right calf veins. On the left, there is normal
compression and augmentation of the common femoral, superficial
femoral and popliteal veins. The left calf veins were
obscured by an overlying bandage.
IMPRESSION:
1. No deep vein thrombosis seen within the right or left lower
extremity.
2. Nonvisualization of the left calf veins.
CT ABD/PELVIS
[**2204-9-18**]
FINDINGS: The lung bases are clear. Lack of intravenous
contrast administration limits the assessment of the solid
viscera. The liver, spleen, pancreas, and adrenals are
unremarkable. High-density material sits within the gallbladder
fundus may represent a stone or sludge. There is a mild
bilateral perinephric stranding, nonspecific. Hypodensity
within the left renal upper pole likely represents a cyst,
although it is difficult to characterize. The ureters are
nondistended. The visualized stomach, large and small bowel are
unremarkable without evidence of obstruction. The visualized
appendix is unremarkable. The descending colon and sigmoid are
also unremarkable. There is a small amount of aortic
atherosclerosis. PELVIS: The bladder and rectum are
unremarkable. There is no ascites.
BONES: The bones appear osteopenic.
IMPRESSION: The etiology for the patient's symptoms is not
identified.
High-density material sits within the gallbladder fundus may
represent a stone or sludge.
ECHOCARDIOGRAM
[**2204-9-18**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is grossly normal
with good free wall motion (only seen in parasternal long axis
orientation). The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function.
Compared with the prior study (images reviewed) of [**2203-1-20**],
the findings are similar. The prior study was also technically
suboptimal.
Brief Hospital Course:
40 year old Caucasian male with a past medical history of morbid
obesity, steroid dependent psoriatic arthritis, insulin
dependent type II diabetes mellitus, obstructive sleep apnea on
CPAP and multiple recent admissions for a left lower extremity
wound/cellulitis s/p wound VAC presenting from a rehabilitation
facility with episodes of shortness of breath, hypoxemia and
palpitations.
#HYPOXEMIA:
Mr. [**Known lastname 35620**] hospital course was most notable for normal oxygen
saturations during the vast majority of his hospitalization.
There was significant concern regarding the accuracy of the
pulse ox because of the patient's dactylitis, and significant
interstitial edema. His intermittent episodes of hypoxemia were
initially concerning for expanding or new pulmonary emboli due
to their acute onset, association with tachycardia and reports
of pre-syncopal symptoms. The patient had also been
subtherapeutic on warfarin prior to admission. The pulmonary
service was consulted and felt that pulmonary emboli were
unlikely the cause of the hypoxemic episodes given their
sub-occlusive nature and stable appearance on CT. Flash
pulmonary edema was considered because of the patient's report
of a 28 lb weight gain prior to admission, association of the
episodes with ambulation/tahcycardia and non-specific CT scan
findings potentially consistent with edema. The patient was
diuresed, with IV and PO furosemide, from an admission weight of
386 lbs to 366 lbs at discharge. Fluids and sodium were
restricted. No direct association between diuresis and the
episdoes of hypoxemia was noted; however the patient did not
experience additional episodes of hypoxemia during the last 12
days of his admission when he was closer to his dry weight. The
patient had a poor quality, but nevertheless essentially normal
echocardiogram and no definitive evidence of pulmonary edema on
any chest imaging. The patient's severe sleep apnea likely
contributed to several episodes of hypoxemia. He was placed on
CPAP at night with occasional supplemental O2. During the day
shift however he was noted to fall asleep occasionally without
the CPAP in place.
#UNRESPONSIVE EPISODE:
This was the patient's primary reason for ICU transfer on
[**2204-9-20**]. Unclear etiology however the patient spontaneously
recovered after 1 minute while an ABG was being performed. No
seizure activity was noted. He was somewhat somnolent, but not
confused after the incident and asked if a blood gas was being
performed. The patient never lost his pulse, and exhibited an
exaggerated respiratory pattern with a rate of [**9-7**] breaths per
minute. ABG results(after 15 sec on a venti mask): Type-ART
pO2-82* pCO2-39 pH-7.44 calTCO2-27 Base XS-1. The patient was
placed on a venti mask and transferred to the MICU. His
neurologic exam after the event was non-focal and no brain
imaging was performed. He had no such episodes during his MICU
course.
#PULMONARY EMBOLI/ANTICOAGULATION:
Mr. [**Known lastname 17385**] was diagnosed with scattered, non-occlusive pulmonary
emboli on [**2204-8-19**] after episodes of tachycardia and hypoxemia.
He was started on a heparin drip at an OSH and transferred to
[**Hospital1 18**]. He was discharged on a heparin drip and increasing
warfarin doses. He had a very complicated transition from
heparin to warfarin, requiring warfarin doses as high as 42mg
daily to maintain a therepeutic INR. His preadmission
medications included 37.5mg of warfarin per day; his INR in the
ED was 1.9. The patient was placed on a heparin drip due to his
subtherapeutic INR and episodes of hypoxemia. LENIs performed
shortly after admission did not reveal evidence of DVT. He again
was very difficult to transition to warfarin. The heparin drip
was stopped in the MICU after concerns over PICC line self
contamination and non-thrombotic pulmonary emboli.
Hematology/Oncology was consulted for formal input into any
workup necessary concerning his high warfarin requirements, as
well as any alternative medications that could be used for
anticoagulation. They recommended checking Factor II/X levels
and wafarin levels. Factor II/X levels were depressed. A
warfarin level was not ordered as the test is a sendout and
would not return this hospitalization. He was restarted on
warfarin 30mg daily while in the MICU and after 3 days of
therapy had an INR of 7.9. This indicated that the patient was
likely not taking 37.5mg of warfarin daily as listed in his
preadmission medications. After resolution of his
supratherapeutic INR he was started on 10mg of warfarin per day
which was quickly titrated up to 20mg daily due to a falling
INR. His INR at discharge was 4.2. He has anticoagulation follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**], a world expert in anticoagulation.
Warfarin was held on the day of discharge.
#AMBULATORY TACHYCARDIA/FREQUENT PREMATURE VENTRICULAR
CONTRACTIONS:
The patient was seen by the cardiology service on [**2204-9-21**]. His
baseline ECG shows a high frequency of PVCs, often >10 per
minute. The patient had several telemetry episodes which
appeared to be sustained ventricular tachycardia. The patient
was asymptomatic during these episodes by all accounts. The
rhythm strips were analyzed by the cardiology fellow and felt to
be artifact. Repeated analysis of these episodes revealed
occasional discordance between the two recorded leads, one
exhibiting the rhythm concerning for VT and the other with NSR
w/ PVCs. The cardiology team could not exclude an arrhythmia
from injected toxic substance. Ambulatory tachycardia appeared
sinus and was thought to be secondary to deconditioning. Atrial
tachycardia remained a possibility but the episodes resolved so
quickly an ECG could not be performed. The cardiology team
recommended continuation of carvedilol for frequent PVCs.
#CONCERN FOR SELF HARM/BEHAVIOR ISSUES:
On ICU day #3, despite no longer needing ICU level care as
determined by the ICU team, the patient refused to be
transferred to the general medical floor and requested a second
opinion. [**Name8 (MD) **] RN staff the patient was found with a "cloudy"
syringe in his room, PICC-line cap open and a white substance at
injection site of PICC-line. The patient denied all accusations
and stated he was using the syringe to apply steroid cream to
his feet, which he is incapable of reaching. The patient was
also noted several times during his hospitalization to be
manipulating telemetry leads and shaking the tele box.
Psychiatry was consulted due to the concern of self-injurious
behavior with possible factitious disorder. Of note, Psychiatry
was consulted in [**2202**] for similar concerns (see note in OMR).
Their recommendations included limit setting, security search of
patient belongings, and clear intra-team communication about his
care plan in order to minimize the patient's ability to distort
and manipulate team members. His PICC line was removed
immediately in this setting. Psychiatry diagnosed the patient
with an adjustment disorder with anxious features. The patient
was made aware of the diagnosis and questioned its validity. He
denied any feelings of anxiety or depression. On multiple
occasions the patient requested to view his medical record, but
never officially pursued the request. He constantly questioned
the judgement of the medical staff stating his prior research,
subscriptions to medical journals and previous advice received
by experts. He consistently complained that PO medications do
not work for him, despite clear diuresis with PO furosemide and
response to corticosteroids. He refused to take warfarin in a
crushed slurry form, which was recommended to ensure he is
actually ingesting the medication. On the day of discharge the
patient was very upset about the decision to be discharged. He
demanded a second opinion regarding discharge with a mildly
supratherapeutic INR, and he refused discharge due to his
reported inability to climb stairs (not consistent with Physical
Therapy documentation) and multiple social issues. See attending
note in OMR dated [**10-4**].
#POSITIVE BLOOD CULTURE:
The patient was reported to have a positive blood culture on
[**2204-9-17**]. The culture appeared to contain multiple organisms
including Gram positive cocci and Gram negative rods. These
cultures were in the setting of continued vancomycin/Zosyn
therapy for his left lower extremity cellutlitis. Given the
polymicrobial nature of the culture and the patient's abdominal
pain/steroid use a CT abd/pelvis was ordered to identify a
potential source. No intrabdominal source of infection was
revealed. The infectious disease was consulted regarding the
lower extremity wound and positive blood culture. They
recommended continued antibiotics, repeat cultures and removal
of the PICC line as soon as possible. Surveillance blood
cultures were drawn over the next two days and yielded no
growth. The final speciation of the lone positive culture
returned: MICROCOCCUS/STOMATOCOCCUS SPECIES, ENTEROBACTER
SPECIES, VIRIDANS STREPTOCOCCI. The ID team felt the blood
culture most likely represented contamination and the left lower
extremity no longer appeared infected. Vancomycin and Zosyn were
discontinued on [**2204-9-24**]. The patient was afebrile throughout
his entire hospital stay.
# LLE WOUND:
Please see extensive history detailed in the HPI. In short, Mr.
[**Known lastname 17385**] has experienced recurrent cellutlits and abscesses in his
left lower extremity. Several of these episodes have been
concerning for necrotizing fasciitis. He has undergone a total
of six operations on the wound including I&Ds, debridements and
fasciotomies. Prior to this admission he was started on
vancomycin and Zosyn by phsyicians at his rehab facility after
an evaluation at the [**Hospital1 18**] ED by the general surgery service.
The general surgery service recommended no antibiotics.
Vancomycin and Zosyn were continued until [**2204-9-24**]. The wound
did not appear actively infected during his hospitalization.
There was minor, physiologic surround erythema and healthy
granulation tissue throughout. QD dressing changes and wound
care was provided. The general surgery service consulted on the
wound again on [**2204-9-20**] and recommended no futher antibiotics,
no debridement and outpatient follow up in 4 weeks. The patient
repeatedly requested second opinions regarding the wound,
despite having seen multiple general surgeons in the past month.
He would eventually like to see a plastic surgeon regarding its
closure/graft potential.
# INSULIN DEPENDENT TYPE II DIABETES MELLITUS
Blood sugar control was not a major issue this hospitalization.
The patient was maintained on Lantus 16/33 and a sliding scale
insulin. He is quite proficient at managing his blood
glucose/carb counting, and maintains a relatively healthy diet.
# PSORIATIC ARTHRITIS
The patient complained of moderate to severe arthritic symptoms
in his hands, knees and shoulders in the week prior to
discharge. Communication with his outpatient rheumatologist, Dr.
[**Last Name (STitle) **], lead to an increase in his dexamethasone dose from 3mg
daily to 4.5mg daily. The patient did not experience significant
relief from the is medication. He continued to request IV and PO
Dilaudid. The pain service was consult regarding this issue and
recommended a long acting opioid. The inpatient rheumatology
team was also consulted and restarted Imuran at 150mg daily. He
was placed on oxycontin 30mg [**Hospital1 **] and provided PRN PO Dilaudid.
The pain service was unable to perform trigger point injections
for his cervicogenic headaches due to current anticoagulation.
#HYPERLIPIDEMIA
Atorvastatin was continued throughout the hospitalization.
#HYPERTENSION
Mr. [**Known lastname 17385**] was normotensive to borderline hypertensive
throughout most of his hospitalization. Lisinopril and
carvedilol were continued at his home doses.
#GLAUCOMA
Eye drops continued.
TRANSITIONAL ISSUES
*******************
-close INR followup, next PT/INR to be drawn on [**2204-10-5**]
-anticoagulation follow up with Dr. [**Last Name (STitle) 2805**] on [**2204-10-5**]
-monitor Chem 7, next to be drawn on [**2204-10-8**]
-general surgery would like to reassess the patient's LLE wound
on [**2204-10-19**]
-the patient needs outpatient psychiatry follow up
-close rheumatology followup regarding psoriatic arthritis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
2. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
reflux
3. Ascorbic Acid 500 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **]
8. Dexamethasone 3 mg PO DAILY
9. DiCYCLOmine 20 mg PO QID IBS
10. Docusate Sodium 100 mg PO BID
11. Duloxetine 30 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. HYDROmorphone (Dilaudid) 4-6 mg PO Q4H:PRN pain
14. Glargine 16 Units Breakfast
Glargine 33 Units Bedtime
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
16. Lisinopril 5 mg PO DAILY
17. Nortriptyline 25 mg PO HS
18. Pregabalin 75 mg PO [**Hospital1 **]
19. Senna 2 TAB PO HS
20. Tizanidine 8 mg PO HS
21. Tizanidine 4 mg PO DAILY:PRN spasms
22. Vitamin D 800 UNIT PO DAILY
23. Potassium Chloride 80 mEq PO DAILY
Hold for K > 4.5
24. Warfarin 37.5 mg PO DAILY16
25. Vancomycin 1250 mg IV Q 12H
26. Piperacillin-Tazobactam 4.5 g IV Q8H
27. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **]
2. Warfarin 0 mg PO DAILY
Do not take dose on [**2204-10-4**]. Dose to be determined by hematology
clinic on [**2204-10-5**].
3. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth Every 12
hours Disp #*20 Tablet Refills:*0
4. Azathioprine 150 mg PO DAILY
RX *azathioprine 50 mg 3 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
5. Vitamin D 800 UNIT PO DAILY
6. Tizanidine 4 mg PO DAILY:PRN spasms
7. Tizanidine 8 mg PO HS
8. Senna 2 TAB PO HS
9. Pregabalin 75 mg PO [**Date Range **]
10. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
11. Potassium Chloride 60 mEq PO DAILY
RX *potassium chloride 20 mEq 3 Tablets by mouth Daily Disp #*30
Tablet Refills:*0
12. Nortriptyline 25 mg PO HS
13. Lisinopril 5 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Glargine 16 Units Breakfast
Glargine 33 Units Bedtime
16. HYDROmorphone (Dilaudid) 4-6 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**12-30**] tablet(s) by mouth Every 4 hours Disp
#*20 Tablet Refills:*0
17. Ferrous Sulfate 325 mg PO DAILY
18. Duloxetine 30 mg PO BID
19. Docusate Sodium 100 mg PO BID
20. Dexamethasone 4.5 mg PO DAILY
RX *dexamethasone 1.5 mg 3 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
21. Carvedilol 12.5 mg PO BID
22. Atorvastatin 80 mg PO DAILY
23. Aspirin 81 mg PO DAILY
24. Ascorbic Acid 500 mg PO DAILY
25. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
reflux
26. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
27. Outpatient Lab Work
[**2204-10-5**]
Please draw PT/INR
Results to be handled by [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Fax: [**Telephone/Fax (1) 35625**]
Diagnosis: pulmonary embolism
28. Outpatient Lab Work
[**2204-10-8**]
Please draw Chem 7
Results to be handled by [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Fax: [**Telephone/Fax (1) 35625**]
Diagnosis: peripheral edema
29. Furosemide 80 mg PO BID
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
left lower extremity wound/cellulitis
Secondary diagnoses:
subacute pulmonary emboli
psoriatic arthritis
obstructive sleep apnea
hypertension
DM type II
adjustment disorder with anxious features
morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 17385**],
It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted for shortness of breath,
palpitations and a low oxygen level. You were diagnosed with
pulmonary emboli, left lower extremity wound/cellulitis and
obstructive sleep apnea. We treated your left lower extremity
cellutlitis with a complete course of antibiotics. Your
pulmonary emboli were treated with heparin and warfarin. At
discharge, your INR was therapeutic and your warfarin dose and
monitoring will be determined by the hematology clinic
appointment on [**2204-10-5**].
Wound care - faxed to [**Date Range 269**], printed here for your reference:
Wound care:
1. Cleanse with commercial wound cleanser daily.
2. Place [**Doctor Last Name 12536**] AMD ( antimicrobial) dressing to wound bed
and pack loosely both tracks with sterile q-tip.
3. Cover with 4x4's, large Soft sorb dressing.
4. Wrap with Kerlix, secure with Medipore tape.
5. Place 6" Velcro ace wrap to secure dressing daily
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STOPPED vancomycin
STOPPED Zosyn
STOPPED dicyclomine
Warfarin to start per hematology clinic recommendations
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2204-10-5**] at 10:15 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2204-10-5**] at 11:00 AM
With: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3062**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2204-10-5**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 3240**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Appointment Tuesday [**2204-10-9**] 9:15am
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"249.00",
"790.92",
"790.7",
"427.69",
"V58.67",
"780.09",
"V58.65",
"799.02",
"415.19",
"356.9",
"E932.0",
"999.31",
"278.01",
"V15.81",
"272.4",
"365.9",
"327.23",
"309.24",
"682.6",
"518.4",
"696.0",
"571.8",
"401.9",
"E988.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
30423, 30525
|
14601, 27008
|
321, 328
|
30779, 30779
|
8805, 8805
|
32223, 33523
|
7445, 7676
|
28222, 30400
|
30546, 30585
|
27034, 28199
|
30930, 31600
|
9508, 9766
|
7716, 8187
|
30606, 30758
|
5576, 5849
|
248, 283
|
31612, 32200
|
356, 5557
|
8821, 9492
|
9788, 14578
|
30794, 30906
|
5871, 7292
|
7308, 7429
|
8212, 8786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,121
| 147,017
|
51559
|
Discharge summary
|
report
|
Admission Date: [**2128-7-8**] Discharge Date: [**2128-7-12**]
Date of Birth: [**2057-2-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo woman with h/o AAA s/p stent and presents iwthg chest pain
and shortness of breath for 1 day. She describes this chest pain
as constant [**9-28**] pain, not sharp, starting near the epigastrium
and extending up to her neck and shoulders bilaterally. She has
baseline shortness of breath [**1-22**] COPD and deconditioning. Denies
that her current SOB is above baseline. Presentation without
notable EKG changes, CTA neg for PE and dissection. Rec'd
sublingual nitro and lopressor in the ED, with minimal relief.
Felt morphine was more beneficial. Admitted for ROMI. Denies
CAD, previous cath.
Past Medical History:
Hyperlipidemia
Hypertension
AAA stented
COPD
osteoporosis with an acute compression fracture
s/p appendectomy
s/p TAHBSO
Meds:
Lisinopril 40 qd
Metoprolol 25 [**Hospital1 **]
nifedipine 90 qday
ASA 81mg
Lipitor 10 mg qd
Oxycontin 40bid
valium 5 mg [**Hospital1 **]
vicodin PRN
Ibuprofen PRN
Social History:
She does smoke 2-3packs a day, no ETOH. Lives with her husband,
daughter and [**Name2 (NI) 7337**]. Her primary care physician is [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**].
Family History:
No known CAD in family
Physical Exam:
VS: T: 98.4 BP: 148/84 HR 97 RR 16 94%RA
HEENT: PERRL, EOMI, MMM, tongue with smoker's stain
Neck: supple, elicits pain on extension, but FROM in all
directions. no lymphadenopathy. TTP along trachea, no
thyromegaly
CV: RRR, 2/6 systolic murmur no radiation to axilla or neck
Chest: CTAB, distant breath sounds, prolonged E/I ratio. TTP
along midline of chest
Abdomen: Soft, NDNT, +BS
Ext: 2+ pulses, Tr edema
Pertinent Results:
[**2128-7-12**] 06:30AM BLOOD WBC-10.3 RBC-4.71 Hgb-12.5 Hct-38.8
MCV-82 MCH-26.6* MCHC-32.3 RDW-15.8* Plt Ct-296
[**2128-7-11**] 05:55AM BLOOD WBC-10.6 RBC-4.58 Hgb-12.2 Hct-37.6
MCV-82 MCH-26.7* MCHC-32.5 RDW-15.7* Plt Ct-281
[**2128-7-10**] 06:10AM BLOOD WBC-9.8 RBC-4.41 Hgb-12.1 Hct-36.5 MCV-83
MCH-27.3 MCHC-33.1 RDW-15.7* Plt Ct-239
[**2128-7-9**] 06:35AM BLOOD WBC-10.7 RBC-4.95 Hgb-13.3 Hct-41.0
MCV-83 MCH-26.9* MCHC-32.5 RDW-15.8* Plt Ct-271
[**2128-7-8**] 01:45PM BLOOD WBC-13.6*# RBC-5.34 Hgb-14.5 Hct-44.3
MCV-83 MCH-27.1 MCHC-32.6 RDW-15.8* Plt Ct-260
[**2128-7-8**] 01:45PM BLOOD Neuts-80.9* Lymphs-13.0* Monos-4.8
Eos-0.4 Baso-0.9
[**2128-7-12**] 06:30AM BLOOD Plt Ct-296
[**2128-7-11**] 05:55AM BLOOD Plt Ct-281
[**2128-7-10**] 06:10AM BLOOD Plt Ct-239
[**2128-7-10**] 06:10AM BLOOD PT-11.9 PTT-25.4 INR(PT)-1.0
[**2128-7-9**] 06:35AM BLOOD Plt Ct-271
[**2128-7-8**] 01:45PM BLOOD Plt Ct-260
[**2128-7-8**] 01:45PM BLOOD PT-12.4 PTT-24.5 INR(PT)-1.1
[**2128-7-8**] 01:45PM BLOOD D-Dimer-2719*
[**2128-7-12**] 06:30AM BLOOD Glucose-94 UreaN-17 Creat-0.7 Na-142
K-3.5 Cl-105 HCO3-28 AnGap-13
[**2128-7-11**] 05:55AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-141
K-3.9 Cl-105 HCO3-26 AnGap-14
[**2128-7-10**] 06:10AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-141
K-4.5 Cl-107 HCO3-27 AnGap-12
[**2128-7-9**] 06:35AM BLOOD Glucose-135* UreaN-17 Creat-0.9 Na-136
K-4.3 Cl-100 HCO3-27 AnGap-13
[**2128-7-8**] 01:45PM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-138
K-4.9 Cl-99 HCO3-31 AnGap-13
[**2128-7-10**] 06:10AM BLOOD CK(CPK)-83
[**2128-7-9**] 07:48PM BLOOD CK(CPK)-75
[**2128-7-9**] 12:40PM BLOOD CK(CPK)-52
[**2128-7-9**] 06:35AM BLOOD CK(CPK)-44
[**2128-7-8**] 09:21PM BLOOD CK(CPK)-53
[**2128-7-8**] 01:45PM BLOOD CK(CPK)-47
[**2128-7-10**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2128-7-9**] 07:48PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-362*
[**2128-7-9**] 12:40PM BLOOD cTropnT-0.03*
[**2128-7-9**] 06:35AM BLOOD cTropnT-<0.01
[**2128-7-8**] 09:21PM BLOOD cTropnT-<0.01
[**2128-7-8**] 01:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2128-7-12**] 06:30AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
[**2128-7-10**] 06:10AM BLOOD Calcium-8.4 Phos-3.0# Mg-2.1
[**2128-7-9**] 06:35AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.0
[**2128-7-9**] 05:32PM BLOOD Type-ART pO2-63* pCO2-50* pH-7.31*
calTCO2-26 Base XS--1
[**2128-7-9**] 03:37PM BLOOD Type-ART Temp-36.1 Rates-/22 pO2-60*
pCO2-46* pH-7.32* calTCO2-25 Base XS--2 Intubat-NOT INTUBA
[**2128-7-9**] 02:26PM BLOOD Type-ART pO2-58* pCO2-51* pH-7.33*
calTCO2-28 Base XS-0
[**2128-7-9**] 12:54PM BLOOD Type-ART pO2-65* pCO2-51* pH-7.35
calTCO2-29 Base XS-0
[**2128-7-9**] 02:26PM BLOOD Glucose-113* Lactate-1.0 Na-136 K-4.0
Cl-102
[**2128-7-9**] 02:26PM BLOOD Hgb-12.5 calcHCT-38 O2 Sat-85
IMAGING:
CTA Chest:
1. No evidence of pulmonary embolism or dissection.
2. No evidence of pneumonia.
.
Cardiology Report ECHO Study Date of [**2128-7-9**]
IMPRESSION: Normal biventricular global and regional systolic
function. No
pericardial effusion seen. Focused emergent study.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2128-7-9**] 16:09.
[**Location (un) **] PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) **] V.
([**Numeric Identifier 106872**])
.
CXR:
The heart size is mildly enlarged. The aorta is tortuous and
calcified. The lungs are clear. The pleural surfaces are smooth
with no pleural effusion. There is no evidence of cardiac
decompensation.
IMPRESSION: No evidence of acute cardiopulmonary process
.
RADIOLOGY Final Report
BILAT LOWER EXT VEINS PORT [**2128-7-9**] 4:35 PM
BILAT LOWER EXT VEINS PORT
Reason: Pt has desat and a tenous respiartory status. Need a
bedside
IMPRESSION: No evidence of DVT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2128-7-10**] 10:53 AM
.Cardiology Report C.CATH Study Date of [**2128-7-9**]
BRIEF HISTORY:
71 year female presents emergently from the medicine floor with
hypoxia,
hypotension, chest and back pain, and 2mm of ST elevation in
lead III.
Past medical history significant for abdominal aortic aneurysm.
INDICATIONS FOR CATHETERIZATION:
CAD
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 GUIDE catheter, with manual
contrast
injections.
Supravalvular Aortography: was performed in the 30 degrees [**Doctor Last Name **]
projection, using 40 ml of contrast injected at 20 ml/sec,
through the
angled pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.93 m2
HEMOGLOBIN: 14.5 gms %
FICK POST ANGIOGRAPHY
**PRESSURES
RIGHT ATRIUM {a/v/m} 22/23/22
RIGHT VENTRICLE {s/ed} 47/23
PULMONARY ARTERY {s/d/m} 47/25/35
PULMONARY WEDGE {a/v/m} 23/27/23
AORTA {s/d/m} 100/63/79
**CARDIAC OUTPUT
HEART RATE {beats/min} 80 75
RHYTHM SINUS SINUS
O2 CONS. IND {ml/min/m2} 125 125
A-V O2 DIFFERENCE {ml/ltr} 61 52
CARD. OP/IND FICK {l/mn/m2} 4.0/2.1 4.6/2.4
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1140
PULMONARY VASC. RESISTANCE 240
FICK POST ANGIOGRAPHY
**% SATURATION DATA (FL)
RA HIGH 52, 52
IVC HIGH 52.2, 51.2
RV MID 53.4, 53.4
PA MAIN 53.2 52.7, 52.5
AO 77.5, 80.4
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 100% O2 VIA NRB
pO2 58
pCO2 51
pH 7.33
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE 60
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 1 minutes.
Arterial time = 36 minutes.
Fluoro time = 8.4 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 80 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Fentanyl 12.5 mcg iv
Cardiac Cath Supplies Used:
6F CORDIS, JR4 INTRODUCER GUIDE
200CC MALLINCRODT, OPTIRAY 200CC
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1) Selective coronary angiography in this right dominant
system
revealed no angiographically apparent flow-liming epicardial
coronary
artery disease. The LMCA was showed no significant disease.
The LAD
had mild luminal irregularities and a 60% stenosis after D1.
The LCx
appeared normal. The RCA appeared normal.
2) Supravalvular aortography showed no significant AI and no
signs of
aortic disection.
3) Left ventriculography was deferred becuase the ejection
fraction
was assessed non invasively.
4) Resting hemodynamics showed elevated filling pressures with
a mean
PCW pressure of 23 mmHg. The baseline cardiac index was low
normal at
2.1 l/min/m2. Central aortic pressure was low at 100/63 mmHg.
There
was near equalization of RA, RVEDP, and PCW wedge pressures. A
stat
echo was obtained the the catheterization laboratory which
showed no
effusion and no evidence of systolic left or right ventricular
dysfunction.
5) Severe hypoxemia was present throughout the case.
6) No oximetric evidence of significant intracardiac shunting.
FINAL DIAGNOSIS:
1. No significant coronary artery disease.
2. Moderate elevation of right and left heart filling pressures.
3. No evidence of intracardiac shunt.
4. Severe hypoxemia.
.
.
PFTs [**2124**]
The pulmonary functions tests revealed amoderate obstructive
ventilatory defect. Specifically, her FVCwas 63% of predicted,
FEV1 was 58% of predicted, for a total of1.29 liters. FVC was
1.97 liters, the ratio of FEV1 to FVC was 91% of predicted. Her
total lung capacity was 99% of predicted,her DLCO was 67% of
predicted, and her DL/VA was 101% ofpredicted.
Brief Hospital Course:
Ms. [**Known lastname 82024**] is a71 y/o woman with history of AAA s/p stent, HTN
who presented with chest pain and was admitted for ROMI.
.
#Chest Pain: Mw. [**Known lastname 106873**] pain extends from chest to chin, most
prominent at neck, reproducible with palpation. Ddimer
waselevated, but had a negative CT for PE, dissection, and no
PNA on CXR. Initial EKG with no ischemic changes from prior.
Given chronicity (pt has had pain x 2 days) and the fact that
it was unrelated to exertion, and negative troponins X 3, she
was to be discharged after an overnight stay, with the thought
that this chest pian most likely represented musculoskeletal
pain, as it was reproducible with palpation.
.
#Hypotension/hypoxia: On admission, patient was hypertensive and
satting well without any supplemental oxygen, despite history of
COPD. However, just prior to planned discharge, Ms. [**Known lastname 82024**], who
had received all her home medications on the morning of
discharge, she triggered for hypotension. During this event,
she became light-headed, nausea, diaphoretic hypoxic to 84% room
air and hypotensive to the 70's with little response to fluid
resuscitation. She received an EKG at the time which was
concerning for 2mm ST elevations in the inferior leads,
worrisome for inferior MI. She received aspirin, plavix,
lipitor and heparin at that time for STEMI. She was brought
emergently to the cath lab, where a cath showed no CAD with
elevated Right sided pressures. She also received LE Ultrasound
which were negative for DVT and echo which showed no pericardial
effusion. Heparin/plavix were stopped at that time. She did
have a troponin leak during this time that was thought to be
secondary to the catheritization procedure. Over the next two
days, her oxygen sats gradually improved to >95% on RA after
starting atrovent/albuterol nebulization treatments. She was
discharged to home on atrovent in addition to her existing
combivent inhaler with follow up with pulmonary for her likely
COPD exacerbation.
.
#Leukocytosis: Pt. had a mild leukocytosis upon admission. She
was afebrile, andCXR and UA were negative, with no localizing
source of infection. Also, do not know her baseline. Resolved
spontaneously by discharge.
.
#HTN: lisinopril, metop, nifedipine at home dose, with somewhat
labile blood pressures ranging from 100s-160s. Pt. has
indicated that she is not always compliant with her medications,
which may have been in part responsible for her hypotensive
episode.
.
#Hypercholesterolemia: continued home statin dose.
.
#Nicotine withdrawal: 21 mcg patch given while in hospital. Pt.
expressed interest in quitting and was written for patch rx.
upon discharge.
Medications on Admission:
Lisinopril 40 qd
Metoprolol 25 [**Hospital1 **]
nifedipine 90 qday
ASA 81mg
Lipitor 10 mg qd
Oxycontin 40bid
valium 5 mg [**Hospital1 **]
vicodin PRN
Ibuprofen PRN
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for on prednisone.
10. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every six (6) hours.
Disp:*2 qs* Refills:*2*
11. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
12. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*2 qhs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease
Lower Back Pain
Chest Pain
Nicotine Dependence
___________________
Hypertension
Discharge Condition:
Good, back and chest pain controlled, satting >95% on room air,
satting 93% on ambulatory sat.
Discharge Instructions:
Please return if you develop increased shortness of breath or
increased chest pain. Please return if you develop dizziness,
nausea, or if your chest pain changes in nature.
Please take all your medications as prescribed. We have changed
your pain medications to oxycontin twice a day and discontinued
your percocet. Please also take ibuprofen around the clock as
instructed. We have also started you on an atrovent inhaler
which you should take once every six hours when feeling short of
breath.
Please continue your smoking cessation switching your patch
every day, and follow up with Dr. [**Last Name (STitle) 3707**] and Dr. [**Last Name (STitle) 2168**] as
below.
Pulmonary function lab has been notified and will call you with
an appt. If you do not receive a call within a few days, please
call them to make an appt. at ([**Telephone/Fax (1) 12124**]
Followup Instructions:
[**2133-7-14**]:40 AM with Dr. [**Last Name (STitle) 3707**]
Dr. [**Last Name (STitle) 2168**], pulmonary, on [**Hospital Ward Name 23**] [**Location (un) 436**] Monday [**7-19**] at
9:30 AM
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2128-7-19**] 9:40
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2128-7-19**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2128-7-19**] 10:00
|
[
"305.1",
"458.9",
"272.0",
"794.31",
"724.2",
"733.00",
"496",
"401.9",
"786.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
15312, 15318
|
11018, 13728
|
324, 330
|
15480, 15577
|
2010, 5159
|
16490, 17124
|
1540, 1564
|
13943, 15289
|
15339, 15459
|
13754, 13920
|
10448, 10995
|
15601, 16467
|
1579, 1991
|
8871, 10431
|
6345, 8852
|
274, 286
|
358, 958
|
5191, 6312
|
980, 1273
|
1289, 1524
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,269
| 125,670
|
42288
|
Discharge summary
|
report
|
Admission Date: [**2198-10-3**] Discharge Date: [**2198-10-9**]
Date of Birth: [**2118-1-20**] Sex: F
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
"RUQ pain, nausea"
Major Surgical or Invasive Procedure:
[**2198-10-3**]: ERCP with stent placement
[**2198-10-5**]: Laparoscopic cholecystectomy
History of Present Illness:
80F Cantonese speaking with PMH of DM, CKD and known gallstones,
who presented to the ED after two days of nausea and sharp RUQ
pain. Her daughters gave her [**Name (NI) **], which did not alleviate the
pain. One day before admission, she began to vomit yellow
watery emesis, not bloody. Then, she began to have black tarry
stool, once a day. At baseline, the patient is ambulatory
without difficulties, but last night, she fell while walking and
was found down by her daughters. This happened two more times
this morning; the daughters believe her fall is secondary to
fatigue. Of note, patient's husband was ill with abdominal
cramps 1 week ago after eating food from a Chinese market and
patient also ate this food shortly before she felt ill.
However, husband's symptoms were more nausea, which resolved
quickly.
.
In the ED, initial vs were: T 102.2 P 110 BP 142/58 O2sat 97%
2L. Patient was given 400mg ciprofloxacin, 500mg metronidazole
as 4L NS in boluses in response to lactate of 4.3 with
improvement to 3.9. Bcx x2 and Ucx were sent prior to receiving
antibiotics. VS on transfer were: T99.1 HR117 BP113/49 RR34
98%2L.
.
On arrival to the ICU, patient's VS were: T 98.2 HR 104 BP
114/56 RR 25 O2sat 97(RA). She was not nauseated, no longer in
pain. Mental status in tact, able to consent for ERCP, ICU, and
sign healthcare proxy form. She was given 1L more NS and
transferred to endoscopy suite for ERCP.
.
ERCP found severe diffuse biliary dilation with multiple filling
defects consistent with stones. Sludge and pus was draining
from ampulla. Stent was placed, small sphincterotomy was
performed.
.
Review of systems:
(+) dysuria
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies frequency or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- DM
- Hypercholesterolemia
- Stage III CKD
- Osteopenia
- H. Pylori
- hx of history colonic polyps
- Low Back Pain
- Mental/Behavioral Problems
Social History:
Emigrated from [**Country 651**] in [**2166**], lives with her husband. Married
with 3 children, her husband is alive and [**Age over 90 **] years old, one son
and two daughter. Lives with son and husband.
-Non smoker
-No ETOH
-Denies any illicits
Family History:
Non contributory.
Physical Exam:
Vitals: T:98.2 BP:114/56 P:104 R:25 18 O2:97 (RA)
General: Alert, oriented, no acute distress, mildly jaundiced
HEENT: Sclera icteric, dry MM, oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles in R lung field, 1/3 up; no rhonchi or wheezes
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly-distended, negative [**Doctor Last Name 515**]
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2198-10-4**] 02:37PM BLOOD Hct-27.0*
[**2198-10-4**] 04:03AM BLOOD WBC-22.9* RBC-2.71* Hgb-9.1* Hct-26.3*
MCV-97 MCH-33.5* MCHC-34.5 RDW-12.9 Plt Ct-88*
[**2198-10-3**] 09:42PM BLOOD WBC-26.4*# RBC-2.77* Hgb-9.2* Hct-27.3*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.2 Plt Ct-92*
[**2198-10-3**] 11:35AM BLOOD WBC-14.8* RBC-3.66* Hgb-11.9* Hct-35.5*
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.2 Plt Ct-160
[**2198-10-3**] 09:42PM BLOOD Neuts-87* Bands-8* Lymphs-3* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2198-10-3**] 11:35AM BLOOD Neuts-71* Bands-15* Lymphs-10* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2198-10-4**] 04:03AM BLOOD PT-13.7* PTT-31.4 INR(PT)-1.2*
[**2198-10-3**] 02:39PM BLOOD PT-13.5* PTT-26.4 INR(PT)-1.2*
[**2198-10-4**] 04:03AM BLOOD Glucose-114* UreaN-24* Creat-1.3* Na-142
K-3.9 Cl-111* HCO3-20* AnGap-15
[**2198-10-3**] 09:42PM BLOOD Glucose-137* UreaN-22* Creat-1.2* Na-141
K-3.5 Cl-110* HCO3-19* AnGap-16
[**2198-10-3**] 11:35AM BLOOD Glucose-237* UreaN-36* Creat-1.7* Na-136
K-4.0 Cl-95* HCO3-26 AnGap-19
[**2198-10-4**] 04:03AM BLOOD ALT-114* AST-107* LD(LDH)-279* AlkPhos-74
Amylase-23 TotBili-1.6*
[**2198-10-3**] 09:42PM BLOOD ALT-123* AST-123* CK(CPK)-269* AlkPhos-88
TotBili-2.3*
[**2198-10-3**] 11:35AM BLOOD ALT-214* AST-247* AlkPhos-143*
TotBili-4.2*
[**2198-10-4**] 04:03AM BLOOD Lipase-44
[**2198-10-3**] 11:35AM BLOOD Lipase-32
[**2198-10-3**] 09:42PM BLOOD CK-MB-2 cTropnT-<0.01
[**2198-10-4**] 04:03AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.3
[**2198-10-3**] 09:42PM BLOOD Albumin-2.7* Calcium-6.5* Phos-1.9*
Mg-2.0
[**2198-10-3**] 11:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG
[**2198-10-4**] 04:50AM BLOOD Lactate-1.1
[**2198-10-4**] 12:39AM BLOOD Lactate-0.9
[**2198-10-3**] 02:36PM BLOOD Lactate-3.9*
[**2198-10-3**] 11:40AM BLOOD Lactate-4.3*
[**2198-10-4**] 04:50AM BLOOD freeCa-1.08*[**2198-10-5**] 10:07AM BLOOD
Hct-31.7*
[**2198-10-6**] 06:15AM BLOOD WBC-15.8* RBC-2.72* Hgb-8.8* Hct-26.5*
MCV-98 MCH-32.3* MCHC-33.0 RDW-13.1 Plt Ct-113*
MICRO:
[**2198-10-4**] STOOL FECAL CULTURE-PENDING; CAMPYLOBACTER
CULTURE-PENDING; OVA + PARASITES-PENDING; FECAL CULTURE - R/O
VIBRIO-PENDING; FECAL CULTURE - R/O YERSINIA-PENDING;
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING INPATIENT
[**2198-10-4**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2198-10-4**] STOOL NOT PROCESSED INPATIENT
[**2198-10-3**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2198-10-3**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-PRELIMINARY {GRAM POSITIVE
COCCUS(COCCI)}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL [**Last Name (LF) **],[**First Name3 (LF) **]
[**2198-10-3**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **]
[**2198-10-3**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM NEGATIVE ROD(S)}; Aerobic Bottle Gram
Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2198-10-3**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM NEGATIVE ROD(S)}; Aerobic Bottle Gram
Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL
IMAGING:
[**10-3**] CXR: IMPRESSION:
1. Mild elevation of the right hemidiaphragm with overlying
right base
atelectasis. No focal consolidation or pleural effusion seen.
2. Focal kyphosis at the thoracolumbar junction with possible
compression of vertebral body(s), not well evaluated and of
indeterminate age.
[**10-3**] CT spine: IMPRESSION: No acute fracture or malalignment.
Mild degenerative change with mild canal narrowing, most
pronounced at C3-C4 level.
[**10-3**] CT head: IMPRESSION: No acute intracranial process.
[**10-3**] CT abd/pelvis: IMPRESSION:
1. Multiple likely stones within the common bile duct with
marked intra- and extra-hepatic biliary ductal dilatation and
gallbladder distention, compatible with choledocholithiasis.
Irregular attenuation of filling defect in the distal common
bile duct could reflect a mixed composition stone versus air
from gas-forming organism. Less likely etiologies include recent
intervention or fistulization with bowel.
2. Distended gallbladder with pericholecystic fluid, without
wall thickening.
3. Hepatic dome lesion could reflect hemangioma but is
incompletely
characterized. Nonurgent evaluation with MR [**First Name (Titles) **] [**Last Name (Titles) 44394**] CT
can be obtained for further evaluation.
4. Diverticulosis without diverticulitis.
5. Likely chronic T12 compression fracture.
[**10-3**] ERCP:
Impression: Successful cannulation of bile duct (cannulation)
Small sphincterotomy was performed
Severe diffuse biliary dilation with multiple filling defects
consistent with stones.
Sludge and pus was draining from ampulla
A 9cm [**Last Name (un) **] 10FR stent was successfully placed.
Normal pancreatic duct
Otherwise normal ercp to third part of the duodenum
Recommendations: Return to ICU
NPO overnight with aggressive IV hydration.
No aspirin, plavix, NSAIDS, coumadin for 5 days
Continue antibiotics for a total of 2 weeks.
Repeat ERCP in 8 weeks for stent removal, sphincteroplasty,
stone extraction and lithotripsy.
Brief Hospital Course:
This is a 80yo F with hx of CKD and known gallstones presents
with cholangitis and melanotic stools.
.
# Cholangitis: Patient was febrile w/ abdominal pain and
dilated CBD and stones on CT chest and had an elevated WBC,
consistent w/ cholangitis. Pt received cipro/flagyl in ED for
?colitis. Upon arrival to ICU, pt was started on Zosyn for
cholangitis, which was continued through HD 4. Pt was taken to
ERCP, many stones ([**11-24**] stones, still in [**11-24**] 3mm-1cm) were
not removed secondary to patient's unstable condition, pus was
drained. Small sphincterotomy was performed and biliary stent
was placed. BP have remained normotensive. LFTs downtrending
after procedure. Pt was NPO overnight with NS 125cc/hr. Per
ERCP recs, no aspirin, plavix, NSAIDS, coumadin for 5 days
because had spincterotomy. Pt will need repeat ERCP in 8 weeks
for stent removal, sphincteroplasty, stone extraction and
lithotripsy. Surgery then recommended cholecyctectomy so pt was
then trasnferred to the floor under ACS service. The patient
subsequently underwent a laparascopic
cholecystectomy on HD 3, from which there were no adverse
events. Post-operatively the patient tolerated diet advancement
without an increase in pain, nausea or vomiting. A course of
antibiotics was continued for 2 days following discharge for a
total of 7 days following ERCP.
# Resp. Post-operatively, the patient was gradually weaned from
oxygen as she experienced desaturations with ambulation. A
chest x-ray was suggestive of a small right-sided pleural
effusion and bibasilar atelectasis without pneumonia or
pneumothorax. She was encouraged to ambulate, use her incentive
spirometer and also received chest PT and nebulizers as needed
and was weaned from oxygen supplemental oxygen by discharge.
# Dark stools. Pt endorsed dark stools, was guaiac positive in
ED. Pt does have h/o h. pylori, but limited look of stomach and
esophagus on EGD appeared normal. Hcts have remained stable. Pt
did not have any other signifcant dark stools. An active type
and screen has been maintained. Pt was started on PPI daily for
possible UGIB. Stools were loose and green so cultures for c.
diff, ova and parasites were performed; results were negative.
The patient will continue on a PPI at discharge and follow-up
with her primary care provider.
# EKG changes. Patient had ST depressions on admission EKG in
precordial leads, resolved by repeat EKG. No known cardiac hx
of in atrius records. CEs were neg. Likely demand related as
changes resolved on repeat EKG in the ICU when rate was lower.
The patient did not complain of further chest pain
post-operatively and remained stable from a cardiovascular
standpoint.
# [**Last Name (un) **] on CKD. Patient's baseline creatinine based on Atrius
records appears to be 1.3, so admission creatinine of 1.7 was
elevated. Likely [**3-14**] to volume depletion as improved
tremendously with fluid rehydration. Responding well to IVF.
Nephrotoxins were avoided and medications were renally dosed.
# Non-gap metabolic acidosis- Patient initially presented w/ gap
of 15 which directly correlated with elevated lactate of 4.3
(normal gap in this patient would be about 9). Hyperchloremia
and non-gap acidosis were subsequently noted, likely [**3-14**] fluid
resuscitation. Maintenance IVF was changed to Lactated Ringer's
for the remainder of the admission until able to saline lock
PIV..
# Dysuria- Patient w/ recent complaint of dysuria. UA w/ mod bac
and + nitrites. Minimal WBCs and LE. The patient was initially
covered broadly w/ zosyn, which was transitioned to
ciprofloxacin given e. coli growth via urine culture. The
patient will continue this regimen for 2 days following
discharge.
# HTN. Patient has not been hypertensive, and with high lactate
likely related to urosepsis. Due to risk for shock, home
enalapril was held and resumed upon discharge.
#DM II. Glipizide was held throughout the hospitalization and
maintained on a Humalog sliding scale. The glipizide was
resumed upon discharge.
# Rehab. The patient received physical therapy during her
admission during which she received caregive education, and
functional mobility and endurance training. Additionally, it
was deemed that she would need additional home physical therapy,
which will be provided by the Visiting Nurses Association.
Medications on Admission:
- brimonidine 0.2% 1 drop each eye [**Hospital1 **]
- vitamin D3 1000U PO tablet
- crestor 20mg daily
- glipizide 10mg daily
- enalapril 20mg daily
- fenofibrate 67mg with meal
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours). Tablet(s)
8. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please resume when you are taking a regular diet; Continue to
monitor your blood sugar 4 times daily .
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Cholangitis
Chronic cholecystitis
Pneumobilia
Urosepsis
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 abdominal pain and found
to have cholangitis, chronic cholecystitis in addition to a
urinary tract infection. You subsequently underwent an ERCP
with stent placement and a laparascopic cholecystectomy. You
recovered in the hospital with well controlled pain and were
able to tolerate a regular diet. You are now preparing for
discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-19**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please contact the Acute Care Service at [**Telephone/Fax (1) 600**] to make a
follow-up appointment within 2 weeks.
Please contact your primary care provider to make [**Name Initial (PRE) **] follow-up
appointment within 1 week to address issue related to your
recent hospitalization including bowel movements containing
blood, a urinary tract infection and all other health
maintenance issued.
Completed by:[**2198-10-10**]
|
[
"574.70",
"518.0",
"511.9",
"041.4",
"724.2",
"585.3",
"599.0",
"733.90",
"250.00",
"403.90",
"276.2",
"567.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87",
"51.23"
] |
icd9pcs
|
[
[
[]
]
] |
14290, 14338
|
8566, 12903
|
288, 379
|
14438, 14438
|
3482, 7018
|
16983, 17412
|
2847, 2867
|
13131, 14267
|
14359, 14417
|
12929, 13108
|
14589, 16455
|
16470, 16960
|
2882, 3463
|
2050, 2394
|
230, 250
|
407, 2031
|
7027, 8543
|
14453, 14565
|
2416, 2563
|
2579, 2831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,754
| 135,635
|
49861
|
Discharge summary
|
report
|
Admission Date: [**2122-11-19**] Discharge Date: [**2122-11-25**]
Date of Birth: [**2053-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
One and a half years of exertional chest pain and shortness of
breath.
Major Surgical or Invasive Procedure:
Cabg x3
History of Present Illness:
69 year old male who presented to an outside hospital with
complaint of a year-and-a-half of exertional chest pain and
dyspnea. He had a stress test positive for ischemia. Subsequent
cardiac catheterization revealed 90% distal left main, 99% left
circumflex lesion, and a 50% lesion at the bifurcation of the
PDA and PLV.
Past Medical History:
BPH
Hypertension
Dyslipidemia
Coronary artery disease
Cataract in left eye
s/p TURP x2
s/p appendectomy
Social History:
Retired civil engineer. Lives at home with his wife. [**Name (NI) 4084**]
smoked and drinks occasional alchohol.
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals stable
General: appears stated age
Chest: lungs clear to auscultation bilaterally
COR: RRR. No murmurs, rubs, gallops appreciated.
Abdomen: soft and nontender without rebound or guarding.
Extremities: warm and well perfused, no edema.
Pulses: 2+ throughout
Pertinent Results:
[**2122-11-19**] 09:58PM HCT-38.2*
[**2122-11-19**] 08:49PM PT-13.8* PTT-58.9* INR(PT)-1.2*
[**2122-11-19**] 05:27PM GLUCOSE-91 UREA N-10 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11
[**2122-11-19**] 05:27PM ALT(SGPT)-11 AST(SGOT)-19 LD(LDH)-154
CK(CPK)-55 ALK PHOS-90 AMYLASE-67 TOT BILI-0.7
[**2122-11-19**] 05:27PM LIPASE-29
[**2122-11-19**] 05:27PM CK-MB-NotDone cTropnT-<0.01
[**2122-11-19**] 05:27PM ALBUMIN-4.0 CALCIUM-9.0 MAGNESIUM-2.0
[**2122-11-19**] 05:27PM %HbA1c-5.8
[**2122-11-19**] 05:27PM WBC-4.7 RBC-4.70 HGB-14.0 HCT-39.1* MCV-83
MCH-29.8 MCHC-35.7* RDW-13.8
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-11-25**] 10:55AM 9.6 3.91* 11.4* 33.5* 86 29.2 34.0 13.6
222
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-11-25**] 10:55AM 104 13 0.8 138 3.5 99 32 11
Brief Hospital Course:
Patient was admitted from outside hospital on the day prior to
surgery and worked up with all labs being within normal value.
Early on the morning of the 10th, he was brought to the cath lab
for insertion of an IABP for chest pain and distal left main
disease. He was [**Last Name (un) 4662**] to the operating room on later in the day
on the 10th and underwent CABG x3 (please see operative note for
full details). Post-operatively he was transferred to the CVICU
for invasive monitoring. POD 1 the IABD was removed without
complication and the patient was extubated.
Transferred to the floor on POD 2. Physical therapy was
consulted and a treatment plan was made. On POD 4 he develeoped
rapid atrial fibrillation overnight and was loaded on amiodarone
via bolus and oral. Convereted to NSR and was maintained on
amiodarone and beta-blockers. Patient remained in normal sinus
rhythm, passed physical therapy assesment and was discharged to
home on POD 5.
Medications on Admission:
Pravachol 40 mg po daily
ASA 81 mg po daily
Lisinopril 5 mg po daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
Please take 2 pills twice daily for one week, then one pill
twice daily for one week, then one pill once daily.
Disp:*50 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take as long as you take the Percocet.
Disp:*60 Capsule(s)* Refills:*0*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
s/p CABG
CAD
Hypertension
Dyslipidemia
BPH
Discharge Condition:
good
Discharge Instructions:
Report redness of, or drainage from incisions
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision.
Shower daily. No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month or while taking narcotics for pain.
Call with any questions or concerns.
Take all medications as directed
Followup Instructions:
1) Dr [**Last Name (STitle) **] in 4 weeks, please call ([**Telephone/Fax (1) 11763**] for appt
2) Cardiology follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2122-12-8**] at 4pm.
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**] ([**Hospital Ward Name **]). Please fax all
previous cardiac info (stress tests, caths, etc) to ([**Telephone/Fax (1) 29889**] prior to appt.
3) Your primary care doctor in [**2-11**] weeks
Completed by:[**2122-11-25**]
|
[
"401.9",
"600.00",
"V45.79",
"414.8",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"39.61",
"97.44",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4463, 4533
|
2229, 3190
|
393, 402
|
4620, 4627
|
1357, 2206
|
5120, 5631
|
1028, 1046
|
3309, 4440
|
4554, 4599
|
3216, 3286
|
4651, 5097
|
1061, 1338
|
283, 355
|
430, 754
|
776, 881
|
897, 1012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,186
| 151,471
|
5652
|
Discharge summary
|
report
|
Admission Date: [**2197-8-14**] Discharge Date: [**2197-9-20**]
Service: MEDICINE
Allergies:
Nitrofurantoin / Sulfa (Sulfonamides) / Hydralazine
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
diarrhea, lethargy
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 87 y/o female with PMH sig for Parkisons Disease,
Dementia, h/o Recurrent UTIs, with recent [**Hospital1 18**] admission
[**2197-8-5**]->[**2197-8-9**] for hypotension and UTI. During this admission,
she was admitted for lethargy and found to have a systolic BP in
the upper 50s. Her hypotension resolved by the time she was
admitted to the medical team, and the thought was that it may
have been d/t medicince effect from changes in her
antihypertensive. Her EKG was without evidence of acute ischemia
and she ruled out for a myocardial infarction. Her lisinopril,
atenolol and norvasc were decreased and she remained
normotensive on this admission. In addition, she was found on
urine culture to have a Urinary tract infection with E. coli.
She was treated with levofloxacin, to complete a 7 day course.
.
She now presents from NH with hypotension, increasing lethargy,
diarrhea and fever. ROS and HPI are extremely limited as patient
is not able to relate history. Initial VS in the ED: 100R, 74,
61/30 24 95% RA. Initial Lactate was 3.4 which decreased to 2.5
after IVF fluids. Labs revealing for new leucocytosis (WBC of
19.9 from 6.2 on discharge) along with new ARF (1.2-->2.8)
.
In the ED, the pt was given CTX (which the E coli is susecptible
to) along with Flagyl. She received aggresse IVF resuscitation
with increased in her BP to 110s systolic.
Past Medical History:
1. Parkinson's disease
2. Baseline dementia on Aricept
3. Hypertension
4. History of recurrent UTIs
5. Right vulvar mass, U/S as above with 2 small connected
collections of fluid in right labium majorum, ? infected
Bartholin gland cysts. Scheduled to see Dr. [**Last Name (STitle) **] on [**2197-6-23**] at
2:30 pm. Recently treated with Ceftriaxone empirically started
on [**2197-6-9**].
6. ? History of upper GI bleed, work-up at [**Hospital1 112**].
7. History of c. difficile infection
.
Social History:
demented nursing home resident living at EPOC in [**Location (un) 55**]
wheelchair bound per nurse [**First Name (Titles) **] [**Last Name (Titles) **]: normally pt cannot talk and
cannot answer any questions; she is normally lethargic per
nursing home nurse; she is totally dependent per nursing home
nurse. As noted in last discharge summary, she is able to follow
simple commands.
Family History:
Noncontributory
Physical Exam:
PE 96.7 67 122/68 16 98%RA
Gen: laying in bed, lethargic but arousable
HEENT: NCAT, parched MM
Neck: supple, JVD flat, no carotid bruits-->but not able to
fully cooperate with exam
Chest: CTAB, no wheezes, rales or rhonci in anterior lung fields
CVS: rrr, no m/r/g but exam limited by upper airway noises
Abd: soft, NABS, NT, ND, no rebound/gaurding
Extrem: no c/c/e, brusing (B)
Neuro: opens eyes to sternal rub, does not follow simple
commands but will squeeze the examiners hand
Pertinent Results:
Imaging:
[**8-14**] CXR: lungs clear, no PTX, CHF or PNA
.
Micro:
[**8-13**] ucx pending
[**8-13**] bcx pending
[**8-14**] C. diff pending
[**2197-8-13**] 11:34PM WBC-19.9*# RBC-3.67* HGB-11.4* HCT-33.1*
MCV-90 MCH-31.1 MCHC-34.5 RDW-15.3
[**2197-8-13**] 11:34PM NEUTS-80* BANDS-4 LYMPHS-8* MONOS-6 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2197-8-13**] 11:34PM PLT COUNT-240
[**2197-8-13**] 11:34PM GLUCOSE-169* UREA N-69* CREAT-2.8*#
SODIUM-146* POTASSIUM-4.9 CHLORIDE-110* TOTAL CO2-20* ANION
GAP-21*
[**2197-8-14**] 12:29AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2197-8-14**] 12:29AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2197-8-14**] 12:29AM URINE RBC-[**3-19**]* WBC-[**12-4**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
Brief Hospital Course:
1) SEPSIS:
Pt was initially treated on floor for UTI but then transferred
to the ICU for septic shock with hypotension, decreased urine
output. Pt was put on broad spectrum antibiotics to cover UTI
as well as C diff. She was on ceftriaxone for E/ coli UTI as
well as IV vanco.
Her hypotension resolved. She remained AF and WBC normalized.
Her repeat urine cultures were negative and she completed 10d
course of ceftriaxone for the UTI.
.
2) C DIFF:
Pt had positive C diff toxin early in the admission and was
started on flagyl and PO vanco. However, treatment of her Cdiff
was prolonger by intervening antibiotics for other infections.
At discharge she requires about 8 more days of vanco and flaygl.
.
3) GI BLEED:
Pt also developed a lower GI bleed while in the ICU. Her hct
remained stable but she had BRBPR. A colonoscopy showed C diff
colitis and ischemic colitis resulting in friable mucosa. As
her sepsis resolved and c diff was treated, she had no further
lower GI bleed.
.
4) ANEMIA:
Initially, her HCt was around 30 and stable. By discharge, it
ranged from 23 to 25 but was stable. Iron studies show anemia
of chronic disease. There is no active bleeding.
.
5) PNEUMONIA: After leaving the ICU, pt developed an elevated
WBC. CXR showed possible pneumonia so she was treated with
ceftriaxone and vanco initially and then switched to cipro. Her
WBC normalized and resp secretions decreased.
.
6) PICC site infection: She developed exudate at site of PICC.
Culture showed pseudomonas. Treated with cipro. PICC changed
to new site.
.
7) cardiac arrhythmia:
EKG [**8-25**] appeared to be possible a-fib c RVR (105) and compared
to prior EKG done on admission which was read by a cardiologist
(sinus rhythm c freq. atrial ectopy), does appear to be more
irregularly irregular. Pt without symptoms during this episode.
Subsequently in NSR c frequent PACs. Thus do not believe a-fib
an element to pt's hypotension. If pt does go into a-fib, would
not be a good candidate for anticoagulation given current
bleeding from below and fall risk.
.
8) HTN: Holding home antihypertensives (amlodipine 2.5 mg,
lisinopril 2.5 mg, atenolol 12.5 mg [**Hospital1 **]) given overall
malnutrition, initial hypotension. Can be restarted as outpt
once BP in stable range.
.
9) Dementia/Parkinsons: For much of the hospitalization,
sinemet was held due to inability to take POs. This was
restarted once PEG placed.
.
10) MALNUTRUTION: Pt suffered from severe malnutrition, likely
long standing and exacerbated by acute illness. Albumin<2.0.
She was likely not getting sufficient nutrition PO. She is also
high aspiration risk and should not take any POs. PEG placed
and started on TFs.
.
11) ANASARCA: DEveloped while in septic shock but persisted due
to hypoalbunemia. Did not attempt diuresis given low albumin.
Once nutritional status improved, expect some degree of
autodiuresis which can be assisted with diuretics if needed.
.
12) CODE STATUS: Initially full code, after family meeting week
before discharge, made DNR/DNI
Medications on Admission:
1. Amlodipine 2.5 mg PO DAILY
2. Atenolol 12.5 mg PO BID
3. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID
4. Lisinopril 2.5 mg qd
5. Aspirin 81 mg qd
6. Multivitamin
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO qd
9. Lansoprazole 30 mg qd
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for peri rash.
2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
6. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain: sublingual.
7. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Aspiration Pneumonia
Parkinson's Disease
C-Diff Colitis
Sepsis
UTI
Malnutrition, severe
Discharge Condition:
Stable
Discharge Instructions:
Return to the hospital for fevers, elevated white blood cell
count, inability to feed, decreased urine output.
Take medications as prescribed.
Followup Instructions:
Once discharged from rehab, should f/u with Dr. [**Last Name (STitle) **], her PCP.
|
[
"507.0",
"E942.9",
"584.9",
"995.92",
"008.45",
"785.52",
"038.42",
"996.62",
"486",
"244.9",
"276.0",
"294.8",
"332.0",
"557.1",
"578.9",
"041.7",
"599.0",
"261",
"285.29",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"43.11",
"45.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8203, 8274
|
4009, 7047
|
278, 291
|
8406, 8415
|
3158, 3986
|
8607, 8694
|
2622, 2639
|
7515, 8180
|
8295, 8385
|
7073, 7492
|
8439, 8584
|
2654, 3139
|
220, 240
|
319, 1689
|
1711, 2205
|
2221, 2606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,634
| 119,876
|
45402
|
Discharge summary
|
report
|
Admission Date: [**2123-5-26**] Discharge Date: [**2123-5-31**]
Date of Birth: [**2042-7-11**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Shellfish
Attending:[**First Name3 (LF) 57533**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
COLONOSCOPY
History of Present Illness:
80yo female with history of diverticulosis, CAD, hypertension,
diabetes, asthma, and recent found fungating 5cm mass in cecum
s/p removal during colonoscopy with no history of surgeries who
presents with bright red/maroon bleeding that started at 11pm.
Patient was in her usual state of health, watching televison
when she had urge to use bathroom and saw BRBPR. Had repeat
urge and had BRBPR second time and came to ED.
.
.
In the ED, initial VS were: BP 170/80. Patient was triggered
for active bleeding and felt lightheaded on arrival.
Approximately 700cc-1L of BRBPR lost while in ED. Given 1U PRBC
with second unit hung. Platelets were ordered and are ready.
She was ordered for 2 additional units of PRBC, but they had not
been given in ED. Surgery was consulted and will follow
patient. IR consulted and is coming in to see patient on
arrival to MICU. GI also consulted and felt there was nothing to
be done from their standpoint secondary to active bleeding.
While in ED, bleeding has slowed down. She had bilateral 16
gauge IVs placed as well as one additional 18 gauge IV. On
sign-out to MICU HR was 80, BP 116/63, though patient is on
metoprolol. HCT was 34.6 on arrival.
.
On arrival to the MICU, patient's VS T 98.6, BP 109/60, HR 71,
RR 14, 100% on RA. Patient reported feeling well. Reported
sudden onset BRBPR slightly after 11pm last night without
abdominal pain, n/v. [**Doctor First Name **] CP/SOB. Denies f/c. Reports
feeling slightly lightheaded on arrival, now improved. Had 2nd
Unit PRBCs running.
Past Medical History:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2102**], multiple PCIs; patent saphenous vein graft
to diagonal, left internal mammary artery to left anterior
descending, stent of left circumflex and OM1 (restented in
[**2115**]), and stent and brachytherapy to OM2.
2. Stable angina with exercise.
3. Congestive heart failure, diastolic dysfunction.
4. Hypertension.
5. Hypercholesterolemia.
6. Type 2 diabetes mellitus with nephropathy and retinopathy.
7. Chronic anemia likely secondary to chronic renal
insufficiency.
8. Iron deficiency anemia.
9. Asthma.
10. Diverticulosis.
Social History:
significant for the absence of current tobacco use. Patient quit
in [**2085**] after 20 years of tobacco use, she quit daily EtOH at
that point as well
Family History:
Mother had MI in her 60s.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.6, BP 109/60, HR 71, RR 14, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, poor dentition, MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM murmur,
no appreciable rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
[**Year (4 digits) **]: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moving all extremities, grossly normal sensation
.
Pertinent Results:
ADMISSION LABS
[**2123-5-25**] 11:40PM BLOOD WBC-10.0 RBC-3.44* Hgb-11.1* Hct-34.6*
MCV-101* MCH-32.2* MCHC-32.0 RDW-13.4 Plt Ct-439
[**2123-5-25**] 11:40PM BLOOD Neuts-53.1 Lymphs-40.2 Monos-3.4 Eos-2.4
Baso-0.9
[**2123-5-25**] 11:40PM BLOOD PT-11.4 PTT-29.9 INR(PT)-1.1
[**2123-5-25**] 11:40PM BLOOD Glucose-218* UreaN-35* Creat-1.5* Na-140
K-4.1 Cl-103 HCO3-28 AnGap-13
[**2123-5-26**] 06:36AM BLOOD CK-MB-3 cTropnT-0.01
[**2123-5-25**] 11:40PM BLOOD Calcium-9.7 Phos-4.1 Mg-1.6
.
HCT TREND
[**2123-5-25**] 11:40PM BLOOD Hgb-11.1* Hct-34.6*
[**2123-5-26**] 06:36AM BLOOD Hgb-12.0 Hct-37.0
[**2123-5-26**] 12:00PM BLOOD Hct-36.6
[**2123-5-26**] 05:39PM BLOOD Hct-34.0*
[**2123-5-26**] 10:00PM BLOOD Hct-34.6*
[**2123-5-27**] 04:06AM BLOOD Hgb-11.3* Hct-34.9*
[**2123-5-27**] 09:50AM BLOOD Hct-32.6*
[**2123-5-27**] 12:34PM BLOOD Hct-34.0*
[**2123-5-27**] 09:00PM BLOOD Hct-35.7*
[**2123-5-28**] 04:27AM BLOOD Hgb-11.7* Hct-37.2
.
DISCHARGE LABS
.
URINALYSIS
[**2123-5-26**] 12:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2123-5-26**] 12:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICRO
[**2123-5-26**] URINE CULTURE - FINAL NEGATIVE
.
IMAGING
[**5-25**] CXR
IMPRESSION: No evidence of acute cardiopulmonary process
.
[**5-26**] CT ABD/PELVIS
CT OF THE ABDOMEN:
Bibasilar areas of dependent atelectasis are noted. Otherwise,
imaged lung
bases are clear. There is no pleural effusion. The heart is
normal in size
without pericardial effusion. Small-to-moderate hiatal hernia is
noted.
The liver is homogeneous in attenuation. No focal hepatic lesion
is
identified. There is no evidence of intrahepatic or extrahepatic
biliary
ductal dilatation. The hepatic vasculature is patent. The
gallbladder is
incompletely distended. There is no gallbladder wall edema or
pericholecystic
fluid collection to suggest acute inflammation. There are no
calcified
gallstones within its lumen. The spleen is unremarkable. The
pancreas
enhances homogeneously without ductal dilatation or
peripancreatic fluid
collection. Adrenal glands are normal. Kidneys enhance and
excrete contrast
symmetrically without evidence of hydronephrosis . A 6-mm left
mid ureteral
stone is unchanged in position without evidence of associated
hydroureteronephrosis. There is a 1.2 x 1 enhancing lesion
arising from the
upper pole of the left kidney (4a:44). Small bowel loops are
unremarkable.
There is no evidence of bowel obstruction. A small
fat-containing umbilical
hernia is noted.
CT OF THE PELVIS:
Areas of active contrast extravasation are seen at the level of
the cecum.
Increased amount of contrast is seen layering at the site of
extravasation on
delayed phase imaging. No additional area of active contrast
extravasation is
noted. Foley catheter is in place. Small locule of gas in the
bladder is
likely related to Foley placement. The rectum and sigmoid colon
are
unremarkable. There is no free air or free fluid within the
pelvis. No
pathologically enlarged pelvic or inguinal lymph nodes are seen.
CTA: Intraabdominal aorta and its branches are notable for
extensive
calcified atherosclerotic disease without associated aneurysmal
changes. The
celiac axis appears patent. There is moderate narrowing at its
origin, likely
related to calcified atherosclerotic disease. A replaced right
hepatic artery
originating from the SMA is noted. The SMA and [**Female First Name (un) 899**] are patent.
Single renal
arteries bilaterally are also patent.
IMPRESSION:
1. Area of active contrast extravasation at the level of the
cecum,
concerning for active bleeding.
2. A 1.2 x 1 cm left renal enhancing lesion is compatible with
RCC. If surgery
is not considered, follow up examination in six months is
recommended to
assess for interval change.
2. Small-to-moderate hiatal hernia.
3. A 6-mm left ureteral stone, unchanged in position since
[**2123-5-11**] exam
without associated hydroureteronephrosis.
.
[**5-27**] COLONOSCOPY
Findings:
Protruding Lesions Several smal polyps under 5mm were noted
throughout the colon. None were removed in the setting of her
recent GI bleed. Medium non-bleeding internal hemorrhoids were
noted.
Excavated Lesions Multiple non-bleeding diverticula with mixed
openings were seen in the sigmoid colon. Diverticulosis appeared
to be of moderate severity. A single non-bleeding 4 cm ulcer was
found in the cecum consistent with her prior polypectomy site.
Several clips were applied with successful hemostasis. Three
endoclips were successfully applied to the cecum for the purpose
of hemostasis.
Impression: Cecal ulcer was noted at the prior EMR site. There
were no stigmata of bleeding. There is no visible residual
adenomatous tissue. Several clips were applied to the close the
defect given recent CT angio evidence of cecal bleeding.
Internal hemorrhoids
Diverticulosis of the sigmoid colon
Several small polyps were noted throughout the colon. None were
removed given her recent GI bleed
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
80 F with hx diverticulosis, CAD, and recent polypectomy on
[**2123-5-10**] p/w acute-onset BRBPR with hospital course complicated by
NSTEMI
# GI bleed:
Pt presented w/acute-onset BRBPR likely due to be bleeding from
recent polypectomy site. CTA of the abdomen/pelvis showed an
area of active contrast extravasation at the level of the cecum
with associated hematoma. Angiogram performed by IR did not
reveal clear source of bleeding. Colonoscopy was performed on
[**5-27**], although no active bleeding was visualized GI clipped two
areas near site of prior polypectomy. She was transfused a total
of 3 units of red blood cells on the day of admission adn her
hematocrit remained stable. There has been no further evidence
of bleeding since the endoscopy. She is Tolerating full regular
diet.
.
# CAD, NSTEMI
The patient has a history of CAD, w/CABG (LIMA-LAD, SVG-D1,
known occluded SVG-OM), multiple PCI to LCx and OM1 last in
7/[**2118**]. While being turned in bed on [**5-27**] she experienced
transient substernal chest pain with ST depression and troponin
trending up to peak of 0.12. Cardiology consulted, felt she had
likely had an NSTEMI rather than demand-related ischemia,
although the latter is possible in light of GI bleed. Her
aspirin was changed to 81mg daily. The plavix was stopped with
plan to continue to hold for at least two weeks. She had one
additional episode of chest pain several days later, without EKG
changes, that resolved with SLNG. This was likely due to her
imdur and other anti-hypertensives being held. After re-starting
imdur she had no further episodes of chest pain.
.
# CHF
Pt on lasix, spironolactone, imdur at home. These were initially
held on admission in setting of GI bleed. Her home regimen was
gradually restarted. On the day of discharge her blood pressures
were 90-100 systolic. We instructed her to hold the amlodipine
until she sees her PCP. [**Name10 (NameIs) **] instructed her to hold her PM dose of
lasix the night of discharge.
.
# Asthma
Maintained as outpatient on albuterol PRN & Flovent (does not
take Spiriva, contrary to notes). Continued outpatient meds.
.
# Diabetes
She was continued with insulin as an inpatient.
.
# Chronic renal insufficiency:
Baseline Cr 1.4-1.6, w/BUN/CR at baseline during admission.
.
# Renal mass:
The patient was found to have an incidental renal mass on
imaging. Dr. [**Last Name (STitle) 665**] discussed with patient. This was entered
into problem list in [**Name (NI) **]. Recommend repeat imaging and consider
urology follow up.
.
=================================
TRANSITIONAL CARE
1. Please check CBC at next PCP [**Name Initial (PRE) **]
2. F/U renal mass with either repeat imaging or referral to
urology
3. F/U blood pressure, amlodipine held on discharge because of
orthostic symptoms, if BP not at goal then restart amlodipine
# consider cardiology follow-up
Medications on Admission:
Albuterol inhaler as needed
amlodipine 5 mg daily
Lipitor 80 mg daily
calcitriol 0.25 mcg qd
Plavix 75 mg daily
Flovent inhaler twice a day 110 2 puff
furosemide 40 mg twice a day
Lantus insulin between 18 units per sliding scale
Imdur 120 mg in the morning and 60 mg in the evening
levothyroxine 50 mcg daily
metoprolol tartrate 75 mg twice a day
Singulair daily
Ditropan 10mg daily
spironolactone 25 mg daily
aspirin 325 mg daily
Nitroglycerin SL prn CP
iron 325mg qd
lipitor 80
multivitamin qd
calcium OTC
Discharge Medications:
1. Albuterol Inhaler [**2-1**] PUFF IH Q6H:PRN SOB
2. Atorvastatin 80 mg PO DAILY
3. Furosemide 40 mg PO BID
hold for SBP <100
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
Start: In am
please start in the AM on [**2123-5-29**]. Hold for SBP<90
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Start: QHS
hold for SBP<90
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Tartrate 75 mg PO BID
hold for SBP <100 HR <60
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Spironolactone 25 mg PO DAILY
hold for SBP<100 and inform H.O.
11. Aspirin 81 mg PO DAILY
12. insulin - lantus [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] providers
13. insulin - humalog per sliding scale per your [**Last Name (un) 387**]
providers
14. Calcitriol 0.25 mcg PO DAILY
15. Montelukast Sodium 10 mg PO DAILY
16. Oxybutynin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
aGastrointestinal bleed
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were found
to have a bleed from your recent polyp removal site. You
underwent repeat colonoscopy and the bleeding stopped. You were
given a blood transfusion. You will need a repeat colonoscopy
in 3 weeks with Dr. [**Last Name (STitle) **].
You also developed chest pain in the setting of your bleed. You
were seen by the cardiology service. Your plavix (clopidogrel)
was stopped. Your aspirin was changed to 81mg (baby aspirin).
Your blood pressure was on the low side of normal. Please DO
NOT take your lasix dose tonight but then restart your typically
twice daily dose tomorrow. Also stop taking the amlodipine
(norvasc) until you see Dr. [**Last Name (STitle) 665**] on Thursday.
Continue your home medications with the following changes:
1. STOP taking plavix (clopidogrel) for the next two weeks
2. CHANGE the dose of aspirin to 81mg daily (baby aspirin)
3. STOP taking amlodipine until you see Dr. [**Last Name (STitle) 665**]
4. HOLD your lasix dose tonight but then restart your regular
twice dialy dosing on Tuesday
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2123-6-3**] at 10:30 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2123-6-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**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
Please discuss need for repeat colonoscopy in 3 months
Department: [**Hospital3 249**]
When: TUESDAY [**2123-6-22**] at 12:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"211.3",
"250.40",
"V15.82",
"410.71",
"V58.67",
"428.0",
"414.02",
"493.90",
"998.11",
"362.01",
"999.9",
"455.0",
"403.90",
"593.9",
"E879.8",
"V45.82",
"280.9",
"250.50",
"428.32",
"569.82",
"414.01",
"410.72",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.01",
"88.47",
"45.43",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
12855, 12861
|
8477, 11348
|
295, 308
|
12953, 12953
|
3422, 8454
|
14216, 15236
|
2692, 2719
|
11908, 12832
|
12882, 12932
|
11374, 11885
|
13104, 14193
|
2734, 3403
|
246, 257
|
336, 1874
|
12968, 13080
|
1896, 2506
|
2522, 2676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,444
| 195,398
|
3771
|
Discharge summary
|
report
|
Admission Date: [**2183-6-30**] Discharge Date: [**2183-7-3**]
Service: MEDICINE
Allergies:
Codeine Phos/Apap/Caff/Butalb
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
[**Age over 90 **] y/o h/o lung adenocarcinoma s/p lobectomy, diabetes, htn, CAD
who was recently treated for RLL PNA at [**Location (un) 745**] [**Location (un) 3678**],
completed course with moxifloxacin on [**6-23**], she had a right
pleural at that time and she refused workup with a
thoracentesis. She also had a S&S study which she did not
perform well on and was places on thickened diet for aspiration
concern. Since that time period she has been intermittently on
oxygen and there is concern she may be chronically aspirating
given she is prone to choke with eating. Today she was
transferred to [**Hospital 100**] rehab where she c/o dyspnea and reportedly
had oxygen sats 70% on room air. Patient had also not been
eating or drinking much in last 3-4 days due to decreased
appetite. Patient is confirmed DNR/DNI.
In the ED patient is afebrile, HR 88, SBP 83/42, 91% room air,
100% on NRB, patient was given 2 liters normal saline with good
response in her SBP to 110s, also received vanco, levo, and
zosyn and was admitted to ICU for further monitoring.
ROS: + dysphagia, productive cough last 3 days, decreased
appetite, minimal PO intake, weakness
CXR showed possible bilobar aspiration, small effusions.
Past Medical History:
Coronary artery disease s/p MI s/p recent adenosine MIBI at NWH
which was negative for any ischemic changes
Hypertension
Diabetes
PVD
s/p PPM
Chronic LBP and LE radiculopathy for which receives lumbar
steroid injections
DJD
Peripheral embolus
s/p TAH
PVD with arterial embolus
s/p SCC excision from forehead
LLL mass s/p Flexible bronchoscopy, left thoracotomy with left
lower lobectomy and node dissection
Lumbar radiculopathy s/p epidural steroid [**11/2174**]
Social History:
Quit smoking [**2154**], rare ETOH, recently was moved to nursing home
at [**Hospital 100**] rehab
Family History:
Non contributory
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Cardiovascular: (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: (Breath Sounds: Diminished: , Rhonchorous:
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x2, Movement: Not assessed, Tone:
Not assessed
Pertinent Results:
[**2183-6-30**] 08:55PM WBC-10.9# RBC-5.13# HGB-15.0 HCT-45.3# MCV-88
MCH-29.3 MCHC-33.2 RDW-14.3
[**2183-6-30**] 08:55PM NEUTS-63 BANDS-11* LYMPHS-14* MONOS-8 EOS-0
BASOS-0 ATYPS-3* METAS-1* MYELOS-0
[**2183-6-30**] 08:55PM PT-13.9* PTT-21.7* INR(PT)-1.2*
[**2183-6-30**] 08:55PM GLUCOSE-255* UREA N-40* CREAT-1.4*
SODIUM-149* POTASSIUM-4.6 CHLORIDE-114* TOTAL CO2-20* ANION
GAP-20
Portable CXR
SEMI-UPRIGHT AP RADIOGRAPH OF THE CHEST: The lung volumes are
low with elevation of the right hemidiaphragm and moderate
bilateral bronchovascular crowding. Additionally, there is a
patchy opacity at the bilateral lower lobes could reflect
atelectasis versus aspiration. Pleural effusions are small.
Please note that the fourth posterolateral rib is incompletely
visualized, correlate with history of prior thoracotomy. Right
chest wall pacer device with right atrial and ventricular leads
in standard location is noted. There is aortic knob
calcifications.
IMPRESSION:
1. Pleural effusions are small.
2. Fourth posterolateral rib discontinuity could reflect prior
surgical defect from a thoracotomy; clinical/surgical
correlation is recommended.
CTA CHEST [**2183-7-2**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Large simple right pleural effusion with complete collapse of
the right
lower lobe.
3. Ground-glass opacity with patchy consolidation in the left
lower lobe is
consistent with pneumonia with small parapneumonic left
effusion.
4. Extensive centrilobular emphysema.
5. Adenopathy as described and long-segment stenosis of the left
branchiocephalic vein and SVC, with prominent thoracic wall
collaterals.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 16949**] was a [**Age over 90 **] y/o F MMP including CAD, DM, h/o lung
adenocarcinoma s/p lobectomy who presented with dyspnea and ARF.
Patient likely had an aspiration pneumonia. She had failed
speech and swallow evaluation recently after repeated
hospitalizations for PNA. She was treated with broad spectrum
antibiotics. Her respiratory status was supported with
supplemental oxygen. She continued to have difficulty with
clearing secretions and high oxygen requirements. She developed
worsening respiratory distress, tachycardia and hypotension.
After discussion with the patient's son, it was determined that
the patient should be treated with comfort measures only.
Medications were withdrawn with the exception of a morphine drip
titrated to comfort. She passed away on [**2183-7-3**] at 11:20 AM from
cardiopulmonary arrest. The patient's son was notified of her
death.
Medications on Admission:
Celebrex 100mg daily
Diovan 80mg po daily
Glyburide 1.25mg daily
Verapamil 180mg po daily
Vitamin d 400 units daily
Gemfibrozil 600mg po daily
Propranolol 20mg po bid
Lexapro 10mg daily
Crestor 10mg daily
Mucinex
Duonebs
Senna
Oxygen prn since had pna
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
PNEUMONIA
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2183-7-6**]
|
[
"V66.7",
"V10.11",
"733.90",
"403.90",
"507.0",
"440.20",
"440.4",
"V10.83",
"518.82",
"715.90",
"585.9",
"414.01",
"584.9",
"V45.01",
"412",
"428.0",
"272.4",
"V12.51",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5731, 5740
|
4472, 5399
|
244, 250
|
5793, 5802
|
2811, 4449
|
5858, 5895
|
2117, 2135
|
5702, 5708
|
5761, 5772
|
5425, 5679
|
5826, 5835
|
2150, 2792
|
197, 206
|
278, 1498
|
1520, 1985
|
2001, 2101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,258
| 126,167
|
18718
|
Discharge summary
|
report
|
Admission Date: [**2200-3-20**] Discharge Date: [**2200-3-28**]
Date of Birth: [**2126-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 73 y/o M with MDS/AML who was admitted to the SICU
after spontaneous splenic rupture. The patient was seen in
clinic on the day of admission and had a syncopal episode in the
waiting room. IVF was started, EKG reportedly unchanged, VSS.
Pt had had sharp LUQ pain while driving to his appt, which
continued at the clinic. By report, no acute abdomen on exam at
that time. CT abdomen done, after which pt c/o dizziness,
diaphoresis, nausea, then became unreponsive with BP 110/60, HR
60s at that time. O2 applied, IVF continued, platelets given,
hydrocortisone 100mg IVP also given. CT abdomen revealed
probable splenic laceration/rupture although the patient could
not receive IV contrast due to renal failure, so this could not
be quantified; pt taken to ED. BP in the ED was reportedly
67/30 -> 137/54 with 1L NS and 1U PRBC; then transferred to
SICU.
Past Medical History:
myelodysplastic syndrome
diverticulosis
AML 12 years ago(treated with chemo and recovered)
HTN
Social History:
Married, two children, does not smoke, having stopped some time
ago. Social alcohol. Perhaps two glasses of wine per day. Coffee
none. He is retired, having worked at D.E.C.
Family History:
Positive for coronary disease and diabetes mellitus.
Physical Exam:
Gen: NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
CV: RRR, nl S1S2, II/VI systolic murmur at LUSB
Lungs: Crackles and dullness to percussion at R base. No
wheezes or rhonchi.
Abdomen: soft, normoactive BS, NT/ND.
Extrem: no c/c/e
Pertinent Results:
Admission Labs:
[**2200-3-20**] 05:30PM GLUCOSE-153* UREA N-31* CREAT-2.3* SODIUM-136
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
[**2200-3-20**] 05:30PM ALT(SGPT)-77* AST(SGOT)-59* ALK PHOS-41
AMYLASE-67 TOT BILI-0.6
[**2200-3-20**] 05:30PM LIPASE-24
[**2200-3-20**] 05:30PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.6
[**2200-3-20**] 05:30PM WBC-6.4# RBC-3.03* HGB-8.9* HCT-28.9* MCV-95
MCH-29.5 MCHC-30.9* RDW-25.7*
[**2200-3-20**] 05:30PM NEUTS-36* BANDS-1 LYMPHS-16* MONOS-47* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2200-3-20**] 05:30PM PLT SMR-LOW PLT COUNT-83*#
[**2200-3-20**] 05:30PM PT-12.4 PTT-19.8* INR(PT)-1.1
[**2200-3-20**] 12:05PM GLUCOSE-120* UREA N-31* CREAT-2.4* SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2200-3-20**] 12:05PM ALT(SGPT)-79* AST(SGOT)-67* LD(LDH)-291*
CK(CPK)-56 ALK PHOS-45 TOT BILI-0.4
[**2200-3-20**] 12:05PM cTropnT-<0.01
[**2200-3-20**] 12:05PM ALBUMIN-3.7 CALCIUM-8.5 PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2200-3-20**] 12:05PM WBC-15.0* RBC-3.71* HGB-10.9* HCT-36.2*
MCV-98 MCH-29.4 MCHC-30.1* RDW-25.7*
[**2200-3-20**] 12:05PM NEUTS-26* BANDS-0 LYMPHS-9* MONOS-64* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1*
[**2200-3-20**] 12:05PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-2+
MACROCYT-3+ MICROCYT-2+ POLYCHROM-OCCASIONAL SCHISTOCY-1+
TEARDROP-1+ ACANTHOCY-1+ ELLIPTOCY-1+
[**2200-3-20**] 12:05PM PLT SMR-VERY LOW PLT COUNT-24*
[**2200-3-20**] 12:05PM GRAN CT-2630
.
[**3-20**] Head CT: IMPRESSION: Normal study.
.
[**3-20**] CT abdomen: 1. Extensive high-density ascites consistent
with hemoperitoneum. The densest fluid is in the left upper
quadrant, which is concerning for splenic rupture. In this
patient with an elevated creatinine, an MRI with gadolinium
could be helpful in confirmimg the source of bleeding.
2. Multiple coarse calcifications within the liver are
consistent with prior granulomatous disease.
3. Linear calcification along the splenic capsule could be the
sequela of prior trauma.
.
[**3-21**] CXR: IMPRESSION: No pneumonia. Marked gastric distention.
.
[**3-24**] CT abdomen/pelvis: 1. Findings again consistent with splenic
rupture. The hematoma around the spleen has increased in size.
The amount of free fluid around the liver has increased also.
There is a large amount of blood in the pelvis as well.
2. Right pleural effusion. Coronary and aortic atherosclerosis.
.
[**3-26**] CXR: 1. Stable elevated right hemidiaphragm.
2. Right basilar atelectasis.
.
[**3-27**] CT abdomen/pelvis: Stable appearance of the spleen. Interval
decrease in the amount of hemorrhage in the abdomen and pelvis.
.
[**3-27**] Echocardiogram (TTE): Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. The aortic valve leaflets are
mildly to moderately thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
Brief Hospital Course:
This is a 73 year old man with MDS/AML who was admitted to the
SICU for spontaneous splenic rupture and is now transferred to
the BMT service for further care.
.
# splenic rupture: The patient presented with abdominal pain and
a falling hematocrit. CT abdomen revealed a likely splenic
rupture. This was managed conservatively, without surgical
intervention. The patient was transfused a total of 7U of PRBC
and 7 bags of platelets while in the SICU. Platelet count was
maintained >100 in the setting of bleeding. Hct stabilized, and
repeat CT showed a stable appearance of the spleen. At
discharge, the patient was pain-free and had a stable
hematocrit.
.
# O2 requirement: While in the SICU the patient developed a new
oxygen requirement, although he did not complain of dyspnea or
cough. He was afebrile initially and had a normal WBC count.
He received several transfusions of blood products while in the
ICU and was likely fluid overloaded. The lung bases were
visible on his CT abdomen and their appearance was consistent
with fluid in the lungs. The patient was diuresed and his
oxygen saturation improved to baseline. An echocardiogram was
done and revealed an EF of 60% and was otherwise unremarkable.
.
# Fever: The patient spiked a fever to 101 degrees F on [**3-26**]. He
had no localizing symptoms. Cultures remained negative at the
time of discharge. CXR revealed no evidence of pneumonia. As
the patient had an elevated bilirubin at that time (likely due
to blood in peritoneum being reabsorbed), levofloxacin and
flagyl were started. The patient remained afebrile thereafter.
Flagyl was discontinued and the patient will complete a course
of levofloxacin as an outpatient.
.
# MDS/CMML: Stable. Hydrea and prednisone were continued per
the patient's outpatient regimen, as were epogen, famvir, and
folate. The patient was transfused to maintain hct>30 and
plt>100 as above.
.
# chronic renal insufficiency(baseline Cr 1.9-2.2): On
admission the patient's creatinine was elevated at 2.4, but by
the time of discharge (after receiving IVF and blood products)
it returned to baseline around 2.0.
.
# HTN: While in the surgical ICU, the patient's blood pressure
was controlled with IV metoprolol and hydralazine. On transfer
to the BMT service, he was put back on his home dose of
atenolol. BP remained well-controlled.
Medications on Admission:
Hydrea 500 mg p.o. MWF
prednisone 15 mg p.o. daily
danazol 200 mg p.o. t.i.d.
atenolol 50 mg p.o. daily (pt not taking)
folic acid 1 mg p.o. daily
Famvir 500 mg p.o. b.i.d.,
protonix 40
Procrit 40,000 units subcutaneously weekly.
Discharge Medications:
1. Danazol 200 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO
qMoWeFrSat: Please take 4x per week.
3. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Epogen 40,000 unit/mL Solution Sig: One (1) mL Injection once
a week.
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
splenic rupture
Secondary Diagnoses:
CMML
hypertension
GERD
Discharge Condition:
good, hematocrit stable
Discharge Instructions:
You have been hospitalized with a rupture of the spleen. If you
experience fever, chills, abdominal pain, nausea, vomiting, or
any other new or concerning symptoms, please call your doctor or
return to the emergency room for evaluation.
.
Please continue to take all of your home medications as
prescribed.
-We have changed your hydrea to 4x per week, so please take it
on Monday, Wednesday, Friday, and Saturdays.
.
Please attend all follow up appointments. You should call to
make an appointment with Dr. [**First Name (STitle) 1557**] for Tuesday of next week.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1557**] on Tuesday of next week.
Please call for an appointment.
|
[
"401.9",
"V10.62",
"238.7",
"289.59",
"585.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
8624, 8630
|
5233, 7586
|
330, 337
|
8753, 8779
|
1888, 1888
|
9393, 9510
|
1562, 1617
|
7867, 8601
|
8651, 8651
|
7612, 7844
|
8803, 9370
|
1632, 1869
|
8707, 8732
|
276, 292
|
365, 1236
|
3379, 5210
|
1904, 3370
|
8670, 8686
|
1258, 1355
|
1371, 1546
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,363
| 161,847
|
52324
|
Discharge summary
|
report
|
Admission Date: [**2153-7-15**] Discharge Date: [**2153-7-18**]
Date of Birth: [**2091-10-21**] Sex: F
Service: Medicine, [**Doctor Last Name **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
woman with a history of thyroid cancer who is status post
thyroidectomy in [**2148**], which was complicated by left vocal
cord paralysis. On [**7-10**] of this year the patient
underwent thyroplasty at [**State 350**] Eye & Ear Institute
with medialization of the left vocal cord. On [**7-15**] of
this year, the patient had increased edema of the vocal cords
as well as tenderness and edema of the left side of her neck,
and was subsequently admitted to the ENT Service at [**Hospital1 1444**].
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to lithium toxicity.
2. Crohn's disease.
3. Status post ileostomy.
4. Chronic obstructive pulmonary disease with apparent
restrictive picture. Pulmonary function tests from [**7-5**]
revealed FVC of 53% or predicted, FEV1:FVC ratio of 98% or
predicted, and an FEV1 of 52% or predicted.
5. Thyroid cancer, status post thyroidectomy in [**2148**]
complicated by left vocal cord paralysis.
6. "Irregular heart beat." Hypertrophic cardiomyopathy,
history of ventricular ectopy.
7. Upper gastrointestinal bleed.
8. History of osteoporosis.
9. Status post total abdominal hysterectomy.
ALLERGIES: PERCOCET, NEURONTIN, PROPULSID, MOTRIN,
CLINDAMYCIN, KEFLEX, CIPROFLOXACIN, PENICILLIN.
MEDICATIONS ON ADMISSION: Outpatient medications included
Phos-Lo, lithium, Coumadin, albuterol, Nephrocaps, Miacalcin,
Atrovent, Serevent, maprotiline, Prilosec, Premarin,
Synthroid, Serax.
SOCIAL HISTORY: The patient has never been married. She
denies any drug or alcohol abuse. The patient has a
45-pack-year history of smoking; she quit three years ago.
PHYSICAL EXAMINATION ON ADMISSION: The patient vitals were
noted to be as follows: Temperature 98.2, heart rate 74,
blood pressure 112/60, respirations 24 per minute, satting
96% on 50% oxygen. Physical examination revealed a patient
who somewhat uncomfortable. She exhibited audible stridor
both on inspiratory and expiratory breathing. The patient's
larynx was found to have swelling over the arytenoid, and
there was swelling over the left arytenoid and diffuse
erythema as well as general edema throughout both vocal
cords. The neck was found to be soft and nontender. Chest
examination revealed decreased breath sounds bilaterally with
intermittent rales.
RADIOLOGY/IMAGING: Chest x-ray on admission revealed the
patient to be osteopenic. There was some question of
possible tracheal deviation in the mediastinum, and the
patient was thought to have a very very small pleural
effusion on the left.
LABORATORY DATA ON ADMISSION: Complete blood count revealed
a white blood cell count of 9.8, hemoglobin of 12.4,
hematocrit of 44, platelets 280. INR 1.6. Chem-7 revealed a
sodium of 137, potassium of 4.6, chloride of 98, bicarbonate
of 22, BUN of 26, creatinine of 6.6, and glucose of 126.
HOSPITAL COURSE: As mentioned above, the patient was
admitted to the [**Hospital1 69**] ENT
Service. She was given steroids and antibiotics. A
bronchoscopy revealed her airway diameter to be approximately
3 mm, which was insufficient for intubation. Because the
patient's neck edema, her Coumadin was briefly discontinued
on [**2153-7-15**], and her right arm AV fistula subsequently
clotted.
On [**2153-7-17**], the patient was seen by transplant surgery
who successfully reopened the patient's AV fistula. The
patient received a short course of dialysis that day and
received a full course of dialysis the following day. The
patient was maintained on a heparin drip and was loaded with
Coumadin in order to keep her AV fistula opened.
On the morning of discharge, as mentioned above, the patient
received a full course of dialysis. She also was seen by
Interventional Radiology who performed a fistulogram which
revealed that the patient had some stenosis in the central
brachial vein at the site of the surgical patch. It was felt
that this are would not be amenable to PTA because of the
recent surgical intervention.
It should be noted that initially the patient was under the
care of the ENT Service and in the Intensive Care Unit
because of her airway instability. However, following
administration of steroids and antibiotics, her laryngeal and
neck edema and tenderness decreased significantly such that
she was felt to be stable enough to be transferred to the
floor. The patient was transferred to the Medical Service on
the evening of [**2153-7-17**], where her preoperative regimen
was continued.
DISCHARGE DIAGNOSES:
1. Laryngeal edema.
2. Thyroid cancer.
3. Status post thyroidectomy (in [**2148**] complicated by left
vocal cord paralysis).
4. Status post thyroplasty (on [**2153-7-10**]) with
medialization of left vocal cord.
5. End-stage renal disease secondary to lithium toxicity.
6. Crohn's disease.
7. Chronic obstructive pulmonary disease.
8. Bipolar disorder.
MEDICATIONS ON DISCHARGE: The patient was discharged on her
home medication regimen. This included the above-mentioned
medications. The patient was also given prescriptions for
azithromycin 500 mg p.o. q.d. times seven days. The patient
received a prescription for Medrol dose pack as well.
CONDITION AT DISCHARGE: Upon discharge, the patient was
afebrile with stable vital signs. She had a blood pressure
of 122/70, heart rate of 66, breathing 16 times per minute.
Her temperature was 98.7 degrees. Laboratories on the
morning of discharge included a complete blood count of 7.1
and a hematocrit of 44. On examination, the patient was
noted to be watching television and receiving dialysis, in no
acute distress. Her mucous membranes were moist. Her neck
incision was clean, dry and intact with no increased swelling
or erythema. Her heart examination revealed a regular rate
and rhythm without murmur, rubs or gallops. Chest
examination revealed good air movement bilaterally without
wheezes. Abdominal examination revealed ileostomy to be in
place without erythema or drainage. The abdomen was soft,
nontender, and nondistended. Extremities revealed no
clubbing, cyanosis or edema.
DISCHARGE FOLLOWUP: The patient was to return to the [**Hospital Ward Name 8559**] at [**Hospital1 69**] for dialysis
in two days. She was to follow up with primary care
physician for her underlying medical conditions.
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2153-7-18**] 15:11
T: [**2153-7-20**] 14:37
JOB#: [**Job Number **]
|
[
"478.6",
"244.9",
"530.81",
"996.73",
"585",
"V10.87",
"478.31",
"296.7",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
4698, 5061
|
5089, 5368
|
1505, 1671
|
3071, 4677
|
5383, 6281
|
6302, 6776
|
197, 726
|
2788, 3052
|
748, 1478
|
1688, 1863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,308
| 109,521
|
54717
|
Discharge summary
|
report
|
Admission Date: [**2184-9-7**] Discharge Date: [**2184-9-7**]
Date of Birth: [**2114-1-25**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 111878**] is a 70M with a history of hep C cirrhosis
(c/b SBP, HE and Varices) who presented with bleeding esophageal
varices. Presented to LGH earlier today with 3 episodes of
hematemesis. GI there tried to band 4 varices but two popped
off. He also received clips to ulcerated tissue and 7cc of
sodium laurate. He received 4U PRBC, 2 FFP, 2 U PLTs with
persistent hypotension requiring norepinephrine 0.1. Patient was
started on PPI and octreotride drip, ceftriaxone, and intubated
prior to transfer. He also received vecuronium. During transport
given 2mg Versed. He received a total of 6 liters of fluid with
no urine ouput per report.
In the [**Hospital1 18**] ED, initial VS were: BP 93/53 (on norepi), 73, 100%
on CMV. Labs were notable for...
-K of 6.5 for which patient received calcium gluconate, insulin
and d50.
-pH of 7.17 with a lactate of 4.3.
-INR 2.0 with fibrinogen 104
-BUN/CR 64/2.9
-HCT 28
-WBC 20
-Plt 131
On arrival to the MICU, patient is intubated and sedated and
unable to provide further history. Initial VS are Temp 93.0 HR
87 BP 79/54 O2 100% on CMV
Review of systems:
patient is intubated and sedated
Past Medical History:
-hep C cirrhosis (c/b SBP, HE and Varices)
-other details unknown
Social History:
patient is intubated and sedated
Family History:
patient is intubated and sedated
Physical Exam:
Vitals: Temp 93.0 HR 87 BP 79/54 O2 100% on CMV
General: intubated, sedated, jaundiced
HEENT: Sclera icteric. Blood dripping from mouth around ET tube.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Coarse upper airway sounds
Abdomen: very distended, no response to palpation
GU: foley
Ext: cold extremities, 1+ pulses, 1+ pitting edema bilaterally
Neuro: pupils pinpoint. No response to pain.
Pertinent Results:
[**2184-9-7**] 12:52AM BLOOD WBC-20.0* RBC-3.27* Hgb-9.3* Hct-28.0*
MCV-86 MCH-28.5 MCHC-33.2 RDW-19.0* Plt Ct-131*
[**2184-9-7**] 02:50AM BLOOD WBC-23.3* RBC-3.25* Hgb-9.4* Hct-28.1*
MCV-87 MCH-29.0 MCHC-33.5 RDW-19.2* Plt Ct-140*
[**2184-9-7**] 12:52AM BLOOD PT-20.9* PTT-38.6* INR(PT)-2.0*
[**2184-9-7**] 12:52AM BLOOD Fibrino-104*
[**2184-9-7**] 02:50AM BLOOD Glucose-214* UreaN-70* Creat-3.0* Na-139
K-5.2* Cl-111* HCO3-18* AnGap-15
[**2184-9-7**] 02:50AM BLOOD ALT-32 AST-84* LD(LDH)-261* AlkPhos-44
TotBili-5.0*
[**2184-9-7**] 02:50AM BLOOD Albumin-2.6* Calcium-8.1* Phos-6.7*
Mg-1.8
[**2184-9-7**] 01:50AM BLOOD Type-ART Rates-14/ Tidal V-400 PEEP-5
FiO2-100 pO2-197* pCO2-52* pH-7.11* calTCO2-18* Base XS--13
AADO2-463 REQ O2-79 -ASSIST/CON Intubat-INTUBATED
[**2184-9-7**] 12:53AM BLOOD Glucose-125* Lactate-4.3* Na-136 K-6.5*
Cl-115* calHCO3-14*
[**2184-9-7**] 02:58AM BLOOD freeCa-1.04*
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Mr. [**Known firstname **] [**Known lastname 111878**] is a 70 year old male with a history of hep C
cirrhosis (complicated by SBP, Hepatic Encephalopathy, and
Varices) on home hospice who presented to LGH with bleeding
esophageal varices and was intubated for an uppper endoscopy. He
was transferred to [**Hospital1 18**] for further management and the patient
was extubated and passed away as consistent with his previously
stated wishes.
ACTIVE ISSUES:
#) Variceal Bleed/Hemorrhagic Shock: The patient was initially
admitted to LGH with hematemesis. He was emergently intubated
for airway protection in the acute setting although his daughter
later reported this was not consistent with his wishes. He
underwent a complex EGD intervention involving 5 bands, clips to
ulcerated tissue and 7cc of sodium laurate. He received multiple
units of blood, platelets, and coagulation factors but still had
persistent hypotension, lactic acidosis and oliguric renal
failure. After transfer to [**Hospital1 18**] he was admitted to the medical
ICU.
A family meeting was held at the bedside with the MICU team and
the patient??????s daughter (HCP) [**Name (NI) **]. She described the
patient??????s recent course including multiple hospitalizations from
cirrhosis resulting in the patient losing his independence. He
had recently moved from his home in [**State 531**] to [**Location (un) 86**] to be
taken care of by his daughter and grandchildren. He has been on
home hospice. [**Doctor Last Name **] describes the patient as feeling that he
was going to be passing away soon and was ready. He saw a priest
yesterday for that purpose. [**Doctor Last Name **] stated that he definitely
did not want to be intubated, but she felt pressure in the ED to
agree to it. She said that he would definitely want the tube
removed now. She voiced understanding that this would result in
his passing away. He was then extubated and passed away
peacefully shortly thereafter with family at the bedside. Time
of death was 4:50 AM on [**2184-9-7**]. Cause of death was hemorrhagic
shock from variceal bleeding from hepatitis C cirrhosis. Autopsy
was declined by the family.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH
records.
1. Ciprofloxacin HCl 750 mg PO 1X/WEEK (MO)
2. Vitamin D Dose is Unknown PO Frequency is Unknown
3. Lactulose 20 mL PO BID
4. Rifaximin 550 mg PO BID
5. Nadolol 20 mg PO DAILY
6. sitaGLIPtin *NF* 50 mg Oral daily
7. Montelukast Sodium Dose is Unknown PO Frequency is Unknown
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"456.20",
"785.59",
"070.54",
"276.7",
"276.2",
"571.5",
"780.65",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5803, 5812
|
3124, 3602
|
303, 315
|
5864, 5874
|
2201, 3101
|
5931, 5942
|
1681, 1716
|
5770, 5780
|
5833, 5843
|
5341, 5747
|
5898, 5908
|
1731, 2182
|
1489, 1524
|
252, 265
|
3617, 5315
|
343, 1470
|
1546, 1614
|
1630, 1665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,177
| 131,184
|
18387
|
Discharge summary
|
report
|
Admission Date: [**2116-3-19**] Discharge Date: [**2116-3-27**]
Date of Birth: [**2033-8-7**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Percocet / Codeine
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
History of Present Illness:
82 y/o woman with a history of lung cancer s/p lobectomy and
adjuvant chemotherapy admitted to the ICU from the emergency
department where she presented with fever and altered mental
status. The history was obtained from review of the notes as the
patient was intubated and sedated at the time of admission to
the ICU.
Per reports, she had several days of diarrhea, abdominal pain,
nausea, vomitting and increased lethergy. She had some
improvement yesterday, but was barely arousable today and was
brought in for evaluation.
In the ED she was found to be febrile to 103, with HR 82, BP
146/77. She had elevated transaminases, a lactate that peaked at
4.7, and a CT torso showed dialted common bile duct. She had a
central venous line placed, and was given 4L of NS and was
intubated due to increased lethargy. She was not hypotensive in
the emergency department. A blood gas obtained after intubation
was 7.29/51/72. She was taken to the [**Hospital Ward Name 516**].
On arrival to the [**Hospital Unit Name 153**] her blood pressure was in the 60s
systolic. She was given further fluid resussication (4 liters,
for 8 liters total) and started on levophed. She was then taken
emergenctly to the [**Hospital Unit Name **] suite where a stent was placed in the
common bile duct and frank pus was expressed.
She returned to the [**Hospital Unit Name 153**] on AC 500 x 14, 100%Fi02 and 5peep. Her
Fi02 was weaned. She was continued on levophed.
ROS was not able to be obtained as the patient was intubated and
sedated.
.
Past Medical History:
1. Adenocarcinoma of the lung,
nonmetastatic, status post resection, Grade T2N0M0. She is
status post Carboplatin and Taxol on [**2111-4-2**],
status post right upper lobectomy on [**2111-1-16**].
2. Hypertension.
3. Hypercholesterolemia.
4. Diverticulosis.
5. Hiatal hernia.
6. Gastroesophageal reflux disease.
7. Status post cholecystectomy, appendectomy, total abdominal
hysterectomy with bilateral salpingo-oophorectomy.
Social History:
SOCIAL HISTORY: The patient lives in [**Location (un) 3844**]. She has a
positive tobacco history. She smokes two packs per day for 52
years; she quit ten years ago. 2 very involved daughters, [**Name (NI) **]
and [**Name (NI) **].
Family History:
Father died of a brain tumor, but no other family history of
cancer.
Physical Exam:
Intuabed, sedated
BP :68/40
HR 120
temp 101
No JVP
RRR s1, s2, no M/G/R
CTA laterally
no edema
Pertinent Results:
[**2116-3-19**] 12:26PM WBC-4.9 RBC-4.52 HGB-13.2 HCT-40.6 MCV-90
MCH-29.3 MCHC-32.6 RDW-16.0*
[**2116-3-19**] 12:26PM ALT(SGPT)-312* AST(SGOT)-173* ALK PHOS-563*
TOT BILI-6.3*
[**2116-3-19**] 12:26PM GLUCOSE-123* UREA N-24* CREAT-1.3* SODIUM-135
POTASSIUM-2.9* CHLORIDE-91* TOTAL CO2-33* ANION GAP-14
[**2116-3-19**] 01:40PM LACTATE-4.7*
CTA
[**Known lastname 50633**],[**Known firstname **] D. [**Medical Record Number 50634**] F 82 [**2033-8-7**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2116-3-19**] 10:57 AM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-3-19**] 10:57 AM
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST; CT PELVIS
W/CONTRAST Clip # [**Clip Number (Radiology) 50635**]
Reason: PE? pna?
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with hx of aneurysm w/ lobectomy and vp
shunt w/ vomiting and
altered ms. hypoxic on RA.
REASON FOR THIS EXAMINATION:
PE? pna?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: [**First Name9 (NamePattern2) 50636**] [**Doctor First Name **] [**2116-3-19**] 12:04 PM
NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE [**Month (only) **] REPRESENT
ASPIRATION VS
PNEUMONIA VS ATELECTASIS.
.
CT abd/pelvis: mild to moderate biliary dilitation with probable
soft tissue
defect in CBD. CHD measures 17 mm. rec MRCP for further eval.
left adnexal cyst, larger than prior. rec US for further eval.
Wet Read Audit # 1 [**First Name9 (NamePattern2) 50636**] [**Doctor First Name **] [**2116-3-19**] 11:54 AM
NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE [**Month (only) **] REPRESENT
ASPIRATION VS
PNEUMONIA VS ATELECTASIS.
Final Report
CT TORSO, [**2116-3-19**]
COMPARISON: [**2111-1-5**].
HISTORY: 82-year-old female with history of aneurysm and
lobectomy and VP
shunt with vomiting and altered mental status.
FINDINGS: Contiguous helical acquisition through the chest,
abdomen and
pelvis was performed with intravenous contrast.
CT CHEST: The heart is normal in size. There is atherosclerotic
disease of
the coronary arteries and aorta. The pulmonary artery and branch
vessel
opacifies normally with no evidence of intraluminal thrombus.
The aorta
opacifies normally with no evidence of aortic dissection. There
is no
mediastinal or hilar lymphadenopathy identified. There is left
basilar air
space disease identified. The right lung is clear. A surgical
clip is noted
at the right lung base. Post-surgical changes within the lungs
are noted
status post right upper lobectomy. There are diffuse
emphysematous changes
identified. There are old right-sided rib fractures noted. The
osseous
structures are otherwise intact. There are degenerative changes
of the
bilateral shoulders and spine.
CT ABDOMEN: There is mild-to-moderate intra- and extra-hepatic
biliary
dilatation which is new compared to the prior study dated [**2110**].
Also noted is
a probable soft tissue-density filling defect within the
mid/distal common
bile duct. The common hepatic bile duct measures 17 mm in
diameter. The
patient is status post cholecystectomy. The pancreas is normal
in appearance
with no evidence of pancreatic ductal dilatation. The spleen,
adrenal glands,
and bowel are normal in appearance. There are multiple
low-density lesions
noted within the kidneys bilaterally which are too small to
characterize but
likely represent renal cysts. There is no free air or free fluid
identified.
There is atherosclerotic disease of the descending aorta. There
is a
ventriculostomy shunt catheter identified.
CT PELVIS: There is a left adnexal cyst which appears somewhat
larger
compared to the prior study and currently measures 2.8 cm. There
is
diverticulosis of the sigmoid and descending colon without
evidence of
diverticulitis. No pelvic masses or lymphadenopathy is
identified. The
osseous structures are intact with degenerative changes noted
within the
lumbar spine.
IMPRESSION:
1) No evidence of pulmonary embolism or aortic dissection.
2) Emphysema and left lower lobe air space disease which may
represent
aspiration versus pneumonia versus atelectasis. Clinical
correlation is
recommended.
3) New intra- and extra-hepatic biliary dilatation with a
probable filling
defect noted within the common bile duct, which could represent
stones,
sludge, or neoplastic process. An MRCP is recommended for
further evaluation.
4) 2.8-cm left adnexal cyst which appears larger compared to the
prior study.
A pelvic ultrasound is recommended for further characterization
given the
patient's post-menopausal status.
[**Year (4 digits) **]:
Twelve spot fluoroscopic radiographs were obtained during [**Year (4 digits) **]
are
provided for review. Scout images demonstrate surgical clips in
the patient's
right upper quadrant, likely related to prior cholecystectomy. A
nasogastric
tube appears positioned near the duodenum. Multiple additional
tubing
catheters overlie the patient. Injection of contrast into the
biliary system
demonstrates a dilated common bile duct with luminal filling
defect. There is
mild dilatation of the intrahepatic biliary ducts. Per the
patient's [**Year (4 digits) **]
report, a single 10-mm stone was present. A plastic stent
catheter was
positioned in the common bile duct. For full details, please
refer to the
patient's [**Year (4 digits) **] note from the same day.
Brief Hospital Course:
82 yo WF w PMHx of Lung adeno ca sp lobectomy, HTN, GERD, Hx of
cerberal aneurysm presents w septic shock [**3-16**] cholangitis,
needing ICU stay, fluids, pressors, brief intubation
1. Septic shock - [**3-16**] cholangitis from choledocholithiasis w +
bacteremia w Strep and Ecoli. Now resolved. SP [**Month/Day (2) **] on [**3-19**] w
removal of sludge/pus and stent placement. Repeat Blood Cx NGTD.
Initially placed on Vanc/Zosyn, abx narrowed to Rocephin based
on sensi. PICC placed for a total of 14 day course. Repeat [**Month/Day (1) **]
in 4 weeks
2. Mild hypoxia - [**3-16**] to fluid overload from aggressive fluid
resuscitation. Repeat CXR shows improvement in fluid overload,
continue to monitor. Incentive spirometer to avoid pna. 2liters
Oxygen prn to keep sats >90%
3. Incidental finding of L adnexal cyst - pt and daughter
informed that PCP will need to do an outpt FU w pelvic
ultrasound
4. Recent episode of SVT vs afib - no such episodes on floor,
tele discontinued
5. Anemia - mild anemia w stable HCT. PCP to follow up at
discharge
5. GERD - continued on ppi
6. Hx of depression - continued on effexor
7. HTN - switched to outpatient meds which included atenolol,
triamterene/hctz
. FEN - regular diet
. Code status - full
. VTE prophylaxis - sq heparin
. Disposition - Discharged to Epic of [**Location (un) **] Nursing home
Medications on Admission:
1. Atenolol 25mg QD
2. Triamterene/HCTZ 37.5/25mg qD
3. Effexor XR 150mg QD
4. Zocor 40mg QD
5. Nexium 40mg QD
6. Provigil 200mg QD
7. KCL 10mEq QD
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-14**]
Drops Ophthalmic PRN (as needed).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous every
twenty-four(24) hours for 6 days.
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day as
needed for excessive daytime sleepiness.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
13. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted the hospital with severe infection in your
bile duct, which had spread to your blood. You were treated with
antibiotics and a procedure called [**Location (un) **] where they took out the
gallstone. You will finish IV antibiotics at the rehab and will
have to come back for repeat [**Location (un) **]
Please return to ED for fevers, chills, shortness of breath,
abdominal pain, nausea, vomiting, bleeding
Followup Instructions:
1. PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3707**], ph; [**Telephone/Fax (1) 2205**], please call and make
appt (you are currently on waitlist, the clinic should call
rehab w appt date)
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2116-4-6**] 11:00
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2116-4-30**] 10:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2116-4-30**] 10:00
|
[
"038.0",
"785.52",
"427.31",
"V12.59",
"V10.3",
"V45.89",
"401.9",
"780.09",
"518.81",
"562.10",
"285.9",
"627.9",
"995.92",
"780.79",
"426.4",
"V88.01",
"427.89",
"276.6",
"311",
"287.5",
"620.8",
"272.0",
"553.3",
"530.81",
"576.1",
"038.42",
"574.51",
"427.32",
"276.4",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"38.91",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11010, 11082
|
8204, 9558
|
299, 324
|
11138, 11145
|
2799, 3617
|
11617, 12221
|
2599, 2669
|
9756, 10987
|
3657, 3767
|
11103, 11117
|
9584, 9733
|
11169, 11594
|
2684, 2780
|
251, 261
|
3799, 8181
|
352, 1873
|
1895, 2330
|
2363, 2583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,342
| 113,484
|
24498
|
Discharge summary
|
report
|
Admission Date: [**2178-6-21**] Discharge Date: [**2178-6-26**]
Date of Birth: [**2111-11-10**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Effexor
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, no intervention
History of Present Illness:
66-year-old man with CAD s/p LAD PCI, right SFA/peroneal bypass
and angioplasty, asymptomatic right subclavian and carotid
disease,
brittle diabetes on insulin pump, hyperlipidemia, and
hypertension, who was POD#3 s/p Right total knee replacement at
the [**Hospital1 **] who developed chest pain with BP in the 180s, and
EKG changes infero-laterally with ST depressions similar to EKG
changes during stress test before surgery and concern for V1-3
STe, which was unchanged from EKG at [**Hospital1 18**] 1mo ago. Given the
EKG changes (not aware of baseline EKG at [**Hospital1 18**]) and CP, he was
started on heparin gtt, and he was transferred to [**Hospital1 18**] for
emergent catheterization, which revealed no changes from c.cath
1mo ago.
.
On arrival to cath lab, he was hypertensive and required a nitro
gtt to maintain SBPs < 160, he was given full dose ASA and 600mg
of Plavix. Upon completion of cath, was transferred to the
floor, hypoxemic on 10 L facemask and tachypneic. Nitro gtt was
discontinued. At ~ 1600, had an acute episode of SOB,
desaturations to 92 on max NC, thus requiring NRB to maintain
sats > 96%, BP at the time was 144/65. He was given IV lasix for
suspected pulmonary edema and haldol for agitation. UOP from
lasix was 1L in one hour and his RR improved to low 20s, though
he remained confused. CTA chest was peformed which preliminarily
showed no PE and a ? RUL consolidation with mild pulmonary
edema. He was briefly transferred to the MICU for continued SOB,
hypoxemia and nursing care. During his MICU course he was given
80 mg IV lasix and put out nearly 1.8 L of urine. He was also
quite agitated and delerious (which has been ongoing) and
received 20 mg olanzapine which calmed him down. He is
transferred to the CCU for further management.
.
Notably, most recent cath findings as follows: SBPs 160s - 180s.
60% LAD, MR, right dominant system with 70% 1st diag, 60% 2nd
diagnoal, moderate LCX disease and 60% small PDA. Per discussion
with cards fellow, it was felt that EKG changes constituted
demand ischemia in setting of acute drop in hematocrit from 35
to 26 and was consistent with prior stress test. Of note, [**5-22**]
cath showed diffuse CAD, EF > 60%, there was no intervention and
findings were similar to above. Also of note, upon transfer to
[**Hospital1 18**], he was given 1 unit pRBC for anemia.
.
At OSH, Labs were notable for HCT 35->26 post op, WBC 4.7->9.5
admission to [**6-21**] with left shift, CO2 31, Cr. 0.7 and
CK/CKMB/Trop 503/6.1/0.26 (high/high/nl(< 0.4)). BNP was 311.
.
Per review of OSH nursing notes, pt has been confused since at
least [**6-19**], has been receving dilaudid for pain. On [**6-20**] AM was
noted to be somnolent and resonded to narcan.
.
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:
DM1 (dx'ed in late 20s) c/b triopathy
CAD s/p PTCA/stent to LAD in [**2-5**]
PVD s/p fem/tib bypass
Enviromental allergies
Non-healing R foot ulcer s/p R first toe amputaton ([**2173-2-11**])
Orthostatic hypotension
Hyperlipidemia
HTN
Depression
[**12-6**]+MR (by echo [**4-8**])
moderate pulm HTN
Social History:
Works as administrator at [**Hospital1 498**] [**Location (un) 5169**]
Smoked pipe for several years in 20s
h/o EtOH abuse ([**7-14**] drinks/day x 10 years) now sober
Family History:
[**Name (NI) 61930**] pt is adopted.
Physical Exam:
Admission PE:
VS: T=98.7 BP=144/46 HR=96 RR= 24 O2 sat= 93% 6 Liters
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2178-6-21**] 01:44PM BLOOD WBC-15.5*# RBC-3.09*# Hgb-9.6*#
Hct-28.0*# MCV-91 MCH-31.0 MCHC-34.2 RDW-13.7 Plt Ct-209
[**2178-6-22**] 05:11AM BLOOD WBC-9.8 RBC-3.09* Hgb-9.5* Hct-27.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.9 Plt Ct-182
[**2178-6-25**] 07:15AM BLOOD WBC-6.4 RBC-3.53* Hgb-10.5* Hct-31.7*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.1 Plt Ct-300
[**2178-6-21**] 01:44PM BLOOD PT-13.5* PTT-39.0* INR(PT)-1.2*
[**2178-6-24**] 04:43AM BLOOD PT-12.3 PTT-29.2 INR(PT)-1.0
[**2178-6-21**] 01:44PM BLOOD Glucose-220* UreaN-12 Creat-0.6 Na-133
K-3.9 Cl-97 HCO3-29 AnGap-11
[**2178-6-25**] 07:15AM BLOOD Glucose-120* UreaN-10 Creat-0.6 Na-140
K-3.8 Cl-102 HCO3-33* AnGap-9
[**2178-6-21**] 01:44PM BLOOD LD(LDH)-273* TotBili-1.7*
[**2178-6-22**] 05:11AM BLOOD ALT-24 AST-55* CK(CPK)-754* AlkPhos-67
Amylase-12 TotBili-1.1
[**2178-6-22**] 05:11AM BLOOD Lipase-9
[**2178-6-21**] 08:37PM BLOOD cTropnT-0.24*
[**2178-6-22**] 05:11AM BLOOD CK-MB-9 cTropnT-0.21*
[**2178-6-21**] 01:44PM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
[**2178-6-25**] 07:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.2
[**2178-6-21**] 01:44PM BLOOD Hapto-96
[**2178-6-23**] 09:19AM BLOOD Ammonia-19
.
Discharge Labs
Microbiology:
[**2178-6-21**] 6:46 pm URINE Source: Catheter.
**FINAL REPORT [**2178-6-22**]**
URINE CULTURE (Final [**2178-6-22**]): NO GROWTH.
[**2178-6-21**]: BCx2 pending
Radiology:
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2178-6-21**] 3:50 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 53630**] [**2178-6-21**] 3:50 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 61931**]
Reason: POD # 2 s/p kmee surgery, chest pain, clean cath Note:
recei
Contrast: OPTIRAY Amt: 100
HISTORY: 66-year-old male, with two-vessel coronary artery
disease and LVEF
on LV gram 60%. Now two days status post knee surgery. Presents
with
shortness of breath.
Chest pain. Evaluate for pulmonary embolism or acute aortic
pathology.
COMPARISON: Limited comparison from prior chest radiograph on
[**2173-4-30**].
TECHNIQUE: MDCT images were acquired from the thoracic inlet to
the lung
bases before and after administration of IV contrast.
Multiplanar reformatted
images were obtained for evaluation.
CTA CHEST: The pulmonary arterial vasculature is normally
opacified to the
subsegmental level without filling defect to suggest acute
pulmonary embolism.
There is an aorta arch with bovine variant, but the aorta is
otherwise normal
in course and caliber without acute pathology. Scattered
vascular
calcifications are noted along the aortic arch. The remaining
great
mediastinal vessels are normal. Moderate coronary calcifications
are noted.
The heart is normal in size without pericardial effusions.
There are bilateral pleural effusions, small on the right and
tiny on the
left. There are mild adjacent bilateral atelectasis. Increased
septal lines
are compatible with mild pulmonary edema. In the upper lobes,
there are hazy
patchy opacities, right greater than left. While this could
represent the
underlying pulmonary edema, early infectious process cannot be
excluded.
There is no pneumothorax. No mediastinal, hilar or axillary
lymphadenopathy
is noted.
The study is not designed for subdiaphragmatic diagnosis but no
gross
abnormalities are noted.
BONE WINDOW: Multilevel degenerative changes are
mild-to-moderate, with
subchondral cysts and Schmorl's node formation. No suspicious
lytic or
sclerotic lesions are noted.
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Mild pulmonary edema. Patchy opacities in the upper lobes,
right greater
than left, cannot rule out early infectious process.
3. Bilateral pleural effusions with dependent atelectasis.
4. Coronary artery disease.
Dr. [**First Name8 (NamePattern2) 5586**] [**Last Name (NamePattern1) **] has discussed the findings with the primary team,
Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 4:33 p.m. shortly after the preliminary interpretation
of the exam.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 8913**] SUN
Approved: SUN [**2178-6-21**] 7:05 PM
CXR:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-6-22**] 8:20
AM
FINDINGS:
The pulmonary vasculature is prominent and there are bilateral
pleural
effusions, consistent with congestive heart failure. There are
also foci of
hazy opacities at the right upper and right lower lobe,
consistent with
infection. No pneumothorax. The cardiomediastinal silhouette
remains
unchanged.
IMPRESSION:
Multifocal infection and increased pulmonary venous pressure.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 251**] [**Name (STitle) 8580**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
CXR:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-6-23**] 7:48
AM
FINDINGS: As compared to the previous radiograph, the
pre-existing
parenchymal opacities show improvement.
No other changes, constant size of the cardiac silhouette, no
evidence of
pleural effusions.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Arterial duplex scan:
Radiology Report ART DUP EXT LO UNI;F/U RIGHT Study Date of
[**2178-6-23**] 2:01 PM
STUDY: Lower extremity arterial duplex.
REASON: Decreased pulse post-total knee replacement.
FINDINGS: Duplex evaluation was performed of the right lower
extremity
bypass. Peak velocities in centimeters per second from
proximal-to-distal are
as follows: Common femoral 115, profunda 142, SFA 150, 91, 94;
proximal
anastomosis 138, vein graft 110,89, 59; distal anastomosis 157,
outflow 105.
IMPRESSION: Patent right lower extremity bypass with no evidence
of stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Carotis U/S:
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2178-6-24**]
10:11 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 61932**] [**2178-6-24**] 10:11 AM
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 61933**]
Reason: pre-op for CABG, assess stenosis
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with CAD, multivessel disease requiring CABG.
REASON FOR THIS EXAMINATION:
pre-op for CABG, assess stenosis
Final Report
STUDY: Carotid series complete.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries.
There is heterogeneous plaque seen bilaterally.
On the right, peak velocities are 94, 107, and 183 in the ICA,
CCA, and ECA
respectively. This is consistent with less than 40% stenosis.
On the left, ICA velocity is 184/50, CCA is 93, the ECA is 210.
The ICA/CCA
ratio is 2.0. This is consistent with 60-69% stenosis.
There is antegrade vertebral flow bilaterally. The right
vertebral waveform
is notched suggesting possible subclavian stenosis. There is a
normal right
CCA waveform.
IMPRESSION: Right ICA less than 40% stenosis. Left ICA 60-69%
stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Venous duplex scan:
Radiology Report UNILAT LOWER EXT VEINS RIGHT Study Date of
[**2178-6-25**] 4:01 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 53630**] [**2178-6-25**] 4:01 PM
UNILAT LOWER EXT VEINS RIGHT Clip # [**Clip Number (Radiology) 61934**]
Reason: SWELLING PAIN RULE OUT DVT ON RIGHT
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with recent knee surgery and more swelling on
right.
REASON FOR THIS EXAMINATION:
rule out dvt on right
Wet Read: [**First Name9 (NamePattern2) 20005**] [**Doctor First Name **] [**2178-6-25**] 4:23 PM
No DVT right lower extremity.
Preliminary Report
No DVT right lower extremity.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Cardiology results:
Cardiology Report ECG Study Date of [**2178-6-21**] 11:39:18 AM
Sinus rhythm. A-V conduction delay. Left atrial abnormality.
Cannot exclude
prior anterior wall myocardial infarction. Left ventricular
hypertrophy.
Secondary repolarization abnormalities most prominent in the
lateral leads.
Compared to the previous tracing of [**2178-5-22**] the lateral ST
segment depressions,
which are new, raise concern for concomitant myocardial
ischemia. Clinical
correlation is suggested.
Cardiac catheterisation:
Cardiology Report Cardiac Cath Study Date of [**2178-6-21**]
1. Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
mild
disease. The LAD had diffuse calcific disease, and the
previously
placed stent(s) was patent. There was 60% stenosis in the
proximal
vessel. There was 70% stenosis of the first diagonal and 60%
stenosis
of the second diagonal. The LCx had moderate, diffuse disease
in a
small vessel. The RCA had a 60% stenosis in a small PDA. The
anatomy
appeared stable when compared to the recent cath of [**2178-5-23**].
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension SBP 167mmHg.
3. Left ventriculography was deferred.
4. Hemostasis of the left femoral arteriotomy site was
successfully
achieved with a 6 French Angioseal device.
FINAL DIAGNOSIS:
1. Unchanged two vessel coronary artery disease.
2. Moderate systemic arterial systolic hypertension.
3. Successful angioseal deployment.
Brief Hospital Course:
66-year-old man with CAD s/p LAD PCI, right SFA/peroneal bypass
and angioplasty, asymptomatic right subclavian and carotid
disease, brittle diabetes on insulin pump, hyperlipidemia, and
hypertension, who was POD#3 s/p Right total knee replacement at
the [**Hospital1 **] who developed chest pain with BP in the 180s, and
EKG changes infero-laterally with ST depressions similar to EKG
changes during stress test before surgery and concern for V1-3
STe, which was unchanged from EKG at [**Hospital1 18**] 1mo ago. He was
started on heparin gtt and transferred to [**Hospital1 18**] for emergent
catheterization, which revealed no changes from cardiac cath 1
month ago.
.
On arrival to cath lab, he was hypertensive and required a nitro
gtt to maintain SBPs < 160, he was given full dose ASA and 600mg
of Plavix. Upon completion of cath, was transferred to the
floor, hypoxemic on 10 L facemask and tachypneic. Nitro gtt was
discontinued. He was transitioned to nasal cannula but then had
an acute episode of SOB, desaturations to 92 on max NC,
requiring NRB to maintain sats > 96%. BP at the time was
144/65. He was given IV lasix for suspected pulmonary edema and
haldol for agitation. CTA chest was peformed which showed no PE
and a ? RUL consolidation with mild pulmonary edema. He was
briefly transferred to the MICU for continued SOB, hypoxemia and
nursing care. During his MICU course he was given 80 mg IV lasix
and put out nearly 1.8 L of urine. He was also quite agitated
and delerious, and received 20 mg olanzapine which calmed him
down. He is transferred to the CCU for further management.
.
Cath findings as follows: SBPs 160s - 180s. 60% LAD, MR, right
dominant system with 70% 1st diag, 60% 2nd diagnoal, moderate
LCX disease and 60% small PDA. Per discussion with cards fellow,
it was felt that EKG changes constituted demand ischemia in
setting of acute drop in hematocrit from 35 to 26 and was
consistent with prior stress test. Of note, [**5-22**] cath showed
diffuse CAD, EF > 60%, there was no intervention and findings
were similar to above. Also of note, upon transfer to [**Hospital1 18**], he
was given 1 unit pRBC for anemia.
.
CCU Course:
# NSTEMI: Felt to be secondary to demand in setting of decrease
in Hct from 35 -> 26 causing enzyme elevations and ST
depressions in lateral leads. Initial concern for STEMI as STE
seen in V1-V3, however this was unchanged from old EKG. No
intervention performed during cardiac cath, and patient was
chest pain free on transfer to CCU. Troponin peaked at 0.24 and
was trending down. He was continued on aspirin, Plavix,
atorvastatin, atenolol and an ACE inhibitor. His lisinopril was
stopped on [**2178-6-23**] in setting of fluctuating blood pressures.
He was monitored on telemetry. His HCT was trended given
concern for ischemia. He was transfused an additional unit of
PRBCs on [**2178-6-23**]. Carotid U/S revealed a right ICA less than
40% stenosis and a left ICA 60-69% stenosis. He will follow up
with CT surgery as an outpatient, plan for CABG.
.
# Diastolic Heart Failure: The patient was breathing comfortably
with sats in the mid-90s on supplemental oxygen at time of CCU
tranfer. His fluid balance was monitored with a goal of net
even to negative 500cc per day. He was continued on a beta
blocker. His lisinopril was stopped on [**2178-6-23**] in setting of
varying blood pressures.
.
# Hypoxemic resp. failure: Respiratory status improved with
diuresis. Respiratory decline most likely due to flash pulmonary
edema, in setting of hypertension, and volume overload (likely
received fluid in OR), 1U PRBCs, as well as adrenergic drive in
setting of CP. CTA revealed mild pulmonary edema and patchy
opacities in the upper lobes, right greater than left, which
could represent an early infectious process. Echo [**2178-6-22**] showed
1+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 61935**] EF (65-70%) and elevated filling pressures
consistent with diastolic dysfunction which could support flash
pulmonary edema etiology. CTA did not reveal any evidence of PE.
PNA seemed less likely based on the location (RUL), however the
patient was febrile and aspiration PNA/HAP remained on
differential. He was continued on empiric antibiotic coverage
with vanc/cefepime/flagyl. CXR on [**2178-6-23**] showed improvment in
previously seen opacities. Patient's antibiotics were stopped,
as it was felt he did not have PNA. His O2 was titrated to keep
his sats above 92%.
.
# Delirium. Slowly improved with holding additional pain
medications. Per OSH records, he had been confused and agitated
since TKR. Confusion thought to be multifactorial, and related
to post-op course, opioids, fever, and hypoxemia. He was given
Zyprexa prn agitation, and also ordered for haldol prn
agitation. His home anxiolytics were held, but sertraline and
buproprion were continued. He was started on vicodin prn pain
after his delerium had resolved, and was tolerating the
medication well at time of discharge.
.
# Fever: Tmax 100.8F over 24 hours prior to CCU transfer.
Source of fever was unknown, but DDx included PNA, possible
wound infection, or post-op fever. His WBC was trended, and he
was initially continued on empiric antibiotics until it was felt
he did not have any clincial signs of PNA. His antibiotics were
then discontinued. His WBC normalized and he was afebrile at
time of discharge with no sign of active infection.
.
# PVD: He was continued on plavix, aspirin, and a statin. His
extremities were warm, and well-perfused during the admission.
An arterial duplex study of his right lower extremity on [**2178-6-23**]
revealed a patent right lower extremity bypass with no evidence
of stenosis. He will be followed up in teh community by vascular
surgery.
.
# s/p R TKR: Patient in soft cast at time of admission, and knee
was not tender to palpation. Dr. [**Last Name (STitle) 61936**] (ortho) was aware of
patient's admission. Ortho team followed patient during his
hospital course. He was continued on partial weight bearing and
continuous power machine. PT was also consulted for
recommendations. He developed increased pain in the knee, for
which he received vicodin prn pain. Dr. [**Last Name (STitle) **] from
Orthopedics called to consult about right knee erythema around
suture site which was felt likely to be inflammation as opposed
to any soft tissue infection, and recommended 10 days of
Cephalexin which was given to pt at discharge. A right lower
extremity ultrasound did not reveal any evidence of DVT.
.
# DM: Patient has h/o brittle diabetes, with A1C 7.9% 1.5 months
ago. He was placed on Lantus 18 plus an insulin sliding scale.
His blood glucose levels were difficult to control during the
admission, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes Center consult was called. He
was restarted on his home insulin pump regimen, with minor
adjustments made after the [**Last Name (un) **] consult.
.
# Autonomic and Peripheral Neuropathy: Patient had orthostatic
hypotension and a very labile BP during admission, which has
been chronic issue. His postural BP as monitored, and his
atenolol and lisinopril were held in setting of fluctuating BPs.
The patient was continued on fludrocortisone.
.
#) Anxiety: On transfer to CCU, patient was agitated and
encephalopathic. He was continued on sertraline and bupropion,
but other anxiolytics were initially held.
.
#) Neuropathy: His gabapentin was initially held.
.
#) OSA: He was continued on Bipap, 15/8 as per home regimen.
.
#) Prophylaxis: He was initially on SC heparin, then switched to
Lovenox for DVT prophylaxis.
Medications on Admission:
Afrin prn
ambien 10 mg prn
aspirin 81 daily
Atenolol 25 daily
Fludrocortisone 0.05 mg q pm
Gabapentin 200 [**Hospital1 **]
Lipitor 40 daily
Lisinopril 10 mg AM and 5 mg PM
Novolog pump
Percocet prn
plavix 75 daily
wellbutrin 200 daily
zoloft 25 daily
viagra 100 prn
vicodin prn
xanax 0.5-1.0 mg q pm prn
vitamins plus b complex q AM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Bupropion HCl 200 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain. Tablet(s)
9. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
HS (at bedtime) as needed for Nasal congestion.
10. Ambien 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous ASDIR (AS DIRECTED).
12. Xanax 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
13. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
14. Viagra Oral
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Location (un) 260**]
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Diabetes Type 1 on insulin pump
Coronary Artery Disease
Peripheral Vascular Disease
Autonomic Dysfunction
Hypertension
Hyperlipidemia
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had some chest pain and changes on your alectrocardiogram at
the [**Hospital **] hospital after your knee operation. You were
transferred to [**Hospital1 18**] for a cardiac catheterization that showed
no change in the blockages in your coronary arteries from
previously. You had a small heart attack but your echocardiogram
was unchanged. The pressures inside of your heart has been high
and you received some diuretics to lower the pressures. You had
some delirium, confusion that is common in the hospital, this
has now improved greatly. You will return in [**Month (only) 216**] to talk to
Dr. [**Last Name (STitle) **] about bypass surgery.
WE made the following changes to your medicine.
1. Increase Aspirin to 325 mg daily
2. Decrease Lisinopril to 5mg twice daily
3. Continue on home insulin pump
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Department: CARDIAC SURGERY
When: THURSDAY [**2178-7-30**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2178-10-8**] at 1:45 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: THURSDAY [**2178-7-30**] at 10:45 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: Cardiology
Who: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: The office of Dr. [**Last Name (STitle) **] will be calling you regarding the
date of your upcoming appointment within 1 month of your
discharge. Please call the office in 2 business days if you have
not heard from the office.
Where: [**Last Name (NamePattern1) 14648**], [**Location (un) 86**], MA
[**Doctor Last Name 3649**] Building [**Apartment Address(1) 40601**]
Phone: ([**Telephone/Fax (1) 32215**]
Department: Orthopaedics
Who: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61936**]
When: The office of Dr. [**Last Name (STitle) 61936**] will be calling you regarding
the date of your upcoming appointment within 1 month of your
discharge. Please call the office in 2 business days if you have
not heard from the office.
Where: [**Last Name (NamePattern1) 14648**], [**Location (un) 86**], MA
[**Hospital1 756**] 5, [**Apartment Address(1) 61937**]
Phone: ([**Telephone/Fax (1) 61938**]
|
[
"518.81",
"250.41",
"292.81",
"583.81",
"250.51",
"V43.65",
"707.15",
"414.01",
"428.33",
"362.01",
"428.0",
"410.71",
"E947.8",
"416.8",
"780.60",
"E849.8",
"250.61",
"440.23",
"458.0",
"311",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
23898, 23974
|
14677, 22292
|
293, 336
|
24243, 24243
|
4951, 11338
|
25360, 27242
|
4145, 4183
|
22676, 23875
|
12730, 12799
|
23995, 24222
|
22318, 22653
|
14514, 14654
|
24394, 25337
|
4198, 4932
|
243, 255
|
12831, 14497
|
364, 3622
|
24258, 24370
|
3644, 3943
|
3959, 4129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,625
| 153,984
|
38424+58214
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-7-8**] Discharge Date: [**2149-7-22**]
Date of Birth: [**2073-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
CORONARY ARTERY DISEASE
Major Surgical or Invasive Procedure:
[**2149-7-10**] Off-pump coronary artery bypass graft x2(saphenous vein
grafts to left anterior descending artery and distal right
coronary artery)
[**2149-7-12**] mediastinal exploration for bleeding
History of Present Illness:
This is a 75 year old male with multiple cardiac risk factors
who presented to [**Hospital **] Hospital with unstable angina and
NSTEMI on [**2149-6-24**]. Cardiac catheterization revealed
multivessel coronary artery disease and he now has been referred
for surgical revascularization.
He has known thrombocytopenia and has been maintained on
steroids.
Past Medical History:
-Hypertension
-Dyslipidemia
-Type II Diabetes (peripheral neuropathy)
-Obesity
Thrombocytopenia on Prednisone
Abdominal Aortic Aneurysm
Right Popliteal Aneurysm
benign prostatic hypertrophy
Hypothyroidism
Sciatica
s/p Left knee arthroscopy
s/p Appendectomy
s/p Tonsillectomy
Social History:
Lives with: Wife
Occupation: Retired Accountant
Tobacco: Denies
ETOH: Denies
Family History:
Denies premature coronary artery disease
Physical Exam:
admission:
Pulse: 55 Resp: 16 O2 sat: 95%
B/P Right: 101/66 Left: 99/63
Height: 6'2" Weight: 296 lb
General: Well-developed obese male in no acute distress
Skin: Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] JVD []
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X], very protuberant
Extremities: Warm [X], well-perfused [X] Edema: trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2149-7-10**] Echo: Pre-Procedure: The left atrium is normal in size.
No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thicknesses are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. Post-Procedure: Patient is on a phenylephrine
drip. Left ventricular systolic function remains normal
(LVEF>55%). Normal ascending and descending aortic contours. No
aortic regurgitation or mitral regurgitation post-procedure.
[**2149-7-22**] 02:25AM BLOOD WBC-10.5 RBC-3.25* Hgb-9.5* Hct-28.5*
MCV-88 MCH-29.1 MCHC-33.2 RDW-14.9 Plt Ct-143*
[**2149-7-21**] 03:18AM BLOOD WBC-10.5 RBC-3.37* Hgb-9.8* Hct-29.9*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.8 Plt Ct-130*
[**2149-7-20**] 03:20AM BLOOD WBC-9.9 RBC-3.40* Hgb-9.9* Hct-30.3*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.8 Plt Ct-127*
[**2149-7-19**] 01:37AM BLOOD WBC-9.5 RBC-3.20* Hgb-9.2* Hct-28.6*
MCV-90 MCH-28.9 MCHC-32.3 RDW-14.8 Plt Ct-115*#
[**2149-7-18**] 03:36AM BLOOD WBC-7.0 RBC-3.03* Hgb-9.0* Hct-26.7*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.3 Plt Ct-70*
[**2149-7-22**] 02:25AM BLOOD Glucose-154* UreaN-41* Creat-1.2 Na-146*
K-4.1 Cl-113* HCO3-27 AnGap-10
[**2149-7-21**] 03:18AM BLOOD Glucose-162* UreaN-44* Creat-1.2 Na-148*
K-4.2 Cl-115* HCO3-26 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 85566**] was admitted prior to surgery for further work-up
and hematology, endocrine and [**Last Name (un) **] were consulted given his
history of ITP. He was given high dose steroids and plasma
transfusion for thrombocytopenia. On hospital day two he was
brought to the Operating Room where he underwent a off-pump
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.
Post-operatively he required pressors for support. He remained
sedated and on post-op day 2 he had clinical signs of cardiac
tamponade and a transesophageal echocardiogram confirmed a
collection around the right atrium causing some compression and
physiological evidence of cardiac tamponade.
Although he remained hemodynamically stable, he was taken to the
Operating Room on [**2149-7-12**] for tamponade drainage. Please see
operative report for details. Again following surgery, he was
transferred back to the CVICU for further care. Over the next
several days he was on/off pressors for hemodynamic support and
remained intubated and ventilator dependent.
Tube feeds started for support on [**2149-7-15**]. There was some
difficulty oxygenating him and a bronchosocpy for atelectasis on
radiographs was done on [**2149-7-15**] which ultimately grew coagulase
positive staph aureus. His X-ray improved and antibiotics were
not started.
He was weaned from the ventilator, extubated and remained so.
His respiratory status improved as diuresis was continued.
Platelet counts remained adequate and steroids were weaned to
his maintainance dose. He tolerated a diet and tube feeds were
removed.
He was extremely deconditioned and was unstable on his feet
preoperatively due to his diabetic neuropathy. He was alert and
oriented although somewhat demanding. Rehabilitation was deemed
appropriate and arrangements made for same. Medications,
precautions, restrictions and follow up were outlined.
Medications on Admission:
Famotidine 20mg daily
Proscar 5mg daily
Glipizide 5mg daily
Levothyroxine 50mcg daily
Lopressor 25mg [**Hospital1 **]
Prednisone 20mg daily
Simvastatin 40mg daily
Terazosin 1mg daily
Diovan 40mg daily
Aspirin 81mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 3 weeks, then 400mg daily x 1 week, then
200mg daily until further instructed.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
18. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous Daily with Breakfast.
19. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous AC and HS: see Humalog Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
Coronary Artery Disease
s/p Off-Pump Coronary Artery bypass graft
s/p reoperation for tamponade
Hypertension
Dyslipidemia
noninsulin dependent Diabetes mellitus
idiopathic thrombocytopeniania
Abdominal Aortic Aneurysm
Right Popliteal Aneurysm
Benign Prostatic Hypertrophy
Hypothyroidism
Sciatica
s/p Appendectomy
s/p Tonsillectomy
obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned/ Max Assist
Incisional pain managed with Ultram and Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Monday [**8-18**] @2:00 pm
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 59840**]in [**1-4**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 72499**] in [**1-4**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2149-7-22**] Name: [**Known lastname 13557**],[**Known firstname 651**] Unit No: [**Numeric Identifier 13558**]
Admission Date: [**2149-7-8**] Discharge Date: [**2149-7-22**]
Date of Birth: [**2073-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Please see follow-up section below for additonal instructions,
including lab work and specialist follow-up.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 96**] Center - [**Hospital1 2314**]
Followup Instructions:
**Please also follow up with Hematology, Dr. [**First Name8 (NamePattern2) 13559**] [**Name (STitle) 13560**]
[**Telephone/Fax (1) 13561**] in [**1-4**] weeks**
It is also advised to follow up with a local endocrinologist to
closely monitor Diabetes given chronic steroid therapy, your PCP
can recommend [**Name Initial (PRE) **] local physician.
[**Name10 (NameIs) 2947**] follow CBC 2x/week
You are scheduled for the following appointments
Surgeon:
Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1477**]) on Monday [**8-18**] @2:00 pm
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) 13562**] ([**Telephone/Fax (1) 10967**]in [**1-4**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 13563**] in [**1-4**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2149-7-22**]
|
[
"276.3",
"410.72",
"403.90",
"414.01",
"585.9",
"423.3",
"458.29",
"272.4",
"E932.0",
"998.11",
"E878.2",
"278.00",
"276.0",
"276.8",
"287.31",
"250.60",
"255.5",
"600.00",
"244.9",
"285.9",
"357.2",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.6",
"96.72",
"34.03",
"36.12",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
10681, 10756
|
3905, 5923
|
343, 546
|
8415, 8652
|
2132, 3882
|
10779, 11847
|
1338, 1380
|
6193, 7932
|
8053, 8394
|
5949, 6170
|
8676, 9468
|
1395, 2113
|
280, 305
|
574, 928
|
950, 1228
|
1244, 1322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,574
| 131,050
|
10407
|
Discharge summary
|
report
|
Admission Date: [**2128-1-16**] Discharge Date: [**2128-1-29**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Unresponsive, Hyperglycemia, DKA
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central Venous Line Placement
PICC Line Placement
History of Present Illness:
This is a 47 year old male with history of type I diabetes
mellitus found unresponsive on day of admission by his father.
[**Name (NI) **] EMS, the patient had a question of blown R pupil, Kussmaul
respirations and no purposeful movement. He was intubated in
field and transferred to [**Hospital3 7569**]. On arrival he was
hypotensive with no purposeful movements. He was given narcan
6mgIV with no response. CT head was negative per OSH and labs
were significant for WBC 50.2 with 28% bands, glucose 1259 with
AG 35, K 7.2. On ABG 6.88/23/94/4.3/89% and lactate 2.6.
CXR was consistant with multifocal penumonia and question of
aspiration. He received zosyn, unasyn, 4L IV NS, 1 amp Ca
gluconate, 1amp HCO3. Given no intensivist available at [**Location (un) **]
ED he was Transfered [**Hospital1 18**] by [**Location (un) 7622**].
On arrival to ED, patient was hypotensive (83/45, hr 80s),
received 4L IV NS, IV vancomycin and zosyn were started. Insulin
drip at 8U/hr was initiated and FS 780 reported prior to ICU
transfer. Levophed drip was initiated
According to family (ex-wife provided history), he has had
recurrent episodes of hyperglycemia (to the 500s) at home. Last
week he was taken to [**Hospital3 7569**] (by ambulance) for
hyperglycemia where he was admitted for several days. Prior to
this he had teeth pulled and was given pain medications but not
antibiotics. He also recently had a fall and was taken to OSH
for stitches to his head. He is known to have peripheral
neuropathy and takes several types of pain medications,
including a duragesic patch. Otherwise he has not had any other
medical issues or symptoms to her knowledge.
Past Medical History:
-IDDM
-Medullary sponge kidney
-Nephrolithiasis
-peripheral neuropathy
-chronic back pain
-gastritis
-gastroparesis
-anxiety
Social History:
Divorced though still in contact with ex-wife. Lives with his
father in [**Name (NI) **], MA. Smoked [**1-23**] ppd x 20 yrs but no longer
smokes. Patient denies abusing any recreational drugs and denies
ETOH abuse, though MICU notes reports that ex-wife endorses that
pt has hx of substance abuse.
Family History:
Mother: Leukemia, currently undergoing chemotherapy
Father: CAD, HTN
Physical Exam:
PHYSICAL EXAM ON ADMISSION
T: 93.7 BP: 86/45 HR:97 RR:20 O2 93% on AC
GEN:intubated, sedated, unresponsive
HEENT:NCAT MMM anicteric, pupils reactive to light, 2mm
anisocoria, pink conjunctiva, ET tube in place could not
visualize OP
Lymph:no LAD
JVP:not appreciated
CV: RRR S1S2 no mrg
PULM: coarse breath sounds bilaterally with good air movement,
no wheezes, rales,
ABD:soft nontender non-distended +BS
EXT: cool but 2+ capillary reflex, 1+pitting edema on upper and
lower extremities (mainly hands, feet), excoriations and
abrasions noted on bilateral shins and L thigh
PULSES: thready radial and DP pulses b/l
NEURO: sedated, not responding to voice or tactile stimulus;
twitchy, shaking movements on occasion in lower extremities
Pertinent Results:
ADMISSION LABS:
[**2128-1-16**] 09:50PM GLUCOSE-780* UREA N-40* CREAT-2.7*#
SODIUM-144 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-9* ANION GAP-33*
[**2128-1-16**] 09:50PM estGFR-Using this
[**2128-1-16**] 09:50PM PT-14.4* PTT-44.1* INR(PT)-1.3*
[**2128-1-16**] 09:10PM GLUCOSE-GREATER TH LACTATE-1.6
[**2128-1-16**] 09:00PM WBC-37.4*# HCT-32*#
[**2128-1-16**] 09:00PM NEUTS-76* BANDS-5 LYMPHS-12* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-2*
[**2128-1-16**] 09:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+ BURR-1+
STIPPLED-1+
[**2128-1-16**] 09:00PM PLT SMR-HIGH PLT COUNT-577*
ARTERIAL BLOOD GAS:
[**2128-1-16**] 09:10PM BLOOD Type-ART pO2-116* pCO2-24* pH-7.01*
calTCO2-7* Base XS--24
CK:
[**2128-1-17**] 02:05PM BLOOD CK(CPK)-1151*
[**2128-1-17**] 04:39AM BLOOD CK(CPK)-928*
[**2128-1-16**] 09:50PM CK(CPK)-361*
URINE:
[**2128-1-16**] 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2128-1-16**] 09:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2128-1-16**] 09:00PM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2 TRANS EPI-0-2 RENAL EPI-[**3-25**]
[**2128-1-16**] 09:00PM URINE GRANULAR-0-2
[**2128-1-16**] 09:00PM URINE MUCOUS-OCC
LIVER FUNCTION:
[**2128-1-17**] 06:00PM BLOOD ALT-18 AST-64* LD(LDH)-760* AlkPhos-122*
TotBili-0.2
CARDIAC ENZYMES:
[**2128-1-16**] 09:50PM BLOOD cTropnT-0.11*
[**2128-1-17**] 04:39AM BLOOD CK-MB-30* MB Indx-3.2 cTropnT-0.22*
[**2128-1-17**] 02:05PM BLOOD CK-MB-27* MB Indx-2.3 cTropnT-0.49*
DISCHARGE LABS:
[**2128-1-29**] 05:25AM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
9.9 2.46* 7.5* 22.1* 90 30.6 34.0 17.0* 411
[**2128-1-29**] 05:25AM
Glucose UreaN Creat Na K Cl HCO3 AnGap
117* 26* 2.8* 141 4.1 107 23
MICROBIOLOGY:
[**2128-1-17**] 4:52 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2128-1-19**]**
GRAM STAIN (Final [**2128-1-17**]):
[**11-14**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2128-1-19**]):
RARE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
----------
CDIFF TOXIN A and B negative x 4
----------
[**2128-1-21**] 1:17 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2128-1-23**]**
GRAM STAIN (Final [**2128-1-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2128-1-23**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
-------------------
IMAGING STUDIES:
CXR [**2128-1-19**]:Multifocal consolidative pulmonary abnormality,
continues to improve in the left lung since [**2128-1-16**], while
the right lung improved between [**2128-1-16**] and [**2128-1-18**], and
has remained stable or worsened slightly since. Findings are
consistent with pulmonary edema, including noncardiogenic
causes, including ingestion and drug reaction, as well as
pulmonary hemorrhage or unusual condition such as chronic or
acute eosinophilic pneumonia.
------
CT Abdomen and Pelvis [**2128-1-19**]:
IMPRESSION:
1. Limited examination secondary to lack of intravenous contrast
and
opacification of small bowel with oral contrast. Possible short
segment of
small bowel wall thickening in the left mid abdomen. The
differential
diagnosis is broad and includes infectious, ischemic and
inflammatory
etiologies for enteritis.
2. Rectal wall thickening and perirectal stranding suggestive of
proctitis.
3. Ascites and anasarca. Lack of intravenous contrast, limits
sensitivity for
the detection of a small intra-abdominal abscess. No large
intra-abdominal
abscess.
4. Bilateral pleural effusions with bibasilar consolidations and
scattered
ground glass opacities suspicious for pneumonia.
5. Unchanged bilateral nonobstructive renal calculi.
6. Right renal low attenuation lesion, incompetely
characterized, likely
representing a cyst.
-------
CXR [**2128-1-25**]: IMPRESSION: Probable marginal improvement in extent
of pneumonia.
-------
MRI c-spine [**2128-1-24**]: CONCLUSION: Mild degenerative disc disease
with a small midline protrusion at C6-7 that does not contact
the spinal cord. The study is limited in quality due to motion
artifact, but there is no definite evidence of neural foraminal
encroachment.
Brief Hospital Course:
This is a 47 year old man with history of Type I diabetes
mellitus found unresponsive at home with hyperglycemia and
metabolic acidosis, likely in DKA, also found to have multifocal
PNA and acute renal failure/metabolic acidosis.
1) Diabetic Ketoacidosis: Pt with a history of type I diabetes
mellitus that has been poorly controlled in the past with
multiple hospital admission for DKA. As per HPI pt found
unresponsive with significantly elevated blood sugar transferred
from OSH for intensivist management of DKA. DKA likely secondary
to infection, with possible sources being pneumonia +/- recent
tooth extraction. Patient admitted to the medical ICU and
insulin drip initiated. [**Last Name (un) **] endocrine consult service
immediately became involved in hospital course. Patient
eventually transitioned to Lantus and Humalog sliding scale.
Given significant renal failure patient's insulin regimen has
required close monitoring and daily adjustments. At this time
renal function continues to improve. Anticipate that Lantus dose
will need to be increased. Currently on Lantus 12 qHS and
relatively aggressive humalog sliding scale. Please monitor
blood glucose carefully and adjust both lantus and humalog as
needed. Would suggest that patient have diabtes follow up at
[**Last Name (un) **] following discharge from rehab.
2) Respiratory Failure: Pt found unresponsive at home and
intubated at OSH and remained intubated when transferred to the
MICU. Found to have combination of pulmonary edema and bilateral
pulmonary infiltrates. Was diuresed which improved respiratory
status. Determined to have sputum cultures positive for MRSA and
treated for multifocal pneumonia with vancomycin and zosyn.
Patient's respiratory status eventually permitted extubation. He
was transferred to the medical floor on 2-3L of oxygen via nasal
cannula and O2 sats have beens stable around 94-96%. Description
of penumonia treatment regimen listed below. Would suggest
continuing to wean oxygen as tolerated.
3) Acute renal failure/ Metabolic acidosis: On admission ABG was
6.88/23/94/4.3/89% and lactate 2.6. Also found to have acute
renal failure with a creatinine of 5.1. Metabolic acidosis felt
to be due to a combination of DKA, rhabdomyolysis, infection and
question of ingestion. Acute renal failure likely secondayr to
dehydration and hypotension secondary to DKA leading to a
pre-renal/ATN picture. Metabolic significantly improved with
resolution of DKA as well as treatment pneumonia. He was
followed by the renal service who also recommended oral
bicarbonate which was discontinued when bicarbonate corrected
and renal function improved. Renal failure has continued to
trend down and is 2.8 at time of discharge. Would suggest
continuing to follow creatinine. Please also monitor bicarbonate
and assess for whether oral bicarbonate supplementation needed.
Continue to renally dose meds and avoid nephrotoxins.
4)Multifocal Pneumonia/MRSA Pneumonia: Sputum sample positive
for MRSA, sensitive to Vancomycin. Patient started on
Vancomycin/Zosyn. Patient has remained afebrile for nearly his
enture time on the medicine [**Hospital1 **]. White count is normal at time
of discharge. As noted abovePatient will need a total of 14 day
course of this antibiotic combination since his last negative
sputum cx ([**2128-1-19**]).Last dose on [**2128-2-1**]. Vancomycin dosed q48
given GFR of 11 at time of discharge. His next dose should be
[**2128-1-30**].
5)Diarrhea: Patient has had diarrhea since about [**2128-1-18**]. He
has been negative for cDiff x 4. We do not think this is
infectious, likely side effect from antibiotic side effect.
However, we have treated him empirically for cdiff with
metronidazole. He will finish a 14 day course on that will be
finished on [**2128-2-2**].
6) Anemia: Found to be anemic to 23 and required 1 unit PRBC
during this admission. Had guiac positive stool. Feel he likely
has gastritis that may be oozing and suggest an EGD as an
outpatient which will need to be scheduled. Please note on day
of DC his Hct 22. We suggest checking a Hct within the next few
days to monitor.
7) Right Upper Extremity Weakness: Pt unable to lift right upper
extremity. Had cervical MRI which was negative for mass or
abscess. Seen by neuro that felt he has a C5/C6 radiculopathy or
an upper trunk plexopathy likely [**2-23**] to being found down. He
will need to have neurology appointment scheduled 1-2 months
from today.
8) Chronic Neuropathic Pain: Patient has hx of chronic pain,
especially in his back. Pain has been managed with fentanyl
patches and IV morphine. He should be con on his outpt dose of
Neurontin 300 mg TID. Given patient's questionable hx of
substance abuse suggest trying to wean down morphine as
tolerated. Suspect that pain will improve when patient not bed
bound and able to be more mobile. Please note he was on percocet
5/325mg [**1-23**] QDailyPRN prior to admission.
9) Scrotal Edema: Pt has significant pain from scrotal edema
which is [**2-23**] fluid resucitation and continued volume
redistribution. We have started him on lasix 20 mg daily.
Suggest monitoring creatinine and stopping this medication if
worsening Cr or if scrotal edema improves.
10) Depression: Pt continued on his lexapro. He does have a
rather flat affect and seems to be rather down given his current
situation. Suggest coordinating counseling during rehab stay and
following discharge.
11) ? Vertigo: Pt on meclizine 20mg Q8PRN as an outpt for
presumed BPPV. We have held this medication given it's sedating
effect given he is on other sedating meds.
12) Hypertension: Patient started on HCTZ 12.5 mg daily for
elevated blood pressure prior to discharge. Suggest checking CHM
7 to monitor electrolytes. [**Month (only) 116**] need to be titrated up.
Patient was a FULL code during this admission.
Medications on Admission:
Klonopin 1mg TID
Fentanyl Patch 75mcg TD X2 Q72H
Flonase 2 sprays/nostril [**Hospital1 **]
Humalog ISS
Lantus 20 units QHS
Lexapro 20mg QHS
Meclazine 20mg Q8PRN
Neurontin 300mg TID
Percocet 5/325mg [**1-23**] QDailyPRN
Nexium 40mg QDaily
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain/fever.
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4
hours) as needed for pain.
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q48
for 3 days: Please dose on [**1-30**] and [**2-1**].
9. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 3 days: Stop Date
[**2-1**].
10. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 3 days: Stop Date
[**2-2**].
11. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous at bedtime: Please see attached sliding scale.
12. Pantoprazole 40 mg Recon Soln Sig: 40mg Intravenous every
twelve (12) hours.
13. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous per sliding scale. please see attached: please see
attached sliding scale.
14. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Diabetic ketoacidosis, Acute renal failure, Methicillin
resistant staph aureus pneumonia, C5/C6 radiculopathy
Secondary: Type I diabetes mellitus, Anemia possibly secondary
to blood loss, Chronic Neuropathic pain, Depression
Discharge Condition:
Stable, clinically improved
Discharge Instructions:
You were transferred to this hospital because you were found to
be unresponsive and were in diabetic ketoacidosis from very high
blood sugar. You were treated in our ICU with IV insulin for the
high blood sugar. You were also found to have a severe pneumonia
and have been treated on antibiotics which you will need to
continue taking until [**2128-2-1**]. You were also found to have renal
failure which is resolving. You are being discharged to rehab
for continued care all your medical problems.
Multiple changes have been made to your medications and your
rehab may make further changes. Your rehab doctors [**Name5 (PTitle) **] explain
these changes when you are discharged home.
If you experience fevers, chills, night sweats, chest pain,
shortness of breath or persistently high blood sugars please
contact your primary care physician or come to the emergency
department for evaluation.
Followup Instructions:
Will require renal follow up. The nephrology department phone
number is ([**Telephone/Fax (1) 773**] to make an appointment.
Will require neurology follow-up 1-2 months after discharge. The
neurology phone number is ([**Telephone/Fax (1) 2528**].
Will require an outpatient upper endoscopy by GI. The GI
procedure scheduling number is ([**Telephone/Fax (1) 2233**].
Should follow up with PCP [**Name Initial (PRE) 176**] 1-2 weeks after discharge from
rehab. Office phone number is [**Telephone/Fax (1) **].
You will require follow up with an endocrinologist. We suggest
you see someone at the [**Hospital **] Clinic. The phone number is ([**Telephone/Fax (1) 34473**].
Suggest that patient be scheduled for outpatient counseling to
assist with coping. Patient should contact his health care
provider for [**Name Initial (PRE) **] list of mental health providers.
Completed by:[**2128-1-29**]
|
[
"008.45",
"785.52",
"401.9",
"536.3",
"250.13",
"357.2",
"584.9",
"250.63",
"311",
"995.92",
"723.4",
"280.0",
"518.81",
"038.9",
"608.86",
"507.0",
"338.29",
"535.51",
"386.11",
"V58.67",
"728.88",
"482.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16260, 16339
|
8715, 14550
|
347, 423
|
16617, 16647
|
3428, 3428
|
17591, 18491
|
2588, 2658
|
14838, 16237
|
16360, 16596
|
14576, 14815
|
16671, 17568
|
5062, 6943
|
2673, 3409
|
4869, 5046
|
275, 309
|
451, 2108
|
3444, 4852
|
2130, 2256
|
2272, 2572
|
6960, 8692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,790
| 127,248
|
12736
|
Discharge summary
|
report
|
Admission Date: [**2127-7-3**] Discharge Date: [**2127-7-10**]
Date of Birth: [**2057-7-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2127-7-4**]: Open reduction internal fixation, left ulnar.
History of Present Illness:
69 yo male with hx CAD s/p cardiac arrest with ICD placement in
[**2125**], NSTEMI [**4-14**], chronic afib, chronic systolic HF (EF 25-30%
[**4-14**]), DMII, HTN, hyperlipidemia who fell off a stool while
painting. Patient hit his head with possible loss of
consciousness. Patient was seen at [**Hospital3 4107**] where he
underwent imaging and was found to have a minimally displaced
left proximal ulnar shaft fracture. Patient had skin abrasions
and lacerations near the site of the fracture. There was some
concern for compartment syndrome or open fracture so pt was
started on antibiotics and then was sent to [**Hospital1 18**] for
evaluation. Head CT in the ER was negative for intracranial
hemorrhage.
.
Pt was evaluated and admitted by the Orthopedic Service and
underwent an [**Hospital1 24785**] on [**7-4**]. Pt was stable immediately after the
surgery but became diaphoretic, weak, hypoxic to 81% on RA and
acutely short of breath on the morning of [**7-5**]. A trigger was
called, and pt was transferred to the CCU for treatment of
presumed acute on chronic systolic heart failure in the setting
of peri-operative volume overload.
.
At baseline, pt reports being about to walk 50 yards before
tiring and becoming short of breath, can climb approximately 1
flight of stairs. He has not had any angina since [**Month (only) 547**] (left
shoulder pain)and no orthopnea or PND at baseline. HE has mild
chronic LE edema. No bleeding trouble onaspirin, Plavix, and
dabigatran (for atrial fibrillation).
.
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 does endorse leg cramping when walking. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: Coronary Artery Disease s/p cath [**2125**] after
cardiac arrest with severe 2vd unable to be intervened upon, on
Plavix. Recent NSTEMI [**4-14**], s/p cath with distal LAD 80%
occlusion followed by 100% more distal occlusion, LCx with
proximal 100% occlusion, RCA with proximal 30% stenosis followed
by two mid aneurysmal segments and a 30% PL stenosis - managed
medically.
-PACING/ICD: ICD, dual chamber [**Company **] ICD, last
interrogation [**2127-6-30**] and was working properly
3. OTHER PAST MEDICAL HISTORY:
- a fib on dabigatran
- chronic systolic CHF, EF 25-30% ([**4-14**])
- H/O cardiac arrest x2
- Bells Palsy
- femoral artery damage in [**2125**] [**2-5**] cath?
- GERD
- sciatica
- obesity
Social History:
Married, lives with wife, retired coordinator of dialysis center
at VA
-Tobacco history: quit 20 years ago, prior 1.5ppd x20 years
-ETOH: former user, none for past 20 years
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
PHYSICAL EXAMINATION:
VS: BP=157/97 HR=96 RR=17 O2 sat= 97% on 4L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: PERRL, EOMI. MMM
NECK: Supple with JVP at chin at 60 degrees
CARDIAC: irregularlly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Crackles present at bilateral lung bases
up 1/4, no wheezes or rhonchi.
ABDOMEN: obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema
SKIN: intact.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
.
On Discharge:
PHYSICAL EXAMINATION:
VS: BP=110-156/74-85 HR=70-87 RR=17 O2 sat= 94%on RA Temp 98.5
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: PERRL, Left eye deviates laterally on EOM exam. Pt has
some double vision and blurriness that is affecting his
ambulation. No other facial weakness noted.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Lungs clear
ABDOMEN: obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema, chronic per pt
SKIN: intact.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
On Admission:
[**2127-7-2**] 08:50PM BLOOD WBC-8.2 RBC-4.01* Hgb-12.4* Hct-37.9*
MCV-95 MCH-31.0 MCHC-32.8 RDW-14.0 Plt Ct-195
[**2127-7-2**] 08:50PM BLOOD PT-17.1* PTT-42.1* INR(PT)-1.5*
[**2127-7-2**] 08:50PM BLOOD Glucose-220* UreaN-25* Creat-1.3* Na-142
K-4.0 Cl-101 HCO3-31 AnGap-14
.
On Discharge:
[**2127-7-10**] 07:25AM BLOOD WBC-7.2 RBC-3.85* Hgb-12.3* Hct-36.4*
MCV-94 MCH-31.9 MCHC-33.8 RDW-14.4 Plt Ct-238
[**2127-7-10**] 07:25AM BLOOD Glucose-212* UreaN-21* Creat-1.0 Na-139
K-3.9 Cl-101 HCO3-31 AnGap-11
.
Other Lab Results:
[**2127-7-7**] 02:30AM BLOOD %HbA1c-7.0* eAG-154*
[**2127-7-7**] 02:30AM BLOOD CK-MB-4 cTropnT-0.36:
.
Imaging/Studies:
ECG ([**7-3**]): Atrial fibrillation with a mean ventricular rate of
84 with ventricular premature depolarizations. Right
bundle-branch block.
.
Forearm Left X-Ray ([**7-4**]): 17 fluoroscopic spot radiographs
demonstrate plate fixation of mid shaft ulnar fracture
.
CXR ([**7-5**]): When compared to the prior chest x-ray the vascular
markings are considerably increased indicating new onset of CHF.
.
CTA Head ([**7-6**]): 1. Head CT shows chronic left thalamic lacune.
Mild-to-moderate brain atrophy. 2. CT angiography of the head
demonstrates somewhat tortuous intracranial arteries and
atherosclerotic disease but no discrete aneurysm is seen.
.
Echo ([**7-7**]): Regional and global biventricular systolic
dysfunction, c/w CAD. At least mild mitral regurgitation.
Moderate pulmonary hypertension. Intracardiac thrombus cannot be
excluded with this study. EF 25-30%.
.
Carotid Ultrasound ([**7-8**]): Right ICA <40% stenosis. Left ICA <40%
stenosis.
Brief Hospital Course:
Pt is a 69 yo male with hx CAD s/p cardiac arrest with ICD
placement in [**2125**], NSTEMI [**4-14**], chronic afib, chronic systolic
HF (EF 25-30% [**4-14**]), DMII, HTN, who is s/p [**Month/Year (2) 24785**] of a left ulnar
fracture complicated by acute exacerbation of chronic systolic
heart failure and development of left-sided partial
ophthalmoplegia.
.
#Left ulnar fracture s/p [**Name (NI) 24785**] - Pt had a successful repair of
his ulnar fracture on [**7-5**]. The arm continues to heal well.
Orthopedics surgery will follow-up as an outpt for repeat
imaging to assess progress of healing.
.
#Acute on Chronic Systolic Heart Failure - Pt became tachypneic
and hypoxic the day following his surgery, triggering a rapid
response on the floor. CXR at the time showed signs of pulmonary
edema consistent with an acute exacerbation of heart failure. In
the perioperative period pt received ~6L fluid which was the
likely cause of his fluid overload. Concern for ACS or PE in the
perioperative setting was less likely, but pt was maintained on
anticoagulation with heparin gtt until ruled out. Pt was
transferred to the CCU for aggressive diuresis with lasix IV. He
was diuresed well and his hypoxia and shortness of breath
resolved.
.
#?Minor Stroke v Neuropathy - On [**7-6**], pt began noticing new
onset double vision and his wife confirmed that his "eyes were
looking in different directions." On neurologic exam, pt was
found to be unable to adduct his left eye though all other
extraocular movements were intact. Pt said the double vision had
gradually been worsening over the previous two hours. Range of
motion was intact in his right eye though with some nystagmus on
horizontal eye movement. His neurologic exam was otherwise
non-focal with no other cranial nerve defects, no mental status
changes, no changes in reflexes or muscle strength. Concern was
for both hemorrhagic stroke given pt's recent history of fall
and his anticoagulation and ischemic stroke given his history of
Afib. Stroke team was called and pt was taken for Stat Head CTA,
which showed no acute intracranial processes. Per neurology,
differential includes isolated cranial nerve neuropathy, very
likely given pt's history of diabetes and Bell's palsy in the
past. Also possible but less likely is a very focal area of
ischemia too small to be seen on CT. Follow-up work-up included
carotid ultrasound which showed no evidence of flow limiting
disease, HgbA1c, and lipid panels which were also within normal
limits.
.
#CAD - Though pt did not complain of chest pain, his troponins
were elevated to 0.22 (baseline 0.09) on admission to the CCU
and EKG at the time showed some depressions in V2-V6, so pt was
maintained on heparin until ACS was ruled out by enzymes and
clinical impression. He was maintained on his home oral regimen
including plavix, aspirin, and statin.
.
#HTN - Pt's BPs were stably elevated to the 150s throughout his
hospital stay. Pt was weaned from a nitro gtt back to oral meds
lisinopril, an increased metoprolol dose of 50mg PO q6hr, and
imdur. Pt's oral BP meds were briefly held/decreased in the
setting of his ?TIA to allow for permissive hypertension but
then restarted after 48 hours.
.
Chronic Issues
.
#Afib - Pt's home dabigatran was held in the perioperative
setting but then re-started once concern for ACS was ruled out.
.
#HL - Stable. Continued statin.
.
#Diabetes - Patient's blood sugars were stable. Metformin was
held in the acute setting but should be re-started as an
outpatient.
.
Transitional Issues
Pt is to follow-up with ortho surgery to monitor healing of his
fracture s/p [**Month/Day (4) 24785**]. Pt should also follow-up with Neurology
regarding his persistent cranial nerve palsy and further imaging
with MRI or CTA of the neck might be required to identify
whether this was a true infarct or a type of diabetic
neuropathy. Finally, pt should follow-up with a cardiologist to
optimize his heart failure regimen. His PCP Dr [**Last Name (STitle) **] is also a
cardiologist and pt has an appt in approximately 2 weeks.
Medications on Admission:
omeprazole 20 mg PO daily
duloxetine 60 mg PO daily
gabapentin 120 mg PO BID
clopidogrel 75 mg PO daily
atorvastatin 80 mg qhs
furosemide 20 mg PO daily
dabigatran 150mg PO BID
Imdur 60 mg PO daily
lisinopril 10mg PO daily
aspirin 81 mg PO daily
metoprolol succinate 150 PO daily
metformin 1000 mg PO BID
ativan 0.5mg PO q6hr prn anxiety
colace 100mg PO BID
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
8. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. Outpatient Lab Work
Please check Chem-7 and CBC on Monday [**2127-7-14**]
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
Left ulnar fracture
Acute on chronic Systolic Congestive Heart Failure
6th cranial nerve stroke
Diabetes mellitus type 2
secondary diagnosis:
atrial fibrillation on dabigatran
Hypertension
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a fall and fractured your ulnar bone in your left arm.
You had it repaired surgically and became short of breath and
was transferred to the CCU for IV medicines to get rid of the
extra fluid. This was successful and you now seem to have no
extra fluid. Your weight at discharge is 234 pounds. During your
CCU stay, it was noted that your left eye is drifting outward.
The neurology team evaluated you and felt you had a stroke that
affected the 6th cranial nerve causing blurriness and double
vision. You have been improving and will see a neurologist in a
month. You heart is still weak and you are at risk for more
fluid overload. Weigh yourself every morning before breakfast
and call Dr. [**Last Name (STitle) 39288**] if weight goes up more than 3 lbs in 1 day
or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start taking tylenol or oxycodone for left arm pain
2. Start taking senna as needed for constipation
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be non weight bearing on your left arm.
-No lifting with left arm.
-Elevate left arm to reduce swelling and pain.
-Do not remove splint. Keep splint dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2127-7-22**] at 9:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2127-7-22**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2127-8-25**] at 4:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please keep your previously scheduled appt with Dr. [**Last Name (STitle) **]
|
[
"V12.53",
"813.22",
"412",
"V15.82",
"434.91",
"724.3",
"368.2",
"351.0",
"997.02",
"V45.02",
"414.01",
"V12.54",
"530.81",
"428.23",
"278.00",
"428.0",
"E884.2",
"427.31",
"414.8",
"250.60",
"401.9",
"357.2",
"377.49",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
12394, 12514
|
6333, 10394
|
291, 355
|
12790, 12790
|
4694, 4694
|
14706, 15706
|
3296, 3411
|
10802, 12371
|
12535, 12535
|
10420, 10779
|
12941, 13894
|
3426, 3426
|
2356, 2844
|
4049, 4675
|
4998, 6310
|
232, 253
|
13906, 14683
|
383, 2247
|
12696, 12769
|
12554, 12675
|
4708, 4984
|
12805, 12917
|
2875, 3065
|
2269, 2335
|
3081, 3280
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,048
| 168,799
|
26668
|
Discharge summary
|
report
|
Admission Date: [**2116-10-26**] Discharge Date: [**2116-11-2**]
Date of Birth: [**2037-11-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Difficulty focusing vision, frontal headache, disorientation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo RHM on Coumadin for porcine AVR in [**2114**], also pacemaker
for sick sinus syndrome. Quite functionally independent at
baseline and cognitively intact, living with wife. Was in his
USOH until 9 am today when he was driving back home and couldn't
seem to focus visually on the road. When he got home he
developed a R frontal headache. He normally has intact vision,
s/p cataract surgery. He noted that when he tried to read the
newspaper he "couldn't focus". He also felt "dizzy" by which he
means imbalanced when walking but did not fall. When his wife
came home she thought he seemed a little disoriented because he
couldn't see the chair she was pointing out to him, but it may
have been due to neglect. His INR had been 1.8-1.9 two weeks ago
so his Coumadin dose was increased at that time, and INR last
Friday was 2.5. He was brought to [**Location (un) 620**] ED where a NCHCT at
18h00 showed a large R parietal IPH with edema and mass effect
but no midline shift. Possible LUE numbness reported at OSH,
denies this currently. At [**Location (un) 620**] tx Profiline 2 vials and Vit K
5 mg at 19h00. INR decreased from 2.6 to 1.8. Currently
receiving 4 U FFP. ROS notable for baseline decreased auditory
acuity. No dysarthria or aphasia.
ROS: denies any fever, chills, weight loss, neckpain, nausea,
vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder
dysfunction, chest pain, shortness of breath, abdominal pain,
dysuria, hematuria, or bright red blood per rectum, rash, muscle
aches, joint pains.
Past Medical History:
-porcine AVR [**2114**], at that time found to have arch
atherosclerosis but no coronary artery disease
-cardiac pacemaker ([**Company 1543**] Adapta), dominantly
ventricular-paced, for sick sinus syndrome
-ingunial hernia
Social History:
Lives with wife, no tobacco, 3 children, 1 son and daughter
present today
Family History:
No brain tumor, ICH, or vascular malformations
Physical Exam:
VITALS: T 99.4 HR 62 paced BP 142/66 RR 18 sO2 100%on 4L nc O2
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Attention: mildly inattentive on DOWbw.
Memory: Registration: [**2-24**] items; Recall [**2-24**] at 5 min.
Language: fluent; Naming difficulties to low frequency objects;
Comprehension intact; no dysarthria, no paraphasic errors.
Prosody: normal. No Apraxia.
Dense L hemi-neglect: would not attend to any stimuli presented
to his L, did not even note his wife when she was standing to
that side, when shown his own L thumb stated it was mine.
CRANIAL NERVES:
II: L hemianopia. Pupils equally round and reactive to light
both directly and consensually, 3-->2 mm bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus.
Mild L ptosis.
V: Facial sensation intact to light touch.
VII: Facial movement symmetrical; no facial droop.
VIII: Decreased auditory acuity bilat.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis. Strength full throughout. No
pronator drift.
REFLEXES: DTRs brisk [**Name2 (NI) 65749**] but symmetric, nml in UEs. L
plantar response extensor, R flexor.
SENSORY SYSTEM: Sensation intact to light touch and
proprioception in all extremities. Extinction to DSS.
COORDINATION: Nml FNF on R, some pastpointing with L hand, [**Doctor First Name **]
nml. No dysmetria.
GAIT: not evaluated
Pertinent Results:
LABS:
[**2116-10-26**] 08:15PM BLOOD WBC-7.5 RBC-3.80*# Hgb-12.5*# Hct-35.7*#
MCV-94 MCH-32.9* MCHC-35.0 RDW-13.6 Plt Ct-165
[**2116-11-2**] 06:40AM BLOOD WBC-7.3 RBC-3.69* Hgb-12.1* Hct-33.6*
MCV-91 MCH-32.9* MCHC-36.1* RDW-13.7 Plt Ct-175
[**2116-10-26**] 08:15PM BLOOD Neuts-69.6 Lymphs-19.9 Monos-8.3 Eos-1.9
Baso-0.2
[**2116-10-26**] 08:15PM BLOOD PT-19.0* PTT-22.8 INR(PT)-1.8*
[**2116-10-30**] 06:50AM BLOOD PT-13.4 PTT-21.3* INR(PT)-1.1
[**2116-10-31**] 11:10AM BLOOD ESR-60*
[**2116-10-26**] 08:15PM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-140
K-3.6 Cl-103 HCO3-30 AnGap-11
[**2116-11-2**] 06:40AM BLOOD Glucose-115* UreaN-26* Creat-1.2 Na-133
K-3.8 Cl-95* HCO3-28 AnGap-14
[**2116-10-26**] 11:46PM BLOOD CK(CPK)-120
[**2116-10-27**] 03:49AM BLOOD ALT-18 AST-26
[**2116-10-27**] 10:14AM BLOOD CK(CPK)-104
[**2116-10-27**] 05:02PM BLOOD CK(CPK)-96
[**2116-10-26**] 11:46PM BLOOD CK-MB-3
[**2116-10-27**] 10:14AM BLOOD CK-MB-2 cTropnT-<0.01
[**2116-10-28**] 03:19AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
[**2116-10-27**] 03:49AM BLOOD Cholest-162
[**2116-10-27**] 03:49AM BLOOD Triglyc-49 HDL-73 CHOL/HD-2.2 LDLcalc-79
[**2116-10-27**] 03:49AM BLOOD %HbA1c-6.1*
[**2116-10-27**] 03:49AM BLOOD TSH-0.92
[**2116-10-27**] 03:49AM BLOOD CRP-7.1*
[**2116-10-31**] 11:10AM BLOOD CRP-46.2*
[**2116-10-26**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2116-10-26**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2116-10-26**] 08:15PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0
MICRO:
Blood Cx ([**10-28**]): Pending
Urine Cx ([**10-28**]): No growth
IMAGING:
ECG ([**10-26**]): Sinus rhythm at a rate of 68. A-V conduction delay.
Compared to the previous tracing of [**2115-2-25**] the inferolateral
ST-T wave changes have improved.
CTA Head ([**10-26**]): IMPRESSION:
1 Stable in appearance 5 x 4 cm intraparenchymal hemorrhage of
the right
parietal lobe with mass effect and vasogenic edema and midline
shift of 1.5 mm that is unchanged from previous examination. No
evidence of arterial venous malformation or an underlying
lesion.
However, this hemorrhage may mask an underlying lesion, and
repeat imaging is recommended to follow up resolution and to
assess for an underlying mass or malformation.
CXR ([**10-27**]): FINDINGS: In comparison with the study of [**2115-3-27**],
there has been placement of a dual-channel pacemaker device,
with the leads in the region of the apex of the right ventricle
and the right atrium. Mild enlargement of the cardiac silhouette
without vascular congestion, pleural effusion, or acute
pneumonia.
CT Head ([**10-27**]): IMPRESSION:
1. Intraparenchymal hemorrhage within the right parietal lobe
that is largely unchanged in size and appearance from previous
examination from [**2116-10-26**]. No worsening mass effect. The
differential diagnosis for this lesion includes a hypertensive
hemorrhage, underlying lesion or arteriovenous malformation.
This intraparenchymal hemorrhage may mask an underlying lesion,
recommend repeat followup imaging to ensure resolution.
CT Head ([**10-28**]): IMPRESSION:
1. Right intraparenchymal hemorrhage within the right parietal
lobe that is largely unchanged in size and appearance from
previous examination from [**2116-10-27**]. No new hemorrhage, no
worsening mass effect, and no associated hydrocephalus. The
differential diagnosis for this hemorrhage includes amyloid
angiopathy, hypertensive hemorrhage, an underlying lesion, or
arteriovenous malformation.
Carotid Ultrasound ([**11-2**]): (prelim) 0% stenosis bilaterally
Brief Hospital Course:
The patient is a 78 year old man with a history of porcine AVR
in [**2114**] on Coumadin (for paroxysmal atrial fibrillation around
the time of the procedure) and sick sinus syndrome s/p PPM, who
presented to an OSH with difficulty focusing his vision, frontal
headache, and disorientation, who was found to have a large 5x4
cm intraparenchymal hemorrhage within the right parietal lobe
with surrounding vasogenic edema and local mass effect with
slight midline shift and compression of the right lateral
ventricle. His bp was 156/88 on admission to the OSH, and his
INR was 2.6. He received Profilnine IV x2 and Vitamin K 5 IV at
[**Location (un) 620**], and was transferred to [**Hospital1 18**] where he received 4 U FFP.
Neurosurgery was consulted on admission to [**Hospital1 18**], and
recommended keeping INR <1.3 and no neurosurgical intervention.
CTA Head showed stable in appearance 5 x 4 cm intraparenchymal
hemorrhage of the right parietal lobe with mass effect and
vasogenic edema and midline shift of 1.5 mm that is unchanged
from previous examination, no evidence of arterial venous
malformation or an underlying lesion.
It was thought that the most likely cause of his IPH was amyloid
angiopathy, but he could not get an MRI to confirm this
diagnosis because of his history of PPM. His Coumadin was
discontinued during this admission. The neurology team spoke
with his cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4105**]) who
agrees not starting ASA or restarting Coumadin given he is at
high risk to re-bleed. CEs: CK 120-104-96, TropT <0.01; FLP Chol
162, TG 49, HDL 73, LDL 79; HgA1c 6.1%; TSH 0.92, LFTs WNL. He
was continued on HCTZ 25 mg daily and Simvastatin 20 daily. His
blood pressure should remain SBP <160. His urine culture showed
no growth, and his blood culture was pending at the time of
discharge.
His CRP was 7.1 on admission, but the patient then started
complaining of headache and had tenderness to palpation of his
left temporal lobe. Repeat CRP was 46.2 and ESR 60. He was
determined to have temporal arteritis clinically, and was
started on Prednisone 60 daily for the next 3 months. Carotid
ultrasound showed 0% carotid stenosis bilaterally on preliminary
report. While in rehab, he should have FSBGs checked at least
daily while on Prednisone, and given an HISS as needed.
Contact: Daughter ([**First Name8 (NamePattern2) 2110**] [**Name (NI) 805**]) [**Telephone/Fax (1) 4105**] (w),
[**Telephone/Fax (1) 65750**] (c)
Medications on Admission:
-Coumadin 5 mg po Mon-Wed-Fri, 2.5 mg poQday the other days
-HCTZ 25 mg Qday
-Simvastatin
-Cosopt and Xalatan eye gtts
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 months.
9. Medication
Humalog Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Right parietal IPH, likely due to amyloid angiopathy
Temporal arteritis
Discharge Condition:
Left sided neglect, no dysarthria, tender to palpation of right
temporal region, extinction to DSS (tactile and visual)
Discharge Instructions:
You were admitted to the hospital with difficulty focusing
vision, frontal headache, and disorientation, and were found to
have a large right parietal hemorrhage. This is most likely due
to amyloid angiopathy. Your Coumadin was discontinued, as you
are at high risk to re-bleed.
The following changes were made to your medications: Your
Coumadin was discontinued. You were started on Prednisone 60 mg
daily for the next 3 months, given that you were found to have
temporal arteritis on exam.
If you develop weakness or numbness, difficulty speaking or
swallowing, decreased vision or blurry vision, or any other
symptoms that concern you, call your PCP or return to the ED.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **]
([**Telephone/Fax (1) 2574**]) on [**2116-12-29**] at 1:30p in the [**Hospital Ward Name 23**] Center, [**Location (un) 6749**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"V45.01",
"V58.61",
"348.5",
"V42.2",
"427.81",
"277.30",
"446.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11360, 11505
|
7958, 10481
|
378, 385
|
11621, 11743
|
4320, 7935
|
12467, 12781
|
2295, 2344
|
10650, 11337
|
11526, 11600
|
10507, 10627
|
11767, 12444
|
2359, 2740
|
277, 340
|
413, 1940
|
3320, 4301
|
2755, 3304
|
1962, 2187
|
2203, 2279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,115
| 199,078
|
45631
|
Discharge summary
|
report
|
Admission Date: [**2179-12-28**] Discharge Date: [**2180-3-1**]
Date of Birth: [**2141-4-24**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
tracheostomy
G tube placement
multiple central line placements
multiple arterial lines
upper endoscopy
bronchoscopy x 3
History of Present Illness:
This is a 38 AAF w/ no sig PMH who initially presented to
[**Hospital 1474**] hospital on [**12-24**] with a [**12-5**] wk h/o SOB, anorexia,
productive cough, subjective fevers/chills, and pleuritic CP.
Her admission VS were notable for a Tm 100.4, BP 106/60, HR 111,
and 87% sat on RA. She was found to have a multilobular bilat
pneumonia and placed on CTX/azithro. Over the next 48hrs, she
became progressively more tachypnic & hypoxic with sats dipping
into the 70s on 2L NC, prompting an ICU transfer and eventual
intubation on [**12-27**]. She was pancx'd and her antibiotic regimen
was empirically broadened to ceftaz/vanc/flagyl. She was
initially on volume-control ventilation but soon switched over
to PCV [**1-5**] high PIPs on the evening of [**12-27**]. Of note, she was
disynchronous with the vent despite maximum doses of propofol,
versed, and morphine gtts and was ultimately started on a
vecuronium gtt on the night of [**12-27**]. CXR [**12-28**] revealed diffuse
bilat infiltrates c/w ARDS vs PCP, [**Name10 (NameIs) **] prompting a bronchoscopy
and empiric administration of bactrim/solumedrol immediately
prior to transfer. All cultures remain negative to date, and
she remains HD stable with no pressor requirement and normal
renal function.
Past Medical History:
Rickets in childhood
C-section x 3, last 13yrs ago
Social History:
: single, lives with her parents, has 3 kids & 1 grandchild
+EtOH: 6-12pk beer/week
+tob: 1/2ppd x 24yrs
+drugs: no IVDU ever, +cocaine, +marijuana
Family History:
mom/uncles/aunts/[**Name2 (NI) 30871**] w/ DM2
Physical Exam:
PE: T 96.0 BP 130/77 HR 130 RR 18 Sat 98%
Vent: PCV 30 x 18, driving pressure 20, peep 10, 100% FiO2
TVs 370s, Sats 97-99%
I/Os: 500cc UO/2hrs, CVP 18
Gen - intubated/sedated/paralyzed, no response to stimuli or
verbal commands, appears comfortable
Heent - pupils minimally reactive bilat, protruberant tongue,
MMM
Neck - RIJ site C/D/I w/o erythema, no LAD or TM appreciated
Lungs - [**Month (only) **] BS/rales at bases L > R but upper lung fields clear
ant
CV - tachy S1S2, no R/M/G appreciated
Abd - soft, NT/ND, NABS, no HSM or masses appreciated
Ext - warm throughout, 1+ DPs bilat, no CT, no peripheral edema,
L A-line site appears C/D/I w/o erythema
Pertinent Results:
ADMIT LABS:
[**2179-12-29**]
12:44a
pH
7.13 pCO2
62 pO2
84 HCO3
22 BaseXS
-9
Comments: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Temp:35.5
freeCa:1.10 Lactate:1.1
O2Sat: 93
[**2179-12-29**]
12:30a
133 107 6 / AGap=9
-------------162
5.0 22 0.4 \
CK: 204 MB: 4 Trop-*T*: <0.01
Comments: Note Updated Reference Ranges As Of [**2178-6-2**]
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 7.5 Mg: 2.4 P: 4.1
ALT: 16 AP: 71 Tbili: 0.2 Alb: 2.3
AST: 27 LDH: 627 Dbili: TProt:
[**Doctor First Name **]: 44 Lip: 12
TSH:1.7
69
11.2 \ 10.2 / 287
/ 32.9 \
N:89.8 Band:0 L:7.8 M:1.5 E:0.6 Bas:0.2
Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Microcy: 3+ Polychr:
OCCASIONAL Ovalocy: 1+ Target: 1+ Schisto: 1+ Tear-Dr:
OCCASIONAL
Comments: MANUALLY COUNTED
PT: 15.0 PTT: 31.1 INR: 1.4
Fibrinogen: 388
UA
Color
Yellow Appear
Clear SpecGr
1.025 pH
5.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Sm Nitr
Neg Prot
Tr Glu
Neg Ket
Neg
[**2180-2-20**] 4:20 pm SWAB Source: G-tube drainage.
**FINAL REPORT [**2180-2-23**]**
WOUND CULTURE (Final [**2180-2-23**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH.
[**2180-2-19**] 8:51 am URINE Site: CATHETER
**FINAL REPORT [**2180-2-20**]**
URINE CULTURE (Final [**2180-2-20**]): NO GROWTH.
[**2180-2-18**] 4:00 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
**FINAL REPORT [**2180-2-22**]**
BLOOD/FUNGAL CULTURE (Final [**2180-2-22**]):
REPORTED BY PHONE TO [**First Name9 (NamePattern2) 97294**] [**Last Name (un) **] @ 0635 ON [**2180-2-20**].
[**Female First Name (un) **] PARAPSILOSIS.
[**2180-2-17**] 4:25 pm URINE Site: CATHETER
**FINAL REPORT [**2180-2-22**]**
URINE CULTURE (Final [**2180-2-22**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 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.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S 2 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I =>4 R
GENTAMICIN------------ 2 S =>16 R
IMIPENEM-------------- <=1 S 8 I
MEROPENEM-------------<=0.25 S 1 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
[**2180-2-11**] 3:02 pm URINE
**FINAL REPORT [**2180-2-13**]**
URINE CULTURE (Final [**2180-2-13**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
VANCOMYCIN------------ =>32 R
[**2180-1-22**] 6:01 pm URINE
**FINAL REPORT [**2180-1-29**]**
URINE CULTURE (Final [**2180-1-29**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
Nitrofurantoin sensitivity available on request.
[**Female First Name (un) **] PARAPSILOSIS. >100,000 ORGANISMS/ML..
WORK UP ID PER DR.[**Last Name (STitle) **] PG# [**Serial Number 97295**] ([**2180-1-27**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
VANCOMYCIN------------ =>32 R
[**2180-2-14**] 4:07 am Immunology (CMV)
**FINAL REPORT [**2180-2-16**]**
CMV Viral Load (Final [**2180-2-16**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2180-2-5**] 4:57 am Immunology (CMV)
**FINAL REPORT [**2180-2-8**]**
CMV Viral Load (Final [**2180-2-8**]):
1,080 copies/ml.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
Time Taken Not Noted Log-In Date/Time: [**2180-2-2**] 12:21 pm
Immunology (CMV)
**FINAL REPORT [**2180-2-4**]**
CMV Viral Load (Final [**2180-2-4**]):
1,320 copies/ml.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
REPORTED BY PHONE TO [**Doctor Last Name 9529**] 11.30A [**2180-2-4**].
[**2179-12-29**] 5:30 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2179-12-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2179-12-31**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2180-1-8**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2179-12-30**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2179-12-30**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2180-1-14**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2179-12-30**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2180-1-12**] 10:15 pm SWAB Site: LIP
**FINAL REPORT [**2180-1-20**]**
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2180-1-20**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
Time Taken Not Noted Log-In Date/Time: [**2180-1-11**] 12:30 am
BLOOD CULTURE TRIPLE LUMEN.
**FINAL REPORT [**2180-1-16**]**
AEROBIC BOTTLE (Final [**2180-1-16**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2180-1-14**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 08:09AM ON [**2180-1-12**] -
4I.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance penicillins, cephalosporins, carbacephems,
carbapenems,
and beta-lactamase inhibitor combinations.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 1 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
[**2180-1-4**] 3:06 pm IMMUNOLOGY FROM ART LINE.
**FINAL REPORT [**2180-1-6**]**
HIV-1 Viral Load/Ultrasensitive (Final [**2180-1-6**]):
Greater than 100,000 copies/ml.
Performed by RT-PCR (ultrasensitive).
Detection range: 50-100,000 copies/ml.
This test is designed primarily to monitor HIV viral load
in known
HIV infected patients. If this result is being used to
diagnose
antibody negative acute infection, please call the
[**Hospital **]
medical director for interpretation of result.
If quantitation beyond 100,000 copies/ml is desired,
please contact
laboratory at ext. [**6-/3193**] within 2 weeks.
IMAGING
[**2179-12-29**] Radiology CHEST (PORTABLE AP)
IMPRESSION:
1). Diffuse bilateral pulmonary edema.
2). Endotracheal tube, nasogastric tube, and right internal
jugular central venous catheter in good position.
3). No pneumothorax.
[**2179-12-29**] Cardiology ECHO
IMPRESSION: Normal LV cavity size and systolic function.
Borderline dilated RV
cavity size with normal RV systolic function. RV pressure
overload. Moderate
tricuspid regurgitation with mild pulmonary hypertension.
Moderate-sized
pericardial effusion without tamponade.
[**2180-1-2**] Radiology CTA CHEST W&W/O C &RECONS
IMPRESSION:
1) No evidence of pulmonary embolism. Respiratory motion
artifact limits evaluation of the subsegmental pulmonary
arteries.
2) Diffuse alveolar and ground glass opacities throughout both
lungs suggestive of ARDS.
3) Moderate pericardial effusion.
[**2180-1-11**] Radiology CT ABD W&W/O C
IMPRESSION:
1) No evidence for abscess or pancreatic pseudocyst.
2) Findings compatible with ARDS.
[**2180-2-19**] Radiology CTA CHEST W&W/O C &RECONS
IMPRESSION:
1) No pulmonary embolism identified.
2) Diffuse, severe ground glass consolidation involving both
lungs, with small cystic changes seen in the upper lung fields.
These findings are compatible with ARDS.
[**2180-2-17**] Radiology CT ABDOMEN W/CONTRAST
1) Ground-glass opacities within the lungs and persistent left
lower lobe consolidation. This could be consistent with ARDS or
PCP/other infectious pneumonia in an HIV postive patient.
2) Findings consistent with mild gastroenteritis.
3)No new abnormalities to explain the patient's fever and left
upper quadrant pain.
4)Malpostioned rectal tube.
[**2180-2-16**] Radiology CT HEAD W/ & W/O CONTRAST
FINDINGS: No previous examination available for comparison.
White and [**Doctor Last Name 352**] matter differentiation is preserved. No
intracranial masses and no hemorrhages are identified. Midline
structures are normal in position. Ventricles and subarachnoid
spaces are normal. No abnormal enhancing lesions are identified.
Basilar cisterns are patent. Cerebellum is normal.
There is prominence of the nasopharyngeal soft tissue seen on
the scout view, direct inspection is recommended to r/o a mass,
as well as possible dedicated neck CT imaging.
No bony abnormalities are seen.
IMPRESSION: Prominent nasopharyngeal soft tissues seen on the
scout view-see above report. Brain parenchyma is unremarkable.
[**2180-2-22**] Radiology CHEST (PORTABLE AP)
IMPRESSION:
1) Interval placement of the right arm PICC line. The tip is in
the superior vena cava.
2) Some improvement in the degree of right lower lobe
infiltration. The infiltration in the remainder of the lung
fields has not changed.
3) No evidence of pneumothorax
Cardiology Report ECG Study Date of [**2180-2-16**] 10:36:32 AM
Sinus tachycardia. Modest diffuse ST-T wave changes with slight
ST segment
elevation - could be due to early repolarization pattern but
consider also,
possible pericarditis. Since the previous tracing of [**2180-2-14**]
right axis
deviation is now absent.
Brief Hospital Course:
Brief HPI and Hospital Course Overview (details are
subcategorized after overview):
Ms. [**Known lastname 976**] is a 38 year old femal with a recent HIV diagnosis
(CD4 200, VL High), H/O Childhood Rickets who had a prolonged
(three months) ICU course for hypoxic/hypercarbic respiratory
failure, presumed secondary to multilobar PNA and then ARDS. She
initially presented to an outside hospital with two weeks of
anorexia, productive cough, subjective fevers/chills, and
pleuritic chest pain. She was febrile and hypoxic with impending
respiratory failure and multilobar infitrates on chest imaging.
She soon required intubation, despite two days of
ceftriaxone/azithromycin. After broadening of her ABX, checking
an HIV without consent (which was positive), she was transferred
to [**Hospital1 18**] for further care.
[**Hospital Unit Name 153**] Course: The patient's respiratory status worsened and soon
met ARDS criteria. Over her course, she has been on the
following ABX: Levoquin, Vancomycin, Zosyn, Meropenem, Ambisome,
and Bactrim/Solumedrol (for empiric PCP [**Last Name (NamePattern4) **]). All cultures have
been negative. Given her declining respiratory status, she
required nontraditional maneuvers for oxygenation including an
abdominal binder/proning, and neuromuscular paralysis. She
received trach/PEG on [**2180-1-24**]. After almost two months on MV,
the she was converted to pressure support. There were multiple
unsuccessful attempts at weaning from steroids, which seemed to
support her oxygenation despite negative PCP. [**Name10 (NameIs) **] etiology of
her respiratory failure was not found, but possibly illicit
drug-induced lung disease with superimposed PNA. Her course was
also complicated by VRE, Citrobacter, Pseudomonas UTIs.
Called-out to Medicine: The patient had no further events other
than paroxysms of anxiety. She was started on Ativan as needed.
She was comfortable with 2-3 liters of supplemental oxygen.
1) Respiratory Failure/ARDS: The patient initially pt had
multilobar pneumonia that evolved into ARDS. She was very
acidotic on admission, and was difficult to oxygenate. She was
put on multiple antibiotics, including levoquin, vancomycin,
zosy, levoquin, meropenem, ambisome, and bactrim plus solumedrol
for empiric PCP. [**Name Initial (NameIs) **] BAL was done which was unremarkable, as were
the other two done during her admission. Multiple sputum and
blood cultures were negative. Her respiratory status declined
progressively during admission, and she required nontraditional
maneuvers for oxygenation including an abdominal binder and
proning, and neuromuscular paralysis with cisatracurium. An
esophageal balloon was placed which revealed elevated
intrathoracic pressures and her PEEP was increased accordingly.
She was ventilated using an ARDSnet strategy and occasionally
with other strategies such as APRV. She required extremely high
amounts of versed (up to 80 per hour) and fentanyl (up to 1300
mcg per hour) for [**Last Name (LF) **], [**First Name3 (LF) **] the latter was changed to a
methadone drip at 10 per hour. She got a trach and peg on [**1-24**],
retrached with larger size on [**2-14**]. She had multiple
unsuccessful multiple attempts at weaning from steroids due to
oxygenation problems despite negative PCP. [**Name10 (NameIs) 616**] almost 2 months
on the ventilator, the sedation was gradually weaned off and she
was converted to pressure support. She had multiple episodes of
agitation where she became tachypnic, tachycardic and
diaphoretic without spiking a fever, which in retrospect were
likely due to both pain and anxiety. She was able to tolerate
minimal ventilatory support and could talk on the Passy Muir
valve by [**2-23**] and was determined to be ready for rehabilitation.
The exact cause of her respiratory failure was never clear, but
was likely from underlying drug induced lung disease with
superimposed pneumonia.
At d/c, she must continue prednisone 40mg daily for control
of her respiratory disease. She will require a slow prednisone
taper over months that is closely supervised by a physician.
[**Name10 (NameIs) **] in her prednisone regimen will be decided by Dr. [**Last Name (STitle) **]
upon follow-up on [**2180-3-25**].
2) HIV - This test was checked at the OSH erroneously without
patient consent. Her CD4 was fluctuated around 200 (low 188, 209
at discharge) and her viral load was >100,000. She received
treatment doses of bactrim for presumed PCP and then this was
changed to atovaquone prophylaxis. HAART was considered but not
felt to be of immediate benefit to the patient so she will
follow up with ID as an outpatient to discuss this further.
Ethics were consulted regarding the issue of whether to inform
the patient's mother and/or fiancee, as the patient was
intubated and sedated and unable to do this herself. The
decision was made to tell her fiancee based on the fact that he
may be need this information to see treatment and that he may be
putting others at risk if he were HIV positive. He was told on
[**2-8**] that he needed to be tested for HIV. The patient was told on
[**2-22**] and she told her mother her status. If it had been felt to
influence her mother's decision making ability, then she would
have been informed sooner.
3) ID: The patient was admitted with PNA/ARDS. She was on and
off many empiric antimicrobial agents for multiple fevers. ID
was involved the majority of her time in the hospital. She had a
culture/ID history directed microbial therapy summarized as
follows:
Positive culture history:
OSH: positive HIV antibody test
[**1-4**]: HIV-1 positive VL
[**1-11**]: 3/4 bottles coag neg staph with line tip positive
[**1-13**]: Lip sore: HSV-1
[**1-22**]: UrCx: VRE and [**Female First Name (un) **]
[**1-24**]: catheter tip coag neg staph
[**2-2**]: CMV viral load 1320 copies per ml, [**2-5**] 1080.
[**2-11**]: UrCx: VRE
[**2-13**]: UrCx: VRE
[**2-17**] Urine: Citrobacter freundii, pseudomonas aeruginosa (both
[**Last Name (un) 36**] zosyn and ceftaz)
[**2-18**]: Blood Cx: budding yeast
[**2-19**]: UrCx: no growth
[**2-20**]: G tube swab: coag neg staph, yeast
Treatments:
*Yeast - The patient had a single positive in fungal isolator
[**2-18**]. Optho eval [**2-22**] showed no [**Female First Name (un) **] in retina. Ambisome was
started [**2-19**] for [**Female First Name (un) **] coverage, changed to fluconazole on
[**2-22**]. Treat for 14 days total per ID (last day [**3-3**])
*UTI with VRE/GNR - The patient had a positive urine culture
with VRE on [**1-22**] and received a course of 14 days of linezolid.
After another urine culture was positive for VRE on [**2-12**], her
foley was replaced and changed to 3 day course of daptomycin for
better urinary penetration. Dapto was discontinued. On [**2-17**] she
was found to have citrobacter and pseudomonas in her urine which
treated with 3 days of ceftaz then zosyn. Most recent urine cx
negative.
*CMV viral load - This was found to be low level positive at
1320 copies. ID recommended gancyclovir for postitive CMV viral
load which was given for 9 days total. This was changed to
Valcyte for secondary proph [**2-16**] as CMV VL negative from [**2-14**],
stopped [**2-22**] as CD4 > 50. She had an opthalmologic exam which
was negative for CMV.
* diarrhea - multiple stool cultures, and A dif A and B toxin
were checked and persistently negative.
* finger necrosis - she developed dry gangrene of her left
distal digits ([**1-8**]). The etiology was unclear, but was likely
via clotting from sepsis/DIC or septic emboli. However, she had
no clear signs of endocarditis and had no vegetiations on ECHO.
On discharge, she was pain free with decreased distal sensation.
No acute treatment was sough, but she will advised to have
surgical follow-up for likely amputation.
4) Agitation/sedation/substance dependence - The patient had a
history of cocaine and alcohol drug use. She was originally on
versed and fentanyl, but the latter was replaced with methadone
to to her extrememly high requirements. She had virtually daily
"episodes" of breathing at RR > 50, pulse > 120, diaphoresis
which were originally thought to respond to boluses of versed,
then to oxygen, then to magnesium, then to conversation. She
says that there were from pain and anxiety over her condition.
Psychiatry was consulted on 3 separate occasions to see the
pateint. They first recommended weaning the agents. The versed
was weaned very slowly, 5% per day, to off. Once it was off the
patient woke up and could talk with a Passy Muir Valve. Next,
the methadone infusion was weaned 10% per day and converted to
oral equivalent at approximately 1:1. Psych was reconsulted and
recommended seroquel for agitation/anxiety. The pt is NOT to be
given benzodiazepines per Psych consultant, as she does not have
anxiety disorder requiring these medications and reintroduction
of benzodiazepines may create drug dependence. She is to be
given seroquel 25mg TID prn for anxiety, in addition to her
standing seroquel dose. This has been shown to work well in
this pt.
5) abdominal pain - The patient had multiple episodes of abd
pain but two separate CT scans of her abdomen negative. The
first time her amylase and lipase were slightly elevated (315
and 156 peak, respectively) but CT showed no pancreatitis. Her
LFT's were slightly elevated during admission but hepatitis
antibodies were negative. The second time she had abdominal pain
she was felt to have gas pain or pain from atovaquone and was
started on simethicone after abdominal CT was negative.
6) Magnesium requirement - The patient has an unusually large
magnesium requirement, which is thought to potentially be from
rebuilding her muscle. She will be discharged on PO magnesium
supplements.
7) EKG changes - The patient was noted to have new T wave
inversions on EKG with possible slight ST elevation on [**2-9**] which
was new since [**1-29**]. Troponins were negative. An echo [**2-11**] was
unchanged from admission, showing mild LV hypertrophy, mod pulm
artery HTN, no effusion, improved TR.
8) Anemia - The patient was noted to have chronic, stable
anemia, and required 4 units of blood total. Iron studies showed
iron 14 (low), TIBC 228 low, TRF 175 (low), B12 + folate normal.
Looks like mixed picture of ACD and [**Doctor First Name **].
9) glycemic control - The patient had hyperglycemia, likely from
steroids. She was controlled with insulin drip, standing
insulin, and sliding scale, which was tapered along with her
steroids.
10) FEN - The patient was fed with TPN, and tubefeeds. She was
given reglan for gastric motility as she had high residual
volumes after G tube feeds. A J tube was placed by GI
endoscopically. She passed her swallow evaluation and could
tolerate food at discharge.
11) access - Multiple lines and tubes were placed including ETT,
tract tube, PEG tube, PICC, subclavians, and A lines.
12) PPx - She was kept on a PPI, sc heparin, and bowel regiemen
when she didn't have diarrhea.
13) Code - She was full code throughout admission.
Medications on Admission:
tylenol,
solumedrol 50 [**Hospital1 **],
MDIs,
lovenox 40 qd,
pepcid,
bactrim 350 tid,
versed gtt,
morphine gtt,
vecuronium gtt,
ceftaz,
vanc,
flagyl
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) U Injection TID (3 times a day).
4. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4H
(every 4 hours) as needed.
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for through 4/1 days: Last day [**2180-3-3**] days: through
4/1 days: Last day [**2180-3-3**].
6. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): [**Month (only) 116**] increase hs dose to 50 mg if necessary .
7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Insulin Regular Human 100 unit/mL Solution Sig: as directed U
Injection ASDIR (AS DIRECTED).
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Tapering to be discussed with pt's pulmonologist. Pt has been
very sensitive to prior attempts to taper streoids.
10. Methadone HCl 10 mg/mL Concentrate Sig: Forty Five (45) mg
mg PO Q6H (every 6 hours): Taper by 5 mg every 2 days (40 QID,
then 35 QID, etc) to off.
11. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO
DAILY (Daily): check weekly potassium levels, if >4.4, then d/c
potassium supplement. .
12. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Hydromorphone HCl 2 mg/mL Syringe Sig: 2-4 mg Injection
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1) Respiratory failure from acute respiratory distress syndrome
from pneumonia
Secondary:
2) Polysubstance Abuse
3) VRE urinary tract infection s/p treatment
4) [**Female First Name (un) **] fungemia - to complete 14 day course
5) cytomegalovirus viremia s/p treatment
6) human immunodeficiency virus infection/AIDS
7) elevated liver function and pancreatic enzymes
8) opiate dependence
9) chronic anxiety
10) persistent hypomagnesemia
11) persistent hypokalemia
12) anemia of chronic disease
13) steroid induced hyperglycemia
14) s/p Tracheostomy
15) s/p PEJ tube placement
Discharge Condition:
patient was talking with a Passy Muir valve and breathing
through a trach collar with supplemental oxygen, with O2 sats in
the high 90's
Discharge Instructions:
You are being discharged to a rehab facility.
Please return if you have shortness of breath, fever above 102
degress, or other concerns.
Followup Instructions:
With Dr. [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) **] at [**Hospital 18**] [**Hospital3 **] 1-2 weeks
after discharge from rehab. Call [**Telephone/Fax (1) 250**] for appointment.
Dr. [**First Name (STitle) **] will decide if you require a surgical evaluation of the
necrotic (dead) parts of the tips of your left fingers.
With Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**] from infectious disease in [**12-5**] weeks to
discuss antiretroviral therapy. ([**Telephone/Fax (1) 4170**]
With the psychiatrist of your choice within 1 month after
discharge from rehab.
With DR. [**Last Name (STitle) **] in Pulmonary clinic on [**2180-3-24**] at 8:50AM,
Phone:[**Telephone/Fax (1) 612**]. Please continue the Prednisone at 40 mg
daily until you see Dr. [**Last Name (STitle) **] to discuss further weaning.
|
[
"E932.0",
"518.84",
"304.70",
"V58.65",
"484.1",
"996.62",
"599.0",
"305.1",
"785.4",
"305.00",
"041.04",
"042",
"078.5",
"285.29",
"112.5",
"251.8",
"054.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.32",
"00.14",
"96.72",
"00.17",
"31.1",
"96.6",
"38.93",
"33.24",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
28293, 28365
|
15311, 26358
|
277, 399
|
28994, 29132
|
2706, 9663
|
29318, 30180
|
1954, 2002
|
26559, 28270
|
28386, 28973
|
26384, 26536
|
29156, 29295
|
2017, 2687
|
9699, 15288
|
228, 239
|
427, 1699
|
1721, 1773
|
1790, 1938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,142
| 122,395
|
49531
|
Discharge summary
|
report
|
Admission Date: [**2131-4-26**] Discharge Date: [**2131-5-26**]
Date of Birth: [**2056-4-5**] Sex: F
Service: Liver Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman status post orthotopic liver transplant on [**2130-12-5**] who had a relatively brief hospital stay and was
discharged on [**2130-12-19**].
She was doing well over the past several months. On
colonoscopy in [**2131-3-15**] she was found to have a cecal
polyp. Further workup revealed on abdominal computed
tomography three liver lesions. By ultrasound guidance,
these lesions were biopsied and the results were consistent
with a hepatic abscess. Preliminary culture results
indicated a gram-negative growth.
Overall, the patient was feeling well. She complained of
some crampy abdominal pain. However, she was not having any
nausea or vomiting at that time. The patient was admitted
for further workup of these liver lesions and management of
them.
PAST MEDICAL HISTORY:
1. Primary sclerosing cholangitis.
2. Ulcerative colitis.
3. Hepatitis B.
4. Cholangitis.
5. Anemia.
6. Anxiety disorder.
7. Liver transplant on [**2130-12-5**].
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, vital signs revealed temperature was 98.7
degrees Fahrenheit, blood pressure was 108/70, heart rate was
96, respiratory rate was 20, and she was saturating at 97% on
room air. In general, the patient was well-appearing and
well-nourished. In no acute distress. Head, eyes, ears,
nose, and throat examination revealed sclerae were anicteric.
Extraocular movements were intact. The mucous membranes were
moist. The neck was supple with no jugular venous
distention. The lungs were clear to auscultation
bilaterally. Cardiovascular examination revealed a regular
rate and rhythm. The abdomen was soft and nondistended.
Slight tenderness in the right upper quadrant. She had a
well-healed scar. There was no evidence of any hematoma at
the biopsy site. Extremity examination revealed no clubbing,
cyanosis, or edema. Neurologic examination revealed the
patient was alert and oriented times three; a nonfocal
examination.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
revealed white blood cell count was 4 and hematocrit was
31.1. CEA was 1.8. Blood urea nitrogen was 17 and
creatinine was 1. AST was 17, ALT was 26, alkaline
phosphatase was 121, and total bilirubin was 0.4.
HOSPITAL COURSE BY ISSUE/SYSTEM: Ms. [**Known lastname 1557**] was a
75-year-old woman status post orthotopic liver transplant in
[**2130-11-15**] with a new diagnosis of colon cancer and
probable hepatic abscess by ultrasound biopsy.
The patient was admitted to the Transplant Surgery Service
under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient was placed
on a regimen of antibiotics including vancomycin,
levofloxacin, and Flagyl.
The patient underwent a hepatic angiogram on [**2131-5-1**]
which showed a focal near occlusion of the hepatic proper
artery, a complete occlusion of the hepatic artery at the
same level after attempted crossing with a guide wire. The
procedure was complicated by dissection, and the patient was
returned to the operating room for hepatic artery
reanastomosis.
She was admitted to the Surgical Intensive Care Unit
postoperatively where she was a little hypotensive and mildly
septic. However, she did not require pressors. After
receiving a transfusion and multiple boluses, the patient
returned to a normal blood pressure.
The patient was evaluated by the Surgical team for management
of her colon cancer. The patient had a repeat computerized
axial tomography to evaluate a liver abscess which showed a
mild increase in the size of the known lesion within the
liver. A repeat biopsy indicated chronic inflammatory
change. No infection.
A repeat ultrasound showed normal blood flow to the liver, so
it was decided to take the patient to the operating room for
a right hemicolectomy for management of her cecal cancer.
The patient did very well postoperatively. Her antibiotic
regimen at that point was vancomycin, levofloxacin, and
Flagyl for her history of Enterobacter cultured from her
initial biopsy upon admission.
A repeat computerized axial tomography of the abdomen
postoperatively showed a new area of irregular hypodensity
within the liver. This was thought to be consistent with
more of an ischemic change.
The patient was experiencing a short period of abdominal
distention; however, this resolved, and the patient was
eventually able to tolerate a regular diet.
Hematology/Oncology was consulted. The pathology of the
colon cancer indicated a mucinous and signet-ring cell
carcinoma, high-grade, poorly differentiated to under
differentiated with invasion to the muscularis propria and to
the subserosa, and [**5-26**] positive lymph nodes. There was no
venous invasion. There was perineural invasion present.
Given her new diagnosis of end-stage III-C T3 N2 M0 by TNM
staging, Oncology recommended adjuvant chemotherapy
of the cecal carcinoma with a chemotherapy combination of
5-fluorouracil and leucovorin. The patient was to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (the Gastroenterologist/Oncologist).
It was thought best that the patient return home with
[**Hospital6 407**] services and proper followup with
both the oncologist (as mentioned) and Dr. [**Last Name (STitle) **] in the
[**Hospital 1326**] Clinic. The patient was discharged on [**2131-5-26**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Colon cancer.
2. Ulcerative colitis.
3. Hepatic abscess.
4. Hepatitis B.
5. Primary sclerosing cholangitis.
6. Anemia.
INVASIVE/SURGICAL PROCEDURES DURING THIS ADMISSION:
1. Status post angiogram complicated by dissection.
2. Status post exploratory laparotomy with hepatic artery
anastomotic repair.
3. Status post right hemicolectomy.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg p.o. once per day.
2. Calcium carbonate 500 mg one tablet p.o. twice per day.
3. Vitamin D 400 International Units one tablet p.o. once
per day.
4. Prednisone 5-mg tablet one tablet p.o. once per day.
5. Valcyte 450-mg tablet two tablets p.o. twice per day.
6. Levofloxacin 500-mg tablet one tablet p.o. once per day.
7. Clopidogrel bisulfate 75-mg tablet one tablet p.o. once
per day.
8. Epogen injection once per week.
9. Lasix 10 mg p.o. once per day.
10. Cyclosporine 50 mg p.o. twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) **] at the
Transplant Center (telephone number [**Telephone/Fax (1) 673**]) on [**2131-5-31**] at 11:30 a.m.
2. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (the
hematologist/oncologist specialist) at the [**Last Name (un) 469**] Center,
Hematology/Oncology suite (telephone number [**Telephone/Fax (1) 22**]) on
[**2131-6-6**] at 2:30 p.m.
3. The patient was to schedule an appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (telephone number [**Telephone/Fax (1) 673**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 28937**]
MEDQUIST36
D: [**2131-5-28**] 19:18
T: [**2131-6-4**] 16:23
JOB#: [**Job Number 103605**]
|
[
"E878.4",
"444.89",
"556.9",
"153.6",
"196.2",
"998.2",
"572.0",
"996.82",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"39.49",
"45.73",
"89.64",
"38.06",
"99.15",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
5652, 6003
|
6030, 6569
|
6602, 7506
|
2471, 5580
|
5595, 5631
|
180, 974
|
996, 2436
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,850
| 137,448
|
9560+56041
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-4-13**] Discharge Date: [**2161-5-22**]
Date of Birth: [**2129-8-16**] Sex: F
Service: TRANSPLANT SURGERY
CHIEF COMPLAINT: End-stage liver disease secondary to
primary sclerosing cholangitis.
HISTORY OF PRESENT ILLNESS: Patient is a 31-year-old female
with longstanding history of primary sclerosing cholangitis
complicated by cirrhosis, portal hypertension, right upper
quadrant abdominal pain and hyperbilirubinemia. Patient had
undergone a liver transplant evaluation and had been on the
waiting list since [**2160-9-30**]. Following evaluation, an
appropriate match was found for living unrelated liver
transplant from her friend. The patient was admitted to the
Medical Center on [**2161-4-13**] for living unrelated liver
transplant.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Primary sclerosing cholangitis.
3. Psoriasis.
MEDICATIONS ON ADMISSION:
1. Calcium.
2. Vitamin D.
3. Mesalamine 1200 mg p.o. b.i.d.
4. Amitriptyline 25 mg p.o. q.h.s.
5. Atarax 50 mg p.o. q.h.s.
6. Mycelex.
7. Phenergan 25 mg p.o. t.i.d. prn.
8. Fiorinal prn.
9. Ultram 50 mg p.o. t.i.d. prn.
10. Ursodiol 500 mg p.o. b.i.d.
ALLERGIES: The patient is allergic to Morphine.
SOCIAL HISTORY: The patient is married without children.
She has an Associates Degree in human services, but was on
medical leave prior to admission for transplant. She stopped
working in [**2158**].
HOSPITAL COURSE: Patient was admitted to the [**Hospital1 346**] on [**2161-4-13**] and taken to the OR,
where she underwent a living unrelated liver transplant. For
details of this surgery, please refer to the dictated
operative note. The patient's intraoperative course was
complicated by portal vein thrombosis. The patient received
7.5 liters of crystalloid, 7 units of fresh-frozen plasma, 13
units of packed red blood cells in the operating room. Urine
output was 2100 cc.
The patient was transferred to the Surgical Intensive Care
Unit while intubated as is customary. The patient's
postoperative course was marked by poor graft function with
persisting coagulopathy requiring multiple transfusions of
fresh-frozen plasma and cryoprecipitate. In the period
following the surgery, the patient did wake up and was alert
and following commands and in no apparent distress. She was
moving all extremities. The patient remained coagulopathic
through postoperative day number two and into postoperative
day number three.
On postoperative day number three, the patient was noted to
be increasingly somnolent and more difficult to arouse.
Later in the day on postoperative day number three, the
patient was observed to have some seizure-like activity
beginning in the upper extremities and generalizing to a
tonic-clonic seizures. Neurology consultation was
immediately requested, and the patient underwent a CAT scan
evaluation of her head. Her CAT scan revealed no immediate
etiology for this seizure. There was no acute hemorrhage.
There is no mass effect or shift of the normally midline
structures.
Given concern for increasing intracranial pressure secondary
to edema given the patient's poor liver function,
Neurosurgery consultation was also requested, and the
decision was made to place an intracranial pressure monitor.
This was placed on postoperative day number four. The
patient had been started on Mannitol for diuresis. The
patient's neurologic examination was closely monitored, and
continued to deteriorate. A CAT scan of the patient's head
obtained on [**2161-4-19**] revealed progression of the patient's
diffuse bilateral cerebral edema. There were also findings
consistent with tonsillar herniation. There was also
possible subarachnoid hemorrhage.
On postoperative day number four, the patient was also
witnessed to have four seizure events, which were initially
focal and which generalized lasting as long as 10 minutes.
Neurology involvement was once again solicited and decision
was made to initiate pentobarbital. Bedside EEG monitoring
was also initiated.
The patient had been relisted for transplant on postoperative
day number three given the persistent poor graft function,
and on postoperative day number five, which was [**2161-4-19**], an
organ became available for the patient. The patient was
taken back to the operating room and underwent cadaveric
liver transplant. The patient received 2 liters of
crystalloid, 2 units of fresh-frozen plasma, 2 units of
packed red blood cells, and 1 unit of cryoprecipitate in the
OR. Her urine output was 2 liters.
Following this second transplant procedure, the patient's
liver function quickly improved and her coagulopathy
resolved. Unfortunately, the patient's neurologic status
remained a grave concern.
On [**2161-4-21**], the patient underwent a repeat CAT scan of her
head, which revealed a reduction in her cerebral edema. The
degree of injury the patient may have suffered secondary to
sustained effusion deficits from the cerebral edema could not
be ascertained from the study.
On [**2161-4-22**], the patient had a fever for which cultures were
sent, and an Infectious Disease consultation was requested.
The patient was started on vancomycin and Zosyn. Cultures
drawn following this event were ultimately negative. X-ray
imaging of the chest suggested the patient may have a
pneumonia.
On [**2161-4-23**], the patient's pentobarbital, was discontinued.
Given her limited liver function, the duration of effect of
the pentobarbital was uncertain. The patient was expected to
wake up slowly. A CAT scan of the patient's head on [**2161-4-24**]
was largely unchanged from the previous study on [**2161-4-21**].
By [**2161-4-25**], the patient was opening her eyes to speech, but
not following commands. Her intracranial pressure had
remained stable at less than 10. The patient's Levophed drip
had been turned off.
On [**2161-4-26**], the patient's Swan catheter was removed and
exchanged with a central venous line. The patient's
intracranial pressure bolt was also removed. In the period
around [**2161-4-26**], the patient's respiratory status was noted
to be particularly poor, and the patient underwent a workup
for pulmonary embolism. A CT angiogram of her chest revealed
no evidence of clot and lower extremity ultrasound also
revealed no evidence of deep venous thrombosis.
By [**2161-4-28**], the patient was occasionally appearing to track
when caretakers were present in her room. She showed minimal
spontaneous movement. The patient was started on tube feeds.
On [**2161-5-1**], the patient once again underwent a CAT scan of
her head to evaluate the degree of cerebral edema. There was
decreased edema evidenced by decreased effacement of the
patient's sulci, but with diffuse patchy hypodensities noted
throughout both cerebral hemispheres.
On [**2161-5-4**], the patient underwent a MRI of her brain to
further evaluate the degree of injury she had suffered.
Extensive bilateral cerebral edema was noted involving the
cortex particularly in the insular region. The degree of
edema was noted to be far less extensive than originally seen
on CAT scan.
On [**2161-5-6**], the patient was taken to the OR for a
tracheostomy. This was performed without complications.
On [**2161-5-9**], the patient again had a temperature spike and
cultures were once again drawn. There was ultimately no
growth from her cultures. The patient's central line was
exchanged over wire. Cultures of the catheter were also
negative.
On [**5-9**], some attempt to wean down the patient's mechanical
ventilation was attempted, but the patient was unable to
tolerate a pressure support trial.
On [**2161-5-13**], an attempt was made to place a percutaneous
endoscopic gastrostomy tube, but this was unsuccessful
secondary to equipment difficulties. Specifically, there
were difficulties encountered in transilluminating through
the patient's abdominal wall.
On [**2161-5-15**], the patient underwent an open gastrostomy tube
placement in the OR without complications. Use of the
gastrostomy tube for feedings was initiated on [**2161-5-19**].
Discharge planning was initiated at about this time with
expectation that the patient could be transferred to a rehab
facility following placement of the G tube. The patient
continued to be seen by the Neurology service as well as
Physical and Occupational Therapies. Although patient
appeared more awake and alert, the patient was really not
following commands and showed minimal spontaneous movement
and little, if any purposeful movement. The patient was
expected to have a prolonged recovery with long-term
prognosis unclear at this point.
The patient's liver function was essentially normal at the
time of discharge. The patient's liver function tests as
well as her coagulation studies had been normal in the days
prior to discharge. The patient's T tube had been capped.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Primary sclerosing cholangitis now status post orthotopic
liver transplant times two.
2. Severe cerebral injury secondary to edema.
3. Respiratory failure bilateral.
4. Aspiration pneumonia versus atelectasis.
DISCHARGE MEDICATIONS:
1. Neoral (final dose to be determined).
2. Magnesium oxide 400 mg p.o. b.i.d.
3. Metoprolol 12.5 mg p.o. b.i.d.
4. Prednisone 50 mg p.o. q.d.
5. Albuterol/ipratropium inhaler 1-2 puffs q6 prn.
6. Prevacid oral suspension 30 mg/nasogastric tube q.d.
7. Nystatin oral suspension 5 mL p.o. q.i.d. prn.
8. Valcyte 450 mg p.o. b.i.d.
9. Keppra 750 mg p.o. b.i.d.
10. Artificial tears 1-2 drops to each eye prn.
11. CellCept 1 gram/nasogastric tube b.i.d.
12. Heparin 5000 units subcutaneously t.i.d.
13. Bactrim SS one tablet p.o. q.d.
14. Fluconazole 400 mg p.o. q.d.
15. NPH insulin 25 units at breakfast and at bedtime.
FOLLOW UP: The patient is to followup with Dr. [**Last Name (STitle) **] in the
[**Hospital 1326**] Clinic within 1-2 weeks following discharge. The
patient is also to followup with the Neurology team within 1-
2 weeks following discharge. The patient is expected to
setup an appointment with her primary care physician
following discharge. The patient will also need to followup
with Hepatology service following discharge.
MISCELLANEOUS: The patient is currently on tube feedings
using Impact with fiber at full strength running at 70
mL/hour through her G tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 32451**]
MEDQUIST36
D: [**2161-5-19**] 01:43:20
T: [**2161-5-19**] 06:11:36
Job#: [**Job Number 32452**]
Name: [**Known lastname 5620**], [**Known firstname **] Unit No: [**Numeric Identifier 5621**]
Admission Date: [**2161-4-13**] Discharge Date: [**2161-5-22**]
Date of Birth: [**2129-8-16**] Sex: F
Service: TRANSPLANT SURGERY
The night of [**2161-5-18**], the patient spiked a temperature
to 101.2 and she was pancultured as per routine protocol.
The blood cultures were negative and the
central venous catheter tip from which these cultures were
drawn partially was D/C'd and eventually grew staph coag
negative as well. The patient continued to have low grade
temperature to 99 and on [**2161-5-21**], she was started on IV
vancomycin for empiric coverage. She defervesced and
continued to do well. She has continued to slowly improve
from the neurologic standpoint and now she is able to move her
left upper extremity more consistently. She grabs her chin
and rubs her face. She also has a strong grip in that hand.
Surveillance cultures were sent again on [**2161-5-21**], and
there has been no growth so far. At this time we find her
stable to be discharged to [**Hospital3 **] to continue her
recovery. Upon her leaving, a last UA C&S and culture were
sent as surveillance as well.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcu q.eight hours.
2. Magnesium oxide 400 mg per G-tube b.i.d.
3. Metoprolol 100 mg per G-tube b.i.d.
4. Albuterol ipratropium inhaler one to two puffs q.six hours
p.r.n.
5. Prevacid oral suspension 30 mg per G-tube q.day.
6. Nystatin oral suspension 5 ml p.o. q.i.d. p.r.n.
7. Valcyte 450 mg per G-tube t.i.d.
8. Keppra 750 mg per G-tube b.i.d.
9. Artificial Tears one to two drops to each eye p.r.n.
10. Bactrim single strength one tablet per G-tube q.day.
11. Fluconazole 400 mg per G-tube q.day.
12. NPH insulin 25 units at breakfast and at bed time.
13. Regular insulin sliding scale.
14. Fentanyl 25 to 50 mcg IV q.six hours p.r.n.
15. Prednisone 10 mg per G-tube q.day.
16. CellCept [**Pager number **] mg per G-tube q.12 hours.
17. Cyclosporine 175 mg per G-tube q.12 hours.
The patient is currently on continuous enteral feeding
through her G-tube with full strength Impact with fiber at 80
ml an hour. She will be seen in transplant clinic in the
next two weeks. Neurology appointment was also scheduled for
her by the transplant coordinator.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5622**]
Dictated By:[**Last Name (NamePattern1) 5623**]
MEDQUIST36
D: [**2161-5-22**] 20:00:37
T: [**2161-5-22**] 20:36:41
Job#: [**Job Number 5624**]
|
[
"518.5",
"286.9",
"996.62",
"789.5",
"780.39",
"444.89",
"576.1",
"452",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"43.19",
"96.72",
"99.15",
"99.04",
"01.18",
"31.1",
"96.6",
"50.59",
"45.13",
"87.53",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8906, 8915
|
8936, 9154
|
11963, 13353
|
914, 1224
|
1445, 8884
|
9840, 11906
|
169, 239
|
268, 792
|
814, 888
|
1241, 1427
|
11931, 11940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,885
| 132,089
|
9767+56063
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-8-26**] Discharge Date: [**2184-8-31**]
Date of Birth: [**2133-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2184-8-26**] MV repair with 34 mm CE Physio II ring
History of Present Illness:
This 51 year old orthodontist reports a history of mitral valve
prolapse that was initially diagnosed around [**2169**]. He has been
followed over the years by serial echocardiograms.
Echocardiogram in [**2184-2-5**] showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 32922**]
prolapse, with dilation of the LV and atrium. This had
progressed
compared to an echo in [**2181**]. Because of the progression in his
disease, he is now being referred for mitral valve replacement
on [**2184-8-26**] with Dr. [**Last Name (STitle) **].
In terms of symptoms, the patient describes intermittent "weird
chest discomfort" that is non exertional and transient,
occurring several days a week. He also has intermittent
palpitations. He denies fatigue, shortness of breath,
lightheadedness, or presyncope.
Past Medical History:
Mitral valve prolapse/regurgitation, originally diagnosed in
[**2169**]
Psoriasis
[**2177**]: right leg fracture, s/p surgery/plate
Cyst removed from back
T&A
Wisdom teeth extraction
Social History:
Last Dental Exam: Every 6 months
Lives with: Wife in [**Name2 (NI) 7658**]
Occupation: Orthodontist
Cigarettes: Smoked no [X]
Other Tobacco use:
ETOH: < 1 drink/week [] [**1-13**] drinks/week [X] >8 drinks/week []
Illicit drug use
Family History:
One older sister with MVP, brother with history of bicuspid
aortic valve/ aneurysm in his 30's.
Physical Exam:
BP: 140/83. Heart Rate: 72. Resp. Rate: 16. Pain Score:0/100
Saturation%: 100.
Height: 74" Weight: 200lb
General: WDWN in NAD
Skin: Warm, Dry and intact. No C/C/E
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, III-IV/VI holosystolic murmur best heard
at
apex
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Right calf with posterior varicosity and spider
varicosities noted below knee. Left without varicosities.
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit - Transmitted murmur
Pertinent Results:
Echocardiogram [**2184-8-26**]
Findings
LEFT ATRIUM: Moderate LA enlargement. 5.5 cm
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Simple atheroma in ascending aorta. Simple atheroma in
aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Partial mitral leaflet flail. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre-Bypass:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are simple atheroma in the ascending aorta,
aortic arch, and in the descending thoracic aorta.
There are three aortic valve leaflets. Mild (1+) aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
P1/P2 mitral leaflet flail. Severe (4+) mitral regurgitation is
seen with reversal of flow in the pulmonary veins during
systole. There is no pericardial effusion.
Post-Bypass:
Left ventricular function is preserved with an estimated EF>55%.
No wall motion abnormalities are present.
Mitral regurgitation is significantly improved - now trace.
There is no mitral leaflet flail or prolapse. There is a good
area of mitral valve coaptation. The peak and mean gradient
across the mitral valve are 9/4mmHg. The pressure [**12-8**] time is
160cm/s. There are no peri-valvular
Mild AI is unchanged. There is no evidence of aortic dissection
s/p decannulation.
.
[**2184-8-31**] 06:00AM BLOOD WBC-6.8 RBC-3.52* Hgb-10.5* Hct-30.4*
MCV-86 MCH-29.8 MCHC-34.5 RDW-12.4 Plt Ct-294
[**2184-8-30**] 06:00AM BLOOD WBC-7.4 RBC-3.20* Hgb-9.7* Hct-27.4*
MCV-86 MCH-30.4 MCHC-35.6* RDW-12.2 Plt Ct-247
[**2184-8-31**] 06:00AM BLOOD PT-12.6* PTT-24.8* INR(PT)-1.2*
[**2184-8-27**] 03:29AM BLOOD PT-12.3 PTT-28.4 INR(PT)-1.1
[**2184-8-31**] 06:00AM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-29 AnGap-11
[**2184-8-30**] 06:00AM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-137
K-4.3 Cl-102 HCO3-31 AnGap-8
[**2184-8-29**] 07:40AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-26 AnGap-12
[**2184-8-31**] 06:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2
[**2184-8-30**] 06:00AM BLOOD Mg-2.2
[**2184-8-29**] 07:40AM BLOOD Mg-2.2
Brief Hospital Course:
The patient was brought to the Operating Room on [**2184-8-26**] where
the patient underwent Mitral Valve repair with 34 mm CE physio
II ring. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He required
epicardial pacing post-op for a junctional bradycardia he has
now recovered with a first degree AV block. POD 1 found the
patient extubated, alert, oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable. Beta blockers were held due to his junctional rhythm he
was gently diuresed toward his preoperative weight. The patient
was transferred to the telemetry floor for further recovery on
POD #1. Chest tubes discontinued without complication. On POD #3
he was noted to be in atrial fibrillation rate controlled at 50
bpm. An EP consult was obtained suggesting that AV nodal
blocking agents should be held and no anticogulation except for
Asprin 81mg daily. He has now been in Sinus rhtym with a first
degree block since the morning of POD #4. His pacing wires came
out on POD 5. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with services in good condition
with appropriate follow up instructions.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**12-8**] tablet(s) by mouth q3h
Disp #*40 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*90 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Mitral valve prolapse
Psoriasis (mild)
Broken leg from skiing accident - [**2177**] required surgery/plate
Cyst removed on back
Tonsillectomy and adenoidectomy
Wisdom teeth extraction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
FOLLOW-UP:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office, [**2184-9-9**] 10:00
[**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2184-9-29**] 1:15
Cardiologist Dr. [**Last Name (STitle) **] [**2184-9-22**] at 3:15pm
Please call to schedule an appt. with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 12817**], in [**3-11**] 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:[**2184-8-31**] Name: [**Known lastname 5711**],[**Known firstname 394**] C Unit No: [**Numeric Identifier 5712**]
Admission Date: [**2184-8-26**] Discharge Date: [**2184-8-31**]
Date of Birth: [**2133-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
Dr. [**Known lastname **] will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor.
This will be followed by Dr. [**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) 102**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2184-8-31**]
|
[
"427.89",
"696.1",
"424.0",
"997.1",
"427.31",
"426.11",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
10013, 10214
|
5566, 7048
|
321, 378
|
7816, 7985
|
2659, 5543
|
8703, 9990
|
1691, 1789
|
7157, 7490
|
7609, 7795
|
7074, 7134
|
8009, 8680
|
1804, 2640
|
271, 283
|
406, 1219
|
1241, 1426
|
1442, 1675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,320
| 177,984
|
1189
|
Discharge summary
|
report
|
Admission Date: [**2104-7-10**] Discharge Date: [**2104-7-19**]
Date of Birth: [**2047-12-5**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Patient is a 36-year-old male
with a history of hepatitis C x30 years, hypertension,
cardiomyopathy, who presents with two days of bloody painless
diarrhea. Patient has a history of diverticuli on recent
colonoscopy three weeks ago. He ate at a restaurant
yesterday for lunch, had chicken, rice, and beans. He was
the only one who ate the meal. One hour later started having
abdominal cramping with bloody diarrhea, about two cups of
melena, and then bright red blood per rectum.
Patient currently denies abdominal pain, fevers, chills, sick
contacts, recent travel, antibiotic use. He has never had a
history of GI bleeding before. His hepatitis C has been
evaluated with liver biopsy recently, which showed no
evidence of cirrhosis. He has had no nausea, no vomiting, no
chest pain, no shortness of breath. He has a baseline
orthopnea. He uses three pillows at night. Patient has no
pedal edema. Patient is not lactose intolerant. Has no food
allergies. The patient states blood has now decreased and
the diarrhea has decreased.
PAST MEDICAL HISTORY: Cardiomyopathy.
Hypertension.
Hepatitis C diagnosed last year not treated.
Diverticuli.
MEDICATIONS AT HOME:
1. Aspirin 325 mg a day.
2. Hydrochlorothiazide 25 mg a day.
3. Simvastatin 20 mg a day.
4. Lisinopril 20 mg a day.
5. Carvedilol 30 mg twice a day.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is retired. Lives at home with
his wife and grandson. [**Name (NI) **] does not use IV drug. He has a
history of tobacco use one pack per day x20 years. He quit
20 years ago.
PHYSICAL EXAMINATION: On physical examination the patient
had a temperature of 97.3, pulse of 75, blood pressure
122/78, respiratory rate of 20, and 99 percent on room air.
General: The patient is in no acute distress. Alert and
oriented times three. HEENT: Dry mucous membranes. No
scleral icterus and no jaundice. Heart: Regular, rate, and
rhythm, no murmurs, rubs, or gallops. Normal S1, S2, no JVD.
Lungs are clear to auscultation bilaterally. Abdomen is
soft, nontender, nondistended, positive bowel sounds, and no
hepatosplenomegaly. Extremities: No clubbing, cyanosis, or
edema. Two plus dorsalis pedis pulses.
LABORATORIES ON ADMISSION: Significant for a hematocrit of
37.9. Normal coagulation profile. Normal electrolytes.
Patient's LFTs, amylase, and lipase were normal.
HOSPITAL COURSE: The patient was initially admitted to the
medical service on [**2104-7-10**]. The patient got large bore
IV's. Received serial hematocrit checks. Was placed in the
ICU for close monitoring and telemetry, and received a GI
consult. Patient received a colonoscopy, which showed blood
in the colon, but no definite source of bleeding. After two
days of persistent bleeding, the patient underwent angiogram,
which located the bleed to the right colon and the patient
underwent vasopressin therapy. Initially, this appeared to
work well. However, on the following day, the patient early
in the morning started to bleed again.
After multiple transfusions from blood loss anemia with swing
in hematocrit from 45 to 22, it was decided to take the
patient to the operating room on [**2104-7-13**]. Patient tolerated
the procedure well, and was transferred back to the ICU for
observation afterwards. After an overnight stay and
confirmed stable hematocrit, the patient was transferred to
the floor. Interventional Radiology sheath was pulled
without complication at that time. Patient's nasogastric
tube was pulled at that time.
Patient was making good urine output, and hematocrits
remained stable. Early in the patient's postoperative
course, the patient experienced postoperative fevers. He had
a urine culture performed, which was negative. The patient
also was told to increase his incentive spirometry and
ambulation. Patient quickly started to pass flatus, and the
patient's diet was advanced without complication and is now
[**2104-7-19**], and the patient was on postoperative day six in
good condition tolerating a p.o. diet without rectal bleeding
and with stable hematocrit.
DISCHARGE INSTRUCTIONS: Patient is discharged in good
condition and may observe a regular diet. He may observe
regular activity except he may not lift anything greater than
10 pounds for six weeks and may not drive while on narcotic
pain medication. He is being sent home with Colace with a
stool softener and Percocet for pain.
FOLLOW-UP INSTRUCTIONS: He is to followup with Dr. [**Last Name (STitle) 468**]
in approximately 1-2 weeks. His staples were removed before
discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2104-7-19**] 22:03:15
T: [**2104-7-20**] 06:08:58
Job#: [**Job Number 7544**]
|
[
"285.1",
"780.6",
"401.9",
"E878.2",
"425.4",
"427.1",
"562.12",
"998.89",
"070.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"47.19",
"45.73",
"45.23",
"88.47",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2596, 4292
|
4317, 4625
|
1365, 1570
|
1802, 2424
|
183, 1229
|
2439, 2578
|
4650, 5032
|
1252, 1344
|
1587, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 196,958
|
48131
|
Discharge summary
|
report
|
Admission Date: [**2119-12-11**] Discharge Date: [**2119-12-15**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54F w/ PMH sig for obesity hypoventilation syndrome, mod pul HTN
(PAP 54), SLE, R CHF now p/w 2 wks of inc DOE, bilat LE edema,
and 12 lb wt gain c/w CHF exacerbation. Init labs notable for
nml WBC, ABG of 7.27/87/69, bicarb 38. Improved after IV lasix
and BIPAP in ED.
Past Medical History:
)morbid obesity s/p hernia repair [**6-2**],
2)OSA on nocturnal BIPAP and 3-5L home O2, obesity
hypoventilation syndrome, COPD, pul HTN (PAP 54) f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **]
3)SLE
4)R CHF
5)chronic anemia (bl 32), iron def anemia
6)asthma
7)restrictive lung dz
8)HTN
9)OA
Social History:
denies ETOH, tob, and illicit drugs
Family History:
mother also needing BiPAP
Physical Exam:
Exam notable for VSS, morbidly obese AAF, poor air entry bilat
w/ diffuse exp wheezes, hypoactive BS w/ mild diffuse TTP, [**1-31**]+
pitting edema bilat to knees
Pertinent Results:
[**2119-12-11**] 06:38PM TYPE-ART PO2-63* PCO2-71* PH-7.39 TOTAL
CO2-45* BASE XS-13
[**2119-12-11**] 06:38PM GLUCOSE-240* LACTATE-2.0 NA+-140 K+-4.4
CL--93*
[**2119-12-11**] 05:42AM TYPE-ART PO2-90 PCO2-94* PH-7.29* TOTAL
CO2-47* BASE XS-14
[**2119-12-11**] 05:42AM LACTATE-0.6
[**2119-12-11**] 04:11AM GLUCOSE-104 UREA N-8 CREAT-0.5 SODIUM-141
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-39* ANION GAP-11
[**2119-12-11**] 04:11AM CK(CPK)-26
[**2119-12-11**] 04:11AM CK-MB-3 cTropnT-<0.01
[**2119-12-11**] 04:11AM CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-1.7
[**2119-12-11**] 04:11AM PLT COUNT-345
[**2119-12-11**] 04:11AM PT-18.8* PTT-28.1 INR(PT)-2.2
[**2119-12-10**] 11:02PM TYPE-ART PO2-69* PCO2-87* PH-7.27* TOTAL
CO2-42* BASE XS-9
[**2119-12-10**] 07:58PM TYPE-ART PO2-57* PCO2-73* PH-7.29* TOTAL
CO2-37* BASE XS-5
[**2119-12-10**] 11:30AM ALT(SGPT)-18 AST(SGOT)-12 ALK PHOS-81
AMYLASE-51 TOT BILI-0.5
[**2119-12-10**] 11:30AM CALCIUM-9.0 PHOSPHATE-2.9# MAGNESIUM-1.6
[**2119-12-10**] 11:30AM WBC-9.4 RBC-4.94 HGB-7.6* HCT-32.6* MCV-66*
MCH-15.3* MCHC-23.2*# RDW-19.5*
[**2119-12-10**] 11:30AM NEUTS-84.1* LYMPHS-11.3* MONOS-3.1 EOS-1.5
BASOS-0.1
[**2119-12-10**] 11:30AM PLT COUNT-377
[**2119-12-10**] 11:30AM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-3+
[**2119-12-10**] 11:30AM PT-14.0* PTT-28.6 INR(PT)-1.2
[**2119-12-10**] 11:15AM URINE HOURS-RANDOM
[**2119-12-10**] 11:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2119-12-10**] 11:15AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
ECHO;
GENERAL COMMENTS: Contrast study was performed with 3 iv
injections of 8 ccs
of agitated normal saline, at rest, with cough and post-Valsalva
maneuver.
Conclusions:
The interatrial septum is bowed towards the left atrium c/w
increaed right
atrial pressure. No evidence for right-to-left shunt after
agitated saline
injection at rest, with cough, or post-Valsalva.
IMPRESSION: No evidence for PFO/right-to-left intracardiac
shunt.
CTA:
CT CHEST WITH IV CONTRAST: There is no axillary lymphadenopathy.
Prominent hilar and mediastinal nodes are seen, greater on the
right side. Heart size is enlarged with a prominent right
ventricle. The main pulmonary artery is dilated measuring 36 mm,
consistent with pulmonary artery hypertension. No central
pulmonary embolus is seen. The study is limited due to the
patient's body habitus and respiratory motion. Diffuse
ground-glass opacities are seen with areas of sparing. This may
represent asymmetric pulmonary edema versus pneumonitis versus
infection. Bibasilar atelectasis is seen. There are no pleural
effusions.
Visualized portions of the upper abdomen are stable in
appearance and better evaluated on CT abdomen from one day
prior. Osseous structures are unremarkable.
IMPRESSION:
1. No evidence of central PE. The study is limited due to the
patient's body habitus and respiratory motion. Segmental and
subsegmental PE cannot be ruled out.
2. Dilated main pulmonary artery consistent with pulmonary
artery hypertension.
3. Diffuse pulmonary ground glass opacities with areas of
sparing, which may be due to asymmetric edema, pneumonitis, or
infection.
4. Prominent hilar and mediastinal lymph nodes.
5. Bibasilar atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
Brief Hospital Course:
The patient was initially admitted to the [**Hospital Unit Name 153**] due to the
declining resp status. She was stablized then transferred to the
floor.
# Pulmonary HTN/Right sided heart failure: She was aggressively
diuresed with lasix 40mg IV BID and placed on diltiazem. As she
was grossly fluid overloaded, this regimen was increased to
lasix 40 IV TID with remarkable diuresis. She diuresed 11 liter
in the [**Hospital Unit Name 153**]. She was started on methylprednisolone on admission,
received 3 doses, and then was placed on a rapid steroid taper.
The etiology of the pulmonary HTN was investigated: no PE by
CTA, TTE with bubble study performed - no evidence of
intra-cardiac shunt. Pulmonary was consulted as the patient sees
Dr. [**Last Name (STitle) **] in clinic who felt that this is most likely caused
by the hernia surgery and obesity hypoventalition. Sleep
apnea/hypoventilation was managed with BIPAP at night.
Bronchoconstriction managed with nebulizer treatments as well as
prednisone. The team discussed treatment of pulmonary artery
hypertension with Pulmonologist, Dr. [**Last Name (STitle) **]. Will not perform
right heart catheterization or start anticoagulation during this
admission. Future consideration would be for right heart
catheterization to confirm elevated PA pressures and test for
response to vasodilator therapy; then, there would be
consideration for pulmonary artery vasodilator therapy with CCB,
but others to include endothelin receptor antagonists,
prostaglandins. The paitnet eventually was weaned down to ther
home O2 requirment and was discharged with instructions to
follow up with Dr. [**Last Name (STitle) **] and resume a weightloss program.
# Acid/Base disturbance: Her baseline ABG with hypercapnia in
the 70's secondary to hypoventilation and obstructive airway
disease; chronic respiratory acidosis
with compensation. She presented with superimposed acute
respiratory
acidosis, thought to be secondary to bronchoconstriction and
variable compliance with BIPAP
# HTN: managed with home regimen
# Iron deficiency anemia: remained stable on iron replacement
therapy.
Medications on Admission:
ALBUTEROL 17 GM INHALENT
TWO PUFFS FOUR TIMES A DAY AS NEEDED
CHERATUSSIN AC 100-10MG/5 Syrup ONE TSP AT BEDTIME AS NEEDED FOR
COUGH [**2117-12-7**] [**2119-10-5**] 4 OUNCES 0 [**Doctor Last Name **]
DILTIAZEM HCL 120MG Capsule, Sustained Release
TAKE ONE BY MOUTH DAILY
FEOSOL 200 mg Tablet
1 Tablet(s) by mouth three times a day [**2119-10-10**] [**2119-10-10**] 180 6
SHIP
FLOVENT 110MCG Aerosol
2 PUFFS TWICE A DAY [**2118-2-8**] [**2119-10-10**] 3 3 SHIP
LASIX 80MG Tablet
ONE EVERY DAY [**2117-8-11**] [**2119-7-4**] 30 3 [**Doctor Last Name **]
METROGEL 0.75% OINTMENT
APPLY TWICE A DAY AS NEEDED [**2117-12-7**] [**2119-3-1**] 1 MEDIUM TUBE
3 [**Doctor Last Name 4209**]
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Prednisone 10 mg Tablet Sig: See below Tablet PO DAILY
(Daily): Take 2 tablets on Saturday and then 1 tablet on Sunday.
Disp:*3 Tablet(s)* Refills:*0*
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
congestive heart failure
pulmonary hytertension
morbid obesity
anemia
Discharge Condition:
good, on home O2 (2.5 L)
Discharge Instructions:
call your PCP if you feel more SOB, have a fever, or have
increased cough.
Hold off on restarting exercise until you see Dr. [**Last Name (STitle) 3029**] on
Wednesday.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-12-20**] 10:30
Provider: [**First Name4 (NamePattern1) 3679**] [**Last Name (NamePattern1) 3680**] Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) NUTRITION Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2120-1-1**] 5:00
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-1-9**]
10:40
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"280.9",
"493.92",
"V45.3",
"518.81",
"780.57",
"276.2",
"428.0",
"416.8",
"401.9",
"278.01",
"710.0",
"789.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8189, 8247
|
4631, 6761
|
292, 299
|
8361, 8388
|
1258, 4608
|
8605, 9440
|
1033, 1060
|
7492, 8166
|
8268, 8340
|
6788, 7469
|
8412, 8582
|
1075, 1239
|
249, 254
|
327, 600
|
622, 964
|
980, 1017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,521
| 190,548
|
47286+58993
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-5-26**] Discharge Date: [**2194-5-31**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
AVR/CABG/Lft atrial oversew [**5-26**]
History of Present Illness:
86yo active man w/known AS followed by serial echo. Has noticed
increased dyspnea on exertion and decreased exercise tolerance.
Echos have shown progression of AS. Pt has had chronic Afib
since [**2193**]. Pt had hospitalization in [**April 2193**] for PNA and
acute renal failure due to dehydration
Past Medical History:
AS
chronic A Fib
Bil. total hip replacements
HTN
right carotid disease
vocal cord CA s/p removal [**2189**]
BPH s/p TURP
skin Ca
RLL PNA [**4-12**]
right shoulder surgery
RIH surgery
Social History:
lives with wife
retired accountant
quit smoking [**2140**]
social ETOH, no recr. drugs
Family History:
brothert with MI at age 60
father CVA/MI at age 85
Physical Exam:
Admission
VS: HR 72 BP 140/90 RR 20
Gen: NAD
Neuro: Grossly intact, strength equal bilat
Chest: CTA bilat
CV: irreg-irred 4/6 SEM radiating to carotids
Abdm: soft, NT/ND/+BS
Ext: warm well perfused, no edema, mild Bilat LE varicosities
Discharge
VS:
Pertinent Results:
[**2194-5-26**] 11:51PM WBC-12.2* RBC-3.09* HGB-9.6* HCT-26.5* MCV-86
MCH-31.1 MCHC-36.3* RDW-16.7*
[**2194-5-26**] 11:51PM PLT COUNT-178
[**2194-5-26**] 05:02PM PT-13.7* PTT-46.9* INR(PT)-1.2*
[**2194-5-26**] 01:44PM GLUCOSE-85 NA+-140 K+-3.8
[**2194-5-26**] 01:38PM UREA N-26* CREAT-1.3* CHLORIDE-112* TOTAL
CO2-25
ECHO Study Date of [**2194-5-26**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for CABG, AVR
Status: Inpatient
Date/Time: [**2194-5-26**] at 09:21
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW01-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *4.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 59 mm Hg
Aortic Valve - Mean Gradient: 34 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo
contrast in the body of the LA. Mild spontaneous echo contrast
in the LAA. Depressed LAA emptying velocity (<0.2m/s) Probable
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
thrombus in the RAA. Normal interatrial septum. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF
(>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal inferior
- normal; mid inferior - normal; basal inferolateral - normal;
mid inferolateral - normal; basal anterolateral - normal; mid
anterolateral - normal; anterior apex - normal; septal apex
-normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Mildly dilated ascending aorta. Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Focal calcifications in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild (1+) AR. Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient received
antibiotic prophylaxis. The TEE probe was passed with
assistance from the anesthesioology staff using a laryngoscope.
The patient was under general anesthesia throughout the
procedure. The rhythm appears to be atrial fibrillation.
patient. See Conclusions for post-bypass data The post-bypass
study was performed while the patient was receiving vasoactive
infusions (see Conclusions for listing of medications).
Conclusions:
PRE-BYPASS:
1. Mild spontaneous echo contrast is seen in the body of the
left atrium. Mild spontaneous echo contrast is present in the
left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). A probable thrombus is seen in
the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal.
3. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are focal calcifications in the aortic arch. There are
simple
atheroma in the descending thoracic aorta. 6. There are three
aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POST-CPB: Patient on infusion of phenylephrine.
1. A well-seated bioprosthetic valve is seen in the aortic
position with
normal leaflet motion and gradients (mean gradient =12 mmHg). No
aortic
regurgitation is seen.
2. Biventricular systolic function is preserved.
3. The aortic contour is normal post decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2194-5-29**] 11:45.
[**Location (un) **] PHYSICIAN
RADIOLOGY Preliminary Report
RENAL U.S. [**2194-5-29**] 10:01 AM
RENAL U.S.
Reason: assess for flow/hydro
[**Hospital 93**] MEDICAL CONDITION:
86 year old man s/p AVR-CABG rising creat
REASON FOR THIS EXAMINATION:
assess for flow/hydro
INDICATION: 86-year-old male with history of CABG and rising
creatinine.
No prior studies are available for comparison.
FINDINGS: The right kidney measures 10.8 cm and the left 9.7 cm.
The parenchymal thickness and echogenicity are normal without
evidence of calculi or hydronephrosis. The right kidney
demonstrates an 8 x 7 mm hypoechogenic focus in the upper pole,
too small to characterize. The left kidney demonstrates a 9 x 7
x 7 mm exophytic hypoechogenic focus that likely represents a
complex cyst.
Sludge within the gallbladder is noted. No evidence of
perinephric fluid.
Doppler evaluation of the kidneys demonstrates symmetric blood
flow throughout either kidneys.
IMPRESSION:
1. No evidence of hydronephrosis. Both kidneys demonstrate
normal blood flow throughout.
2. Tiny hypoechogenic focus within the upper pole of the right
kidney, too small to characterize.
3. 9 x 7 x 7 mm exophytic complex cyst in the mid pole of the
left kidney. Six-month followup is recommended if clinically
indicated.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**]
Brief Hospital Course:
Mr [**Name13 (STitle) **] was admitted to [**Hospital1 18**] on [**5-26**] for cardiac surgery.
Please see the operating room report for details, in summary he
had on AVR(#25 Mosaic Porcine)CABG x2(LIMA-LAD, SVG-OM)oversew
Lft atrium. He tolerated the operation well and was transferred
to the cardiac surgery ICU. He returned to the operating room
several hours later because of post-operative bleeding, no
source was identified and he again was brought to the ICU in
stable condition. He did well in the immediate post-op period
and was extubated. On POD1 he remained in the ICU to wean from
his vasoactive IV medications. On POD2 Mr [**Name13 (STitle) **] was transferred
to the step down floor for continued post-op care. A repeat
creat check noted an elevated Cr to 2.6,and a renal consult was
called. On POD3 the creat continued to rise but the patient
otherwise continued to make post-operative progress and his
epicardial wires were removed, as were his mediastinal chest
tubes. His creatinine dropped to 2.3. His remaining left
pleural chest tube was removed. He has remained hemodynamically
stable, but is progressing slowly with mobility. He is ready to
be discharged to rehab.
Medications on Admission:
Atenolol 50'
Norvasc 5'
Lisinopril 20
HCTZ 12.5
Coumadin 2'
Omeprazole 20'
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: then decrease to 400 mg daily for 1 week,
then 200 mg daily. Tablet(s)
6. Warfarin 2 mg Tablet Sig: Zero (0) Tablet PO ONCE (Once) for
1 days: to be dosed daily for target INR 2.0-3.0 for AFib.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
s/p AVR(#25Mosaic)CABGx2LIMA-LAD,SVG-OM)Oversewing Lft atrium
[**5-26**]
PMH: AS, HTN, Afib, Carotid dz,CRI(1.2), Vocal cord CA s/p
removal, skin CA, rotator cuff repair, B THR, TURP,
hemorroidectomy, Rt ing hernia
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or
swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
wound clinic in 2 weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] in [**3-9**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2194-5-30**] Name: [**Known lastname 3023**],[**Known firstname 16081**] D Unit No: [**Numeric Identifier 16082**]
Admission Date: [**2194-5-26**] Discharge Date: [**2194-5-31**]
Date of Birth: [**2107-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Please follow up with Nephrologist as an out patient in [**1-7**]
weeks to folow creatinine increase.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 7333**] - [**Location (un) **]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2194-5-31**]
|
[
"997.3",
"424.90",
"511.9",
"585.9",
"V10.21",
"433.10",
"424.1",
"285.1",
"V43.64",
"998.11",
"403.90",
"V10.83",
"530.81",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.99",
"36.11",
"99.04",
"35.21",
"99.07",
"36.15",
"34.04",
"39.61",
"34.03",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
11201, 11412
|
7778, 8972
|
288, 329
|
10281, 10288
|
1327, 1691
|
10490, 11178
|
987, 1039
|
9097, 9921
|
6573, 6615
|
10043, 10260
|
8998, 9074
|
10312, 10467
|
1717, 6536
|
1054, 1308
|
229, 250
|
6644, 7755
|
357, 658
|
680, 866
|
882, 971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,312
| 153,323
|
51749
|
Discharge summary
|
report
|
Admission Date: [**2156-9-27**] Discharge Date: [**2156-10-6**]
Date of Birth: [**2094-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 562**]
Chief Complaint:
diarrhea, vomitting, worsening dyspnea, jaundice
Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis - 1 L removed
History of Present Illness:
62-year-old gentleman with history of asthma, severe obstructive
lung disease, dyslipidemia, hypertension, and atrial
fibrillation who presented to the ED today w/ 1 wk hx of watery
diarrhea, [**10-20**] [**Male First Name (un) 1658**]-colored stools/day w/ occ. blood, nausea,
vomitting approx daily, jaundice, weakness, worsening of his
baseline SOB and dyspnea on exertion, and fatigue. No abdominal
pain, pruritis, CP, PND, or orthopnea. -F/C/S, -HA, -vis
changes. Pt drinks 8oz of whiskey daily for the last 10 years.
No recent travel. Never had these symptoms before. No pain
anywhere.
ED COURSE
In the ED, placed on 4L NC, combivent nebs x3 given, prepped for
CT scan. EKG showed rapid AF, given 10mg IV diltiazem, then 20mg
then 10mg. Levo/Flagyl given for possible lung/abd infection.
CBC had WBC of 11, LFTs showed obstructive pattern and CEs neg.
CT-PA positive for PE, heparin was held pending [**Name (NI) **], pt given
5mg valium, a 2nd IV placed, and transferred to the MICU.
Past Medical History:
-Intrinsic asthma w/chronic obstruction: Last spirometry shows
FEV1 of 1.78 liters, FEV1-to-FEC ratio of 59%
-Bronchiectasis
-AFib
-HTN
-Dyslipidemia
-Erectile dysfunction
-GERD
-Allergic rhinitis
-Last admitted to [**Hospital1 18**] [**Date range (1) 107189**] for severe gastroenteritis c/b
ARF
Social History:
Lives at home by himself. Works as a social worker with
HIV/AIDS. EtOH use 1-2 drinks/night. Denies tobacco and drug
use.
Family History:
Brother died age 40 of MI, mother CVA at age 75, early arthritis
in brother
Physical Exam:
VS: 96.3, HR 120-180, BP 102-140/70s, RR 16, sat 97% 4L NC
GEN: resting comfortably, jaundiced, in no distres
HEENT: PERRL, EOMI, icteric scleral, mildly injected
Neck supple, nontender, no bruits,
Oropharynx: sublingual jaundice, poor dentition
PULM: decreased BS on RLL, crackles at bases bilaterally, R>L,
mild wheezes anteriorly. Able to speak comfortably in full
sentence, no use of excessory muscles.
CARD: tachycardic, s1, s2, wnl, no murmurs rubs or gallops
ABD: obese, distended, vericosities, TTP RUQ, no rebound, no
guarding, hepatomegally by percussion.
EXT: radial pulses 2+, dorsalis pedis 1+
NEURO: CNII-XIIintact, strength 5/5 upper and lower.
Pertinent Results:
[**2156-9-27**] 03:45PM PLT COUNT-320
[**2156-9-27**] 03:45PM NEUTS-77.0* LYMPHS-17.4* MONOS-3.2 EOS-1.8
BASOS-0.7
[**2156-9-27**] 03:45PM WBC-11.3* RBC-3.54* HGB-11.7* HCT-35.3*
MCV-100* MCH-33.1* MCHC-33.2 RDW-18.5*
[**2156-9-27**] 03:45PM ALBUMIN-2.9*
[**2156-9-27**] 03:45PM CK-MB-NotDone cTropnT-<0.01
[**2156-9-27**] 03:45PM LIPASE-41
[**2156-9-27**] 03:45PM ALT(SGPT)-63* AST(SGOT)-215* CK(CPK)-35* ALK
PHOS-330* TOT BILI-8.4*
[**2156-9-27**] 03:45PM GLUCOSE-122* UREA N-9 CREAT-0.8 SODIUM-135
POTASSIUM-3.4 CHLORIDE-87* TOTAL CO2-29 ANION GAP-22*
[**2156-9-27**] 05:47PM LACTATE-2.6*
[**2156-9-27**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-LG UROBILNGN-8* PH-6.5 LEUK-NEG
[**2156-9-27**] 11:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.043*
RUQ U/S [**9-27**]: 1. Echogenic liver, commonly seen in hepatic
steatosis. However, other forms of liver disease and more
advanced liver disease, including significant hepatic cirrhosis
and fibrosis cannot be excluded on the basis of this study. 2.
Ascites. 3. Normal appearance of gallbladder.
CT C/A/P [**9-27**]: 1. Interval development of moderate-to-large
abdominal ascites. 2. Tiny filling defect in the subsegmental
branches of the posterior segment of the left lower lobe,
compatible with acute PE.
3. Left greater than right basal patchy opacities, as well as
bronchial wall thickening and minimal post-inflammatory,
bronchiectasis, persistent in changes since the prior study,
mean reflect recurrent aspiration, infectious causes are also in
the differential. 4. Fatty liver. Limited evaluation for focal
liver lesions. Questionable focus of increased attenuation in
the posterior right lower lobe, as there is clinical concern;
MRI with gadolinium could be performed. 5. 13 mm nodular density
in the lingula, 3 months follow up is recommended.
TTE [**9-28**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The right
ventricular cavity appears moderately dilated with borderline
normal free wall function. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. 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. Physiologic mitral regurgitation is seen (within
normal limits). The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. IMPRESSION:
Suboptimal image quality. Mild left ventricular hypertrophy with
preserved systolic function. Probable right ventricular dilation
with borderline normal function. Compared with the report of the
prior study (images unavailable for review) of [**2153-1-12**], the
right ventricle now appears dilated with low-normal function.
LENIs [**9-28**]: FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] of
both lower extremities including the common femoral, superficial
femoral, and popliteal veins demonstrate normal flow,
augmentation, compressibility, and waveforms without evidence
for intraluminal thrombus. IMPRESSION: No DVT in either lower
extremity.
CT Chest [**9-30**]: 1. Increased moderate bilateral pleural effusion
with bibasilar alveolar opacities, mostly on the left,
atelectasis versus pneumonia. 2. Mild bibasilar areas of
bronchiectasis and bronchial wall thickening suggest
peribronchial inflammation. 3. Lingular atelectasis without
suspicious lesion for neoplasia. 4. Severe fatty liver and
ascites. 5. Bilateral gynecomastia.
Cultures:
**Blood: 9/22 [**1-7**] coag neg staph, 9/24,25,26 NGTD
**Urine [**9-28**], 26 NGTD; 25 1K staph
**Serologies: HBV and HCV VL and serologies negative
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE
- R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL
CULTURE - R/O E.COLI 0157:H7-FINAL; CLOSTRIDIUM DIFFICILE TOXIN
A & B TEST-FINAL; VIRAL
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB-FINAL INPATIENT
[**2156-9-28**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM
ANTIBODY-FINAL
LABS ON DISCHARGE:
WBC 6.8 Hct 25.0 Plts 234
Na 138 K 4.9 Cl 102 HCO3 31 BUN 28 Cr 1.7 Glu 98
Ca 8.6 Mg 1.8 Phos 3.5
INR 2.3
AST 113 ALT 49 AlkPhos 181 TBili 4.7
Brief Hospital Course:
62 yo M w h/o alcoholism, hyperlipidemia, COPD and afib p/w
watery diarrhea, jaundice and increasing SOB admitted to MICU,
then called out to medical floor.
.
1) Diarrhea: Initially with 10-15 watery bowel movements/day.
Although pt initially described some blood to the BMs, he later
stated that he only rarely noticed small amounts of red blood
upon wiping with toilet paper and not in the stool itself.
Stools studies for E.Coli, Salmonella, Shigella, Campylobacter,
and C diff were negative. O&P tests were also negative. There
was evidence of cecal to ascending bowel wall thickening on his
admission CT abd/pelvis but this was in the setting of no
accompanying abdominal pain and an unimpressive lactate thus
making an embolic or frank ischemic colitis less likely. It was
thought that the diarrhea was likely viral in nature, which then
preciptated low BPs in a gentleman on multiple BP agents (SBP
noted to drop as low at 60s in MICU while pt sleeping, would go
back up to 80-90s with stimulation), which then possibly lead to
a low flow state and possible watershed ischemia. He was managed
conservatively off antibiotics and his diarrhea slowly improved
over a course of [**5-12**] day. At the time of discharge, he was
having well formed BMs, approximately 4/day.
2) Renal failure: Baseline creatinine 0.9, rose to 1.7 during
hospital course and now stable at 1.7. UA on [**9-29**] showed 39 WBC
and muddy brown casts on sediment suggesting ATN. FeNa is 0.04
on [**9-29**] which is c/w a prerenal picture likely due to low ECV
[**2-7**] diarrhea. At no point did the pt develop oliguria. Renal U/S
showed no postrenal obstruction. Hepatorenal syndrome was also
considered in the setting of hepatitis. Hepatology consulted,
who felt that the clinical picture was not consistent with HRS.
He was initally treated with midodrine, octreotide, and albumin,
which was discontinued after 1-2 days. Medications were dosed
renally and [**Last Name (un) **], sotalol on hold until Cr resolves. Pt was
encouraged to take in pos and not given further IVFs during last
2 hospital days as was overall hypervolemic on exam. Cr stable
at 1.7 by time of discharge. He will need daily renal function
checks.
.
3) Jaundice/Liver disease: HepB/C, CMV, EBV serologies negative,
Alpha 1-antitrypsin test negative. AST/ALT ratio c/w of
alcoholic hepatitis and liver US suggestive of hepatic steatosis
or cirrhosis. Also found to have new onset moderate to large
ascites on admission. Abd CT showed area of increased
hyperattenuation in R lobe, raising a concern for HCC. AFP
within normal limits. Hepatology was consulted who felt that
hepatitis was likely [**2-7**] EtOH cirrhosis (pt drinks 6-8 ozs of
whiskey/day) vs. NASH. All imaging did not show frank
obstructive lesion that could cause obstructive cholestasis.
Elevated conjugated bilirubinemia thought to be [**2-7**] acute
illness. Statin was held during hospital course. A diagnostic
paracentesis was performed upon admission that revealed a SAAG >
1.1, no SBP, and negative cytology and cultures. 2 days prior to
discharge, the pt had an ultrasound guided therapeutic
paracentesis performed with 1 L removed with improvement in his
SOB. LFTs continued to trend downward until discharge. He will
f/u with hepatology as an outpt and will need an outpt liver MRI
as well as outpt EGD.
.
4) SOB/PE: Likely multi-factorial in a patient with baseline
COPD, OSA and on home O2. Was found to have a small subsegmental
PE on chest CTA on admission, which was not thought to be a big
contributing cause to his complaints of worsening SOB. The pt
was therapeutic on coumadin and heparin gtt was not initiated.
As pt very sedentary at baseline, PE thought to be [**2-7**] to
sedentary lifestyle. LENIs negative.
SOB unlikely thought to be [**2-7**] to COPD flare. New onset ascites
thought to be largely contributing and his sxs did improve after
a 1L therapeutic paracentesis. TTE showed no evidence of L sided
heart failure. He will continue on coumadin for an INR goal [**2-8**]
indefinitely for atrial fibrillation and PE.
.
5) Afib/tachycardia: Stable. In NSR on final 4 days of hospital
course. Monitored on telemetry, which was eventually
discontinued. Diltiazem, sotalol held on admission due to
hypotension initially on presentation. Diltizem restarted day
prior to discharge, which pt tolerated well. He will need
sotalol restarted as an outpatient once his renal function
recovers.
.
6) COPD/asthma: O2 sats 95% on 2L by discharge. On home O2 at
baseline. Continue home nebs, and CPAP overnight.
.
Code status: Full Code
Medications on Admission:
Warfarin 2.5 mg daily
Diltiazem CR 180mg daily
Losartan 50mg daily
Furosemide 40mg daily
Fluvastatin 40mg daily
Sotalol 180mg [**Hospital1 **]
Spiriva
Montelukast 10mg daily
Pantoprazole 40mg daily
Fluticasone 3puffs [**Hospital1 **]
Flonase 50mcg daily
Albuterol inh Q4H prn
Viagra/Cialis/Levitra 20mg PRN
Vitamin D2 1000 units daily
MVI with minteral daily
Potassium gluconate 595mg daily
Discharge Medications:
1. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed. Capsule(s)
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Three (3) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H PRN ().
10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
12. Insulin Regular Human 100 unit/mL Solution Sig: per attached
sliding scale sheet units Injection ASDIR (AS DIRECTED).
13. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Diarrhea
Acute renal failure
Alcoholic hepatitis
Cholestatic jaundice
Ascites - new onset
Secondary diagnosis:
COPD
Atrial fibrillation
Asthma
Prostate Cancer
Hyperlipidemia
Hypertension
Discharge Condition:
Stable, sating 93-96% on 2L NC. Ambulating with assitance.
Discharge Instructions:
You were admitted to the hospital with watery diarrhea,
worsening of your baseline shortness of breath, low blood
pressure, and jaundice. No clear bacterial cause was found for
your diarrhea, and this improved during your hospitalization.
You were found to have an inflammed liver with increased amounts
of bile, leading to jaundice. You were seen by liver specialists
who believe this is most likely related to your history of
drinking whiskey. You have 1 L of fluid removed from your
abdomen.
Your breathing improved prior to discharge. Your kidneys also
started working harder than usual and your kidney function needs
to be monitored after leaving the hospital.
The following changes were made to your medications:
1) Losartan, lasix, and sotalol are being held for increased
kidney function and the low blood pressure you had.
2) You were also started on imodium as needed for loose stools.
3) We are holding fluvastatin until your liver numbers go back
to baseline.
Please call your physician or return to the ED if you experience
any of the following: fever > 101, worsening shortness of
breath, worsening diarrhea, abdominal pain, or any other
symptoms concerning to you.
Followup Instructions:
You will need to follow-up with a hepatologist, or liver
specialist, named Dr. [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**]. You have an appointment
on [**11-3**] at 1:30pm at the [**Hospital **] Medical Building on the [**Hospital Ward Name 12837**], [**Location (un) **]. Please call [**Telephone/Fax (1) 2422**] if you need to make
changes.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week.
You also have the following appts:
1)Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34890**]/DR. [**Last Name (STitle) 3172**] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2157-5-4**] 11:30
Completed by:[**2156-10-6**]
|
[
"599.0",
"584.9",
"327.23",
"V10.46",
"303.01",
"530.81",
"796.3",
"571.1",
"787.91",
"401.9",
"427.31",
"291.81",
"415.19",
"493.20",
"573.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"54.91",
"94.62",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13631, 13704
|
7241, 11815
|
362, 409
|
13955, 14016
|
2681, 7040
|
15247, 15922
|
1906, 1985
|
12257, 13608
|
13725, 13725
|
11841, 12234
|
14040, 15224
|
2000, 2662
|
274, 324
|
7059, 7218
|
437, 1430
|
13856, 13934
|
13744, 13835
|
1452, 1750
|
1766, 1890
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,703
| 176,534
|
31127
|
Discharge summary
|
report
|
Admission Date: [**2163-9-17**] Discharge Date: [**2163-9-28**]
Date of Birth: [**2099-6-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
1. Pelvic angiography and embolization of distal branch
pseudoaneurysm site of active bleeding from left internal
pudendal (coils and gelfoam).
2. Open reduction and internal fixation, right sacroiliac joint.
3. Open reduction and internal fixation, left sacroiliac joint.
4. Open reduction and internal fixation, anterior column
fracture, with retrograde columnar screw.
5. Placement of Right femoral [**Location (un) 260**] filter (Bard G2 type).
History of Present Illness:
64 year old male pedestrian who was crushed under his car at low
speed. No reported LOC. He was transported from the scene
directly to the [**Hospital1 18**] emergency room.
Past Medical History:
1. Coronary artery disease
2. CABGx4 15 years ago
3. History of myocardial infarction
4. Gout
5. Hypercholesterolemia
6. s/p melanoma resection
Social History:
Married, lives with supportive wife, and has a daughter-in-law
who is an internist at [**Hospital6 **]. Non-smoker.
Occasional EtOH. No drug use.
Family History:
Non-contributory
Physical Exam:
On discharge:
Gen: NAD, resting comfortably
HEENT: PERRL, IOMs intact
Chest: CTAB
CV: RRR, S1,S2, no murmurs
Abd: S/ND/NT, +BS, no masses
Extremities: WWP, no edema, 2+ pulses, incisions CDI, ROM
limited by pain in lower extremities, non-weight bearing. RUE
with splint in place.
Pertinent Results:
CT chest/abdomen/pelvis ([**2163-9-18**]): IMPRESSION:
1. Extensively comminuted displaced fractures of the left
superior and
inferior pubic rami. The fracture of the superior pubic ramus
extends into the the acetabulum and is associated with small
active extravasation and contrast pooling at this site, most
likely related to injury of the external pudendal artery.
2. Innumerable fractures of both sacral alae, extending into the
sacroiliac joints, with marked diastasis and off-set on the left
("open book" fracture of the left hemipelvis), with associated
moderate hematoma anterior to the right sacral ala, likely
related to venous hemorrhage.
3. Hematoma in the right psoas muscle, which may relate to
lumbar transverse process fractures.
4. Small amount of free fluid is noted within the pelvis,
consistent with
hematoma. Small amount of fluid is also noted within the
posterior pararenal spaces bilaterally. However, there is no
evidence of visceral injury in the abdomen or pelvis.
5. Fractures L5 bilateral and L4 right transverse processes.
6. Small bilateral pleural effusion.
7. Small axial hiatal hernia.
.
AP pelvis ([**9-18**]):
PELVIS: Single AP view of the pelvis demonstrates markedly
displaced and
extensively comminuted fractures of the left superior and
inferior pubic rami, with apparent involvement of the ischium
but no definite acetabular
involvement in this limited view. There is a so-called "open
book" fracture of the left hemipelvis with marked diastasis of
the left sacroiliac joint with significant, roughly 15-mm
superior offset of the left iliac [**Doctor First Name 362**]. There is poor
visualization of the known multiple bilateral sacral alar
fractures. The right hemipelvis appears, otherwise, intact.
.
CT abdomen/pelvis ([**9-18**]):
IMPRESSION:
1. Slight interval increase in size of intra-abdominal and
pelvic hematomas. It is unclear if this increase represents
hemorrhage formed from the time of the prior CT until the
embolization versus more acute hemorrhage. If the hematocrit
continues to drop, a repeat CT angiogram could be performed
using the current study has a new baseline post-embolization.
2. Open-book fracture of the left hemipelvis with sacral alar
and left
inferior and superior pubic rami fractures. Alignment appears
relatively
unchanged from the prior study.
3. Fractures of L5 lateral and L4 right transverse processes.
.
[**2163-9-28**] 07:50AM BLOOD WBC-14.8* RBC-3.38* Hgb-10.6* Hct-31.3*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.0 Plt Ct-405
[**2163-9-28**] 07:50AM BLOOD Plt Ct-405
[**2163-9-28**] 07:50AM BLOOD Glucose-99 UreaN-26* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-28 AnGap-11
[**2163-9-28**] 07:50AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.3
Brief Hospital Course:
Pt is a 64 year old male pedestrian who was crushed under his
car at low speed. No reported LOC. He was transported from the
scene directly to the [**Hospital1 18**] emergency room. He was admitted to
the Trauma Service.
Due to the mechanism of his injury and the fact that he began to
have a decreasing blood pressure an emergent
chest/abdomen/pelvis CT was performed which showed small active
extravasation and contrast pooling at this site, most likely
related to injury of the external pudendal artery. He was taken
emergently to angiography where he underwent embolization of
distal branch pseudoaneurysm site of active bleeding from left
internal pudendal (coils and gelfoam). He tolerated this well.
He had a total of 4 units of PRBCs in before transfer to the ICU
in hemodynamically stable condition.
His ICU course was without significant events. On hospital day
number four ([**9-20**]) he underwent open reduction, internal fixation
of his pelvic fractures. This was complicated post-operatively
by a SIRS response in his lungs with desaturation to 85% SpO2,
and RR in the 30s, fever=102, pulmonary edema on CXR. He was
reintubated. This was followed by supportive care and his
respiratory status improved to baseline.
.
On hospital day 7, ([**2163-9-23**]) the patient underwent percutaneous
placement of an IVC filter to reduce his risk of pulmonary
embolis. he tolerated this procedure well.
.
Neurosurgery was consulted because of fractures of both
transverse processes of L5 and L4. The neurosurgical service
felt that no neurosurgical intervention was required, based on
the physical examination and the images provided. It was
recommended to have him fitted for a lumbar brace, provide
adequate pain control and follow-up in [**5-20**] weeks with new X-rays
in the [**Hospital 4695**] clinic. He was instructed to wear his TLSO
brace when he was >30 degrees upright. My feeling is that the of
L4 and L5 transverse processes fractures are part of the pelvic
fracture construct, and their treatment is that of the pelvic
fracture.
.
Of note, the patient had his troponin enzymes cycledx3 and were
negative. It was not felt that he had any acute coronary event.
.
His pulmonary symptoms had resolved and he was discharged with
SpO2>95% without respiratory symptoms. The patient was felt to
be at very high VTE risk because he would likely be bed bound
for >6 months. A removable IVC (Bard G2) filter was placed.
.
On the days preceeding discharge, he was unable to urinate
without a foley catheter and was discharged with a foley in
place.
.
The patient suffered a brief post-operative ileus. An NG tube
was placed briefly. On the day of discharge he was tolerated a
regular diet and passing stool. Of note, the patient reported
frequent bowel movements on hospital days 9 and 10. His c-diff
studies were negative but the clinical suspicion was high and
thus he was started on a one-week course of oral flagyl.
.
The patient was discharged on hospital day 12 in stable
condition. On the day of discharge his HCT was 31.3 which was
stable. He was provided with plans for follow-up with
orthopaedic surgery and spine surgery.
Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) **], toprol, statin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Enoxaparin 30 mg/0.3 mL Syringe Sig: 0.3 ML's Subcutaneous
Q12H (every 12 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for possible c-diff for 5 days.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**]
Discharge Diagnosis:
s/p Pedestrian struck by auto
1.Pelvic fracture - comminuted displaced fractures of the left
superior and inferior pubic rami; innumerable fractures of both
sacral alae, extending into the sacroiliac joints, with marked
diastasis and off-set on the left ("open book" fracture of the
left hemipelvis).
3. Traumatic injury of the external pudendal artery.
4. Hematoma in the right psoas muscle
5. Fractures L5 bilateral
6. Fracture of L4 right transverse processes
7. Small bilateral pleural effusion
8. Small axial hiatal hernia
Discharge Condition:
Good
Discharge Instructions:
DO NOT bear any weight on either lower extremity for the next
6-8 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1005**] in Orthopaedic surgery.
Please call to make an appointment [**Telephone/Fax (1) 1228**].
Please follow-up with Dr. [**Last Name (STitle) **] in Trauma surgery. Please call
to make an appointment: [**Telephone/Fax (1) 6429**]
Please follow-up with Dr. [**Last Name (STitle) **], in [**Hospital 4695**] Clinic.
Please call to make an appointment: [**Telephone/Fax (1) 1669**]
|
[
"997.4",
"272.0",
"274.9",
"518.82",
"805.4",
"995.93",
"V45.81",
"414.01",
"E814.7",
"924.9",
"902.89",
"813.82",
"808.43",
"958.4",
"285.1",
"412",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"93.54",
"96.04",
"38.93",
"00.33",
"88.49",
"99.04",
"79.39",
"96.71",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8934, 8979
|
4408, 7562
|
344, 795
|
9551, 9558
|
1681, 4385
|
9680, 10114
|
1346, 1364
|
7676, 8911
|
9000, 9530
|
7588, 7653
|
9582, 9657
|
1379, 1379
|
1393, 1662
|
275, 306
|
823, 998
|
1020, 1166
|
1182, 1330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,935
| 167,873
|
3788
|
Discharge summary
|
report
|
Admission Date: [**2150-7-18**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2100-3-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 yo F s/p MVR, ASD closure [**6-1**] with severe sharp SS CP
starting yesterday AM, now with radiation to back and left
shoulder with some shortness of breath. Pain was crampy, sharp,
and constant in nature, [**11-4**] at worst (now [**4-4**] with morphine),
nonexertional but worse with deep inhalation and laying supine.
Pt also c/o light-headedness this am upon awakening, but no
syncope. + fevers beginning overnight. Pt describes SOB as
secondary to pain - she has had difficulties with incisional
pain and SOB since [**Doctor First Name **]; had one admission mid may for SOB, no
interventions were done, however this pain was different than
previous.
.
In [**Name (NI) **], pt received morphine 4mg with good relief of pain;
however, she became hypotensive with BP down to 81/48 - up to
99/70 with fluid bolus. FAST exam showed small pericardial
effusion with good 4 chamber motion. No evidence of tamponade
physiology.
Past Medical History:
1. Mitral valve prolapse with severe mitral regurgitation
- s/p MV repair and annuloplasty [**2150-6-1**] with 28 mm band
- s/p secundum ASD closure on [**2150-6-1**]
2. Mild pulmonary hypertension
3. Hypertension
4. diverticulitis s/p sigmoid resection
5. s/p appy
6. anxiety / depression
7. [**Date Range 17005**]
8. HA
Social History:
Volunteer at NEBH. Never smoked. Drinks [**4-30**] ETOH beverages per
week. Lives with mother.
Family History:
Mother with MVR/TVR at age 73. Father died of MI at age 50.
Physical Exam:
VS: T 97.8, BP 103/68, HR 113, RR 27, O2 100% on 4L NC
Gen: WDWN middle aged female in mild distress due to pain. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP not elevated.
CV: RRR, normal S1, fixed split S2, no murmurs/rubs/gallops, no
S3/S4. PMI nondisplaced.
Chest: midline sternotomy site, appears well-healed, no
paradoxical chest motion.
Resp: mild bibasilar crackles, no wheezes or rhonchi. mild
tachypnea with shallow breaths. no accessory muscle use.
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. 2+ distal pulses
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2150-7-18**] 08:45AM BLOOD WBC-13.2* RBC-4.69# Hgb-13.2# Hct-38.4#
MCV-82# MCH-28.2# MCHC-34.5 RDW-16.6* Plt Ct-431
[**2150-7-20**] 05:10AM BLOOD WBC-8.0 RBC-4.03* Hgb-11.2* Hct-34.2*
MCV-85 MCH-27.9 MCHC-32.8 RDW-16.9* Plt Ct-418
[**2150-7-18**] 08:45AM BLOOD Neuts-74.2* Lymphs-18.4 Monos-6.6 Eos-0.5
Baso-0.4
[**2150-7-18**] 08:45AM BLOOD PT-11.6 PTT-26.1 INR(PT)-1.0
[**2150-7-18**] 08:45AM BLOOD Glucose-119* UreaN-14 Creat-0.7 Na-134
K-4.4 Cl-99 HCO3-22 AnGap-17
[**2150-7-18**] 08:45AM BLOOD CK(CPK)-50
[**2150-7-19**] 05:56AM BLOOD CK(CPK)-56
[**2150-7-18**] 08:45AM BLOOD cTropnT-<0.01
[**2150-7-19**] 05:56AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-7-19**] 05:56AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0
[**2150-7-19**] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-7-19**] 11:30AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
Urine cx: negative
Blood cx: negative to date x3
.
CTA [**7-18**]:
IMPRESSION:
1. There is a moderate-sized new pericardial effusion.
2. Sternal decissence. Bony irregularity is detected in the bony
oppositional regions with stranding of the surrounding
subcutaneous and mediastinal fat. There are also prominent
superior mediastinal lymph nodes which were not present on
previous study. Infection in the region of the sternal
decissence cannot be excluded.
3. No pulmonary embolism or aortic dissection identified.
4. Bilateral small pleural effusions with associated relaxation
atelectasis, more prominent on the left.
.
CXR: IMPRESSION: Improving bibasilar atelectasis. Persistent
bilateral pleural effusions, slightly decreased on the left.
.
[**7-20**] TTE: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. A mitral
valve annuloplasty ring is present. The mitral annular ring
appears well seated and is not obstructing flow. The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate sized inferolateral pericardial effusion without
evidence for hemodynamic compromise.
Brief Hospital Course:
50 yo F s/p MVR, ASD closure [**6-1**] presenting with severe sharp
substernal CP, SOB, and brief episode of light-headedness. The
patient had a CTA chest performed to rule out PE and dissection,
notable for sternal dehiscence, moderate pericardial effusion
and fat stranding with lymphadenopathy. EKG with diffuse PR
depressions and ST elevations. Cardiac enzymes were negative.
Cardiothoracic surgery was conulted. Pt's presentation felt to
be consistent with post-pericardiotomy syndrome. She was
started on ibuprofen and colchicine with significant improvement
in her pain.
On hospital day #2, the pt became febrile to a temperature of
101.2. CXR showed atelectasis at the lung bases; CXR, UA and
urine culture, and blood cultures were nonsuggestive of
infection. Cardiothoracic surgery was consulted for the
possibility of infection secondary to sternal dehiscence;
however, the CT team felt that there was no clinical evidence to
support this. Fever subsided later that day with high-dose
NSAIDs and the patient was (afebrile) for the remainder of her
hospital course.
The patient was monitored on telemetry for the duration of the
hospital stay with no significant events. The patient was
maintained on a bowel regimen, PPI, sc heparin tid and was
discharged to home in good condition.
Medications on Admission:
Atenolol 25mg po qd
Atorvastatin 40mg po qd
Effexor (unknown dose)
Sertraline 100mg po qd
Clonazepam 0.5mg po tid
docusate 100mg po bid
vitamin C
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 months.
Disp:*60 Tablet(s)* Refills:*2*
3. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily). Capsule, Sust.
Release 24 hr(s)
4. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Post pericardiotomy syndrome
Discharge Condition:
Chest pain resolved and vital signs stable
Discharge Instructions:
If you experience any increasing chest pain/ tightness,
palpitations, shortness of breath, swelling in your legs, blood
in the vomit or stool, or dark stools you should call you
doctor, but if he/she is not available you should go to the
nearest emergency.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2150-8-31**]
11:20
You have an appointment scheduled for Friday [**7-31**] at 1:30
with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 133**] for post hospitalization
follow-up.
|
[
"401.9",
"416.0",
"429.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7080, 7138
|
4927, 6229
|
281, 287
|
7211, 7256
|
2574, 4904
|
7562, 7896
|
1721, 1782
|
6426, 7057
|
7159, 7190
|
6255, 6403
|
7280, 7539
|
1797, 2555
|
231, 243
|
315, 1246
|
1268, 1592
|
1608, 1705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,221
| 162,496
|
14947
|
Discharge summary
|
report
|
Admission Date: [**2136-10-17**] Discharge Date: [**2136-10-26**]
Date of Birth: [**2085-4-9**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 51-year-old woman
with a history of breast cancer, who was in her usual state
of health while she was dressing herself in the morning of
admission. She noticed her vision became blurry and things
were moving and waving. She had a doctor's appointment and
when she arrived, she was lightheaded and dizzy. Her blood
pressure was 180/100. She had difficulty talking and
difficulty with comprehending with what was being said. She
had word finding difficulties, and her speech was dysarthric.
She was sent to [**Hospital 8**] Hospital, and then transferred to
[**Hospital1 69**] after head CT showed
question of an aneurysm.
PAST MEDICAL HISTORY:
1. Partial mastectomy.
2. COPD.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: Temperature 99.8, blood pressure
116/60, respiratory rate 16, and sats 95%. In general, in no
acute distress, alert and awake. Cardiac: Had tachycardia,
but a regular rhythm. Pulmonary: Chest was clear to
auscultation. Neurologically: Awake, alert, and oriented
times three. Language was fluent. Comprehension was intact.
Motor strength was full strength in the upper and lower
extremities. Sensory was intact grossly to pain, pin prick,
and light touch. Her coordination finger-to-nose was normal,
but slower on the left. Reflexes diminished globally. Toes
were mute bilaterally.
Patient was admitted to the ICU for close neurologic
evaluation. MRI/MRA showed right MCA bifurcation, aneurysm
7-8 mm and two small ACA aneurysms. She was seen by Stroke
Neurology service for TIA symptoms.
On [**2136-10-18**], patient underwent arteriogram which showed
right MCA aneurysm and two ACA aneurysms. Post procedure,
the patient was awake, alert, and oriented times three with
no groin hematoma and positive pedal pulses. Patient was
also seen by Pulmonary Medicine due to her most recent
diagnosis of COPD. They recommended pulmonary function
tests, Atrovent, early extubation for coiling, and early
ambulation, DVT prophylaxis, and incentive spirometry.
On [**2136-10-22**], patient underwent a coiling embolization of a
10 x 6 x 5 right MCA aneurysm without complication. Patient
was started on aspirin and Heparin with goal PTT of 60-75.
Post procedure, she was awake, alert, and oriented times
three with symmetric smile, no diplopia. Strength was [**4-2**] in
all muscle groups. She had positive pedal pulses. Her
sheath was intact. She continued on Heparin. Goal of PTT
60-80.
She was taken back to angio on [**10-24**] and had coiling of a
left ICA aneurysm without complication. Patient was awake,
alert with speech fluent. Naming was intact. Face is
symmetric. EOMs full, no drift. Strength was [**4-2**]. She
continued to remain stable. Her sheath was D/C'd. Heparin
was discontinued, and patient was transferred to the regular
floor on [**2136-10-25**]. Discharged home on [**10-26**] with followup
with Dr. [**Last Name (STitle) 1132**] in two weeks.
MEDICATIONS ON DISCHARGE:
1. Atrovent two puffs q.i.d.
2. Metoprolol 2.5 p.o. b.i.d.
3. Famotidine 20 mg p.o. b.i.d.
4. Nicotine 14 mg topically q.d.
5. Dilantin 100 mg p.o. t.i.d.
6. Percocet 1-2 tablets p.o. q.4h. prn.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2137-1-1**] 12:04
T: [**2137-1-1**] 12:20
JOB#: [**Job Number 43775**]
|
[
"437.3",
"435.8",
"496",
"V10.42",
"272.0",
"401.9",
"V10.3",
"427.89",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3143, 3339
|
921, 3117
|
170, 810
|
832, 898
|
3364, 3674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,739
| 144,123
|
8166
|
Discharge summary
|
report
|
Admission Date: [**2194-5-17**] Discharge Date: [**2194-5-27**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
CC: CP, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
.
HPI: 81yom with h/o CMML, CAD, CHF, and known portal
hypertension (Known grade 3 varcies, transferred from [**Last Name (un) 4068**]
where he orginally presented. Patient reports he was on [**Location (un) 28985**] this week and not compliant with his normally low-Na diet.
He did take all meds as usual. While on [**Location (un) **] he did not
sleep in his usual hospital bed, and instead had to sleep in a
chair due to increased dyspnea. He would feel his anginal pain
if he slept laying down. He developed a progressive worsening
DOE and increased leg girth over past week. Overnight he went
to OSH due to acute onset of increased dyspnea and [**6-8**] CP. He
denies angina since arrival at the hospital after he was given
morphine, asp, nitro, lasix 20 IV, metoprolol 5mg x2.
In the ED he was seen by cards fellow, no ST elevation, felt
to be demand ischemia d/t fall in Hct from 30s-->27. Baseline
hct in 30s, has dropped over past week. He denies any melena or
BRBPR or hematemesis, n/v, however, in the ED, he endorsed dark
melanotic stools for one week, and bright red blood in his stool
for several days. In ED, he was guiac-positive, although he is
on iron. He also takes coumadin for his hypercoag state. He
has undergone multiple laser ablations at [**Hospital3 5097**] for his
watermellon stomach. Reports seeing his doctors recently, with
[**Name5 (PTitle) **] recent change in medications. Per report, GI aware patient
is here.
Also noted R>L LLE and LENI was done. No DVT noted.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post non-Q-wave
myocardial infarctions in [**Month (only) 958**], [**Month (only) 547**], and [**2190-6-30**].
The patient has had multiple cardiac interventions. In [**2190-2-28**] the patient had percutaneous transluminal coronary
angioplasty and PTCRA of the left anterior descending artery
and first diagonal. Then in [**2190-6-30**] the patient had
percutaneous transluminal coronary angioplasty of the first
diagonal, and then in [**2190-8-30**] the patient had a
percutaneous transluminal coronary angioplasty to the
posterior descending artery on [**2190-9-3**], and then was
taken back to the catheterization laboratory for recurrent
chest pain on [**9-6**] and had percutaneous transluminal
coronary angioplasty to the first diagonal which had a 90%
lesion. The patient also has a history of congestive heart
failure with an ejection fraction of 50% to 55%.
2. Gastrointestinal bleed. The patient has had significant
gastrointestinal bleeding in the past. Grade III varices. The
patient also has gastric ulcers. He also has a "watermelon
stomach." for which he has had 4 laser ablations.
3. Hypercoagulable stable, status post splenic infarct,
multiple pulmonary emboli, cerebrovascular accident and
portal vein thrombosis.
4. Chronic renal insufficiency with a baseline creatinine
of 1.8 to 2.
5. Gastroesophageal reflux disease.
6. Hypercholesterolemia.
7. Hypertension.
8. Benign prostatic hypertrophy.
9. Chronic myelomonocytic leukemia; followed by Dr. [**Last Name (STitle) 29050**] at
[**Hospital3 17310**].
10. Right groin hematoma, status post cardiac
catheterization.
11. Right thigh cellulitis.
.
Social History:
Soc Hx: Lives with wife in [**Name (NI) **]. Gets care at St Es and
[**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**]. Quit smoking 50 years ago. Has one drink pr
day (used to have scotch now drinks on glass of [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]).
Retired Electrician.
Physical Exam:
PE - VS T=97.3 P=80 BP=118/49 RR=27 99% on NRBM
Gen- sitting in bed, slightly tachypneic, speaking in full
sentences, in NAD
HEENT- PERRLA, EOMI, o/p clear
Neck- soft & supple; JVP to earlobes
CV- RR, no m/r/g
Pulm- decreased BS bil, bibas crackles
Abd- +BS, s/bt/nd
Ext- W&D, 2+DP/radial pulses
Pertinent Results:
[**2194-5-27**] CXR - Interval development of left lower lobe
atelectasis.
Some improvement in the magnitude of bilateral pulmonary
infiltration with significant degree of residual bilateral
pulmonary infiltration still present.
[**2194-5-27**] Renal U/S - No evidence of hydronephrosis. Scarred right
renal parenchyma
[**2194-5-26**] ECHO - The left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is mild regional left ventricular systolic dysfunction.
Resting regional wall motion abnormalities include
inferior/inferolateral hypokinesis and probably distal
septal/apical hypokinesis (however the apex is not well
visualized). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-1**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (tape reviewed) of
[**2194-5-18**], left ventricular systolic function is probably
similar. Mitral regurgitation appears similar to slightly
increased.
[**2194-5-25**] CT Head - No intra- or extra-axial hemorrhage. No change
since prior CT dated [**2194-5-21**]
[**2194-5-22**] CXR - No significant interval change over the last 24
hours, the patient with marked congestion, probably pulmonary
edema and possible overlying infectious processes
[**2194-5-21**] CT Head - Severely limited exam, secondary to patient
motion. Slight area of increased density within right anterior
temporal [**Doctor Last Name 534**], unlikely represents a hemorrhage or hematoma. No
definite intra or extra-axial hemorrhage is identified
[**2194-5-21**] Abdomenal U/S - Markedly limited exam. Unusual,
incompletely assessed vascular structure in the left abdomen
measuring up to 5.2 cm. Findings discussed with Dr. [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) **] in the afternoon of [**2194-5-23**]
[**2194-5-17**] WBC-103.4*# RBC-3.40* Hgb-8.2* Hct-27.4* MCV-81* Plt
Ct-586*
[**2194-5-27**] WBC-114.8* RBC-3.78* Hgb-10.2* Hct-32.4* MCV-86 Plt
Ct-345
[**2194-5-17**] Neuts-62 Bands-3 Lymphs-4* Monos-25* Eos-1 Baso-3*
Atyps-0 Metas-1* Myelos-0 NRBC-1* Other-1*
[**2194-5-27**] PT-17.4* PTT-70.1* INR(PT)-2.0
[**2194-5-17**] PT-23.1* PTT-38.8* INR(PT)-3.5
[**2194-5-27**] Glucose-199* UreaN-76* Creat-4.5* Na-140 K-4.2 Cl-113*
HCO3-9* AnGap-22*
[**2194-5-17**] BLOOD Glucose-141* UreaN-38* Creat-2.6* Na-142 K-3.7
Cl-106 HCO3-21* AnGap-19
[**2194-5-26**] BLOOD ALT-26 AST-61* LD(LDH)-881* AlkPhos-168*
[**2194-5-24**] BLOOD Lipase-45
[**2194-5-17**] BLOOD CK-MB-12* MB Indx-5.4
[**2194-5-17**] BLOOD cTropnT-0.37*
[**2194-5-17**] BLOOD CK-MB-31* MB Indx-8.0* cTropnT-1.24*
[**2194-5-17**] BLOOD CK-MB-24* MB Indx-7.6* cTropnT-1.44*
[**2194-5-18**] BLOOD CK-MB-39* MB Indx-10.7* cTropnT-1.26*
[**2194-5-18**] BLOOD CK-MB-31* MB Indx-9.1* cTropnT-1.37*
[**2194-5-19**] BLOOD CK-MB-21* MB Indx-8.1* cTropnT-1.23*
[**2194-5-20**] BLOOD CK-MB-13* MB Indx-8.4* cTropnT-1.20*
[**2194-5-21**] BLOOD cTropnT-1.36*
[**2194-5-24**] BLOOD CK-MB-4 cTropnT-2.11*
[**2194-5-24**] BLOOD CK-MB-4 cTropnT-1.97*
[**2194-5-17**] BLOOD Calcium-7.8* Phos-4.2 Mg-2.0 Cholest-83
[**2194-5-17**] BLOOD Iron-10*
[**2194-5-17**] BLOOD calTIBC-360 VitB12-GREATER TH Folate-GREATER TH
Ferritn-115 TRF-277
[**2194-5-17**] BLOOD Triglyc-134 HDL-20 CHOL/HD-4.2 LDLcalc-36
[**2194-5-22**] BLOOD TSH-3.1
[**2194-5-22**] BLOOD Free T4-1.3
[**2194-5-24**] BLOOD Cortsol-32.3*
[**2194-5-24**] BLOOD Cortsol-21.3*
[**2194-5-23**] BLOOD Phenyto-10.6
Brief Hospital Course:
Assessment: 81yom with h/o CMML, CAD, CHF, and known portal
hypertension (Known grade 3 varcies) presenting with chest pain,
guiaic positive stool, and HCT drop.
Plan:
1. chest pain--presented to OSH with his anginal equivalent,
pain resolved there with asa/morphine/ntg/metoprolol. Has
remained pain-free since. Concern for ACS - probable
angina/demand ischemia, exacerbated by his anemia/bleeding, &
CHF exacerbation. Ruling in with positive CK & troponin.
- follow serial EKGs, monitor for any recurrence of angina
- cycle enzymes, telemetry
- continue aspirin, low-dose metoprolol (monitor closely on BB
as this could mask GI bleed), stating (increase to high-dose
statin); no anticoagulation given GIB
-cardiology planning to follow up
2. guiac positive stool + Hct drop--serial Hcts - pt with known
varices, ulcers, & watermelon stomach for which he has had argon
treatments. Concern for any of these etiologies; however, given
his NSTEMI & CHF, would not do EGD at this time, and instead
manage medically. Hct 35 on 4/35.
- transfuse to hct>30s; lasix prn w/ transfusion
- serial hct Q6hrs; IV ppi [**Hospital1 **]; 2 large bore IVs
- gently correct coagulopathy - got vitamin K in ED, hold
coumadin - would not reverse INR given his hypercoagulable
state; this was discussed with GI, hem/omc, & cardiology
-no NG lavage done d/t known varices and elevated INR
- GI following; plan for EGD when medically stable
3. CHF - pt with probable CHF, on lasix as outpt. Clinically in
decompensated CHF - likely due to medication non-complicance and
dietary indiscretions on his recent vacation.
- gently diurese with IV lasix
- low-dose metoprolol for ACS - hold ace given his GIB
- plan for repeat echo here
4. WBC 103K with immature cells on smear - pt with known CML, on
hydrea as outpt. Per [**Hospital3 **] records, last CBC on [**3-24**]
with WBC 71, hct 35, plt 439. Other records unavailable - his
outpt oncologist is in private practice, and not on-call over
the weekend.
- obtain records, & ensure his WBC count is at baseline
- make certain smear consistent with priors (r/o blast crisis);
heme-onc to review smear
- continue hydrea as per home regimen
- case was discussed with heme/onc team, who concurred with
continuing current hydrea dose, & will review peripheral smear.
They decided not to pursure active treatment of the patient
oncology issues while the patient was in the ICU.
5. ARF atop CKD - unknown baseline
-check urine lytes, resuscitate as needed
6. hypercoagulability - pt w/ recurrent VTE, also h/o CVA; on
coumadin as outpt. Holding [**1-1**] GIB, restart when medically
stable.
6. hypothyroidism - cont synthroid
The patient continued to deteriorate while in the ICU. Several
attempts to wean the patient off the vent were unsuccessful.
The family decided to discontinue support and the patient was
made CMO. He expired [**2194-5-27**] soon after support was withdrawal.
The family was present.
Medications on Admission:
ALLERGIES: The patient denies any drug allergies but states
he has had some arm itching at sites of MORPHINE INJECTION.
.
Home Meds:
Coumadin 4mg QD, Lasix 40 QD, Metoprolol XL 25 QD, Aspirin 325,
Imdur 60mg [**Hospital1 **], Proscar 5mg qd, synthroid 50 qd, hydrea 500
(?QD), Flomax .4 mg QD, Protonix 40 QD, Folate, Iron, MVI, Nitro
SL prn, Procrit, Lipitor 10mg QD.
.
Discharge Medications:
The patient expired while in the hospital.
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Respiratory Failure
CML
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"410.71",
"V45.82",
"205.10",
"578.9",
"276.0",
"584.9",
"414.01",
"518.81",
"486",
"276.2",
"285.1",
"428.0",
"244.9",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11502, 11541
|
8066, 11014
|
241, 247
|
11604, 11629
|
4202, 8043
|
11685, 11695
|
11435, 11479
|
11562, 11583
|
11040, 11412
|
11653, 11662
|
3885, 4183
|
185, 203
|
275, 1795
|
1839, 3495
|
3511, 3870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,884
| 142,944
|
42788+58553
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-29**]
Date of Birth: [**2036-11-28**] Sex: M
Service: SURGERY
Allergies:
Haldol / Penicillins
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
rectal cancer
Major Surgical or Invasive Procedure:
Attempted transanal endoscopic microsurgery
(TEM), proctectomy, end-colostomy with mobilization of
splenic flexure.
History of Present Illness:
The patient is a 65yo male with a rectal mass that had
appearance of a sizeable rectal cancer. His biopsy showed just
an adenoma. His previous biopsy was complicated by significant
bleeding. We did
check the CEA, which was slightly elevated at 4.9. We did an
MRI of the pelvis which most of the time tend to be one of the
best studies which we can get, however, in his case because of
absence
of any fat in his body, it was really not diagnostic. He
underwent an ultrasound today which was also very difficult, but
showed may be a T2 lesion at best but some areas cannot be
really well evaluated. He is complaining of some phlegm and
some coughing that has been persistent and he is going to get an
x-ray at your office tomorrow. Otherwise, he has been in the
same health. He has occasional abdominal cramping and he is
having some diarrhea. He occasionally passes some blood. He
has been
trying to eat, but unable to gain much weight. He presents for
surgical staging with TEM.
Past Medical History:
Past Medical History: HTN, COPD, PVD, 'abnormal heart beat'
Past Surgical History:
Aortobifemal bypass with repair of left CFA aneurysm
([**2099-5-6**])Left fem-BK [**Doctor Last Name **] bypass with in situ vein ([**2099-5-13**])
Right fem-PT bypass w/ SVG ([**2099-10-7**])
right inguinal hernia repair
Social History:
Lives with daughter and her family. Heavy smoker 1.5 pack/day
for 50 years, EtOH 4 beers/day, denies drugs
Family History:
non-contributory
Physical Exam:
At time of discharge
97.7 62 136/67 16 95RA
NAD
RRR
breathing easily
Abd soft, ND, NT, no R/G
Ext no edema, R LE in multipodus boot
Pertinent Results:
[**2102-5-25**] 05:00AM BLOOD WBC-8.0 RBC-2.93* Hgb-9.1* Hct-27.3*
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.7 Plt Ct-270
[**2102-5-23**] 06:48PM BLOOD WBC-15.2* RBC-3.52* Hgb-10.8* Hct-33.1*
MCV-94 MCH-30.7 MCHC-32.6 RDW-15.3 Plt Ct-291
[**2102-5-26**] 02:48PM BLOOD Glucose-158* UreaN-13 Creat-0.5 Na-133
K-4.2 Cl-94* HCO3-31 AnGap-12
[**2102-5-26**] 02:48PM BLOOD Calcium-8.3* Phos-3.8 Mg-1.6
Brief Hospital Course:
The patient underwent attempted transanal microsurgical excision
of his tumor which was unsuccessful. He was converted to
proctectomy with end colostomy. Due to his many medical
comorbidities he was transferred to the ICU post-operatively. He
was closely monitored and did well overall. His urine output was
low and required multiple fluid boluses to support. He was
extubated and had good oxygen saturations on 2-3L NC and was
slowly weaned off of oxygen.
On POD#1 he was transferred from the ICU to a regular floor bed.
He was monitored closely on telemetry. His blood pressure was
elevated in the 190s and his home atenolol and lisinopril were
restarted and his BP decreased appropriately. His
anticoagulation was held. The vascular surgery service saw the
patient and evaluated his R femoral to peroneal bypass and felt
it was stable and recommended outpatient follow-up with Dr.
[**Last Name (STitle) 1391**]. The patient has a history of alcohol withdrawal and
was monitored on a CIWA scale. He did not require any ativan or
valium for withdrawal. He was also given thiamine.
On POD#2 he had gas in his ostomy bag and his diet was advanced
to clears. His foley catheter was removed but he failed to void
and it was replaced. He was started on flomax.
On POD#3 peripheral IV access was obtained and his right IJ
central line was removed. His stoma continued to have gas but no
output, and he was given a dulcolax suppository to his stoma
without effect. He was also given milk of magnesia.
On the remaining post-operative days his ostomy began putting
out an appropriate amount of stool and gas. He was restarted on
his home medications and the reglan was discontinued. He was
tolerating a regular diet and voiding. He worked with PT who
recommended home with home PT. His family came in and underwent
teaching regarding his care at home. He was discharged home and
will follow-up in colorectal surgery clinic.
Medications on Admission:
1. atorvastatin 20 daily
2. aspirin 325 daily
3. docusate sodium
4. oxycodone 5 prn
5. Daliresp 500 mcg daily
6. Symbicort 80-4.5 mcg [**Hospital1 **]
7. ProAir HFA 90 mcg 1-2 per day
8. Plavix 75 mg daily
9. atenolol 50 [**Hospital1 **]
10. lisinopril 20 daily
11. omeprazole 40 daily
12. nicotine 14 mg/24 hr Patch 24 hr daily
13. calcium carbonate 200 mg calcium TID prn
14. thiamine HCl 100 daily
15. acetaminophen prn
Discharge Medications:
1. roflumilast 500 mcg Tablet Sig: One (1) Tablet PO daily ().
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. budesonide-formoterol 80-4.5 mcg/actuation HFA Aerosol
Inhaler Sig: Two (2) puffs Inhalation [**Hospital1 **] (2 times a day).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze/SOB.
11. atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
16. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
rectal cancer
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 to the hospital after proctectomy and end
colostomy for surgical management of your rectal cancer. Samples
from your colon were taken and this tissue has been sent to the
pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth.
If you have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids.
You have an incision that can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
You have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have [**1-23**]
bowel movements daily. If you notice that you have not had [**First Name8 (NamePattern2) 691**]
[**Doctor Last Name 3945**] from your stoma in [**1-23**] days, please call the office. You
may take an over the counter stool softener such as colace if
you find that you are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if you notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for buldging or signs
of infection listed above. Please care for the ostomy as you
have been instructed by the wound/ostomy nurses. You will be
able to make an appointment with the ostomy nurse in the clinic
1 week after surgery, You will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until you are
comfortable caring for it on your own.
Followup Instructions:
Call the colorectal surgery office to make an appointment for
follow-up two weeks after surgery with the colorectal surgery
outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At that
appointment you will be set up with an appointment for your
second post-operative check.
Call [**Telephone/Fax (1) 160**] to make this appointment.
Please also call the clinic to make an appointment with the
wound ostomy nurses approximately 1 week after discharge
Please contact Dr.[**Name2 (NI) 1392**] office to schedule a follow-up
vascular surgery appointment.
Completed by:[**2102-5-29**] Name: [**Known lastname 14528**],[**Known firstname **] Unit No: [**Numeric Identifier 14529**]
Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-29**]
Date of Birth: [**2036-11-28**] Sex: M
Service: SURGERY
Allergies:
Haldol / Penicillins
Attending:[**First Name3 (LF) 94**]
Addendum:
Final diagnosis: adenoma
Nutritional status: moderate malnutrion
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) 102**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**]
Completed by:[**2102-8-18**]
|
[
"V85.0",
"707.15",
"443.9",
"401.9",
"496",
"305.1",
"263.0",
"211.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.10",
"48.69"
] |
icd9pcs
|
[
[
[]
]
] |
11388, 11601
|
2497, 4418
|
294, 412
|
6527, 6527
|
2086, 2474
|
10281, 11299
|
1901, 1919
|
4891, 6371
|
6490, 6506
|
4444, 4868
|
11316, 11365
|
6703, 10258
|
1536, 1760
|
1934, 2067
|
241, 256
|
440, 1430
|
6542, 6679
|
1474, 1513
|
1776, 1885
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,916
| 105,213
|
49333
|
Discharge summary
|
report
|
Admission Date: [**2134-1-11**] Discharge Date: [**2134-1-22**]
Date of Birth: [**2070-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lisinopril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
AVR/MAZE
History of Present Illness:
63 yo M with CAD, known AS (EF 40%, Peak gradient 88, mean
gradient 54, [**Location (un) 109**] 0.7), Atrial Fibrillation s/p cardioversion on
[**2133-12-24**] who presents from [**Hospital3 **] ED with flash
pulmonary edema.
Of note, further history per him: he states he started to have
chest pain and shortness of breath this past Thursday and was
told by the RN to double his lasix from 20 po qd to 20 po bid.
He states, on Thursday through Saturday, he felt okay with this
medication change, however on Sunday night, he stayed awake all
night burping and had to sit up straight in his bed to breath.
He also complained of PND/orthopnea. This went away and then
again this PM, his wife and him went out to dinner and he ate
salty foods including baked potato and lamb chops and went home
to lay down in bed and awoke with chest pressure and feeling as
though he had to gasp for air. He was also diaphoretic, but
denied any N/V/LH.
He called 911 with approximately 1 hr of SOB/CP and via
paramedics, he was found to be in acute pulmonary edema en route
to the ED. He of note called Dr. [**Last Name (STitle) **] with these complaints
and told to go to the ED stat. He was noted to be pale and
diaphoretic and initial VSS were BP 180/110, HR 120's, and 100%
on NRB. He was immediately given Lasix 100mg IV x 1, Nitrospray
x 3 en route and taken to [**Hospital3 **]. At [**Hospital3 **],
CXR was consistent with pulmonary edema and he was given nitro
tabs as well as he was started on a nitro gtt with BP falling
into 80-100's with HR 70's. He was also given Morphine 1mg IV x
1, phenergan, and albuterol. His nitro was stopped once his MAPs
decreased. His UOP with the Lasix 80IV x 1 was ~750cc. He was
transferred to [**Hospital1 18**] directly to the floor for further
management.
He currently denies any chest pain or shortness of breath and
feels comfortable now. He states at baseline, he cannot walk up
steps without SOB and sleeps on 2 pillows which has been stable.
Past Medical History:
1. Aortic stenosis (EF 40%, Peak gradient 88, mean gradient 54,
[**Location (un) 109**] 0.7)
2. Atrial Fibrillation - on amio, s/p DC cardioversion on
[**2133-12-24**]
3. CAD- mild (30% rca and 30% om1- [**11-29**])
4. BPH
5. GERD
6. TIA - [**2123**]
7. HTN
8. sciatica
9. chronic anemia ? early MDS
10. Bell's palsy
Social History:
Social History: lives with wife, daughter, and granddaughter,
retired park ranger, from [**Male First Name (un) **], no smoking, occasional
alcohol, no drugs.
Family History:
Family History: brother had heart problems when young
Physical Exam:
5' 6" 89 kg. PE: 98.4, 96/60, 70, 24, 100% on 2L (97% on RA)
Gen- lying in bed in NAD, AAOx3
Neck- JVD ~7cm at 30 degrees, supple
HEENT- moist MM, OP clear
CV- RR, nl S1, no S2 appreciated, +3/6 SEM at RUSB, radiation to
carotids bilaterally, +pulsus parvus et tardus
Chest- mild bibasilar crackles
Abd- soft, NT/ND, +BS
Ext- no C/C/E +2pulses bilaterally
Pertinent Results:
[**2134-1-11**] 06:10AM PT-14.0* PTT-25.4 INR(PT)-1.2
[**2134-1-11**] 06:10AM PLT COUNT-327
[**2134-1-11**] 06:10AM HYPOCHROM-1+
[**2134-1-11**] 06:10AM NEUTS-79.8* LYMPHS-13.7* MONOS-4.9 EOS-1.2
BASOS-0.4
[**2134-1-11**] 06:10AM WBC-11.3* RBC-3.75* HGB-11.2* HCT-33.4*
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.9
[**2134-1-11**] 06:10AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2134-1-11**] 06:10AM CK-MB-NotDone cTropnT-<0.01
[**2134-1-11**] 06:10AM CK(CPK)-74
[**2134-1-11**] 06:10AM GLUCOSE-119* UREA N-24* CREAT-1.2 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-31* ANION GAP-11
[**2134-1-11**] 12:45PM URINE MUCOUS-RARE
[**2134-1-11**] 12:45PM URINE RBC-109* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2134-1-11**] 12:45PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2134-1-11**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2134-1-11**] 06:00PM PT-13.8* PTT-28.5 INR(PT)-1.2
[**2134-1-11**] 06:00PM PLT COUNT-347
[**2134-1-11**] 06:00PM HYPOCHROM-1+
[**2134-1-11**] 06:00PM NEUTS-76.8* LYMPHS-15.3* MONOS-5.2 EOS-2.2
BASOS-0.4
[**2134-1-11**] 06:00PM WBC-10.4 RBC-3.87* HGB-11.3* HCT-34.2* MCV-89
MCH-29.1 MCHC-32.9 RDW-14.9
[**2134-1-11**] 06:00PM TRIGLYCER-56 HDL CHOL-41 CHOL/HDL-2.8
LDL(CALC)-64
[**2134-1-11**] 06:00PM VIT B12-383
[**2134-1-11**] 06:00PM ALBUMIN-3.7 CHOLEST-116
[**2134-1-11**] 06:00PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-65
AMYLASE-64 TOT BILI-1.3 DIR BILI-0.4* INDIR BIL-0.9
[**2134-1-11**] 06:00PM GLUCOSE-120* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-9
[**2134-1-11**] 06:14PM O2 SAT-97
[**2134-1-11**] 06:14PM TYPE-ART PO2-91 PCO2-43 PH-7.40 TOTAL CO2-28
BASE XS-0 INTUBATED-NOT INTUBA
[**2134-1-11**] 06:14PM TYPE-ART PO2-91 PCO2-43 PH-7.40 TOTAL CO2-28
BASE XS-0 INTUBATED-NOT INTUBA
[**2134-1-11**] 06:52PM %HbA1c-6.0*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
[**2134-1-22**] 06:05AM BLOOD PT-18.2* PTT-81.2* INR(PT)-2.1
[**2134-1-21**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-1.2 Na-138
K-4.9 Cl-101 HCO3-32* AnGap-10
[**2134-1-21**] 07:05AM BLOOD Mg-2.7*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
[**2134-1-22**] 06:05AM BLOOD PT-18.2* PTT-81.2* INR(PT)-2.1
[**2134-1-21**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-1.2 Na-138
K-4.9 Cl-101 HCO3-32* AnGap-10
[**2134-1-21**] 07:05AM BLOOD Mg-2.7*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
Brief Hospital Course:
A/P: 63 you M with PMHX of critical AS (EF 40%, Peak Gradient
88, Mean Gradient 54, [**Location (un) 109**] 0.7), nonobstructive CAD, Afib on
amiodarone s/p DC cardioversion [**2133-12-24**], HTN who presents with
flash pulmonary edema to OSH and transferred here for further
management.
1. COR- non-obstructive CAD history.
- ?cause for chest pain likely from critical AS instead of
obstructive coronary disease.
- will continue to ROMI
- continue ASA for now, pt states has not been held yet
pre-operatively. Will need to discuss with surgeons in AM if
want to continue ASA.
- continue lipitor but increase dose to 80 qd (as too late now
but can help progression of AS disease)
- hold carvedilol temporarily as BP now 90's likely secondary to
overdiuresis and multiple NTG tablets. And pt is pre-load
dependent with his critical AS and thus should not bring down BP
too much.
2. PUMP- Critical AS with EF 40%, Peak Gradient 88, Mean
Gradient 54, [**Location (un) 109**] 0.7
- Possibly, pt in CHF secondary to high salt intake at dinner
today. However, pt has also been having chest pain for the past
few days and may have coronary cause for CHF.
- Pt diuresed will with over 750 cc out.
- Pt appears euvolemic to hypovolemic now and since pre-load
dependent, will not diurese further.
- Continue lipitor for critical AS
- AVOID nitrates in critical AS patients, will be cautious with
carvedilol and holding parameters for SBP<100.
- [**Month (only) 116**] be able to proceed with surgery as clinically not in CHF
anymore. Contact CT surgery in AM.
- ?cath in AM to further assess for critical AS pre-operatively.
Will keep NPO for now.
3. Rhythm- LBBB with LAD. Currently in NSR. Hx of Afib s/p
cardioversion [**12-24**].
- continue amiodarone.
- If afib recurs, consider repeat cardioversion.
- Coumadin was held per CT surgeons in anticipation for cath on
[**1-13**]. Will continue to hold for now. Can rediscuss with attg in
AM of ?starting heparin gtt.
4. HTN - pt now relatively hypotensive given overdiuresis, lots
of nitro.
- hold cozaar/carvedilol (with BP parameters) until SBP>100.
5. Hx of TIA- continue ASA, lipitor.
6. PPX- SC heparin tid, PPI
7. Full CODE
Pt cathed on [**1-11**] which revealed mild diffuse disease with LAD
30%, CX 40%, RCA 40%, LVEDP 19, right dominant.
Referred to Dr. [**Last Name (STitle) **] for AVR/ Maze procedure and left atrial
appendage stapling , which he underwent on [**2134-1-12**]. Pt received
a [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical valve. Pt. had a brief period of
hypotension at induction per Dr.[**Name (NI) 3502**] operative note.
Transferred to CSRU in stable condition on Epinephrine, Insulin,
Nitroglycerin, and Levophed drips. Extubated in evening, and
remained on low-dose epi and levophed drips on POD #1. Pt went
back into afib and amiodarone and carvedilol were restarted.
Lasix diuresis started also. Chest tubes were DCed on POD #2
heparin was started for mech . valve anticoag. on POD #3, and
paciding wires DCed. Also unsuccessful at cardioversion.
Coumadin was also started and EP consult obtained. Transferred
to [**Hospital Ward Name 121**] 2 on POD #4 and began work with PT/ ambulation. POD #5
foley was replaced for retention. Had been restarted on Flomax.
Remained on heparin drip while coumadin dosing to elevate INR
took place. Also seen by case management for VNA eval on POD #6.
Continued to work with PT for increasing activity level. Taking
po percocet for incisional discomfort. Coreg and lasix both
increased on POD #9. DC ed home in stable condition on POD #10
with INR 2.1.
Medications on Admission:
1. ASA 81 qd
2. Amiodarone 200 [**Hospital1 **]
3. Lipitor 10 qd
4. Flomax 0.4 qd
5. Carvedilol 25 po bid
6. Cozaar 75 [**Hospital1 **]
7. Folate 400 mcg daily
8. Coumadin held on [**1-6**].
9. lasix 20 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO BID (2 times a day): [**Hospital1 **] x 2
weeks then QD.
Disp:*45 Capsule, Sustained Release(s)* Refills:*2*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Hospital1 **] x 2 weeks then QD.
Disp:*45 Tablet(s)* Refills:*2*
9. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once a
day: pt to take 5 mg Fri/Sat/Sun. Then as directed by [**Hospital 197**]
clinic .
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
s/p AVR/ Maze proc.
AS
AFib
HTN
BPH
GERD
TIA
anemia,
Bell's Palsy
legally blind
Discharge Condition:
good
Discharge Instructions:
INR check [**1-23**] and [**1-25**] with results to [**Hospital 119**] [**Hospital 197**]
clinic
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 10 days
Dr [**First Name (STitle) **] in [**12-31**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2134-2-15**]
|
[
"424.0",
"600.00",
"458.29",
"428.0",
"276.5",
"401.9",
"414.01",
"530.81",
"427.31",
"746.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"89.60",
"39.61",
"37.33",
"88.56",
"99.61",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
11230, 11281
|
6018, 9617
|
326, 337
|
11404, 11410
|
3325, 5995
|
11708, 11867
|
2893, 2933
|
9879, 11207
|
11302, 11383
|
9643, 9856
|
11434, 11685
|
2949, 3306
|
252, 288
|
365, 2345
|
2367, 2685
|
2717, 2861
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,804
| 174,706
|
7929
|
Discharge summary
|
report
|
Admission Date: [**2123-5-14**] Discharge Date: [**2123-5-18**]
Date of Birth: [**2073-5-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
uncontrolled pain
Major Surgical or Invasive Procedure:
R total knee replacement
History of Present Illness:
49 y/o s/p R total knee replacement with uncontrolled pain. Pt
was receiving morphine PCA 1 mg q 6 min w/ cont'd pain. Epidural
placed. Pt was comfortable but he was sleepy after epidural
because he received 36 mg morphine at the PACU. In addition he
had episodes of apnea with SBP to 90 requiring phenylephrine to
reach SBP of 100. UOP >30cc/hr throughout. Transferred to [**Hospital Unit Name 153**]
for continued close monitoring.
Past Medical History:
HTN, b/l osteoarthritis
Social History:
lives in [**Location **] with wife. previously functional of ADLs.
initially from [**Country **]. primary language is porteguese, but
he is able to speak english and refuses need for translator.
Family History:
non-contributory
Physical Exam:
Vitals- T 96.7, BP 87/51 (65), HR 90, RR 19, 100% on 3L NC
gen- sleepy but arousable, responds to questions, [**4-4**] pain in R
knee
heent- EOMI. Pinpoint pupils, equal b/l. + mild proptosis and
scleral injection. non-icteric. OP clear. membranes moist
pulm- CTA anteriorly. no r/r/w
CV- RRR. normal S1/S2. no m/r/g
Abd- soft, NT/ND. NABS
EXT- R knee braced in CPM device. immobile. wrapped w/ pressure
gauze and covered w/ ice packs. tube draining sanguinous fluid.
Able to wiggle R toes. palpable DP pulse, w/ warm extremities. L
leg w/ no erythema, swelling or tenderness, SCD in place.
Neuro- alert and oriented to person, place "[**Hospital Ward Name **] building",
time; CN II-XII intact. language appropriate.
Pertinent Results:
[**2123-5-14**] 08:23PM HCT-32.6*
Brief Hospital Course:
The patient was admitted and taken to the OR on [**5-14**] for a right
TKA
Post operatively the patient required large doses of morphine
for pain controle. His respiratory status became depressed on
these dose of morphine. The acute pain service placed an
epidural that provided effective pain controle. After the
epidural was placed his systolic blood pressure dropped to the
low 70s. He was started on pressures and volume resusitated.
He had to be transferred to the MICU that evening because the
PACU is not kept open over night. Initially post operatively
the patient had a large output from his drain. His Knee was
flexed at 60 degrees and ice applied which stopped the output.
POD 1: the patient did well and was started on CPM. His pain
improved and was wheened off the epidural and pressures and
transferred to the floor. He was started on lovenox. Physical
therapy was consulted and worked with him towards goal of being
independent.
POD 2: the dressing was changed and the drain was pulled.
The remainder of his hospital course was unremarkable. Physical
therapy continued to see him daily until safe to discharge.
Medications on Admission:
Meds on transfer:
amlodipine 10mg qday
keflex 1g q8 (x 6 doses)- day 1=[**6-14**]
Lovenox 40 SQ qday (on hold)
HCTZ 25mg qday
Percocet prn
Lisinopril 5mg daily
Hydromorphone 10 mcg/ml + Bupivacaine 0.1% 1 mg/ml ED
Infuse at 8-12 ml/hr
Phenylephrine gtt
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. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily) for 24 days.
Disp:*QS box* Refills:*0*
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**3-31**]
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Right knee osteoarthritis
post-op anemia
hypotension
Discharge Condition:
stable
Discharge Instructions:
Please cont with weight bearing as tolerated right leg. Oral
pain medication as needed. Lovenox for anti-coagulation as
needed. Please cont with physical therapy. Please call/return if
any fevers, increased discharge from incision, or trouble
breathing.
Followup Instructions:
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Where: [**Hospital6 29**]
MUSCULOSKELETAL UNIT Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2123-5-25**] 11:15
Completed by:[**2123-5-18**]
|
[
"292.81",
"401.9",
"E935.8",
"458.29",
"715.36",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54",
"99.04",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
3973, 4017
|
1942, 3082
|
346, 372
|
4114, 4122
|
1882, 1919
|
4424, 4618
|
1111, 1129
|
3385, 3950
|
4038, 4093
|
3108, 3108
|
4146, 4401
|
1144, 1863
|
289, 308
|
400, 836
|
858, 883
|
899, 1095
|
3126, 3362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,361
| 170,609
|
48286
|
Discharge summary
|
report
|
Admission Date: [**2196-11-22**] Discharge Date: [**2196-12-6**]
Date of Birth: [**2140-9-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Right internal jugular central venous catheter placement.
Orogastric feeding tube placement.
History of Present Illness:
This is 56 year old man with alcohol abuse (bottle of wine every
day since age 16; his last drink was 2 days ago on Sunday) who
presented with epigastric, back, and chest pain associated with
nausea and vomiting (nonbiliary, nonbloody). He denied fever,
chills, dyspnea, diarrhea, melena or hematochezia. In ED, his
serum Lipase was elevated at 1028 and his liver function tests
were mildly abnormal (AST 59, ALT 62). His ultrasound did not
show any signs of gallstones or sludge. He was admitted for
alcoholic pancreatitis. In ED, he required 10 mg of Valium
because of high score on CIWA scale as well as Morphine. ROS:
all remaining systems were reviewed and symptoms were negative.
Past Medical History:
Alcohol abuse and dependency.
Hypertension
Fatty liver disease
Thyroid cancer S/P resection on Levothyroxin
Social History:
He lives with a wife and a daughter. [**Name (NI) **] smoking. He drinks a
bottle of wine every day since age 16. No more drinking on
weekends. No history of alcohol withdrawal or admissions.
Family History:
Alcoholism
No pancreatic cancer.
Physical Exam:
Admission:
Temp:97.2 HR:106 BP:156/97 Resp:18 O(2)Sat:99 Normal
Constitutional: shaky
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Soft, Nondistended +_TTP epigastric no R/G Rectal:
Heme Negative
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Normal
Pertinent Results:
Admission:
[**2196-11-21**] 08:45PM BLOOD WBC-7.9# RBC-4.72 Hgb-15.5 Hct-44.0
MCV-93 MCH-32.8* MCHC-35.3* RDW-12.7 Plt Ct-147*
[**2196-11-21**] 08:45PM BLOOD PT-13.7* PTT-23.1 INR(PT)-1.2*
[**2196-11-21**] 08:45PM BLOOD ALT-59* AST-62* LD(LDH)-270* AlkPhos-101
TotBili-0.8
[**2196-11-21**] 08:45PM BLOOD Lipase-1028*
[**2196-11-21**] 08:45PM BLOOD cTropnT-<0.01
[**2196-11-21**] 08:45PM BLOOD Albumin-4.4 Calcium-9.0 Phos-3.6 Mg-1.4*
Cholest-259*
[**2196-11-21**] 08:45PM BLOOD TSH-0.064*
[**2196-11-21**] 08:45PM BLOOD Triglyc-99
Discharge:
[**2196-12-6**] 06:26AM BLOOD WBC-6.3 RBC-4.08* Hgb-12.8* Hct-37.1*
MCV-91 MCH-31.3 MCHC-34.5 RDW-13.0 Plt Ct-419
[**2196-12-6**] 06:26AM BLOOD Glucose-85 UreaN-2* Creat-0.7 Na-144
K-3.6 Cl-105 HCO3-28 AnGap-15
[**2196-11-30**] 05:01AM BLOOD ALT-29 AST-37 LD(LDH)-293* AlkPhos-78
TotBili-0.5
[**2196-12-5**] 03:48AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.7
Sputum 1:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Sputum 2:
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
URINE CULTURE (Final [**2196-12-2**]):
PRESUMPTIVE GARDNERELLA VAGINALIS. 10,000-100,000
ORGANISMS/ML..
.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
OF THREE COLONIAL MORPHOLOGIES.
.
.
[**11-21**] RUQ US IMPRESSION:
1. Normal gallbladder without gallstone.
2. Diffusely echogenic liver without focal lesions, most
compatible with
diffuse fatty infiltration. Other forms of advanced liver
disease such as
cirrhosis and fibrosis cannot be excluded.
.
[**11-24**] CT ABD/PELVIS W&W/O C IMPRESSION:
1. Extensive fat stranding around the pancreas consistent with
pancreatitis.
Focal area of hypo-enhancement seen in the pancreatic head
concerning for
early necrosis.
2. Probable thrombus in the SMV.
3. Small bilateral pleural effusions.
4. Small amount of ascites.
.
[**12-5**] CXR: Currently there is interval improvement of pulmonary
edema with normal cardiomediastinal silhouette including the
lungs. Small amount of left pleural effusion is present.
Otherwise, the examination is unremarkable.
Brief Hospital Course:
This is 56 year old man with alcohol abuse who presented with
epigastric pain, nausea, vomiting, and elevated serum Lipase
consistent with alcoholic pancreatitis. His ultrasound did not
show any signs of gallstones or sludge. He was admitted for
medical management with CIWA, NPO, IV fluids, antiemetics, and
pain medications. On [**11-23**], pt began to have worsening agitation,
confusion, visual hallucinations, and significant disorientation
that had been worsening despite escalating doses of
benzodiazepines to treat alcohol withdrawl. Desptite aggressive
management, pt continued to have escalating agitation, and
patient was transferred to the ICU for further management.
ICU COURSE: on the second hospital day, the patient was admitted
to the [**Hospital Ward Name 332**] ICU due to worsening withdrawal symptoms and the
need for closer nursing monitoring. He required increasing doses
of benzodiazepines, and he was switched from oral Valium to an
intravenous infusion of Ativan. Due to his agitation and
tremulousness, and his increasing abdominal pain, he was
intubated and sedated with Fentanyl/Versed. An orogastric tube
was placed and patient was administered oral contrast in
preparation for a CT scan of his abdomen and pelvis. The full
report is above. The CT showed severe pancreatitis with focal
area of hypo-enhancement in the pancreatic head concerning for
early necrosis. There was also concern of thrombus in the SMV
for which patient underwent an abdominal ultrasound with doppler
that showed no thrombus. The general surgery service was
consulted at this time; they recommended against
anticoagulation, given the low liklihood of SMV thrombus. They
also recommended for serial abdominal exams and supportive care
with intravenous hydration and weaning of benzodiazepine as
able. There were no acute surgical issues. From a respiratory
standpoint, the patient was noted to have increased (purulent)
secretions from his endotracheal tube. These were sent for
culture which grew E.coli sensitive to fluoroquinolones and coag
positive staph aureus, sensitive to methicillin. The patient
was treated with an 8 day course of levofloxacin that ended on
[**2196-12-5**].
The patient was able to be extubated on [**11-29**] without
complication. His fentanyl was weaned off and Versed was
decreased slowly as tolerated. Withdrawal symptoms slowly
subsided. Haldol, which had been started while he was intubated
for delirium and agitation, was also weaned off. During
postextubation period, pt had one positive BCx for coag negative
staph, for which his RIJ CVL was pulled; this was unfortunately
contaminated after pulled and not cultured. Regardless, pt
received 5d course of Vancomycin, ended [**2196-12-5**].
His mental status slowly improved back to baseline, pt was
tolerating PO foods/liquids. The patient was then transferred
back to the general medical floor in stable condition. He was
seen by Physical Therapy, who cleared him for return to home.
He met with Social Work, who further counselled him regarding
his alcohol abuse, and he was provided with resources in his
community to assist with maintaining abstinance. He was
provided resources for both inpatient and outpatient programs.
He was discharged to home with follow up with his PCP.
Medications on Admission:
Lisinopril 10 mg
Levoxyl 200 mcg
Discharge Medications:
1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute alcoholic pancreatitis
# Severe alcohol withdrawl, with delerium tremens
- required intubation
# Ventilator associated pneumonia/Healthcare associated
pneumonia
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 treatment of pancreatitis
and alcohol withdrawal. Due to the severity of the withdrawal
symptoms, you had to be intubated and treated with intravenous
medicines for withdrawal. The hospital course was complicated by
development of pneumonia and bacteria in your blood.
You have been provided resources in your community to help you
stay off of alcohol. You are strongly encouraged to utilize
these resources.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 40715**]
Appointment: Tuesday [**2196-12-13**] 10:40am
|
[
"577.0",
"041.84",
"478.5",
"276.3",
"784.51",
"307.9",
"E939.4",
"518.4",
"518.81",
"401.9",
"997.31",
"784.42",
"244.0",
"041.4",
"571.0",
"780.09",
"V10.87",
"303.01",
"291.0",
"787.22",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"94.62",
"96.6",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8289, 8295
|
4733, 8014
|
320, 440
|
8510, 8510
|
2043, 4710
|
9132, 9391
|
1513, 1547
|
8097, 8266
|
8316, 8489
|
8040, 8074
|
8661, 9109
|
1562, 2024
|
265, 282
|
468, 1157
|
8525, 8637
|
1179, 1288
|
1304, 1497
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,725
| 174,962
|
20238
|
Discharge summary
|
report
|
Admission Date: [**2172-9-16**] Discharge Date: [**2172-11-12**]
Date of Birth: [**2133-6-2**] Sex: M
Service: NMED
Allergies:
Demerol
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
HA,vomiting, L sided hemiparesis
Major Surgical or Invasive Procedure:
Craniotomy with brain tumor resection
PEG tube placement
History of Present Illness:
39 yo man with metatstatic renal cell CA, lungs, single met to
brain, c/b seizure d/o, none since [**2172-9-4**], had SRS yesterday,
developed HA last night, vomiting this AM, left sided
hemiparesis worsened over the day. Came to ED, started on
Decadron and mannitol. Also reloaded with 600 mg Dilantin. MRI
shows hemmorhagic met s/p SRS with surrounding edema and 1 cm
shift. Tumor size the same with central necrosis. He is stable
now on Decadron and Mannitol and Dilantin. Hemiparesis
resolving. Some remaining slurred speech and bilat CN 6 deficit,
as well as some impaired position sense in arm/face and
decreased use of L trap. Also hyperrelexive in L leg +/- arm.
Now on floor with stable vitals.
Past Medical History:
1. renal cell carcinoma dx [**11-8**], met to lung and
brain, s/p nephrectomy [**11-8**]
2. Hypertension
Social History:
He is married with a daughter. [**Name (NI) **] doesn't smoke or drink EtOH.
No drugs. His wife and daughter are very involved in his care.
Family History:
Significant for hypertension and diabetes
Physical Exam:
T afeb BP 139/93 HR 82 RR 16 O2 sat
General appearance: well appearing
Heart: regular rate and rhythm without murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally.
Abdomen: soft, NT
Extremities: no clubbing, cyanosis or edema
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues.
Mental Status: The patient is inattentive with digit span
forwards of 5. He is drowsy appearing but keeps his eyes open
throughout the exam. He repeats well and though his speech is
sparse, he is fluent and can name high frequency objects.
Cranial Nerves: Visual acuity was not tested. The visual fields
appear full to threat. The optic discs are difficult to
visualize
due to inattention. Eye movements are normal, the pupils react
normally to light, both directly and consensually. Sensation on
the face appears intact to light touch, pin prick. There is an
obvious left facial droop, less so with smiling. Hearing is
intact to finger rub. There is no nystagmus. The palate elevates
in the midline. The tongue protrudes in the midline and is of
normal appearance. The sternocleidomastoid and trapezius muscles
are intact bilaterally.
Motor System: There is an obvious left pronator drift, and fine
movements are slowed on the left.
D T B WE FE FF IP HS Q TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**]
R 5 5 5 5 5 5 5 5 5 5 5 5
L 4+ 4+ 5 4+ 4- 4 4 4 5 5 5 5
Reflexes: The tendon reflexes are present, but slightly brisker
on the left with a few beats triceps clonus, and spread to
finger
from the brachioradialis jerk. There is no ankle clonus. The
plantar reflexes are flexor bilaterally.
Sensory: Sensation appears intact to pin prick, light touch, and
position sense in all extremities and trunk but he is fairly
inattentive.
Coordination: There is no ataxia on the right with the
finger/nose test.
Gait and stance: deferred
Pertinent Results:
[**2172-9-16**] 05:30PM BLOOD WBC-7.2 RBC-4.12*# Hgb-13.8* Hct-37.2*
MCV-90# MCH-33.5*# MCHC-37.1* RDW-15.6* Plt Ct-235
[**2172-9-16**] 05:30PM BLOOD Neuts-75.0* Lymphs-17.3* Monos-7.3
Eos-0.2 Baso-0.1
[**2172-9-16**] 05:30PM BLOOD Plt Ct-235
[**2172-10-1**] 06:20AM BLOOD WBC-16.5* RBC-3.91* Hgb-13.1* Hct-36.4*
MCV-93 MCH-33.4* MCHC-35.9* RDW-14.3 Plt Ct-296
[**2172-10-1**] 06:20AM BLOOD Plt Ct-296
[**2172-9-16**] 05:30PM BLOOD PT-13.0 PTT-21.5* INR(PT)-1.1
[**2172-9-16**] 05:30PM BLOOD Glucose-132* UreaN-22* Creat-1.0 Na-137
K-4.3 Cl-99 HCO3-24 AnGap-18
[**2172-9-17**] 06:30AM BLOOD ALT-57* AST-29 AlkPhos-104 TotBili-0.5
[**2172-9-16**] 05:30PM BLOOD Calcium-10.6* Phos-2.9 Mg-2.0
[**2172-9-21**] 03:30PM BLOOD Albumin-4.5
[**2172-9-15**] 08:05AM BLOOD Phenyto-9.8*
[**2172-9-30**] 06:15AM BLOOD Phenyto-18.0
[**2172-10-1**] 06:20AM BLOOD Phenyto-PND
MRI initial ([**9-17**]):
Presumed central necrosis and hemorrhage within the right
posterior frontal metastatic tumor, with accompanying increase
in surrounding edema and mass effect.
MRI repeat([**9-21**]):
1) Unchanged appearance of rim enhancing mass within the right
cerebral hemisphere resulting in a large amount of vasogenic
edema with leftward shift of the mid-line by approximately 1.5
cm.
2) Stable appearance of a focus of T2 prolongation in the left
posterior parietal lobe, of unknown significance. This finding
does not appear neoplastic, as there is no associated contrast
enhancement of a definable mass.
Chest CT ([**9-25**]):
1) Interval progression of metastatic disease with increase in
size of left lower lobe pulmonary masses, interval development
of new bilateral adrenal masses, and new 5 mm left lower lobe
pulmonary nodule.
2) No evidence of pneumonia.
3) New low attenuation lesion within the left kidney, which is
only partially imaged on this study, concerning for a
metastasis. CT of the abdomen can be performed for further
evalutation.
Head CT [**11-4**]:
There are multiple masses in the brain parenchyma with
associated surrounding vasogenic edema, most pronounced in both
cerebral hemispheres. There is a mild amount of rightward shift
of the normal midline structures. There is no evidence of a
metastatic lesion to the skull. There are post-operative changes
from a right temporal craniotomy.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to manage cerebral edema that occurred
s/p stereotactic radiosurgery for his brain met.
The following issues were addressed druing this admission:
1.Neuro: An ititial MRI showed a significant amount of edema
surrounding a hemorrhagic brain met s/p SRS. A 1 cm midline
shift had resulted, causing his symptoms. He was initially
started on Dexamethasone 6IV q6h and Mannitol 25 q6. After an
initial improvement, he began to worsen on exam. This included
a L facial droop, slurred speech, weak L shoulder, almost
totally plegic L upper extremity, weak LLE, position sense and
light touch impaired in L arm, leg spared. He also had other
mild deficits. As a result, his mannitol was titrated up ,and
when this didn't improve matters, his decadron was increased to
10 mg IV q6h. A repeat MRI was obtained which showed no cahnge
in the edema or midline shift. Neurosurgery was also
reconsulted and decided that no surgical intervention was needed
at the time. He then began to turn around, and his symptoms on
exam began to slowly improve. He improved slowly, with strength
returning to his LLE and LUE. His left soulder and his LUE in
general were the slowest to recover. He gradually decreased his
facial droop and regained full power in his LLE. His LUE gained
strength, but was not at full power on discharge. He was also
having trouble ambulating due to a persistent lean to the left.
As he improved, the mannitol was gradually weaned to off, and
his decadron was slowly dropped to a final dose of 6 mg q8h.
His exam was essentially stable for the next few days as his
medicines were titrated down. On the following day, he was
noted to be more lethargic than normal and to be less aware of
his surroundings. He did have periods of clarity though, and
could carry on a conversation and answer normally. He then had
an episode of vomiting, and what appeared like a period of
unresponsiveness to his nurse. A head CT was performed which
was ultimately read as worsening edema and possible herniation,
but was initially ambiguous. Regardless, he had clinically
worsened, and vomited several times. He also had 2-3 episodes
of tonic seizure activity followed by post-ictal
nonresponsiveness. He was given 1 mg Ativan and his
neuro-oncologist was called and was en route. He was closely
monitored and had stable vitals with an O2 saturation in the
high 90s. He then proceeded to have a unilateral dilation of
his right pupil which indicated acute herniation. He was then
quickly treated with 100 g IV mannitol and a total of 18 mg IV
decadron. Before this was totally in, he also had dilation of
his left pupil. Soon after medication administration, he was
intubated, hyperventilated, and with this resuscitation, his
pupils returned to their normal diameter and were equal. He had
to be sedated on a propofol drip due to constant rigors, and was
sent for immediate neurosurgery. He went for right frontal
craniotomy with resection of tumor to treat uncal herniation of
right insular mass with edema. He was treated in the SICU from
[**2172-10-1**] until [**2172-10-6**], he was then treated by the neurosurgery
team until [**2172-10-16**] at which time he was transferred back to the
oncology/medicine service. At the time when he was transferred
back to medicine he was having fevers and tachycarcia. Blood
cultures were negative and he was started on Levofloxacin,
Flagyl, and Vancomycin. He was afebrile on antibiotics and they
were continued for 3 days. After the antibiotics were stopped
he was febrile again and they were restarted for a 10 day
course.
He was noted to have a decrease in his mental status. An LP
was done which was negative. Ampicillin was added to his
antibiotics for possible Listeria. Blood cultures and urine
cultures remained negative. His mental status continued to
decrease and he was started on manitol. His aggitation
increased and he was treated with round the clock Haldol. His
brain metastasis were treated with 5 days of whole brain XRT.
After the third dose of XRT he had some improvement of his
mental status, however it decreased again after his 4th dosage
of XRT. He had a PEG placed during his XRT as he was no longer
able to feed himself adequately. Throughout this time he had
microseizures.
Over the next week and a half after his WBXRT was complete his
mental status remained unchanged with possibly some minor
improvment. A repeat head CT showed increased edema and
increased midline shift. He was very gradually weaned off of
the Manitol over the next 10 days. After his antibiotics course
was complete they were stopped and he spiked a fever. At that
time he had blood cultures with one set of corynebacterium and
one set positive for coagulase negative staph. These were felt
to be contaminant however he was continued on 10 days empiric
antibiotics. He had a PICC line placed on [**2172-11-6**] for access.
He was started on Megace for treatment of his renal cell
carcinoma. He will now be discharged to a [**Hospital1 1501**] for further
monitoring and treatment. He will continue on Antibiotics,
Steroids, seizure prophylaxis, and PEG Tube feedings.
2.Seizure prophylaxis: He had been on dilantin before this
admission, and was continued on his dose of 300 [**Hospital1 **]. He had
daily levels checked, with a goal of 15 or greater. This proved
to be difficult to attain. This may be due to the fact that
decadron can increase the metabolism of dilantin and he was on
high doese of the steroid. He was gradually moved up on
dilantin, as he was requiring frequent one time doses in
addition to his standing dose. He eventually got to 500 [**Hospital1 **].
As his decadron was weaned though, his level began to increase,
and we started to back down on his doses. His albumin was
normal, so free dilantin levels were not checked. He was
continued on Keppra and Dilantin for seizure prophylaxis post
neurosurgery.
3.HTN: He was put on his home dose of metoprolol and maintained
good BPS throughout without issue.
4.Nausea:He experienced some nausea on and off during the
admission. This was treated well with prn Zofran. It became
less of an issue later in the admission, as it had resolved.
5.Pain control/HA: He had a severe headache due to his edema.
Initially, he was given dilaudid, but we needed a good neuro
exam, so this was stopped. He was treated with Tylenol
initially, then high doses of Vioxx. After he began improving,
and did so for several days, his HA improved. We also added some
oxycodone at this point as he was clearly getting better nad we
could afford to use narcotics to control his pain. He had some
additional pains in his back and neck as he nearly slipped in
the bathroom and feels that he pulled a muscle in his back. The
neck tension is probably a combination of HA pain and anxiety.
He treated these well with hot packs.
After neurosurgery he was less responsive. We continued to
treat his pain with Oxydodone as needed. His aggitation was
treated with Haldol around the clock with extra given PRN as
needed.
6.Cancer: He was initially considered a possible cure, as his
brain met will likely disappear after the SRS, his kideny is
removed, and his lung mets are shrinking post-therapy and could
be resected. However, he had a low grade fever and a CXR
followed by chest CT were obtained. They were negative for
pneumonia, but did show a new lung met as well as bilateral
adrenal mets. This likely means he is no longer totally
cureable and that his treatment will need to be altered.
He has undergone 5 days of WBXRT for brain metastasis. At
this time he will be discharged to a nursing facility that can
observe him. His mental status has changed a great deal from
baseline. It is felt that this is due to a combination of
seizure effect, brain metastasis, and brain edema from WBXRT.
There is some hope that his mental status changes may resolve
over time. He will follow up with Dr.[**Name (NI) 54350**] office in one
month to determine further treatment options.
Medications on Admission:
1. Dexamethasone 4mg [**Male First Name (un) 239**]
2. Lorazepam prn
3. Oxycodone prn
4. Ranitidine 150mg [**Hospital1 **]
5. Toprol 50 mg [**Hospital1 **]
6. Dilantin 200mg in the morning, 300mg in the afternoon
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig:
Three (3) Packet PO TID (3 times a day).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
11. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO Q8H
(every 8 hours) as needed.
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
18. Phenytoin 100 mg/4 mL Suspension Sig: Four [**Age over 90 1230**]y
(450) mg PO Q8H (every 8 hours) as needed for oral dosing:
please hold feeds for an hour prior to giving Phenytoin and an
hour after dose.
19. Megestrol Acetate 40 mg/mL Suspension Sig: Four Hundred
(400) mg PO QD (once a day).
20. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
21. Haloperidol 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Regular insulin sliding scale to
cover blood sugars.
23. Vancomycin HCl 10 g Recon Soln Sig: One (1) g Intravenous
Q12H (every 12 hours) for 10 days.
24. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 10 days.
25. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 10 days.
26. Haloperidol Lactate 5 mg/mL Solution Sig: Four (4) mg
Injection TID (3 times a day).
27. Dexamethasone Sodium Phosphate 10 mg/mL Solution Sig: One
(1) Injection Q6H (every 6 hours).
28. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous
Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]
Discharge Diagnosis:
Cerebral edema after stereotactic radiosurgery resulting in
multiple neurological deficits, headache, and nausea/vomiting.
Renal cell carcinoma metastatic to lungs and brain.
Hypertension
Seizure disorder
Discharge Condition:
Patients mental status has deteriorated markedly from admission.
He currently responds to pain only. He can move all
extremities L>R. He does moan frequently but has no verbarl
responses and does not follow basic commands. He requires
assistance with all activities of daily living. He is fed by
PEG tube. There is no evidence that he is actively seizing at
this time.
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience any fevers, hypotension, or uncontrollable pain.
Come to appointment at [**Hospital1 18**] on [**11-30**].
Continue all medications.
Followup Instructions:
Have an MRI at 8:30 AM on [**2172-11-30**] [**Hospital Ward Name 23**] [**Location (un) **]
Follow up in Dr.[**Name (NI) 54350**] office Monday [**11-30**] at 11:00
AM, [**Hospital Ward Name 23**] [**Location (un) **].
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2172-11-30**] 11:00
|
[
"197.0",
"997.09",
"198.3",
"293.0",
"780.6",
"780.39",
"263.9",
"401.9",
"348.4",
"276.5",
"198.7",
"780.09",
"781.94",
"707.09",
"E879.2",
"189.0",
"788.20",
"342.90",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"03.31",
"38.93",
"96.04",
"92.29",
"43.11",
"01.59",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16792, 16867
|
5693, 13757
|
297, 356
|
17116, 17492
|
3374, 5670
|
17742, 18147
|
1393, 1436
|
14021, 16769
|
16888, 17095
|
13783, 13998
|
17516, 17719
|
1451, 1792
|
225, 259
|
384, 1089
|
2049, 3355
|
1807, 2033
|
1111, 1218
|
1234, 1377
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,719
| 197,896
|
6821
|
Discharge summary
|
report
|
Admission Date: [**2150-6-2**] Discharge Date: [**2150-6-5**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Macrodantin / Ivp Dye,
Iodine Containing
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with Aortic stenting
History of Present Illness:
84 yo F with HTN, CAD s/p MI x 2 and multiple PCIs (PTCA ramus
[**2136**], RCA [**2141**], Cypher prox LCx [**2148**] c/b large RP bleed
requiring evacuation), CHF (EF 55-60% [**2148**]), PAF, COPD admitted
to [**Hospital3 **] on [**2150-5-31**] with CP & exacerbation of COPD.
At home developed acute onset SSCP without radiation associated
with SOB. No nausea, vomiting or diaphoresis. Pain resolved
after EMS arrived and given nitro, ASA.
.
At OSH, troponin was 0.05 -> 0.92 -> 0.94 (peak). Original BNP
[**2061**] but no evidence of CHF on CXR. Pt was having arrhythmia,
?PAF & NSVT however on am of transfer with symptomatic 12 beat
VT, pt had dizziness & palpiations. Later during
hospitalization, pt with R shoulder pain that slowly moved
substernal, and EKG showed new deep ST depressions in V2-6.
Relief of pain with sl nitro & morphine. Given beta-blocker,
20mg IV lasix, IV heparin gtt, azithro, IV solumedrol.
Transferred for cath.
.
At cath (no official report yet available), right dominant with
moderate distal RCA disease, large ramus without obstruction,
patent LCx stent, ?D1 obstruction. Distal aorta noted to be
stenotic and stent placed, but then noticed extravasation of
contrast -> ? dissection, but stat CT abdomen without contrast
extravasation. Admitted to CCU for close monitoring.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She 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 paroxysmal
nocturnal dyspnea, orthopnea, syncope or presyncope.
Past Medical History:
CAD: MI [**2136**], PTCA to ramus; MI [**2141**], PTCA to RCA
CHF: [**2145**] echo with EF 40-45%, aortic root dilation, [**2-4**]+ ar,
1+mr
[**Name13 (STitle) 650**] COPD
HTN
Hypercholesterolemia
GERD
PVD
Nephrolithiasis
Paroxysmal atrial fibrillation
s/p RP bleed [**3-7**] cardiac cath requiring evacuation & repair of
femoral artery (occluded R external iliac artery, stenosed R
common iliac artery)
.
PSH:
-CCY
-Spinal fusion
-Thyroid nodule removal (benign)
-Appendectomy
-C/S
-TAH (Bleeding)
-Breast bx x 4, all benign
.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: CABG, NONE
.
Percutaneous coronary intervention, in [**2136**], [**2141**] & [**2148**] anatomy
as follows:
- s/p prior PTCA to ramus in [**2136**],
- PTCA to RCA in [**2141**],
- stenting of proximal Cx with Cypher in [**11-9**] c/b large right
groin hematoma and nerve damage (occluded right EIA, stenosed
right common iliac artery)
.
Pacemaker/ICD, NONE
Social History:
Social history is significant for the absence of current tobacco
use (60 pack yrs, quit [**2148**]). There is no history of alcohol
abuse. There is no family history of premature coronary artery
disease or sudden death. She lives alone and does most ADLs.
Uses walker and cane. Has son and daughter-in-law in area.
Family History:
Both sisters died of breast cancer in 50's. Mother died at 100,
father at 85. Son with DM.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 96.4, HR 60, BP 109/55, RR 16, O2sat 93% on 3L NC
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, soft 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. Diminished BS throughout.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Right
abdominal wall hematoma.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT dopp
Left: Carotid 2+ Femoral 2+ DP 2+ PT dopp
Pertinent Results:
[**2150-6-2**] 11:30PM BLOOD WBC-11.9* RBC-4.43 Hgb-12.7 Hct-37.3
MCV-84 MCH-28.8 MCHC-34.1 RDW-14.6 Plt Ct-306
[**2150-6-3**] 04:14AM BLOOD WBC-11.5* RBC-4.35 Hgb-12.1 Hct-35.9*
MCV-83 MCH-27.9 MCHC-33.8 RDW-14.1 Plt Ct-277
[**2150-6-3**] 06:20PM BLOOD Hct-36.4
[**2150-6-5**] 06:25AM BLOOD WBC-7.5 RBC-4.65 Hgb-13.3 Hct-38.9 MCV-84
MCH-28.6 MCHC-34.2 RDW-13.9 Plt Ct-284
[**2150-6-2**] 11:30PM BLOOD PT-12.0 PTT-26.1 INR(PT)-1.0
[**2150-6-2**] 11:30PM BLOOD Glucose-131* UreaN-23* Creat-1.0 Na-137
K-4.9 Cl-98 HCO3-29 AnGap-15
[**2150-6-5**] 06:25AM BLOOD Glucose-87 UreaN-25* Creat-0.8 Na-141
K-3.4 Cl-101 HCO3-32 AnGap-11
[**2150-6-2**] 11:30PM BLOOD CK(CPK)-50
[**2150-6-3**] 04:14AM BLOOD CK(CPK)-40
[**2150-6-2**] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2150-6-3**] 04:14AM BLOOD CK-MB-NotDone cTropnT-0.02*
MEDICAL DECISION MAKING
EKG demonstrated sinus @ 65bpm, LVH, deep TWI V2-V6 new compared
to [**2150-5-26**].
.
TELEMETRY demonstrated:***
.
2D-ECHOCARDIOGRAM performed on [**11/2148**] demonstrated:
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. Left ventricular
wall thicknesses are normal. Overall left ventricular systolic
function is mildly depressed. The calculated myocardial
performance index was 0.35 (MPI A = 4460. ms; MPI B = 331 ms).
Tissue velocity imaging E/e' is elevated (>15) suggesting
increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Resting
regional wall motion abnormalities include mild inferior wall
hyppokinesia.. Right ventricular chamber size and free wall
motion are normal. There is no mass/thrombus in the right
ventricle. The aortic root is moderately dilated. The ascending
aorta is mildly dilated. There are complex (>4mm) atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is mild pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion. The effusion
appears loculated.
.
ETT performed on [**2150-1-5**] demonstrated:
Modified [**Doctor First Name **]. 2 min. +SOB. -CP. No ST-changes.
.
CARDIAC CATH performed on [**2148-11-25**] demonstrated:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed a single vessel CAD. The LMCA was patent. The LAD had
mild
non-obstrcutive disease. The LCx had an 80% proximal stenosis.
The RCA had a 30% proximal and a 50% distal stenoses.
2. Resting hemodynamics revealed a normal left sided filling
pressure. There was a moderate systemic arterial hypertension
with SBP of 160 mm Hg.
3. Left ventriculography was deferred.
4. There was difficulty with right femoral access. Having
obtained a femoral access on the left, an abdomianl aortography
revealed an
occluded right external iliac artery and a 60% stenosis at the
origin of the right common iliac artery. Left iliac artery was
patent. There was a diffuse aortic atherosclerosis with a 70%
distal stenosis, an infrarenal aneurism and a 20 mm Hg gradient.
5. The lesion in the proximal LCX was predilated with a 2.0 mm
balloon and stented with a 2.5 mm Cypher stent with lesion
reduction to 80%. The final angiogram showed TIMI III flow with
no residual stenosis, no dissection and no embolisation. (see
PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal LV diastolic function.
3. Occluded right external iliac artery, stenosed right common
iliac
artery.
4. Diffuse aortic atherosclerosis; dital aortic stenosis;
infrarenal
aneurism.
5. Succesful stenting of the LCX lesion (drug eluting)
.
.
Cardiac Cath [**2150-6-2**]:
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated
single vessel coronary artery disease. The LMCA had no
angiographically
apparent flow-limiting disease. The LAD had mild luminal
irregularities. The LCx had a patent prior stent. The RCA had
a 30%
proximal stenosis and a 50% distal stenosis.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 30 mmHg. Systemic arterial pressure
was normal
with a central aortic pressure of 130/60 mmHg. There was no
transaortic
valve gradient on pullback of the catheter from the LV to the
aorta.
3. Left ventriculography by hand injection showed a severe
anterolateral
area of hypokinesis.
4. Descending aortography demonstrated severe atherosclerosis of
the
descending aorta and common iliac arteries. There was a 90%
angiographic stenosis at the distal descending aorta with a
systolic
pressure gradient of 20 mmHg.
5. Stenting of distal aorta with a 10x29mm bare metal stent with
resultant dissection at mid-proximal part of stent. No
perforation for
compromise of flow to iliac vessels. Urgent CT scan ruled out
perforation or large intramural hematoma.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Anterolateral hypokinesis.
4. Peripheral arterial disease and severe stenosis of the
descending
aorta.
5. Stenting of distal complex aortic lesion with a bare metal
stent.
6. Small dissection of distal aorta post stenting which did not
compromise flow to the iliac arteries.
.
.
OTHER TESTING:
CXR @ OSH ([**2150-6-1**]): Focal infiltrate in right lung base, no
CHF. Borderline cardiomegaly.
.
CT Abdomen/pelvis without contrast ([**2150-6-2**]):
CT ABDOMEN WITHOUT CONTRAST: There is dense airspace opacity at
the dependent portions of the right lung base, and probably a
small amount of right-sided pleural fluid. There is a smaller
amount of airspace opacity in dependent portions of the left
lung base.
.
Liver parenchyma shows normal non-contrast appearance, but there
is moderate intrahepatic biliary ductal dilatation, and severe
extra-hepatic ductal dilatation, with the common bile duct
measuring up to 13 mm in greatest axial dimension. Gallbladder
is not visualized, likely surgically absent. Pancreas and spleen
are unremarkable. There are bilateral adrenal adenomas,
measuring 4 cm on the left, and 2.1 cm on the right. Stomach and
intra-abdominal loops of bowel appear normal, except to note
small lipoma in the second portion of the duodenum. Kidneys are
slightly atrophic bilaterally, and there are
multiple bilateral hypodensities, which likely represent cysts,
but are incompletely characterized. Contrast is being excreted
bilaterally, consistent with contrast from recent cardiac
catheterization procedure.
.
There is no sign of contrast extravasation, and no free fluid is
seen within the abdomen. There is no free intraperitoneal air,
or abnormal intra-abdominal lymphadenopathy.
.
CT PELVIS WITHOUT CONTRAST: There is moderate sigmoid
diverticulosis, but no sign of acute diverticulitis. Pelvic
loops of large and small bowel are otherwise normal. Contrast is
seen within the bladder, which is decompressed with a Foley
catheter in place. There is no free pelvic fluid or abnormal
pelvic or inguinal lymphadenopathy.
.
A short intravascular stent is seen in the distal aorta, just
above the iliac bifurcation. Just proximal to the uppermost
portion of the stent is slight dilatation of the abdominal aorta
to 2.4 cm. There is moderate atherosclerotic calcification of
the abdominal aorta and its branches throughout. Complete
assessment is limited without intravenous contrast.
.
OSSEOUS STRUCTURES: There is diffuse osteopenia. Multiple
perineural cysts are seen in the lower sacrum on the left. No
suspicious osseous lesions are seen. There is no fracture.
.
IMPRESSION:
1. No evidence of rupture of the abdominal aorta. Short
intraaortic stent seen in place just above the iliac
bifurcation.
2. Moderate atherosclerotic calcification of the abdominal aorta
and its branches throughout, with focal dilatation of the
infrarenal abdominal aorta to 2.4 cm just above the uppermost
portion of the stent.
3. Dense right lower lobe opacity, concerning for aspiration
versus
infection.
4. Moderate-to-severe intra- and extra-hepatic biliary ductal
dilatation, the common bile duct measuring up to 13 mm.
5. 1.2-cm lipoma in the second portion of the duodenum.
Bilateral adrenal adenomas.
.
LABORATORY DATA: OSH
Hct 40.8, Plt 295, Cre 1.0, INR pending
CK 65 -> 67; Tn peak 0.94 per above
Brief Hospital Course:
Patient is an 84 year old female with known CAD s/p prior PTCA
to ramus (94), RCA (99) and proximal CX with DES ([**11-9**]) c/b
large R groin hematoma presented to OSH on [**5-31**] with chest pain
and COPD exacerbation. Found to have elevated troponin (peak
0.94) and transferred here for cardiac cath. She is now s/p
cardiac catheterization and aortic stent with concern for
dissection, admitted to CCU for further monitoring.
.
#.Aortic dissection: Ms. [**Known lastname 25822**] is now status post distal
aortic stent. During the procedure there was extravasation of
contrast, raising the concern of a dissection. A CT scan of the
abdomen was performed which showed no aortic rupture and no
signs of dissection. She is to continue on her home B-blocker,
nitrate, ASA, Plavix.
.
#. CAD: Patient presented with ST depressions on ECG but no
signs of occlusion on cardiac catheterization. Unclear as to
what actually caused her anterolateral ST depressions and T wave
inversions. One possibility includes coronary spasm. She is to
continue on ASA, plavix, statin, B-blocker.
.
#. Pump: EF 40-50%. Euvolemic. Patient to continue on home
Furosemide, Aldactone and B-blocker.
.
#. Rhythm: History of PAF. Patient denies being on coumadin at
home.
will defer to outpatient cardiologist, whether to start
anticoagulation. She is to continue on home B-blocker.
.
#. COPD: Started on steroids and azithromycin at OSH for flare,
these were stopped on admission. Patient is to continue on home
fluticasone.
Medications on Admission:
MEDICATIONS on TRANSFER:
Heparin gtt
Prednisone 40mg qd
Lovenox (one dose yesterday)
Imdur 30mg
Protonix
Azithromax IV
Spironolactone 12.5mg
Plavix 75mg
Aspirin 325mg
Toprol 50mg
Lipitor 10mg
Flovent inhaler
Ambien
IV lasix x 1 on [**6-2**]
.
HOME MEDICATIONS:
lovenox 40mg sc daily
lipitor 10mg daily
toprol XL 25mg daily
ASA 325mg daily
plavix 75mg daily
aldactone 12.5mg daily
zithromax 500mg daily
colace 100mg daily
protonix 40mg daily
imdur 30mg daily
prednisone 40mg daily
lasix 20mg daily
fluticasone 220 inhaler 2 puffs [**Hospital1 **]
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).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr 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. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Aldactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
10. Furosemide 20mg PO daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Aortic Stenosis
Discharge Condition:
Stable, breathing well without chest pain
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted into the hospital for evaluation of your chest
pain. A cardiac catheterization was done which showed no
defects in your coronary arteries. However, there was a
narrowing of your abdominal aorta which was stented. Please
continue with your Aspirin and Plavix as you are. Your chest
pain may be due to acid reflux. Please continue with your
protonix medication.
You became hyotensive during your hospital stay and your Lasix
was discontinued. Please stop taking this medication.
Please continue with your remaining home medications as
instructed.
If you experience worsening chest pain, shortness of breath,
abdominal pain, fainting, fevers or any other concerning
symptoms then please call your doctor or report to the nearest
emergency room.
Followup Instructions:
Please follow up with your cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Ph:
[**Telephone/Fax (1) 25821**]. Date/Time: [**2150-6-16**] at 2pm.
|
[
"V45.82",
"276.51",
"427.31",
"440.0",
"530.81",
"E879.0",
"410.71",
"998.2",
"428.0",
"401.9",
"414.01",
"272.0",
"496",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"00.40",
"37.22",
"88.53",
"00.45",
"88.55",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
16055, 16126
|
13078, 14583
|
294, 341
|
16186, 16230
|
4490, 8139
|
17150, 17333
|
3455, 3549
|
15179, 16032
|
16147, 16165
|
14609, 14609
|
9661, 13055
|
16254, 17127
|
3564, 3564
|
14870, 15156
|
3586, 4471
|
243, 256
|
369, 2116
|
14634, 14852
|
2138, 3106
|
3122, 3439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,878
| 169,055
|
6693+55777
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-8-7**] Discharge Date: [**2159-8-22**]
Date of Birth: [**2087-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
balsalmic vinegar / pollen / WelChol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain, transfer for NSTEMI
Major Surgical or Invasive Procedure:
[**2159-8-17**]
Coronary Artery Bypass Graft Surgery x 3 LIMA-> left anterior
descending artery, reverse saphenous graft -> Diagonal, obtuse
marginal
History of Present Illness:
71 year old male who on [**2159-8-4**] started feeling "chest fatigue"
similar to previous episodes while climbing the stairs. After
laying down on the bed, pain only increased in severity and
lasted approx 1. 5hrs until presentation to ED. He initially
presented to OSH where EKG showed LBBB (present in [**2156**]) and
first degree AV block. Labs significant for Hct of 24.4 and
initial trop of 0.91 in the context of guiac + rectal exam. He
was transfused 2 units of pRBC with Hct rising appropriately to
32. For NSTEMI, he was continued on Asprin, atenolol and
crestor. He was also initially started on heparin drip but this
was discontinued at 40 hrs when serial hct showed continued
decline. He remained chest pain free with serial CE peaking at
trop of 19.5. He was transferred to [**Hospital1 18**] for further
management. Upon cardiac catheterization he was found to have
left main disease. He is now being referred to cardiac surgery
for revascularization.
Cardiac Catheterization: Date:[**2159-8-10**] Place:[**Hospital1 18**]
LMCA: 90% distal plaque
LAD: ostial proximal high grade/ diffuse mid disease
LCX: ostial disease/Ramus disease
RCA: large dominant vessel minimal disease
Past Medical History:
Diabetes Mellitus type II
Hyperlipidemia
Hypertension
Obstructed Sleep Apnea on CPAP
Degenerated Joint Disease
Anemia
Past Surgical History:
s/p tonsillectomy
s/p Left hip replacement [**2141**]
s/p right hip replacement [**2156**]
s/p left cataract surgery
Social History:
Lives at home with [**Age over 90 **] yr old mother and sister. [**Name (NI) **] helped raise
his sister's children and considers them to be his own family.
Currently works in youth detention center rehabilitation
- denies tobacco, ETOH, IVDA
Family History:
father died suddenly at the age of 45 of unknown cause
mother is a survivor of gynecologic CA
sister is a survivor of breast CA
Physical Exam:
Pulse:52 Resp:18 O2 sat:100/RA
B/P Left:152/67
Height:5'[**58**]" Weight:113.5 kgs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade __II__
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ []
Extremities: Warm [X], well-perfused [] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: P Left:P
DP Right: P Left:P
PT [**Name (NI) 167**]: P Left:P
Radial Right:P Left:P
Carotid Bruit Right: None Left:None
Labs:[**2159-8-9**]
9.8
5>----<243
31.1
PT:13.3 PTT:21.9 INR:1.1
140 107 10
----I----I----<170
4.1 23 1.0
Pertinent Results:
[**2159-8-17**] ECHO (TEE)
LEFT ATRIUM: Moderate LA enlargement.
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: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV systolic function.
AORTA: Normal ascending aorta diameter. Simple atheroma in
aortic arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta. No thoracic aortic dissection.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Significant AS is present (not
quantified) Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Mild PR.
Conclusions
PRE-CPB:
The left atrium is moderately 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. 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 aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. No thoracic aortic dissection is
seen.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. Aortic stenosis is present (not
quantified). The peak gradient across the aortic valve is
26mmHg, the mean gradient is 16mmHg with CO of 6.5L/min. Trace
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trace to mild
mitral regurgitation is seen.
POST-CPB:
The LV systolic function remains normal. There is no change in
valvular function. There is no evidence of aortic dissection
[**2159-8-22**] 05:14AM BLOOD WBC-7.7 RBC-2.98* Hgb-8.3* Hct-25.3*
MCV-85 MCH-27.8 MCHC-32.7 RDW-15.3 Plt Ct-311
[**2159-8-21**] 05:06AM BLOOD WBC-8.6 RBC-3.06* Hgb-8.4* Hct-25.5*
MCV-83 MCH-27.4 MCHC-32.9 RDW-14.8 Plt Ct-241
[**2159-8-22**] 05:14AM BLOOD Glucose-141* UreaN-28* Creat-1.3* Na-137
K-4.6 Cl-102 HCO3-25 AnGap-15
[**2159-8-21**] 04:53AM BLOOD Glucose-130* UreaN-25* Creat-1.3* Na-138
K-4.0 Cl-103 HCO3-26 AnGap-13
[**2159-8-20**] 04:56AM BLOOD Glucose-196* UreaN-30* Creat-1.3* Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
[**2159-8-14**] 07:05AM BLOOD CEA-9.7*
Brief Hospital Course:
71 year old male w history significant for type II diabetes,
hypertension, hyperlipidemia, and 3-vessel CAD on medical
management who was transferred from [**Hospital 1474**] Hospital on [**2159-8-8**]
with NSTEMI s/p cardiac cath demonstrating 3-vessel and
significant left main coronary artery disease in addition to
recent history of severe
constipation, GI bleed, and s/p colonoscopy on [**2159-8-10**]
demonstrating several small polyps and large malignant-appearing
circumfirential mass in the proximal ascending colon that was
biopsied and found on preliminary pathology report to be
consistent with invasive adenocarcinoma.
Gastroenterology/Colorectal surgery and Oncology were all
consulted. The patient was brought to the Operating Room on
[**2159-8-17**] where the patient underwent Coronary Artery Bypass x 3
with LIMA-LAD, SVG-Diag and SVG-OM. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. Mr. [**Known lastname 25516**] [**Last Name (Titles) 5058**]
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. Aggressive bowel regimen was initiated. He was
evaluated by colorectal surgery and the timing for operative
resection of the patient's colonic lesion was discussed. He
developed urinary retention, Foley was re-inserted and Flomax
started. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication, per protocol. He was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 5 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. Postoperative hypergylcemia was better
controlled with the addition of Lantus insulin. Mr. [**Known lastname 25516**]
remained in house for insulin teaching. He was discharged to
home with PT services. All appropriate follow up instructions
were advised. There were multiple discussions with the patient
regarding the timing and location for his colon mass resection.
The patient will follow up with his PCP Dr [**Last Name (STitle) 23509**] at and Dr.
[**Last Name (STitle) **] at the [**Hospital3 2358**] regarding the resection. A liver MRI
was done on [**2159-8-22**] prior to discharge to assess for liver
metastases. All images and reports were given to the patient for
follow up appointments.
Medications on Admission:
aspirin 81mg
atenolol 25mg [**Hospital1 **]
docusate 100mg [**Hospital1 **]
erythromycin 0.5% ointment QID
famotidine 20mg [**Hospital1 **]
gemfibrozil 600mg daily
glipizide xl 10mg daily
insulin SS
lisinopril 40mg daily
metformin 1000 [**Hospital1 **]
MVI
SLN prn chest pain
pioglitazone 30mg daily
polyethylene glycol 17grams daily
rosuvostatin 40mg daily
vitamin D 400IU daily
senna 1 daily
Discharge Medications:
1. Senna Lax 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*1*
2. polyethylene glycol 3350 17 gram/dose Powder Sig: [**2-4**] packets
PO DAILY (Daily) as needed for constipation.
Disp:*60 1* Refills:*1*
3. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
4. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
8. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) cream
Ophthalmic QID (4 times a day).
Disp:*QS 1 month * Refills:*0*
9. 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*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
12. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 0* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily).
16. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
17. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
18. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*1*
19. Colace 100 mg Capsule Sig: Three (3) Capsule PO twice a day.
Disp:*180 Capsule(s)* Refills:*1*
20. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: One (1)
40 units Subcutaneous once a day.
Disp:*30 40 units* Refills:*0*
21. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Colon cancer
Secondary Diagnosis:
Iron deficiency anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] # [**Telephone/Fax (1) 170**] on:[**2159-9-13**] at 1:00
Cardiologist:Dr [**Last Name (STitle) 2912**] on [**9-10**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 23509**] in 1 week - follow up as instructed
with Dr. [**Last Name (STitle) **] at [**Hospital3 2358**] for colon cancer mass resection
Phone number: [**Telephone/Fax (1) 25517**]
**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:[**2159-8-22**] Name: [**Known lastname 4374**],[**Known firstname **] Unit No: [**Numeric Identifier 4375**]
Admission Date: [**2159-8-7**] Discharge Date: [**2159-8-22**]
Date of Birth: [**2087-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
balsalmic vinegar / pollen / WelChol
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient unable to receive MRI liver today due to scheduling
issues. Patient to get Liver MRI as an outpatient.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2159-8-22**]
|
[
"153.6",
"401.9",
"280.0",
"410.71",
"535.50",
"250.00",
"715.90",
"414.01",
"197.7",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.25",
"36.12",
"39.61",
"37.21",
"36.15",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
13792, 13969
|
5755, 8434
|
334, 486
|
11548, 11768
|
3213, 5732
|
12609, 13769
|
2272, 2401
|
8878, 11326
|
11425, 11425
|
8460, 8855
|
11792, 12586
|
1876, 1995
|
2416, 3194
|
263, 296
|
514, 1713
|
11502, 11527
|
11444, 11481
|
1735, 1853
|
2011, 2256
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,130
| 170,112
|
38965+58250
|
Discharge summary
|
report+addendum
|
Admission Date: [**2101-1-21**] Discharge Date: [**2101-2-4**]
Date of Birth: [**2021-4-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Painful left foot
Major Surgical or Invasive Procedure:
[**2101-1-28**] Aortic Valve Replacement(21mm Pericardial) and Single
Vessel Coronary Artery Bypass Grafting utilizing saphenous vein
graft to right coronary artery.
[**2101-1-24**] tunnel line placement
[**2101-1-24**] Extraction of 5 teeth, numbers 3, 14, 20, 23 and 26.
History of Present Illness:
Mr. [**Known lastname 86426**] is a 79 year old male with extensive medical
history, including known aortic stenosis, who presented to OSH
for management of painful ischemia of the left foot. Despite
endovascular intervention on [**2100-12-21**], the patient developed
gangrene of the left toes. Surgical intervention has been
withheld in the setting of known aortic stenosis, coronary
disease and end stage renal failure. He presents to the [**Hospital1 18**]
for consideration of AVR/CABG prior to vascular bypass.
Past Medical History:
- Aortic stenosis, History of Syncope
- Coronary artery disease
- Hypertension
- Hypercholesterolemia
- Non-ischemic cardiomyopathy
- Diabetes mellitus
- Peripheral vascular disease with gangrenous left foot
- Anemia
- End Stage Renal Failure
- Paroxysmal atrial fibrillation
- s/p Left tibial artery stent [**2100-12-17**]
- s/p AICD (Guidant),
- s/p RUE AV fistula for dialysis
- s/p Tonsillectomy
Social History:
Lives with: wife
[**Name (NI) 1139**]: 4 pack years, quit 20yrs ago
ETOH: 1 wine/week
Family History:
Non-contributory
Physical Exam:
Pulse: 81 Resp: 20 O2 sat: 97%RA BP Right: 105/80
Height: 5'5" Weight: 63.5 kg
General: Elderly male in no acute distress
Skin: Dry [x] intact [] lipoma- mid- sternum
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[] cool, poorly perfused, gangrenous left toes, no edema,
multiple scabs lower extremities
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 1+ Left:NP
PT [**Name (NI) 167**]: NP Left:NP
Radial Right: 1+ Left: 1+
Carotid Bruit: no bruits appreciated
Pertinent Results:
[**2101-1-21**] WBC-11.6* RBC-3.50* Hgb-10.0* Hct-31.5* Plt Ct-202
[**2101-1-21**] PT-17.2* PTT-46.9* INR(PT)-1.5*
[**2101-1-21**] UreaN-96* Creat-6.1* Na-143 K-4.3 Cl-108 HCO3-17*
AnGap-22*
[**2101-1-21**] ALT-2 AST-14 LD(LDH)-334* AlkPhos-69 TotBili-0.6
[**2101-1-21**] Albumin-3.6 Calcium-8.4 Phos-6.5* Mg-2.2
[**2101-1-21**] %HbA1c-5.9
[**2101-1-21**] Chest CT Scan:
1. Heavy calcification of the aortic valve, with calcifications
seen along the left lateral wall of the ascending aorta.
Remainder of the aorta beyond the aortic arch is more heavily
calcified. Coronary artery calcifications.
2. Multiple tiny peripheral and subpleural lung nodules, some
calcified, all measuring less than 4 mm. These may represent
noncalcified as well as
calcified granulomas, however, if the patient is at high risk
for
intrathoracic malignancy, followup CT chest would be recommended
in 12 months' time, otherwise no further followup would be
recommended by the [**Last Name (un) 8773**] society guidelines.
3. Small areas of consolidation, in the right upper and left
lower lobes, most probably infectious or inflammatory in
etiology, however, followup CT may be considered to document
resolution and to exclude underlying malignancy, particularly in
the right upper lobe.
4. Prominent lymph nodes, particularly in the retroperitoneum.
Clinical significance of these is indeterminate, and followup CT
would be recommended to evaluate stability of mediastinal and
retroperitoneal lymph nodes.
5. Cholelithiasis.
[**2101-1-25**] Echocardiogram:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2101-1-25**] Carotid Ultrasound:
There is less than 40% stenosis within the internal carotid
arteries bilaterally.
[**2101-2-4**] 06:42AM BLOOD WBC-13.0* RBC-3.23* Hgb-9.8* Hct-30.6*
MCV-95 MCH-30.4 MCHC-32.1 RDW-20.0* Plt Ct-171
[**2101-2-2**] 07:30AM BLOOD Neuts-83* Bands-0 Lymphs-4* Monos-4
Eos-8* Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2101-2-2**] 07:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+
[**2101-2-4**] 06:42AM BLOOD Plt Ct-171
[**2101-2-4**] 06:42AM BLOOD PT-26.7* PTT-47.6* INR(PT)-2.6*
[**2101-2-2**] 07:30AM BLOOD Fibrino-550*
[**2101-2-1**] 04:32AM BLOOD Eos Ct-420
[**2101-2-4**] 06:42AM BLOOD Glucose-120* UreaN-30* Creat-4.0* Na-144
K-3.5 Cl-102 HCO3-31 AnGap-15
[**2101-2-3**] 05:25AM BLOOD ALT-36 AST-52* LD(LDH)-444* AlkPhos-109
TotBili-1.7*
[**2101-2-2**] 07:30AM BLOOD Lipase-62*
[**2101-2-4**] 06:42AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.5
[**2101-1-24**] 08:14AM BLOOD calTIBC-228* Ferritn-307 TRF-175*
[**2101-1-21**] 04:50PM BLOOD %HbA1c-5.9
[**2101-1-23**] 06:50AM BLOOD PTH-208*
[**2101-1-24**] 04:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2101-1-29**] 09:20AM BLOOD Vanco-12.9
SPECIMEN SUBMITTED: AORTIC VALVE LEAFLETS.
Procedure date Tissue received Report Date Diagnosed
by
[**2101-1-28**] [**2101-1-29**] [**2101-2-2**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**]/vf
Previous biopsies: [**Numeric Identifier 86427**] Teeth #s: 3, 14, 20, 23, and
26..
DIAGNOSIS:
Aortic valve leaflets:
Calcific valvulopathy.
Brief Hospital Course:
Mr. [**Known lastname 86426**] was admitted to the cardiac surgical service. Given
atrial fibrillation, he was maintained on intravenous Heparin.
He otherwise remained stable on medical therapy and underwent
extensive preoperative evaluation by the vascular, renal and
dental services. Given his declining renal function, a temporary
tunnelled catheter was placed for dialysis on [**1-24**].
Vascular surgery saw the patient for dry gangrene of the left
toes. He was eventually cleared by the Vascular service and
required teeth extraction prior to cardiac surgical
intervention. Preoperative course was also notable for a
positive urine analysis which was treated with a three day
course of Ciprofloxacin. On [**2101-1-28**] he was taken to the
operating room and underwent coronary artery bypass grafting x1
(saphenous vein grafted to the right coronary artery)/Aortic
Valve Replacement (#21mm CE Magna tissue valve). Please refer to
Dr.[**Name (NI) 10342**] operative report for further details. Cardiopulmonary
bypass time=115 minutes. Cross clamp time=83minutes. Mr.[**Known lastname 86426**]
was intubated and sedated, transferred to the CVICU in stable
but critical condition, requiring Epinephrine to optimize
cardiac function. In the first twenty four hours he was weaned
from sedation, awoke, and was extubated. He underwent
hemodialysis on post operative day one and pressors were weaned
as tolerated. Hematology was consulted due to arterial clots
noted intraoperative, see TEE report, and was worked up for DIC
but was felt to be vitamin K deficient. Coumadin had been
started on post operative day one and held when INR > 2.5,
restarted [**2-3**] with 1 mg, as required anticoagulation for atrial
fibrillation. He remained in the intensive care unit for
hemodynamic and pulmonary monitoring but on post operative day
four he was transferred to the floor for the remainder of his
stay. Physical therapy worked with him however limited by left
foot dry gangrene. He continued to progress and underwent
dialysis [**2-4**] am. He is ready for discharge to rehab with plan
for follow up with vascular surgery at [**Hospital1 **] for left foot
dry gangrene. Rehab to call consult to Dr [**Last Name (STitle) 67625**], [**First Name3 (LF) **] he can
follow his foot at rehab.
Medications on Admission:
Transfer Meds: Protonix 40', Nifedipine 60', Lipitor 10',
Metoprolol 25'', Zemplar 1mcg', Ancef 1g q8h, Lasix 80 po qd,
Regular Insulin Sliding Scale, Acetylcysteine 600'', Procrit
10,000U sc qweek, [coumadin at home for a-fib]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary Artery Disease s/p CABG
End Stage Renal Failure, on Dialysis
Atrial Fibrillation
Hypertension
Dyslipidemia
Peripheral Vascular Disease with Dry Gangrene of Left Toes
Discharge Condition:
Alert and oriented x2 nonfocal
pivot w/ assist of 2 no weight bearing left foot
Sternal and left foot pain managed with neurotin TID and tylenol
prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Please keep toes separated with 2x2 to keep between toes dry -
left foot with dry gamgrene - to follow up with vascular surgery
consult to be called at rehab to Dr [**Last Name (STitle) 67625**], plan for surgery
in [**Month (only) **] after recovery from heart surgery
Followup Instructions:
[**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] see appointments below
HC - Dr [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] - Thrusday [**2-17**] at 915 am
HC - Dr [**First Name (STitle) 1075**] [**3-4**] at 1130 am
Primary Care Dr. [**Last Name (STitle) 70216**] after discharge from rehab
Consult to be called at rehab
Please call consult to Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 67625**] for vascular follow up at
rehab on monday [**2-7**] - will need further surgery on left foot in
[**Month (only) **]
Completed by:[**2101-2-4**] Name: [**Known lastname 13683**],[**Known firstname **] A Unit No: [**Numeric Identifier 13684**]
Admission Date: [**2101-1-21**] Discharge Date: [**2101-2-4**]
Date of Birth: [**2021-4-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 135**]
Addendum:
Import Discharge Medications
Discharge Medications:
1. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed for lle dry skin .
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
13. HD catheter flush
Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 5068**] UNIT DWELL PRN line
flush
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
14. mid line flush
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
15. HD medication
Paricalcitol with HD
16. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
17. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-18**]
Tablets PO Q6H (every 6 hours) as needed for pain/temp.
18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once for 1
doses.
19. Warfarin 1 mg Tablet Sig: MD to order Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 437**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary Artery Disease s/p CABG
End Stage Renal Failure, on Dialysis
Atrial Fibrillation
Hypertension
Dyslipidemia
Peripheral Vascular Disease with Dry Gangrene of Left Toes
Discharge Condition:
Alert and oriented x2 nonfocal
pivot w/ assist of 2 no weight bearing left foot
Sternal and left foot pain managed with neurotin TID and tylenol
prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
Please keep toes separated with 2x2 to keep between toes dry -
left foot with dry gamgrene - to follow up with vascular surgery
consult to be called at rehab to Dr [**Last Name (STitle) 13685**], plan for surgery
in [**Month (only) 6111**] after recovery from heart surgery
Followup Instructions:
[**Hospital1 2057**] heart center [**Telephone/Fax (2) 5412**] see appointments below
HC - Dr [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] - Thrusday [**2-17**] at 915 am
HC - Dr [**First Name (STitle) **] [**3-4**] at 1130 am
Primary Care Dr. [**Last Name (STitle) 13686**] after discharge from rehab
Consult to be called at rehab
Please call consult to Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13685**] for vascular follow up at
rehab on monday [**2-7**] - will need further surgery on left foot in
[**Month (only) 6111**]
**Daily INR/Coumadin dosing for INR goal=2.0
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2101-2-4**]
|
[
"403.91",
"V58.61",
"707.14",
"269.0",
"521.00",
"585.6",
"427.31",
"440.24",
"414.01",
"599.0",
"425.4",
"272.4",
"584.9",
"424.1",
"424.90",
"285.21",
"250.00",
"V45.02",
"429.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.95",
"38.95",
"38.93",
"37.36",
"35.21",
"39.61",
"23.09"
] |
icd9pcs
|
[
[
[]
]
] |
13354, 13437
|
6468, 8763
|
338, 613
|
13680, 13831
|
2517, 6445
|
14647, 15412
|
1705, 1723
|
11361, 13331
|
13458, 13659
|
8789, 9019
|
13855, 14624
|
1738, 2498
|
281, 300
|
641, 1161
|
1183, 1585
|
1601, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,610
| 199,608
|
34779
|
Discharge summary
|
report
|
Admission Date: [**2119-9-11**] Discharge Date: [**2119-9-18**]
Date of Birth: [**2068-6-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
EtOH intoxication and facial trauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, pt is a 51-yo man w/ EtOH abuse who presented to the ED
on [**9-10**] with acute EtOH intoxication and facial truama. He is
unable to recall the events leading to his facial trauma. He
drinks [**1-25**] gallon of vodka daily, smokes [**1-25**]-PPD of cigarettes,
and smokes marijuana, but denies using any other drugs of abuse,
including IV drugs. He has reportedly detoxed numerous times
previously but has been unable to maintain sobriety. He does
report a history of Delirium Tremens as well as EtOH withdrawal
seizures, but is unable to describe in better detail. He was
admitted to the floor for EtOH detox (EtOH level on arrival
554). On the floor he required increasingly high and more
frequent dosing of Benzos, and suffered a [**1-25**] minute long
seizure approx 24hours prior to transfer. In total, he has
received >250mg PO Valium and 6mg IV Ativan over the last
48hours. He additionally received 4mg IV Haldol for agitation
prior to transfer to the MICU. He was transferred the MICU for
closer monitoring given his need for increasingly high and more
frequent Benzo dosing.
Past Medical History:
EtOH abuse - s/p multiple attempts at EtOH detox; has suffered
from EtOH withdrawal numerous times, including DTs and
withdrawal seizures
Social History:
Homeless
EtOH abuse
Physical Exam:
VS - Temp 98F, BP 134/83, HR 113, R 25, O2-sat 99% RA
GENERAL - disheveled and bruised man, anxious, pulling at
restraints, actively hallucinating
HEENT - + edema / ecchymosis over left orbit and ear; PERRL,
EOMI, sclera anicteric, dry MM
NECK - supple
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, nl S1-S2, no MRG
ABDOMEN - +BS, soft/NT/ND, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ radials / DPs
SKIN - no rashes, lesions, jaundice, or ecchymoses
NEURO - awake, A&Ox2 (to self, to month/year, to [**Location (un) 86**]),
non-focal
Pertinent Results:
[**2119-9-10**] 09:45PM WBC-5.7 RBC-4.10* HGB-12.6* HCT-37.7* MCV-92
MCH-30.7 MCHC-33.4 RDW-14.5
[**2119-9-10**] 09:45PM PLT COUNT-137*
[**2119-9-10**] 09:45PM PT-11.4 PTT-25.7 INR(PT)-0.9
[**2119-9-10**] 09:45PM FIBRINOGE-324
[**2119-9-11**] 07:25PM GLUCOSE-83 UREA N-5* CREAT-0.5 SODIUM-140
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2119-9-11**] 07:25PM CALCIUM-7.3* PHOSPHATE-1.8* MAGNESIUM-1.6
[**2119-9-11**] 01:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2119-9-13**] 05:09AM BLOOD ALT-114* AST-259* LD(LDH)-412*
AlkPhos-159* TotBili-1.1
[**2119-9-10**] 09:45PM BLOOD ASA-NEG Ethanol-554* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
STUDIES:
.
CT C-spine ([**9-10**]) - No acute fracture or malalignment involving
the cervical spine.; Emphysema.
.
CT Head ([**9-10**]) - No acute intracranial hemorrhage.
.
CT Sinus/Mandible/Maxillofacial ([**9-10**]) - Multiple facial
fractures including comminuted fractures of the nasal bones and
minimally displaced fractures of the left zygomatic arch and
left pterygoid. Right mandibular fracture is more likely
chronic.; Mild chronic sinus disease.
.
CXR PA/lateral ([**9-12**]) - Right lower lobe opacity concerning for
aspiration/pneumonia. Right basilar atelectasis and small right
pleural effusion. Left-sided rib fracture, likely subacute.
.
ECG - NSR @ 70bpm, nl axis / intervals, low limb voltage, early
R-wave progression, no prior for comparison.
.
Brief Hospital Course:
MICU COURSE
.
#. EtOH withdrawal -
Pt presented for detox from EtOH, has h/o DTs and withdrawal
seizures. He was started on CIWA protocol and given Valium 5 mg
every 4 hours as standing benzo dose. He had a 60-120 second
seizure on the night of admission that was terminated with 20mg
Valium load. His standing and as needed Valium doses were
increased to 20mg every 2 hours with 1 hours CIWA dosing. He was
well-controlled initially and then had increasing agitation that
was unable to be controlled with escalating doses of Valium. On
hospital day #2, he was actively in DTs and was transferred to
the MICU. For the first few days, he had a very high BDz
requirement, >200mg valium, per CIWA. Was switched to IV
Ativan. On the day prior to call out, pt only required 12 mg of
IV ativan. Total Benzo requirements quite high (250mg
valium/48hours). Also received MVI / thiamine / folate. SW was
consulted for EtOH abuse & referral to stabilization units. He
was transferred back to the floor on as needed Valium per CIWA
scale, but had not required valium in 48 hours at the time of
discharge.
#Tobacco use: A nicotine patch was placed during
hospitalization.
.
#. Facial trauma - Pt p/w bruised left eye / ear, but unable to
relay more information re: trauma. CT-scans showed multiple
facial fractures, and pt was seen in ED by Plastic Surgery who
felt that fractures were only operative for cosmetics and that
the pt should f/u in 1 week for interval exam. Pain was
controlled with IV morphine and then he was transitioned to
oxycodone 5mg prn. He was discharged with oxycodone and
instructed to follow up as needed with plastic surgery.
.
#. FEN - Regular diet, IVF hydration, electrolyte repletion
.
#. Access - PIV
.
#. PPx - SQ Heparin, H2-blocker, bowel regimen PRN
.
#. Code - FULL CODE
Medications on Admission:
None
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Alcohol abuse
Seizures
Delirium tremens
Comminuted nasal bone fracture
Minimally displaced left zygomatic fracture
Left lateral pterygoid fracture
Discharge Condition:
Good. Hemodynamically stable and afebrile. Not required
benzodiazepam for greater than 48 hours prior to discharge
Discharge Instructions:
You were admitted for alcohol withdrawal and facial trauma. A CT
of your head was performed that showed multiple facial
fractures. Plastic surgery was consulted and didn't recommend
any surgery. However, if you should choose you may pursue
elective surgery for cosmetic purposes by calling Plastic
surgery at ([**Telephone/Fax (1) 2868**]. Your alcohol withdrawal was
complicated by seizures and an admission to the ICU for delirium
tremens (DT's).
You will be discharged with some narcotics for pain relief. You
should abstain from drinking alcohol.
Please return to the Emergency department if you should have
increasing facial pain, fevers, nausea, vomiting, seizures,
chest pain or any other symptoms that are concerning to you
Followup Instructions:
Follow up as needed with primary care physician
Completed by:[**2119-9-18**]
|
[
"291.0",
"303.01",
"305.20",
"786.59",
"799.02",
"802.4",
"276.52",
"801.01",
"E968.9",
"802.0",
"305.1",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5752, 5758
|
3750, 5552
|
350, 356
|
5968, 6085
|
2244, 3727
|
6867, 6946
|
5607, 5729
|
5779, 5947
|
5578, 5584
|
6109, 6844
|
1696, 2225
|
275, 312
|
384, 1482
|
1504, 1644
|
1660, 1681
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,504
| 121,198
|
37276
|
Discharge summary
|
report
|
Admission Date: [**2175-11-17**] Discharge Date: [**2175-12-7**]
Date of Birth: [**2130-7-23**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
stomach cancer requiring resection
Major Surgical or Invasive Procedure:
[**2175-11-17**]
Total gastrectomy with Roux-en-Y reconstruction,
resection of adrenal tumor and feeding jejunostomy.
[**2175-11-26**]
CT guided drainage of intra abdominal abcess
[**2175-11-27**]
Right PICC line placement
History of Present Illness:
45M with recently diagnosed gastric adenocarcinoma seen on [**10-16**]
EGD for upper GI bleed. EUS consistent with T2 lesion, and
subsequent CT abd/pelvis demonstrated adrenal mass. He was
admitted to the hospital for resection.
Past Medical History:
Hep C (interferon) no h/o cirrhosis or varices, s/p IFN
treatment 12 years ago
PSH:
-Left inguinal hernia repair many yrs ago
-Hiatal hernia repair
-Exploratory laparotomy in setting of MVA 20 yrs ago
Social History:
-Currently lives in [**Hospital1 27663**]. Truck driver.
-etoh 4-5 drinks q 1-2 months
-current smoker 1 PPD >20 yrs
-denies past current illicit drug use
Family History:
Fa: HTN, DM and colon ca diagnosed at 65 yo.
Physical Exam:
temp 98 HR 80 BP 130/80 RR 16
HEENT NCAT conjunctiva pale sclera anicteric PERRLA
Neck supple, no thyromegly
Chest clear
COR RRR
Abd soft, non tender normal bowel sounds
Ext no edema, calves soft
Pertinent Results:
[**2175-11-17**] 07:42PM WBC-8.9 RBC-3.63* HGB-10.8* HCT-32.2* MCV-89
MCH-29.8 MCHC-33.5 RDW-17.0*
[**2175-11-17**] 07:42PM PLT COUNT-205
[**2175-11-17**] 07:42PM GLUCOSE-99 UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-5.4* CHLORIDE-113* TOTAL CO2-22 ANION GAP-10
[**2175-11-17**] 07:42PM CALCIUM-7.9* PHOSPHATE-4.6* MAGNESIUM-1.5*
[**2175-11-19**] Chest CTA : 1. Moderate bilateral pleural effusions and
associated atelectasis, possible small superimposed
consolidation.
2. No segmental or larger pulmonary embolus seen.
[**2175-11-22**] UGI :
There is no evidence of obstruction, leak or fistula at the
esophagojejunostomy anastomosis site.
[**2175-11-26**] CT Chest/abd/pelvis : 1. Interval development since
[**2175-11-19**] of multifocal airspace consolidation, most compatible
with multifocal pneumonia, but possibly early ARDS.
2. Subacute eccentrically located subsegmental pulmonary
embolism involving the posterior aspect of the right lower lobe,
that can be seen in retrospect on [**2175-11-10**] with
ischemia/infarction of pulmonary parenchyma on [**2175-11-19**], now
mostly resolved.
3. Small anastomotic leak in the region of surgical drain left
of the blind limb of the esophagojejunostomy.
4. Enlarged subcarinal lymph nodes, up to 1.5 cm in short
axis.
[**2175-11-26**] CT guided drainage of abdominal abcess : Successful
CT-guided drainage of an intra-abdominal abscess left of the
blind
limb of the esophagojejunal anastamosis without immediate
complication.
[**2175-11-29**] Non invasive venous studies : No evidence of bilateral
lower extremity DVT.
Brief Hospital Course:
Mr. [**Known lastname 7173**] was admitted to the hospital and underwent the
aforementioned procedure which was tolerated well. He returned
to the recovery room in stable condition with good vital signs
and adequate pain control. He was transferred back to the
surgical floor for further recovery where he continued to make
good progress. He did have some tachycardia on post op day 2
with O2 saturations of 95% on 4L nasal cannula. He had a Chest
CTA which was negative for PE and he continued with DVT
prophylaxis. He underwent vigorous chest PT and incentive
spirometry and his O2 saturations improved.
An upper GI was done on [**2175-11-22**] which revealed no anastomotic
leak. He had a feeding jejunostomy placed at the time of
surgery and tube feedings were begun after his bowel function
returned. His surgical wound was healing well without evidence
of erythema. He was up and walking without difficulty but
continued to have periods on tachycardia and a mild O2
desaturation. He also had a rising WBC. A CT of the
chest/abdomen and pelvis was done on [**2175-11-26**] which revealed a
fluid collection around the EJ anastomosis as well as a PE in
the Right lower lobe. It also showed multifocal pneumonia. A CT
guided drainage was subsequently done on the fluid collection
and he was placed on IV heparin for his PE. He was also placed
on Vancomycin, Zosyn and Flagyl until organisms were identified.
The Infectious Disease service was consulted as he multiple
organisms in the gram stain of his wound culture including
yeast. They recommended Micofungin instead of Flagyl until
sensitivities were available. Mr. [**Name13 (STitle) **] looked much better
after drainage of his abscess and his WBC was decreasing. He
remained afebrile.
Coumadin was started for his PE and INR's were checked daily.
His heparin was changed to Lovenox to allow him more mobility
and the Lovenox was discontinued when his INR was 2.0. Dr.
[**Last Name (STitle) **] will monitor his INR and dose his Coumadin starting
[**Last Name (LF) 766**], [**2174-12-11**].
He had a PICC line placed for long term antibiotics and
Vancomycin and Zosyn were changed to Ertapenum. His Micofungin
will also continue. The length of antibiotic therapy is yet to
be determined. He will have a fistulogram next week followed by
an appointment with Dr. [**Last Name (STitle) **] and he will also be followed
by the Infectious Disease service as an outpatient with weekly
CBC's, BUN,creatinine and LFT's to follow.
After a long hospital stay he was discharged home on [**2175-12-7**]
with [**Date Range 269**] services for IV antibiotics, PICC line care and drain
care as well as Coumadin teaching. He remains NPO and all of
his nutrition is coming from J tube feedings of Replete with
fiber cycled at 120cc/hr over a 14 hour period. Hopefully as
his nutritional status improves his leak will seal off and he
will be able to begin an oral diet.
Medications on Admission:
none
Discharge Medications:
1. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
every twenty-four(24) hours.
Disp:*14 Recon Soln(s)* Refills:*2*
2. Micafungin 100 mg Recon Soln Sig: One Hundred (100) mg
Intravenous once a day.
Disp:*14 solns* Refills:*2*
3. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4H (every 4 hours) as needed for pain.
Disp:*1 bottle* Refills:*2*
4. Oxycodone 5 mg/5 mL Solution Sig: 10-15 mg PO Q3H (every 3
hours) as needed for pain.
Disp:*500 mls* Refills:*0*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
Disp:*1 bottle* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Crush and give via J tube.
Disp:*60 Tablet(s)* Refills:*2*
7. Ibuprofen 600 mg Tablet Sig: Six Hundred (600) mg PO every
six (6) hours as needed for pain: crush and give via J tube.
Disp:*120 mg* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Take
2 1/2 tablets Friday, 1 1/2 tablets Saturday, 2 1/2 tablets
Sunday and have INR checked [**Age over 90 766**], crush and give via J tube.
Disp:*100 Tablet(s)* Refills:*2*
9. tube feedings
Replete with fiber
Cycle from 6PM to 8AM at 120cc/hr.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Hospital1 269**], [**Hospital1 1559**]
Discharge Diagnosis:
Primary diagnosis
1. Gastric carcinoma and adrenal mass
2. Adrenal myelolipoma
3. Anastomotic leak
4. Pulmonary embolism
5. Acute blood loss anemia
Secondary diagnosis
1. Hepatitis C
2. GERD
3. S/P Exploratory laparotomy after trauma
4. S/p Umbilical hernia and LIH repair with mesh
5. S/P multiple orthopedic surgeries
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please get plenty of rest and continue to ambulate several times
per day.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or [**Hospital1 269**] nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Call Dr.[**Last Name (STitle) **] on [**Last Name (STitle) 766**] for a follow up appointment in [**12-9**]
weeks. He knows that you are on Coumadin and will regulate your
dose. Call him on [**Month/Day (2) 766**] afternoon to find out what dose of
Couumadin to take on [**Month/Day (2) 766**] night.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2981**] for a follow up appointment
next week. you will need a fistulogram prior to your
appointment and his secretary will set that up for you.
Call the Infectious Disease Clinic at [**Telephone/Fax (1) 457**] for a follow
up appointment with Dr. [**First Name (STitle) **] [**2175-12-20**] and [**2176-1-5**].
Completed by:[**2175-12-11**]
|
[
"E878.2",
"338.18",
"568.0",
"227.0",
"486",
"998.59",
"V58.62",
"530.81",
"567.22",
"415.11",
"305.1",
"V58.61",
"151.6",
"112.89",
"997.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"54.59",
"96.6",
"54.91",
"38.93",
"07.21",
"43.99"
] |
icd9pcs
|
[
[
[]
]
] |
7359, 7448
|
3099, 6036
|
303, 529
|
7813, 7813
|
1481, 3076
|
10952, 11661
|
1201, 1247
|
6091, 7336
|
7469, 7792
|
6062, 6068
|
7958, 9057
|
9073, 10929
|
1262, 1462
|
229, 265
|
557, 788
|
7827, 7934
|
810, 1012
|
1028, 1185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,967
| 125,551
|
29323
|
Discharge summary
|
report
|
Admission Date: [**2126-9-18**] Discharge Date: [**2126-9-26**]
Date of Birth: [**2061-12-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Exertional dyspnea
Pulmonary hypertension
Major Surgical or Invasive Procedure:
Right Heart Catheterization
Paracentesis
History of Present Illness:
This is a 64 y.o. female with severe pulmonary arterial
hypertension who presents with one month of worsening exertional
dyspnea. At baseline, she is on 6 litres oxygen at home as well
as bosentan, and was able to walk 50 feet until 1 month ago. She
subsequently had increasing exertional dyspnea and she is now
only able to walk 20 feet on level ground. She was admitted
electively for right heart catheterizaton to further
characterize her pressures and possibly adjust her epoprostenol
dosing. She also complains of increasing abdominal distention
with some mild pain secondary to expanding ventral hernia but
denies any nausea or vomitting. She does have diarrhea which is
at baseline secondary to epoprostenol therapy vs. scleroderma.
.
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.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for exertional dyspnea
above. Otherwise there is no chest pain, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1) Severe pulmonary artery hypertension -Initially presented in
[**3-1**], multifactorial aetiology (diastolic CHF, emphysema,
possible
rhematologic condition (CREST))
2) Emphysema
3) Raynaud's phenomenon - likely CREST syndrome-Positive [**Doctor First Name **]
with
positive anticentromere antibodies.
4) Diastolic congestive heart failure
5) Alcoholic-induced cardiomyopathy
5) Chronic Atrial fibrillation-Failed attempts at cardioversion.
Now, rate controlled. Anticoagulated with warfarin with goal of
[**12-29**]
6) Hypertension
7) Right upper lobe pulmonary nodule and mediastinal LAD on CT
in [**10-1**].
8) Ventral Hernia
9) Cataracts
10) Chronic Anemia-Baseline Hct around 30. Normal iron studies.
Social History:
Ms. [**Known lastname **] is an ex-nurse who lives alone in [**Location (un) 3320**]. She has two
daughters whom live in the area. She smoked heavily in the past
but stopped 30 yeasr ago. She also drank heavily but stopped 1
year ago. She never had any seizures or withdrawl symptoms.
Family History:
The patient's father had a stroke at 65 years of age. Her mother
had lung cancer.
Physical Exam:
VS: T97.6, BP 104/38, HR 74, RR 16, O2 94% on 5L
Gen: WDWN elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. +
Telangiectasias.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, loud P2, no S3 or S4, no murmurs.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Intermittent crackles
at bases.
Abd: Obese, soft, + ventral hernia, no evidence of incarceration
or strangulation, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: 1+ pitting edema to shins. No femoral bruits.
Skin: + stasis dermatitis, no ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; 1+ DP
Pertinent Results:
[**2126-9-26**] 05:45AM BLOOD WBC-4.5 RBC-3.06* Hgb-8.3* Hct-26.6*
MCV-87 MCH-27.3 MCHC-31.4 RDW-16.2* Plt Ct-149*
[**2126-9-26**] 05:45AM BLOOD PT-20.6* PTT-38.0* INR(PT)-2.0*
[**2126-9-26**] 05:45AM BLOOD Glucose-86 UreaN-30* Creat-1.3* Na-140
K-3.8 Cl-107 HCO3-22 AnGap-15
[**2126-9-25**] 04:39AM BLOOD Albumin-3.5
[**2126-9-23**] 07:00AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1
[**2126-9-24**] 02:20PM ASCITES WBC-1850* RBC-6500* Polys-75* Lymphs-8*
Monos-13* Basos-1* Mesothe-1* Macroph-2*
[**2126-9-24**] 02:20PM ASCITES TotPro-3.5 Glucose-83 LD(LDH)-148
Amylase-12 Albumin-2.0
GRAM STAIN (Final [**2126-9-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2126-9-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2126-9-30**]): NO GROWTH.
Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS.
[**2126-9-19**] ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
11-15mmHg. Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is moderately dilated. There is
moderate global right ventricular free wall hypokinesis. There
is abnormal systolic septal motion/position consistent with
right ventricular pressure overload. The aortic arch is 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. Mild (1+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is a large pericardial effusion. The effusion appears
circumferential. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of [**2126-5-31**], the
effusion is larger. Echocardiographic signs of tamponade maybe
absent in the presence of elevated right sided pressures. The
mitral and tricuspid inflows are difficult to assess in the
presence of atrial fibrillation
[**2126-9-19**] Abdominal US
Scans of the four quadrants of the abdomen and pelvis
demonstrate a large
volume of ascites, which represents a distinct change from
previous ultrasound scan of [**2125-10-4**] which showed no ascites.
The ascites is also seen to extend into a large umbilical
hernia. The fluid is anechoic showing no signs of septations or
exudative appearance.
CONCLUSION: Large volume ascites including ascites within an
umbilical
hernia.
[**2126-9-20**] Cardiac Catheterization
COMMENTS:
1. Hemodynamic assessment revealed severely elevated pulmonary
arterial
systolic pressures, with PASP 91 mmHg at baseline. Cardiac
index is
preserved at 2.3 L/min/m2 but reduced compared to prior RHC.
Moderate
elevation of right-sided filling pressures, with RVEDP 15 mmHg.
Mild
elevation of left-sided filling pressures, with LVEDP 13 mmHg.
Elevated
PVR at 800 dynes-sec/cm5.
2. Drug therapy noted above entailed increasing flolan dose
from 38
ng/kg/min to 41 mcg/kg/min, with resultant hemodynamic
measurements
noted above after 15 minutes at new dose.
FINAL DIAGNOSIS:
1. Severe pulmonary hypertension
2. Plan per Dr. [**Last Name (STitle) **] (notified) and CCU team (notified)
[**2126-9-25**] CT chest w/o contrast
IMPRESSION:
1. Given the technical differences and lesser degree of
inspiration, the
diffuse centrilobular interstitial pulmonary abnormality is
essentially
stable.
2. Increased size of pericardial and pleural effusions,
increased ascites, new findings of anasarca and interlobular
septal thickening at the lung bases, all suggesting worsening
volume overload.
3. Enlarged pulmonary arteries consistent with pulmonary
arterial
hypertension.
4. Stable 4-mm right middle lobe lung nodule.
5. Moderate coronary atherosclerosis.
6. Aortic valve calcification.
[**2126-9-24**] Paracentesis, US guided
IMPRESSION: Successful therapeutic and diagnostic paracentesis
with removal of 1.5 liters of ascites.
Brief Hospital Course:
A/P 64 yo female with severe pulmonary hypertension (multiple
etiology- CREST, diastolic heart failure), chronic atrial
fibrillation, emphysema, diastolic heart failure, and large
ventral abdominal hernia presents with exertional dyspnea.
# Pulmonary artery hypertension - The patient was continued on
her sildenafil and epoprostenol. She was taken to cardiac
catheterization and was found to have elevated pressures in the
right and left heart with equalization of diastolic pressures.
It was thought that she had cardiac tamponade but
pericardiocentesis was not attempted as the pericardial effusion
was posterior to the heart and the risk of an anterior approac
outweighed any potential benefit. Also, she was found to have a
mildly depressed cardiac index to 2.3. The patient's
epoprostenol was increased to 41 ng/kg/min while maintaining her
weight at 67 kg (weight should always remain the same as weight
the patient started medication). Dr. [**Last Name (STitle) **] was involved in this
decision making process. The patient's symptoms slightly
improved with the increased dose and she tolerated it well.
Her dyspnea continued, and it was felt that this was partly due
to her large volume ascites. The patient had difficulty with
orthopnea and early satiety. It was felt that although the
patient's overall hemodynamics had worsened, she may get
improvement in her symptoms with a therapeutic paracentesis.
After her paracentesis, her symptoms markedly improved and she
was discharged home on her regular home 6L O2 with good O2
saturations. Her orthopnea, dyspnea on exertion, and early
satiety all improved after her paracentesis. Dr. [**Last Name (STitle) **] was aware
of this, and it was felt that she should be discharged home with
followup and a decision for further paracentesis can be made in
a future appointment.
.
# Acute on Chronic Diastolic CHF - The patient's EF>55%. The
patient's ascites was likely due to right sided heart failure,
mostly with a diastolic component but also worsened by her
severe pulmonary hypertension. After her paracentesis, her
symptoms improved as above. She was maintained on her home dose
of lasix to remove excess fluid. She will continue her other
outpatient medications at her current home doses. During a
future appointment, a discussion will be made with the patient
and family as to a trial of inotropes and diuresis for
improvement in symptoms. This was discussed with Dr. [**Last Name (STitle) **] and
this will be followed up as an outpatient.
.
# Ascites: The ascitic fluid was found to have >250 PMNs. The
cultures remained negative. This was consistent with culture
negative neutrocytic ascites and she was treated with
antiobiotics as recommended. She was treated with a 7 day
course of levofloxacin 250 mg daily. Her symptoms improved
after paracentesis.
.
# Atrial fibrillation - The patient's rate was well-controlled
on her digoxin dose. Her warfarin was held prior to her
catheterization, and she was restarted on her coumadin while on
a heparin bridge. At dishcarge, her INR was 2.0.
.
# Diarrhea: A GI consult was called intially at admission since
the patient has chronic diarrhea. Currently it is unclear as to
whether this is due to her epoprostenol (known to cause
diarrhea), or to her CREST syndrome. The patient was started on
a 10 day regimen of Rifaximin per GI request. An outpatient
xylose breath test and small bowel followthrough will be
scheduled by the GI service when she attends [**Hospital **] clinic. Her
diarrhea was at baseline at discharge.
.
# Emphysema - Her emphysema and O2 requirement remained stable.
She will continue supplemental O2 at 6L (home dose).
.
# GERD - The patient will continue her home dose of omeprazole.
.
# Communication - with patient and daughter who is HCP -
[**Telephone/Fax (1) 70442**]
.
# During this admission, the patient decided to become DNR/DNI.
This was confirmed with the attending and HCP as well. The
patient was aware that her long term prognosis is poor, and at
this point most of our therapeutic interventions are aimed at
symptom control and palliative care. At discharge, a hospice
discussion was done with the patient, but further discussions
will be made as an outpatient. The patient understood her
situation, and her HCP was made aware of her clinical status and
prognosis. At discharge, her symptoms were improved and she was
discharged in stable condition.
Medications on Admission:
Citalopram 20 mg daily
Warfarin 2.5 mg 5 days per week, 5mg Monday and Friday
Digoxin 125 mcg daily
Epoprostenol 38ng/kg/min
Furosemide 40 mg [**Hospital1 **]
Lisinopril 5 mg daily
Oxygen 6L nasal cannula
Omeprazole 40 mg qHS
Sildenafil (Revatio) 20 mg TID
Discharge Medications:
1. 3-in-one commode
please provide on discharge b/c pt has impaired mobility
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Epoprostenol 0.5 mg Recon Soln Sig: AS DIRECTED Recon Soln
Intravenous INFUSION (continuous infusion): 41
nanograms/kg/minute IV INFUSION at 67 kg as patient's weight.
Disp:*QS Recon Soln(s)* Refills:*2*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO AS DIRECTED: 1
tablet on Monday and Friday.
12. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO ASDIR (AS DIRECTED):
0.5 tablet on Tuesday, Wednesday, Thursday, Saturday, and
Sunday.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis: Pulmonary Hypertension
Secondary Diagnosis: Chronic Diastolic Heart Failure
CREST syndrome
Atrial Fibrillation
Discharge Condition:
Stable; improvement in dyspnea
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted for worsening shortness of breath. You had a
heart catherization and your Epoprostenol dose was increased.
You also had fluid in your abdomen therefore you had a
paracentesis procedure to remove fluid. This improved your
symptoms.
Please take all medications as prescribed. Please go to all
appointments as scheduled.
If you develop any of the following concerning symptoms, please
call your PCP or Dr. [**Last Name (STitle) **]: shortness of breath, chest pain,
fainting, increased swelling in your abdomen or legs, fevers, or
chills.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2126-9-27**] 10:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2126-9-27**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2126-9-27**]
11:00
[**Hospital **] clinic with Dr. [**Last Name (STitle) 31960**] [**2126-10-2**] 4:45 pm [**Telephone/Fax (1) 463**]
|
[
"425.5",
"530.81",
"443.0",
"428.0",
"553.1",
"789.59",
"416.0",
"285.29",
"428.33",
"492.8",
"427.31",
"553.21",
"787.91",
"710.1",
"401.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
14105, 14156
|
8141, 12571
|
358, 401
|
14330, 14363
|
3774, 7243
|
15071, 15577
|
2773, 2856
|
12879, 14082
|
14177, 14177
|
12597, 12856
|
7260, 8118
|
14387, 15048
|
2871, 3755
|
277, 320
|
429, 1718
|
14240, 14309
|
14196, 14219
|
1740, 2454
|
2470, 2757
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,021
| 178,109
|
45811
|
Discharge summary
|
report
|
Admission Date: [**2175-11-26**] Discharge Date: [**2176-1-30**]
Date of Birth: [**2096-9-20**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Penicillins
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
Insertion of left subclavian line on [**2175-11-27**].
S/p electrical cardioversion on [**2175-11-27**] for rapid Afib
right knee arthrocentesis
PICC line placement
[**Last Name (un) **]-intestinal feeding tube insertion
Endo-tracheal intubation and mechanical ventilation
History of Present Illness:
79 yo F with history of hypertrophic cardiomyopathy (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],
pacemaker placement, EF 65%), CRI (baseline Cr 1.4), COPD (on
prednisone taper currently), status-post recent right total knee
replacement ([**2175-11-9**], with pre-operative antibiotics), s/p
TAH-BSO, appendectomy, distant SBO, presenting with RLQ
abdominal pain x several hours, fever. Patient recently
status-post right TKR at [**Hospital6 2910**], with
post-operative course complicated by persistent oxygen
requirement (94-2L => 70s-80s on RA), delirium (described
below).
Was discharged from NEBH on [**2175-11-14**] to [**Hospital 100**] rehab, where
remained until [**2175-11-16**], when was transferred back to [**Hospital1 18**] for
presumed CHF, at which time myocardial infarction was excluded
by serial cardiac enzymes, CTA negative for PE. She was diuresed
for elevtaed BNP, but persistently desaturated with minimal
exertion to 80s. Patient was on coumadin post-operatively for
DVT prophyalxis, and developed some hemoptysis (while on bridge
with IV UFH). Her hospital course was complicated by
leukocytosis with CTA evidence of ground glass opacities that
were read as consistent with CHF or pneumonia, for which she was
empirically treated with levofloxacin (completed in-house?). She
was discharged back to [**Hospital 100**] rehab on prednisone taper, pain
control, and lasix for CHF on [**2175-11-23**].
Patient was doing well until the morning of [**2175-11-25**], when she
awoke with achy, non-radiating RLQ abdominal pain, subjective
fever, anorexia. Her symptoms improved and appetite returned
after a BM x 1 (unclear whether bloody, pus, or black), and she
remained stable until the morning of admission ([**2175-11-26**]), when
pain returned in a similar location, and with a similar quality.
In both instances, the pain was constant, and, in the second
case, did not ease with oxycodone or BM. On [**11-25**], fever was
noted to 101.4, and patient was referred to [**Hospital1 18**] for further
evaluation. No nausea, vomiting, hematemesis, diarrhea, BRBPR,
melena, hematuria, dysuria, back pain, rash, cough, HA, vision
changes, chest pain, increased shortness of breath, increased
joint pain.
Of note, her family has noted some "intermittent confusion"
since her R TKR, consisting of right arm tremor, weakness,
dysarthria/speech difficulty, and dysphagia for liquids/solids.
She has had attacks of difficulty "opening my mouth," though she
claims to comprehend speech, and denies other focal weakness or
numbness, urinary incontinence. These attacks have been ascribed
to medications (opiates), but are not related temporally to
medication administration.
Past Medical History:
CHF
CAD
HOCM EF 65%, s/p EtOH septal ablation [**9-22**]
complicatedby complete heart block s/p pacer
knee arthritis
s/p [**10-24**] R TKR
HTN
carotic stenosis
CRI baseline 1.4
COPD/emphysema
Restrictive lung disease
GERD
PVD
s/p appy
diverticulitis
VRE
s/p TAH/BSO
Social History:
Lives alone. One son locally. One daughter in [**Name2 (NI) **]. Approx. 100
pack-yr smoking history. Rare EtOH.
Family History:
Non-contributory, no history of IBD
Physical Exam:
VS 97.4/96.9 100-120/30 CVP 14-19 96-99-2L
I/O in MICU: +3.4L, UOP = 1300 ml since MN (~ 50-60 cc/hr)
Gen: NAD
Neck: No JVD appreciated.
Cor: RRR S1, S2, II/VI SEM at base, variably increased with
Valsalva. -r/g
Chest: CTA B with scattered wheeze
Abd: Soft, distended, hypoactive BS, RLQ > LLQ tenderness with
light palpation; + mild shake tenderness
Extr: R knee TKR c/d/i without ooze, non-tender. No c/c/e, 2+ DP
in both pulses.
Neuro: AAOx3, appropriately interactive.
Pertinent Results:
Echo (TEE) [**2175-12-18**]: ____________
.
Echo (TTE) [**2175-12-15**]: 1. The left atrium is mildly dilated. 2.
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. 3. The aortic valve leaflets (3) are mildly thickened.
Mild (1+) aortic regurgitation is seen. 4. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. 5. There is mild pulmonary artery systolic hypertension.
6. No obvious evidence of endocarditis seen. 7. Compared with
the findings of the prior report (tape unavailable for review)
of [**2175-12-4**], there has been no significant change.
.
Echo [**2175-12-6**]: EF>60%. The left atrium is elongated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CXR [**2175-12-15**]: A permanent pacemaker remains in place. There has
been placement of a right PICC line, terminating in the superior
vena cava, and a feeding tube, coursing below the diaphragm.
Removal of a left subclavian vascular catheter is noted. The
heart is mildly enlarged. There is vascular engorgement and
worsening perihilar haziness as well as an increasing bilateral
interstitial pattern. Small pleural effusions are noted
bilaterally. IMPRESSION: Worsening congestive heart failure with
increasing interstitial edema.
.
LENI [**2175-12-12**]: No DVT.
.
CXR [**2175-12-8**]: Mild interstitial pulmonary edema and greater
caliber to the mediastinal veins suggest cardiac decompensation
is progressed since [**12-4**]. Moderate cardiomegaly is
longstanding. Tip of the left subclavian central venous line
projects over the lateral margin of the SVC and should be
withdrawn 1-2 cm to avoid mural trauma. Transvenous right atrial
and right ventricular pacer leads follow their expected courses
from the right pectoral pacemaker. No pneumothorax.
.
AXR [**2175-12-8**]: Limited study secondary to body habitus. No
evidence of free air. Contrast is seen in the colon, likely
secondary to the patient's video oropharyngeal swallow study.
Gas is seen in the stomach. Note is made of degenerative changes
of the lumber spine. IMPRESSION: No evidence of free air.
.
Brief Hospital Course:
79-year-old female, who recently underwent a right total knee
replacement at the [**Hospital1 **], who was admitted from Rehab for
fever, abdominal pain, and diarrhea with leukocytosis and CT
scan evidence of colitis. Initial hospital course outlined by
problem.
.
## ID:
--C. Diff Colitis: She was initially treated broadly with
levofloxacin and metronidazole since she had been on prednisone
at the Rehab for a COPD exacerbation. However, once her C. diff
toxin assay returned positive, her antibiotics were weaned to
only metronidazole. Abdominal pain and diarrhea reduced
dramatically after continued flagyl. Repeat c. diff studies
were negative x4 days. Her end date for flagyl will be 7 days
after stopping her levoquin. Ideally we would continue the
flagyl for 7 days until stopping all antibiotics, however to
avoid polypharmacy, ID favors the former plan.
.
--Coag negative staph line infection: Developed central line
catheter infection with 2/4 bottles postive and postive line
culture. The line was removed and she was started on
vancomycin. Surveillance cultures were initially negative,
however a single bottle grew out coag neg staph 3 days after
starting treatement. Given the presence of her pacer and knee
replacement, it was decided in consultation with infectious
disease to extend her vancomycin course to 4 weeks. TTE was
negative for obvious endocarditis and a right knee tap by her
orthopedic surgeon grew no organisms. All surveillance cultures
were subsequently sterile. A TEE was not performed given the
lack of further positive cultures and the great degree of
anxiety that the procedure generated in this patient.
.
--Rash/cellulitis: The Pt. developed a weeping, erythematous
rash on her flanks bilaterally that was painful. This was
thought to be a mild cellulitis, however worsened despite being
on vanco for her line sepsis. Under the direction of ID,
levoquin was added for gram negative coverage and her cellulitis
appeared to improve. Toward the end of her hospital stay she
continued to have persistent erythema with some tenderness on
palpation, however was afebrile with a normal WBC. This was
felt to be related to her anasarca and should improve with
mobilization of her fluid. She will have to have this area
watched for skin breakdown related to the edema.
.
## CHF / AFib with RVR: Experienced 3 episodes of atrial
fibrillation with rapid ventricular rates symptomatic for chest
pain and hypotension. On each occasion she failed rate conrol
with IV CCB's and BB's and needed resusitation with fluids and
cardioversion. First episode was treated with amio and
cardioversion. Second episode was treated with cardioversion
only. third episode was attempted with ibutilide, then
cardioversion which was transiently successful. She was then
taken to the EP lab for an AV nodal ablation. She already had
had a pacemaker placed in [**2173**] for her EtOH septal ablation.
Amiodarone was stopped. Anticoagulation was continued. She
continued to be in heart failure which was slow to diurese in
the setting of her anasarca, hypoalbuminemia, and HOCM. She
responded slowly with IV lasix without any worsening of her
renal function. She will need continued, but careful, diuresis
given the low oncotic state of her plasma.
*** ACEI and BB held for low blood pressures surrounding afib
with rapid vent rate with hypotension. ACEI will need to be
restarted.
.
##. Fluids and Nutrition: Unfortunately, due to malnutrition
(hypoalbuminemia) and deconditioning she was difficult to
diurese. IV lasix did result in an increase in urine output,
but it was a challenge to achieve net negative fluid balance
(in's included IV Abx and tube feed volume). She had a speech
and swallow evaluation done on HOD#16 which revealed moderate
remaining aspiration risk. As such, she has been tube fed with
the goal of transitioning her back to PO as tolerated. This
will likely need to be performed in consultation with nutrition.
.
## Ortho: Her right knee was also noted to be stiff and painful.
This was thought to be due to her recent surgery, but with her
recent bactermia a septic arthritis could not be ruled out so
orthopedics was consulted to tap the knee. The fluid revealed a
hemarthrosis, but no evidence for infection on the gram stain.
Prior to discharge her orthopedic attending okay'd her for full
weight bearing status on her right knee.
.
## Heme: maintained on coumadin for Afib with goal INR 2.0-2.5.
(held for intervention) and restarted on [**12-19**]
.
## Pulm: h/o COPD, s/p recent 3 week prednisone taper for COPD.
O2 via NC, albuterol and atrovent nebs. [**Month/Year (2) 4010**] was increased.
At the end of her stay albuterol was stopped for worsening
benign essential tremor.
.
MICU Update:
Brief summary of prior hospital course: 79F with HOCM s/p septal
ablation with hospitalized [**2175-11-26**] for c diff colitis after
total knee replacement in [**10-24**] and rehab at [**Hospital **] Rehab. This
hospitalization c/b AF RVR requiring ablation and pacer
placement [**12-17**], diastolic CHF exacerbation, pulmonary edema and
anasarca, poor nutrition, coag neg staph line infection,
recurrent candiduria, delerium, and right abdominal wall
cellulitis.
.
She was sent to CCU [**1-3**] with hypotension and intubated for
resp distress during a code. For 3 days previous to event, she
had episodes of hypothermia and hypoxia on floor presumably
interpreted as worsening pulmonary edema requiring additional
diuresis. CTA at that time with no PE, but bilat ground glass
with some pockets of consolidation and small bilat effusions.
Diuresis continued with effect but on AM of [**1-3**] pt dropped SBP
to 70's, minimally responsive to 1.5L NS IVF. Dopamine gtt
started at 19.1 prior to CCU transfer with effect BP 79/31.
.
In the CCU, hypotension presumed to be septic shock, WBC up to
20, creat up to 1.2 from 0.9. Loose bowels noted. BP was very
responsive to low dose levophed and vasopressin. Cosyntropin
stim performed after random cortisol < 15 without appropriate
rise. Stress dose steroids were started. Ventilation complicated
by poor compliance and high PIPS, was placed on PCV then changed
to AC for unclear reasons. Antibiotic treatment broadened to
include caspofungin for candiduria not improving on fluconazole,
aztreonam for hospital acquired pneumonia in pt allergic to PCN,
and continued vancomycin for h/o coag neg staph bacteremia.
Weaned off levophed and vasopressin overnight with MAPS > 60.
In CCU, multiple attempts made at central line placement, s/b
left subclavian hematoma despite FFP reversal of
anticoagulation. Hct drop presumed due to volume shifts 29->25%
s/p 4 units prbcs [**Date range (1) 97594**].
.
MICU Course as of [**2176-1-17**]:
Pt was transferred to the MICU for further management of septic
shock.
.
# Pseudomonas Pneumonia - Responded to combination of aztreonam
and gentamicin. Further fever work up showed no endocarditis,
no pacer abscess, no other growth from cultures.
.
# Hypoxic Respiratory Failure: Initial resp failure was due to
the combination of pneumonia and fluid overload and weaning was
complicated by difficulty with diuresis and baseline
interstitial/restrictive lung disease of unclear etiology.
Patient was transitioned to pressure support ventilation, and
continued a slow wean with plans for possible tracheostomy if
the pt was unable to extubate by [**2176-1-23**]
.
# Anemia: Hct has stabilized at 25-26, adequate retics
.
# CRI: Initially had elevated Cr on transfer which improved with
diuresis and hemodynamic stability.
.
# Diastolic CHF, h/o HOCM s/p septal ablation: Pt was restarted
on ACE and BB for BP control and afterload reduction with IV
lasix and chlorthalidone for diuresis.
.
# CAD: Pt was ruled out for MI and then continued on asa,
lipitor, BB and ACE-I as BP tolerates.
.
# AF s/p ablation and pacer: Pacer dependent, will need rate
turned down by EP (currently at 80) after either extubation or
tracheostomy and stabilization of respiratory status.
.
Code: DNR/DNI, no electricity of chest compressions
Communication: Daughter (HCP) and son
Addendum: As per legnthy and frequent family meetings, including
a meeting between the family, Dr. [**Last Name (STitle) 4427**], and Dr. [**Last Name (STitle) 58318**] on
[**2176-1-23**], the decision was made to extubate the pt. when she was
thought to have the most promising picture for respiratory
success, with no further plans for future intubation despite the
post-extubation outcome.
Therefore, on [**2176-1-29**], the pt was felt to be doing well with a
high RISB, decreased bicarb from diamox treatment, and HOB
upright. At this point, the medical team felt that the pt. is at
a point where she has the best chance to succeed with an
extubation. The pt. was subsequently extubated. The pt. was
succeeding for a number of hours with moderate respiratory
effort and family encouragement, but then progressively became
more tired with increased WOB and slowly decreasing oxygen
saturations. As per the decided plan of action, and as per the
patients wishes to be DNR/DNI, the pt was made as comfortable as
possible through this time of increased air hunger without any
further intubation attmepts. The pt. subsequently expired on
[**2176-1-30**] and was not attempted to be resussitated due to her DNR
order.
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H:PRN.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed.
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q2H (every 2 hours) as needed.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
17. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 40mg total on [**11-23**], then taper to 20mg total each day
for [**11-24**] - [**11-26**], then taper to 10mg total each day for [**11-27**] -
[**11-29**].
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
20. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed for wheezing, SOB.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for wheezing, SOB.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: For C. difficile colitis.
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Dose may need to be adjusted. Goal INR = [**2-23**].
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
16. Furosemide 10 mg/mL Solution Sig: Forty (40) mg IV Injection
[**Hospital1 **] (2 times a day) for 1 days: Adjust as needed for goal
diuresis of approximately 4 liters of fluid at a rate of
500-1000cc daily.
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Respiratory failure
Psudomonas Pneumonia
C. difficile colitis
Myocardial infarction - due to demand related ischemia (peak
TropT = 0.18)
Hypertrophic Obstructive cardiomyopathy
Atrial Fibrillation with rapid ventricular response
Sepsis
Total knee replacement - right leg
Chronic renal insufficiency
Chronic obstructive pulmonary disease
congestive heart failure
coronary artery disease
Central line infection
coagulase negative staph bacteremia
malnutrition
Discharge Condition:
Expired
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2175-12-18**]
2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2207**]
Date/Time:[**2175-12-18**] 2:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2176-5-1**] 12:40
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-23**] weeks.
|
[
"428.31",
"427.31",
"518.84",
"491.21",
"482.1",
"427.81",
"995.92",
"117.9",
"V43.65",
"682.2",
"425.4",
"785.52",
"410.71",
"V53.31",
"996.62",
"255.4",
"599.0",
"038.9",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.26",
"99.62",
"96.6",
"96.72",
"88.72",
"37.27",
"37.34",
"00.17",
"99.04",
"81.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20204, 20219
|
7260, 12047
|
307, 582
|
20721, 20730
|
4307, 7237
|
20753, 21276
|
3761, 3798
|
18450, 20181
|
20240, 20700
|
16612, 18427
|
12064, 16586
|
3813, 4288
|
246, 269
|
610, 3321
|
3343, 3610
|
3626, 3745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,471
| 156,199
|
3066+55439
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-3-8**] Discharge Date: [**2106-3-16**]
Date of Birth: [**2027-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Non-healing sternal wound
Major Surgical or Invasive Procedure:
[**2106-3-8**] Sternal debridement and resection of sternum. Bilateral
pectoralis muscle closure of open sternal wound on the left with
a thoracoacromial based flap on the right. Thoracoacromial based
pectoralis musculocutaneous flap as compared to muscle flap on
the left.
History of Present Illness:
Mrs. [**Known lastname 4698**] is a 79-year-old female who in [**2105-11-24**]
underwent an ascending aortic root enlargement with an aortic
valve replacement and coronary artery bypass surgery. She has a
fairly obese habitus and large breasts and had separation of the
lower pole of her sternotomy incision. She has been undergoing
Vac dressings and intravenous Vancomycin as an outpatient.
Despite medical therapy, she has had very poor healing of her
wound. She has wires showing at the bottom of a very deep, the
incisional dehiscence. She is presenting for wound revision and
probably sternal debridement.
Social History:
Widowed and lives alone, currrently was at rehab. Quit smoking
20 yrs ago. Denies alcohol or recreational drug use.
Family History:
Non-contributory. Two brothers had CABGs in their late 60s.
Sister has a pacemaker.
Physical Exam:
Vitals: Temp afebrile, BP 123/62, HR 79, RR 20, SAT 99%on room
air
General: obese female in no acute distress, in wheelchair
HEENT: oropharynx benign, upper and lower dentures
Neck: supple, no JVD
Sternal Wound: VAC in place; slightly tender to palpation;
sternum stable
Heart: regular rate, normal s1s2, soft systolic murmur
Lungs: clear bilaterally
Abdomen: oese, soft, nontender, normoactive bowel sounds
Ext: PICC in right arm, warm, [**2-26**]+ pitting edema,
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2106-3-8**] 06:42PM BLOOD WBC-8.5 RBC-3.54* Hgb-11.2* Hct-32.2*
MCV-91 MCH-31.6 MCHC-34.9 RDW-16.8* Plt Ct-297
[**2106-3-8**] 06:42PM BLOOD PT-13.8* INR(PT)-1.2*
[**2106-3-8**] 06:42PM BLOOD UreaN-15 Creat-0.8 Na-138 Cl-108 HCO3-20*
[**2106-3-8**] 06:42PM BLOOD Mg-1.3*
[**2106-3-10**] Successful replacement of the in situ single-lumen PICC
for a new 4-French 46-cm single-lumen PICC with tip in the
superior vena cava.
Brief Hospital Course:
Mrs. [**Known lastname 4698**] was admitted and taken directly to the operating
room. Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] performed a sternal debridement
with bilateral pectoralis muscle closure of open sternal wound
on the left with a thoracoacromial based flap on the right.
Several JP drains were placed at that time. Following the
operation, she was immediately extubated and taken to the CSRU
for observation. Medical therapy including intravenous
Vancomycin was resumed. She maintained stable hemodynamics and
transferred to the SDU for continued care and recovery. The
wound and JP drainage was monitor closely. She remained
afebrile. She remained reasonably comfortable but required
Percocet for adequate pain control. Due to a non-functional PICC
line, a new PICC line was placed on [**3-10**]. She remained
in a normal sinus rhythm - no atrial arrhythmias were noted.
Physical therapy was consulted for assistance with strength and
conditioning. Mrs. [**Known lastname 4698**] had a small amount of wound
separation that was sutured with a total of five 4-O nylon
sutures with good approximation. On [**2106-3-15**] the plastics
service removed one of three JP drains. Here remaining JP
drains continued to decrease in output of serosanguinous
drainage. On POD 8 Mrs [**Known lastname 4698**] was 1kg below her preop weight
with poor exercise tolerance, no SOB, or Chest pain. Her blood
pressure was stable. Her sternotomy incision was clean, dry,
and intact without evidence of infection. She was discharged to
[**Hospital6 459**] in good condition, cardiac diet, sternal
precautions, and instructed to follow up with Dr. [**First Name (STitle) **] in one
week and Dr. [**Last Name (STitle) **] in one to two weeks.
Medications on Admission:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): sub Q injections.
16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. Miconazole Nitrate 200 mg Suppository Sig: One (1) Appl
Vaginal HS (at bedtime) for 7 days.
18. Sodium Chloride 0.9 % Parenteral Solution Sig: Three (3) ML
Intravenous DAILY (Daily) as needed: for peripheral IV flush if
present.
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 6 weeks: via PICC line.
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
21. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
22. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
13. Vancomycin HCl 1000 mg IV Q12H
14. 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.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*30 ML(s)* Refills:*0*
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*qs qs* Refills:*0*
19. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Sternal Wound Infection/Dehiscence, Coronary Artery Disease and
Aortic Stenosis - status post coronary artery bypass grafting
and aortic valve replacement in [**2105-11-24**], History of
Postoperative Atrial Fibrillation/Flutter, Hypertension,
Hypercholesterolemia, Osteoarthritis, Asthma, Obesity, Chronic
Pedal Edema, Venous Insufficiency, Chronic UTI's, Right Breast
Cancer s/p Lumpectomy [**2104**], s/p left hip replacement [**2095**], s/p
right hip replacement [**2103**], s/p cataract surgery, s/p
hysterectomy
Discharge Condition:
Good
Discharge Instructions:
Local wound care. Ensure patient wears supportive bra at all
times.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**1-25**] weeks, call for appt
[**Telephone/Fax (1) 170**].
Plastic surgeon, Dr. [**First Name (STitle) **] in one week, call for appt
[**Telephone/Fax (1) 1416**]
Completed by:[**2106-3-16**] Name: [**Known lastname 557**],[**Known firstname 1049**] Unit No: [**Numeric Identifier 2287**]
Admission Date: [**2106-3-8**] Discharge Date: [**2106-3-16**]
Date of Birth: [**2027-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient's discharge diagnosis is sternal wound dehiscience.
Patient did not have a sternal wound infection.
Major Surgical or Invasive Procedure:
[**2106-3-8**] Sternal debridement and resection of sternum. Bilateral
pectoralis muscle closure of open sternal wound on the left with
a thoracoacromial based flap on the right. Thoracoacromial based
pectoralis musculocutaneous flap as compared to muscle flap on
the left.
Social History:
Widowed and lives alone, currrently was at rehab. Quit smoking
20 yrs ago. Denies alcohol or recreational drug use.
Family History:
Non-contributory. Two brothers had CABGs in their late 60s.
Sister has a pacemaker.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2106-3-16**]
|
[
"E878.2",
"V43.64",
"996.1",
"401.9",
"V43.3",
"V45.81",
"998.31",
"V10.3",
"272.0",
"427.31",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.82",
"77.61",
"38.93",
"34.01",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
10465, 10674
|
2439, 4204
|
9931, 10207
|
9070, 9077
|
1990, 2416
|
9194, 9893
|
10357, 10442
|
6410, 8401
|
8530, 9049
|
4230, 6387
|
9101, 9171
|
1466, 1971
|
234, 261
|
603, 1216
|
10223, 10341
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,969
| 138,907
|
6539
|
Discharge summary
|
report
|
Admission Date: [**2182-8-15**] Discharge Date: [**2182-8-20**]
Date of Birth: [**2114-7-22**] Sex: M
Service:
ADMISSION DIAGNOSIS: Coronary artery disease
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3924**] is a 68-year-old
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who was referred for an
outpatient cardiac catheterization on [**8-14**] due to
progressive exertional angina and a positive cardiac MRI. He
is a 68-year-old marathon runner who reported a three to four
month history of exertional angina who stated that he had
been having symptoms of mild back and substernal chest
discomfort that radiated down both arms when running or
walking quickly. These symptoms always resolved with rest.
He stated that he had also been feeling the need to belch
frequently. The patient apparently underwent a cardiac
catheterization in [**2177**] and was medically managed for his
coronary artery disease. On [**2182-8-1**] the patient
had a cardiac MRI which revealed mild LV enlargement with an
ejection fraction of 43% and multiple WMA consistent with
multivessel disease. He has not had any symptoms occurring
at rest or waking him from sleep. The patient denied any
claudication, orthopnea, edema, paroxysmal nocturnal dyspnea
or lightheadedness.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Coronary artery disease
SOCIAL HISTORY: Two cigars per week smoking.
SURGICAL HISTORY:
1. Left knee arthroscopy
2. Appendectomy
FAMILY HISTORY: Father with angina in his 50s who died of a
myocardial infarction at the age of 68.
ALLERGIES: He has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Cozaar 50 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
5. Multivitamin
He was seen and underwent a cardiac catheterization at the
[**Hospital6 256**] on [**8-15**] which
demonstrated an ejection fraction of 40%, apical akinesis,
anterolateral and inferior hypokinesis on this right dominant
system with left main 80% distal disease involving the
bifurcation. LAD was occluded after the first diagonal. The
left circumflex showed mild disease. The mild disease of the
OM1 and AV branch. The RCA showed 40% mid and 19% distal
disease before the bifurcation. Secondary to these findings
the patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery
bypass grafting.
HOSPITAL COURSE: The patient was admitted to the [**Hospital6 1760**] after cardiac catheterization
and was taken to the Operating Room on [**8-16**] where
he underwent a coronary artery bypass grafting x4 as follows:
left internal mammary artery to LAD, saphenous vein graft to
OM with a jump graft to a diagonal and saphenous vein graft
to our PDA. His postoperative ejection fraction was 50%.
The procedure was performed by Dr. [**Last Name (STitle) 70**], assisted by Dr.
[**Last Name (STitle) 25067**], as well as Dr. [**Last Name (STitle) **]. Postoperatively, the
patient went to the cardiothoracic surgery recovery unit. He
required some Neo-Synephrine to maintain his blood pressure
as well as some fluids and he did very well. He did,
however, have a significant rub noted on auscultation. He
had some episodes of atrial fibrillation for which amiodarone
was added.
On postoperative day #1, serial electrocardiograms were
performed which demonstrated mild ST segment elevations in
leads V2 and V3 with tapering of the T-waves. Given concern
that these may have represented ischemia, a bedside
transthoracic echocardiogram was obtained which showed good
LV contractile function of the anterior wall, basal, anterior
septum inferior and lateral walls. The apex and distal
anterior septum were not well seen. There was no evidence of
tamponade based on this and overall the ejection fraction was
mildly depressed. The echocardiogram was not consistent with
any new wall motion abnormalities and the patient was
diagnosed as having postoperative pericarditis.
He was kept in the cardiothoracic surgery recovery room until
postoperative day #2, when he was transferred to the floor.
His chest tubes were removed without complications. The
patient ambulated early and was transfused 1 unit of packed
red blood cells during his postoperative course.
By postoperative day #4, he was without complaints, able to
ambulate upstairs. He was afebrile and hemodynamically
stable. His rhythm was regular. His sternum was stable and
dry and his extremities demonstrated minimal edema. His
hematocrit was 27.5 and he was doing well enough that it was
felt that he was stable for discharge. The patient was
tolerating a regular diet.
DISCHARGE MEDICATION:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. for 7 days
3. Potassium chloride 20 milliequivalents p.o. b.i.d. for 7
days
4. Colace 100 mg p.o. b.i.d.
5. Protonix 40 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Motrin 400 mg q6h prn
8. Amiodarone 400 mg p.o. t.i.d. for 2 days, then 400 mg
p.o. b.i.d. for 2 days, then 400 mg p.o. q.d.
9. Percocet 1 to 2 p.o. q 4 to 6 hours prn
DISCHARGE DIAGNOSES:
1. Coronary artery disease with angina, status post coronary
artery bypass grafting x4
2. Hypertension
3. Hypercholesterolemia
DISCHARGE INSTRUCTIONS: He was instructed to follow up with
Dr. [**Last Name (STitle) 70**] in two to four weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 02-358
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2182-8-20**] 11:57
T: [**2182-8-20**] 12:07
JOB#: [**Job Number 20702**]
|
[
"423.9",
"272.0",
"427.31",
"401.9",
"V17.3",
"414.01",
"305.1",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.13",
"88.53",
"37.22",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
1540, 1670
|
5127, 5258
|
2457, 5106
|
5283, 5597
|
1693, 2439
|
153, 178
|
207, 1321
|
1343, 1414
|
1431, 1523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,755
| 164,065
|
41955
|
Discharge summary
|
report
|
Admission Date: [**2113-1-28**] Discharge Date: [**2113-2-2**]
Date of Birth: [**2036-1-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
fever, cholangitis
Major Surgical or Invasive Procedure:
[**1-28**] ERCP
History of Present Illness:
Pt is a 77 y/o female with a PMH notable for stage IV
cholangiocarcinoma on chemotherapy, previous obstructive
jaundice with CBD stent (metal stent placed [**10/2112**]), T2DM was
transferred from [**Hospital3 **] for evaluation for cholangitis
and sepsis. She was admitted to [**Hospital1 **] with fevers, mental
status changes and was found to have marked lab abnormalities,
including the following: Na 125, AST 130, ALT 139, AP 46, Tbili
4.9, lacate 2.5. UA was positive for bacteria. Hct was 16.9, plt
69, WBC 2.7 with ANC 2300 and 30% bandemia. Her total Bili rose
to 10.5, with AST 952, ALT 526 and AP to 311. Blood cultures
grew gram negative rods and gram positive bacilli in both sets.
Pt was hypotensive early morning of [**1-27**], and was admitted to
the ICU and she was briefly on pressors.
She has been getting chemotherapy since mid-[**Month (only) 359**] after her
most recent discharge with Dr. [**Last Name (STitle) **] at [**Location (un) 5503**] (2 weeks
on, 1 week off, last day was [**2113-1-23**]).
.
Review of systems:
(+) Per HPI.
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies arthralgias
or myalgias. Denies rashes or skin changes.
Past Medical History:
1) Borderline Diabetes Mellitus, Type 2
2) Hyperlipidemia
3) cholangiocarcinoma, stage IV
4) stricture at bifurcation of main biliary duct s/p stent
5) portal vein thrombosis on Fragmin daily
Social History:
Lives in [**Location **], was living with husband but now husband in
rehab facility. She had four children, but one committed suicide
in [**2112**]. Her remaining three children are in the area. Her son
[**Name (NI) **] is her HCP. Drinks 3 wine glasses/week, never smoked, no
drugs.
Family History:
Father died of asbestos related cancer, daughter has h/o blood
clots, son had a kidney transplant
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 99.1 BP 126/62 RR 10 O2 sat 92% 2LNC.
General: pleasant female, Alert, oriented, no acute distress,
jaundiced
HEENT: EOMI, icteric sclera, dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: no use of acccessory muscles, decreased at bases
bilaterally, no crackles or wheezes
CV: port-a-cath right upper chest, RRR, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, mild TTP in RUQ, non-distended, few nodules in
subcutaneous tissue palpated, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses,
Neuro: A&Ox3, appropriate, moving all extremities
Discharge exam:
Patient is pleasant, in no distress, and is seen ambulating in
the hallway without difficulty. She remains mildly jaundiced.
She has decreased breath sounds at lung bases, but she is not
hypoxic or tachypneic. Her abdomen is soft and very mildly
distended. She has 2+ edema on bilateral LE
Pertinent Results:
LABS:
On admission:
[**2113-1-28**] 01:08AM BLOOD WBC-10.8 RBC-3.38* Hgb-10.5* Hct-29.7*
MCV-88 MCH-31.1 MCHC-35.4* RDW-17.8* Plt Ct-58*#
[**2113-1-28**] 01:08AM BLOOD Neuts-86* Bands-3 Lymphs-5* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2113-1-28**] 01:08AM BLOOD PT-14.6* PTT-26.9 INR(PT)-1.4*
[**2113-1-28**] 01:08AM BLOOD Fibrino-505*
[**2113-1-28**] 01:08AM BLOOD Glucose-121* UreaN-13 Creat-0.7 Na-136
K-3.5 Cl-106 HCO3-21* AnGap-13
[**2113-1-28**] 01:08AM BLOOD ALT-529* AST-548* LD(LDH)-223
AlkPhos-289* TotBili-9.0* DirBili-7.5* IndBili-1.5
[**2113-1-28**] 05:22AM BLOOD Lipase-8
[**2113-1-28**] 05:22AM BLOOD CK-MB-3 cTropnT-0.03*
[**2113-1-28**] 01:08AM BLOOD Albumin-2.5* Calcium-7.7* Phos-1.5*#
Mg-2.0
[**2113-1-28**] 05:22AM BLOOD Triglyc-264* HDL-6 CHOL/HD-30.8
LDLcalc-126
[**2113-1-28**] 06:16AM BLOOD Vanco-21.7*
[**2113-1-28**] 01:35AM BLOOD Lactate-2.1*
IMAGING:
[**1-28**] ERCP:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Evidence of a previous sphincterotomy was noted
in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a balloon catheter using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
Biliary Tree Fluoroscopic Interpretation: A previously placed
metal stent was seen in the common bile duct. The stent was not
seen in the duodenum but terminated in the very distal CBD.
Cholangiogram demonstrated tumor ingrowth and occlusion of the
middle-upper third of the stent. The left hepatic duct appeared
to be cut off without contrast filling its branches. The right
hepatic duct was opacified with contrast. Balloon sweep x 2 was
performed with extraction of sludge. A 11cm by 10FR pancreatic
stent was placed successfully into the right hepatic system with
good drainage.
[**1-29**] CXR:
IMPRESSION:
Right internal jugular central line has its tip in the distal
SVC near the
cavoatrial junction, unchanged. Persistent but smaller right
pleural effusion as well as a left pleural effusion and
associated patchy bibasilar airspace opacity which could reflect
compressive atelectasis although bibasilar pneumonia cannot be
entirely excluded. No evidence of pulmonary edema. No
pneumothorax. Overall mediastinal contours are stable. Heart
size is difficult to assess given low lung volumes and the
presence of the effusions.
CTA to r/o for PE
IMPRESSION:
1. No pulmonary embolism, aortic dissection, or aneurysm
identified.
2. No focal opacification concerning for pneumonia. Bilateral
moderate to
large pleural effusions with adjacent atelectasis.
3. Increased perihepatic and perisplenic simple-appearing fluid.
4. Faint hypodensity in right hepatic dome possibly represents
liver
metastases.
[**2113-2-2**] 11:07AM BLOOD WBC-7.9 RBC-3.20*# Hgb-9.8*# Hct-29.5*#
MCV-92 MCH-30.5 MCHC-33.2 RDW-17.6* Plt Ct-307
[**2113-2-2**] 05:04AM BLOOD Glucose-92 UreaN-5* Creat-0.6 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-11
Brief Hospital Course:
Pt is a 76 y/o female with a PMH notable for stage IV
cholangiocarcinoma on chemotherapy, previous obstructive
jaundice with CBD stent (metal stent placed [**10/2112**]), T2DM, who
presents from OSH for concern for septic shock from cholangitis
and need for ERCP.
.
# Severe sepsis: Patient admitted with fevers, hypotension and
found to have klebsiella and enterococcus growing in blood
cultures at [**Hospital3 **]. Subsequent blood cultures cleared
at [**Hospital1 18**]. She was seen by the ID service who advised a 10 day
course of IV zosyn (4.5 gm every 8 hours iv to be completed on
[**2-8**]) to be completed after her ERCP. It was felt that
her cholangitis was the source of her bacteremia. They
suggested that her outpatient providers could consider repeat
abdominal CT scan to r/o septic phlebitis or abscess in liver
after abx course over; however, if she decides to pursue
palliative care with her oncologist this will not be necessary
(read below)
#Cholangitis: Presented initially with fevers, abdominal pain,
and hyperbilirubinemia. Has history of obstructive jaundice and
previous stenting due to her cholangiocarcinoma. ERCP showed
blockage of left hepatic duct and migration of previously placed
stent. Hepatic duct felt to be closed secondary to compression
by tumor. Previously placed stent was removed, and a new one
placed. Her bilirubin trended downward after the procedure, and
was 4.6 on the day of discharge. However, her alkaline
phosphatase trended upward and was above 437 on discharge.
# Anemia: Reportedly had hct drop to 16 on admission at OSH. Pt
had recent chemo (which could certainly drop her counts- had
pancytopenia on admission to [**Hospital1 **], all of which normalized at
[**Hospital1 18**]) . Pt had brown, guaiac positive stool, so given her
recent fragmin use, may have a slow bleed. Hemolysis and DIC
labs normal. Hematocrit was stable at [**Hospital1 18**] after transfusion
of two units of PRBCs and was 29.5 on discharge. Will hold
fragmin for now, per discussion with her primary oncologist, Dr
[**Last Name (STitle) **].
# Stage IV cholangiocarcinoma: Seen at OSH for chemotherapy,
with recent treatment, last day on [**2113-1-23**]. CT from [**Hospital1 **] on day
of admission reportedly shows extension of tumor burden, and
this is also suggested by ERCP. I discussed her case with her
Oncologist at Southhaven, Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He will see her
after her discharge. He suspects that she will need to
transition to palliative care. I have discussed with the
patient only that the tumor has expanded, and that she needs to
speak with Dr [**Last Name (STitle) **] to discuss next steps and prognosis.
# Left portal vein thrombosis: likely [**2-9**] tumor invasion as
discussed above. Pt had been on Fragmin daily per notes from
OSH. This seems to have been held given recent Hct drop. Her
fragmin will be held, per Dr [**Last Name (STitle) **], as she is at risk for
large GI bleed given guiaiac positive stool, and as her care
will likely proceed in a palliative direction given tumor
extension on chemotherapy.
# Diabetes Mellitus: Well controlled in hospital. Would
continue to hold metformin given her LFT abnormalities. When we
checked finger sticks, sugars were consistently below 200, and
mostly under 150.
# edema. Patient with pitting bilateral LE edema that developed
after vigorous hydration in the ICU. Would diurese gently with
lasix for a couple of days and watch electrolytes closely.
# Pleural effusions: Seen on CT scan. Again, felt to be from
vigorous hydration after hypotensive. She was seen by the
Interventional Pulmonary Service and they did an ultrasound
which demonstrated pleural effusions too small to tap. Patient
was not hypoxic and in no respiratory distress.
Medications on Admission:
1. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day.
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation q6 hours prn.
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 units
Injection TID (3 times a day).
4. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 gm Intravenous Q8H (every 8 hours): TO COMPLETE TREATMENT
ON [**2113-2-8**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 31356**] Healthcare Center - [**Location (un) 730**]
Discharge Diagnosis:
1. Cholangitis
2. Bacteremia
3. Cholangiocarcinoma, stage IV
4. Portal vein thrombosis
5. Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 69**] for
evaluation and treatment for an infection in your bile duct and
bacteria in your blood. You had a procedure called an ERCP
whereby a endoscope was put into your bile duct. The
Unfortunately, this procedure showed that the gallbladder cancer
is causing the bile ducts to be compressed, which is why you
need the stent.
You had two different types of bacteria in your blood, and you
were seen by the infectious disease doctors, who recommended a
total of 10 days of IV antibiotics for this infection. You will
receive these antibiotics through your port, and will receive
the antibiotics at the rehab facility. You can be discharged
once the antibiotics are over.
When you were admitted to [**Hospital3 **] initially, your blood
counts were very low, and there was concern for blood loss in
your gut. Your fragmin was held. Please continue to hold this
medication. This has been discussed with Dr [**Last Name (STitle) **].
You have an appointment to see your oncologist, Dr [**Last Name (STitle) **], on
[**2-9**]. At that point you should discuss with him your
prognosis given that your cancer has grown despite chemotherapy.
Followup Instructions:
[**Hospital1 6136**] Centers for Cancer Care
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], oncologist
[**Location (un) 8973**], [**Telephone/Fax (1) 91064**]
[**2113-2-9**] at 3:45
|
[
"996.59",
"452",
"250.00",
"785.52",
"511.9",
"E878.8",
"276.2",
"272.4",
"038.8",
"155.1",
"576.1",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
12326, 12417
|
6501, 10334
|
324, 341
|
12569, 12569
|
3424, 3431
|
13928, 14136
|
2310, 2410
|
11197, 12303
|
12438, 12548
|
10360, 11174
|
12720, 13905
|
2450, 3095
|
3111, 3405
|
1416, 1776
|
265, 286
|
369, 1397
|
3445, 6478
|
12584, 12696
|
1798, 1992
|
2008, 2294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,808
| 161,457
|
3560
|
Discharge summary
|
report
|
Admission Date: [**2149-10-4**] Discharge Date: [**2149-11-12**]
Date of Birth: [**2084-1-3**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Enterocutaneous fistula
Major Surgical or Invasive Procedure:
Hickman catheter placement times two.
History of Present Illness:
Pt present to the hospital with a malfuntioning VAC dressing.
He has hx of rectal cancer s/p [**Month (only) **] who recieved colostomy and
devleoped an entrocutaneous fistula and a large open wound on
the abdomen
Past Medical History:
Rectal CA
s/p [**Month (only) **]
s/p Bowel resections x 2 with Colostomy
Mechanical Mitral Valve
Parastomal hernia
Small Bowel Obstruction
NIDDM
Social History:
Pt denies tobacco, etoh, and illicit drug use.
Family History:
CAD
Physical Exam:
95.9 111 98/65 18 97%RA
NAD, AOx3
no M/R/G, irregular rate, slightly tachy
CTA-B
Large open abdominal wound, apparent EC fistula
Ext: moving x4, no gross deficts
Pertinent Results:
[**2149-11-12**] 05:27AM BLOOD WBC-5.8 RBC-3.59* Hgb-10.6* Hct-31.9*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.4 Plt Ct-184
[**2149-11-12**] 05:27AM BLOOD Plt Ct-184
[**2149-11-11**] 06:00AM BLOOD Glucose-206* UreaN-23* Creat-1.3* Na-140
K-3.5 Cl-104 HCO3-25 AnGap-15
[**2149-10-24**] 03:11AM BLOOD ALT-48* AST-28 AlkPhos-195* TotBili-3.4*
[**2149-10-22**] 03:00AM BLOOD Lipase-131*
[**2149-11-11**] 06:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.6
Brief Hospital Course:
Pt was admitted for further wound care. His VAC dressing was
replaced and he was placed on heparin for his AF. Early in his
hospital course, he developed fever to 102. He was cultured and
found to have MRSA in the blood. He was started on Vancomycin
and meropenem. Picc line was d/c'ed. Entrostomal therapy was
consulted, who followed and assisted with dressing changes
throughout. He defervessed over a few days, and was continued
on vancomycin for three weeks per ID recommendation. Over the
course of his stay he had a few bouts of Atrial fibrlation that
were easily controled with IV lopressor. He was treated for
anemia of chroic diease and blood loss. He recieved units of
PRBCs from time to time for this. PT was consulted and they
worked with him throughout his admission. By d/c he was able to
walk on his own. His dressings were changed every 2-3 days as
necessitaed by leakage and need for VAC change. He was on TPN
throughout his hospital course. He eventually tolerated clears,
and took this in addition to his TPN. Tube feeds were initiated
into the distal limb of his bowel at the fistula, but these were
only continued for a few days, due to adeuate calories via TPN
and PO. On [**10-15**] the pateint was found in repiratory distress
and was transfered to the SICU. He did not require intubation,
he was in the unit for 9 days, and was moved back to the floor.
Please see formal chart for unit stay details. He reciened TEE
for his bacterimia which showed no vegitation on his valve.
Once returned from the unit, he was tanked up nutriotionally,
continued with the dressing changes and did well. He had a
hickman catheter placed in the OR, but unfortunatly, he had this
pulled out accidently. Another catheter was placed in
radiology. After this he did well, his INR is currenlty
incresing to a goal of [**12-31**]. He was discharged to rehab on [**11-12**]
Medications on Admission:
combivent
coumadin
lopressor
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q4H (every 4 hours) as needed.
2. Octreotide Acetate 0.1 mg/mL Solution Sig: One (1) syringe
Injection Q8H (every 8 hours).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
5. Warfarin Sodium 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
8. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) syringe
Injection Q3-4H () as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
enterocutaneous fistula
Discharge Condition:
good
Discharge Instructions:
return to clinic if you experience pain, increased output or
other concering sign at your wound. Please titrate coumadin to
INR of [**12-31**]. Bridge with heparin in the meantime
Followup Instructions:
first week of [**Month (only) **] with Dr. [**Last Name (STitle) **], call his office for an
appointment
Completed by:[**2149-11-12**]
|
[
"V58.61",
"250.00",
"569.81",
"997.4",
"V10.06",
"280.0",
"041.11",
"427.31",
"593.89",
"518.82",
"V43.3",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"38.93",
"86.07",
"99.15",
"88.72",
"96.6",
"93.59",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
4221, 4293
|
1490, 3387
|
295, 335
|
4361, 4367
|
1033, 1467
|
4597, 4733
|
827, 832
|
3466, 4198
|
4314, 4340
|
3413, 3443
|
4391, 4574
|
847, 1014
|
232, 257
|
363, 578
|
600, 747
|
763, 811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,049
| 185,046
|
32898
|
Discharge summary
|
report
|
Admission Date: [**2121-12-31**] Discharge Date: [**2121-12-31**]
Date of Birth: [**2046-1-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Hemoptysis (pt is a poor historian and all information was
gleaned from conversation w/ [**Hospital1 **] overnight nurses)
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
75y/o F w/ pharyngeal cancer s/p trach/PEG placement now
undergoing chemotherapy/XRT presenting with progressive bloody
trach secretions and fever at her nursing home. Per report, she
had been in her USOH until the day of admission when she
developed fevers and had progressive bloodly secretions from her
trach. She apparently had been having some bloody trach
secretions for some time since she had started her
XRT/chemotherapy but these increased yesterday. She was
hemodynamically stable at her NH and was evaluated by the MD
there who started her on vancomycin and sent her to the hospital
for further evaluation. No one at the NH was present during her
episode and they were unable to confirm the acuity or volume of
the reported hemoptyis.
.
In the ED, she was initially febrile to 102.8 but had no
complaints and was satting well on RA but was put on O2 because
of increased secretions. She was initially tachycardic to the
140s but decreased to the low 100 after 2L of NS. Her labs were
significant for hyponatremia and borderline neutropenia and she
received cefepime (had already received vancomycin at her NH).
CTA showed only known metastatic pulmonary disease w/out
infiltrate or obvious source of her bleeding. Blood and urine
cultures were sent and she was admitted to the ICU for further
management.
.
In the ICU, she denied any difficulty breathing, N/V, abdominal
pain, chest pain, HA, difficulty with vision, diarrhea, dysuria,
or weakness. She did complain of some neck and mouth pain.
Past Medical History:
1. Pharyngeal cancer (currently undergoing daily XRT and weekly
cetuximab)
2. Dementia NOS
3. EtOH abuse
4. Hypertension
Social History:
Former tobacco and EtOH abuse with unclear last use. Lives in
[**Hospital1 **]. Has guardian ([**Name (NI) 3608**] [**Name (NI) 4334**] [**Telephone/Fax (1) 5350**] or
[**Telephone/Fax (1) 74331**]). Nurses at [**Hospital1 **] report she has no family.
Family History:
N/C
Physical Exam:
PE: 99.6, 152/62, 103, 17, 99% on 10L 40% FM
Gen: Sitting up in bed in NAD, pleasant but inconsistent story,
speaking in full sentences, copious secretions
HEENT: Swollen erythematous lips w/ dried blood, O/P w/
significant erythema and apthous ulcers, trach in place but
surrounding skin erythematous and irritated, 1cm x 2cm stage 1
ulcer underneath trach pad anteriorly
CV: Tachycardic, palpable heave, no obvious M/R/G
Lungs: Copious pink/yellow secretions yield rhonchi w/ deep
inspiration, prolonged expiratory phase, no crackles, clear w/
normal inspiration
Abd: S/NT/ND, +BS, G tube in place and non-erythematous, no HSM,
ecchymoses scattered over abdomen at injection sites
Ext: No peripheral edema, no cyanosis/clubbing, 2+ LE pulses,
WWP, midline in place in RUE w/out erythema or tenderness
Neuro: Oriented to self and place, inconsistent history when
crosschecked against [**Hospital1 **] records, moving all extremities,
intact distal sensation to light touch
Skin: HEENT exam as above, blanching pinpoint erythematous rash
on shins, chest, arms, and upper back
Pertinent Results:
[**2121-12-30**] 10:00PM PT-12.7 PTT-25.0 INR(PT)-1.1
[**2121-12-30**] 10:00PM PLT COUNT-357
[**2121-12-30**] 10:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2121-12-30**] 10:00PM NEUTS-48* BANDS-18* LYMPHS-10* MONOS-13*
EOS-6* BASOS-2 ATYPS-1* METAS-2* MYELOS-0
[**2121-12-30**] 10:00PM WBC-2.3* RBC-3.24* HGB-9.9* HCT-29.3* MCV-90
MCH-30.6 MCHC-33.9 RDW-14.6
[**2121-12-30**] 10:00PM LACTATE-1.9
[**2121-12-30**] 10:00PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-1.7*
MAGNESIUM-1.9
[**2121-12-30**] 10:00PM LIPASE-71*
[**2121-12-30**] 10:00PM ALT(SGPT)-24 AST(SGOT)-50* ALK PHOS-90
AMYLASE-43 TOT BILI-0.3
[**2121-12-30**] 10:00PM estGFR-Using this
[**2121-12-30**] 10:00PM GLUCOSE-152* UREA N-18 CREAT-0.5 SODIUM-132*
POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-27 ANION GAP-15
[**2121-12-30**] 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2121-12-30**] 10:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2121-12-31**] 05:34AM PT-12.7 PTT-23.9 INR(PT)-1.1
[**2121-12-31**] 05:34AM PLT SMR-NORMAL PLT COUNT-320
[**2121-12-31**] 05:34AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2121-12-31**] 05:34AM NEUTS-56 BANDS-6* LYMPHS-13* MONOS-18* EOS-7*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-12-31**] 05:34AM WBC-2.6* RBC-2.88* HGB-8.8* HCT-25.9* MCV-90
MCH-30.5 MCHC-33.8 RDW-14.8
[**2121-12-31**] 05:34AM CALCIUM-7.4* PHOSPHATE-1.9* MAGNESIUM-1.6
[**2121-12-31**] 05:34AM GLUCOSE-123* UREA N-11 CREAT-0.3* SODIUM-135
POTASSIUM-3.1* CHLORIDE-104 TOTAL CO2-24 ANION GAP-10
.
CXR [**12-30**]: No acute cardiopulmonary process.
.
CTA [**12-31**]: 1. No evidence of pulmonary embolism. No definite
cause for hemoptysis identified. 2. Multiple pulmonary nodules
consistent with metastatic disease. 3. Asymmetric soft tissue
thickening of supraglottic larynx may relate to known malignancy
but is incompletely evaluated on this chest CT.
.
Bronchoscopy [**12-31**]: No endobronchial lesions seen; hemoptysis
presumed secondary to oropharyngeal mucosa
Brief Hospital Course:
75y/o F w/ pharyngeal cancer s/p trach/PEG placement now
undergoing chemotherapy/XRT presenting with progressive bloody
trach secretions and fever at her nursing home; found to have
fever here in the ED.
.
1. Bloody trach secretions: Non-massive. Hct currently 29 which
is unlikely to be significantly lower than her baseline. No
frank hemoptysis currently and no PE; no infection seen on CT.
No obvious metastatic lesion eroding into a pulmonary vessel. No
clear source seen on bronchoscopy. Etiology presumed to be
oropharyngeal mucusitis. Given oral care for mucusitis.
.
2. Fever: Febrile on arrival to the ED but afebrile once arrived
in unit. Received cefepime/vancomycin. ANC ~ 1100 currently and
on XRT and chemotherapy. UA negative and CTA not showing an
obvious infiltrate. Abdominal exam benign. Lactate negative and
BP stable. Fever is a known complication of cetuximab but last
dose was 5 days ago. He should continue on vancomycin and
cefepime to complete a total course of 7 days even if cultures
are negative. [**Hospital1 **] SHOULD CALL THE [**Hospital1 18**] MICROBIOLOGY LAB
([**Telephone/Fax (1) 4645**]) TO FOLLOW UP BLOOD AND SPUTUM CULTURES.
.
3. Pharyngeal carcinoma: Followed at MEEI per report and
currently undergoing chemo/XRT. Primary oncologist Dr. [**First Name (STitle) **] to
be contact regarding her admission here. She will return to
[**Hospital1 **] to resume XRT/chemotherapy per regular schedule.
.
4. Hypertension: Continued clonidine.
.
5. Rash: Erythematous blanching non-pruritic diffuse rash.
unclear chronicity. no eosinophil elevation to suggest allergy.
known cetuximab related rashes tend to be actinoform in nature.
platelet count normal. Fever but no other abnormalities to
suggest DIC and rash not c/w this diagnosis. Redman's syndrome
was also entertained, but she did not develop a rash after her
second dose of vancomycin.
.
6. Hyponatremia: Ddx hypovolemia vs. SIADH in setting of
pulmonary mets. Received 1L NS in ICU, with improvement of
sodium from 132 to 135.
.
7. Dementia: Continued galantamine.
Medications on Admission:
Albuterol inh q6h
Aspirin 325mg daily
Cetuximab weekly (last dose Thursday)
Clonidine patch 0.2mg daily
Dalteparin 5000u daily
Advair 250/50mg [**Hospital1 **]
Diflucan 100mg daily (last dose 1/15 - ? source)
Zyprexa 2.5mg qhs
Galantamine 8mg daily
Protonix 40mg daily
Vancomycin 1g [**Hospital1 **] (1st dose 1/15 in PM)
Ativan prn
Percocet prn
Benadryl/Compazine/Zantac/Tylenol prn chemotherapy
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every six (6) hours.
2. Cefepime 2 gram Recon Soln Sig: Two (2) grams Intravenous
every eight (8) hours for 6 days.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cetuximab 2 mg/mL Solution Intravenous
5. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO once a day.
6. Dalteparin (porcine) 5,000 unit/0.2 mL Syringe Sig: One (1)
inj Subcutaneous once a day.
7. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inh Inhalation twice a day.
8. Diflucan 100 mg Tablet Sig: One (1) Tablet PO once a day:
Unclear if patient taking or if course complete; defer to rehab
to determine whether to take.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 6 days.
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Galantamine 4 mg Tablet Sig: Two (2) Tablet PO daily ().
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-22**]
hours as needed for chemo.
14. Ativan Oral
15. Percocet Oral
16. Zantac Oral
17. Compazine Oral
18. Benadryl Oral
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pharyngeal cancer (currently undergoing daily XRT and weekly
cetuximab)
Discharge Condition:
Stable, satting 100% on trach mask.
Discharge Instructions:
You were admitted with hemoptysis. A bronchoscopy was performed
to look for a source of bleeding, and nothing was seen. The
bleeding was presumed secondary to oral and pharyngeal mucusitis
from radiation and chemotherapy. In addition, you had a fever to
102.8F in the emergency room; cultures were taken from blood,
urine, and sputum, and no clear infection was identified. You
should continue to get antibiotics for a total of 7 days.
.
Please take all of your medications as directed. If you develop
worsening cough, fever, chills, coughing up blood, or other
concerning symptoms, please seek medical attention immediately.
Followup Instructions:
Please follow up with your oncologist as planned.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"149.0",
"528.01",
"276.1",
"V44.1",
"V44.0",
"294.8",
"707.8",
"E879.2",
"519.09",
"197.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
9529, 9608
|
5750, 7809
|
439, 453
|
9724, 9762
|
3538, 5727
|
10436, 10601
|
2421, 2426
|
8257, 9506
|
9629, 9703
|
7835, 8234
|
9786, 10413
|
2441, 3519
|
277, 401
|
481, 1990
|
2012, 2135
|
2151, 2405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,027
| 190,396
|
7449
|
Discharge summary
|
report
|
Admission Date: [**2201-1-21**] Discharge Date: [**2201-1-25**]
Date of Birth: [**2166-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
34 yo M with history of alcohol abuse and bipolar disorder,
multiple admission for alcohol withdrawal. He was found down at
the subway stop. Pt is inconsistent historian, initially reports
that he was hit by a car and after that he coughed and had blood
tinged sputum along with R sided body pain, on repeat question
he says he was walking on sidewalk today and recalls no
accident. He admits to a recent alcohol binge with 1/2 gallon
vodka per day, on day of admission he drank Listerine. On
presentation to [**Name (NI) **] pt was alert but tachycardic and
hypertensive. CT scan of head was unremarkable, C-spine
unremarkable with no fracture. "Pan-scan" CT unremarkable. The
pt received 15 Valium and 10mg IV ativan without effect and was
started on Ativan gtt with good control of heart rate (from 120
to 90's) and lowering of blood pressure (from 150 systolic to
100's systolic) Laboratories unremarkable except for mildly
elevated LFT's and positive tox screen for alcohol.
He reports he still feels unwell and aches all over his body.
.
In the MICU, the patient was placed on a p.o. CIWA scale for
prophylaxis of delirum tremens and his hypertension and
tachycardia were controlled with metoprolol. Pain s/p fall was
controlled with percocet. He was given potassium supplementation
as well as IV thiamine, folate, and vitamin B12. His trileptal
was continued for treatment of bipolar depression. He was given
a full diet. He did complain of some diffuse chest pain which
lasted for 12 hours and dissipated somewhat over time. EKG with
signs of ischemia. He was overall medically stable and is being
transferred to the medical floor for continued treatment of
alocohol withdrawl.
Past Medical History:
1. Bipolar Disorder
2. Alcohol Abuse
3. Hypertension
4. ? seizure disorder since age 14
5. L tension PTX (s/p chest tube) and L rib fractures mid-[**2200**]
s/p ped vs. car
6. cigarette smoking
7. cocaine abuse
Social History:
unemployed, lives in shelter
- alcohol abuse since age 13
- current smoker for "long time"
- hx of cocaine abuse
- spent 2 yrs in jail from [**2190**]-[**2192**] for assaulting a police
officer
- hx of confabulating and lying in the past
- reportedly has 4 month old son with girlfriend
Family History:
Pt is reportedly adopted, family history unknown.
Physical Exam:
T 97.6 P 91 BP 110/61 RR 16
Gen: NAD, flat affect
Eyes: Sclerae anicteric
Mouth: MM somewhat dry
Neck: Supple, no point tenderness in C-spine
Chest: Lungs CTA b/l
Abd: Diffusely tender, non distended. Nl bowel sounds
Ext: Some eccymosis on R Femur. No pedal edema.
Neurol: Mild tremor, no asterixis.
Psych: Denies suicidal or homicidal ideation.
Pertinent Results:
Na 134 Cl 92 BUN 12 AGap=20
K 3.7 HCO3 22 Cr 0.8
CK: 432 MB: 14 MBI: 3.2 Trop-T: <0.01
Ca: 9.3 Mg: 1.6 P: 2.6 D
ALT: 46 AP: 145 Tbili: 0.5 Alb: 3.9
AST: 63 LDH: Dbili: TProt:
[**Doctor First Name **]: 27 Lip: 42
Serum EtOH 162
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
87
WBC 10.1 Plts 208
Hct 39.0
N:77.2 L:18.4 M:3.3 E:0.3 Bas:0.8
Anisocy: 1+ Microcy: 1+
PT: 11.3 PTT: 31.1 INR: 1.0
EKG: Sinus tachycardia, no ischemic changes
EKG on HD 2 is NSR.
Imaging: Head CT nl, C-spine: no fracture, CXR nl, Abd/Pelvis CT
no evidence of trauma.
Brief Hospital Course:
Assessment/Plan: 34 year old gentleman with history of bipolar
disorder and alcohol abuse admitted to MICU after being found
down. Apparently had been been drinking Vodka and listerine.
Concern for delirium tremens with some tachycarida,
hypertension, tremulousness, and anxiety. Appeared to have some
signs of withdrawal on admission but did not appear in florid
d.t.'s. Over HD1 he required roughly 50 mg valium total (was
getting hourly CIWA assessment). Benzodiazepine requirement
decreased over the following day.
1) Alcohol withdrawal Delirium tremens, initial signs of mild
autonomic instability and anxiety/tremulousness. Now appears
resolved
-continue PO diazepam PRN per CIWA scale every 3-4 hours.
Patient did not require any while on the regular medical floor.
-will use metoprolol to control blood pressure and heart rate.
Metoprolol 12.5 tid switched to atenolol 37.5 po qday for once a
day dosing. Tolerated well by patient.
.
2) S/p fall/trauma. Unclear what precipitated pts fall.
Regardless no sign of trauma on imaging. Head CT nl and C-spine
cleared.
-percocet for pain control
-hard collar off
-complained of r hip and shoulder pain during hospital stay.
XRays negative. No eccymosis, edema on physical. Patient able to
ambulate and cleared by physical therapy for activity as
tolerated.
- patient complained of pain and requested increasing narcotics
dosing. Had multiple conversations with patient regarding likely
increased resistance to rehab placement in patient with
increasing narcotic requirements and ? source of pain. Made
agreement to hold oxycodone dose at 10 mg q4 prn and add motrin
for anti-inflammatory component of pain.
.
3) Alcohol abuse, positive serum tox
-replete magnesium
-thiamine, folate, multivitamin
-addictions consult called- seen by psychiatry and social work
regarding addiction history. Determined to not need inpatient
psychiatric criteria for admission. Per psych, patient also did
not meet inpatient detox criteria as he had been in [**Hospital1 18**] for 3
days achieving detox. Given information regarding local
addiction treatment centers by social work.
.
4) Listerine ingestion, no frank evidence of toxicity at this
time.
.
5) Bipolar disorder
-continue trileptal
- patient on outpatient klonopin tid. restarted day 3 of
admission.
-no suicidal or homicidal ideation
-per psychiatry: patient well known to their service. Evauluated
and determined to not need inpatient psychiatric care. Felt
patient stable to discharge to outpatient psychiatry. Given 1
week prescriptions for trileptal and klonopin along with
information for the BEST outpatient [**Hospital 27299**] clinic to
establish primary psychiatry care. They have open/[**Last Name (un) **]-in
appointments daily throughout the week for new patients.
.
7) Hypertension
-currently on metoprolol 12.5 TID for control of autonomic
symptoms. CHanged to atenolol as above. Tolerated well by
patient.
.
8) Smoking
-on nicotine patch
.
9) Episode of chest pain- low suspicion for ACS, EKG without
ischemic changes.
FEN--advanced diet as tolerated.
Access: 1 PIV.
Ppx: Pneumoboots
.
Full code.
.
Contact: Girlfriend [**Name (NI) 27300**] [**Name (NI) **].[**Telephone/Fax (1) 27301**]
.
Dispo to local shelter with PCP and psychiatric [**Name9 (PRE) 702**].
Medications on Admission:
(has not been taking any recently)
1) Atenolol 100 daily
2) Trileptal 600 twice daily
3) Klonopin 1 mg TID
.
All/ADR's: None known.
Discharge Medications:
1. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*28 Tablet(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*42 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*14 Cap(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*21 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours: Patient was given a two day supply of oxycodone; no
prescription provided.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Alcohol withdrawal
2. Scrotal ulcer
3. Chronic pain
.
Secondary:
1. Bipolar Disorder
2. Alcohol Abuse
3. Hypertension
4. Question seizure disorder since age 14
5. Left tension pneumothorax (s/p chest tube) and left rib
fractures mid-[**2200**] s/p pedestrian vs. car
6. Cigarette smoking
7. Cocaine abuse
Discharge Condition:
Afebrile, vital signs stable. Patient given two days of all his
medications as well as prescriptions for two-weeks of
oxcarbazepine and klonapin. Two days of oxycodone were given to
the patient but no prescription was provided.
Discharge Instructions:
You were hospitalized for alcohol detoxification. You should
continue to take thiamine, folate, and a multivitamin.
.
Your blood pressure was noted to be high during hospitalization.
You were started on atenolol for blood pressure control.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, tremors, or any other
concerning symptoms.
.
Please take your medications as prescribed. You have been given
two days of medications from our pharmacy and prescripations for
oxcarbazine, klonapin, folic acid, thiamine, multivitamin, and
atenolol. You need to speak to your primary care doctor about a
prescription for oxycodone.
- You should continue to take oxcarbazepine and klonapin for
seizure disorder.
- You should continue to take thiamine, folate, and multivitamin
for history of alcohol use.
- You should take atenolol for blood pressure.
.
Please schedule a follow-up appointment with your primary care
doctor within two weeks.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name5 (NamePattern1) 27302**]
[**Doctor Last Name 27303**], within two weeks. Please call [**Telephone/Fax (1) 27304**] if
you have any questions or concerns. You should speak with your
primary care doctor for further management of your chronic pain
and a prescription for oxycodone.
|
[
"291.0",
"719.45",
"786.50",
"303.01",
"401.9",
"296.80",
"719.41",
"V60.0",
"E888.9",
"780.39",
"305.1",
"608.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7872, 7878
|
3657, 6932
|
333, 340
|
8239, 8469
|
3045, 3634
|
9491, 9839
|
2612, 2663
|
7115, 7849
|
7899, 8218
|
6958, 7092
|
8493, 9468
|
2678, 3026
|
275, 295
|
368, 2056
|
2078, 2290
|
2307, 2596
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,316
| 177,847
|
39406
|
Discharge summary
|
report
|
Admission Date: [**2169-9-27**] Discharge Date: [**2169-10-10**]
Date of Birth: [**2112-10-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
56 year old man with HIV, DM2, CAD, h/o seizures, alcoholic
cirrhosis and known varices s/p banding on [**2169-9-18**] initially
presented to OSH with bright red hematemesis. Initial VS: Temp
97.3F, BP 81/47, HR 111, R 22, SaO2 99% RA with initial Hct
31.6. He continued to have hematemesis with worsening
hypotension (SBP 60s) despite IVF and PRBCs (7L NS + 5units
PRBCs total). Femoral CVL placed and he was started on Dopamine
and Octreotide gtts and given protonix 40mg IV. Endoscopy
attempted but unsuccessful due to continued hematemesis. He was
intubated and repeat endoscopy with successful sclerotherapy and
placement of 2 bands (reportedly [**4-24**] bands fired). He was
transferred here for further care and concern given passage of
maroon stool per rectum.
.
In our ED, initial vs were: HR 108 113/56 on dopamine 20 100%.
He was continued on versed and fentanyl added for sedation. Labs
remarkable for HCT 32, INR 1.5 from 1.2. He had no further
bleeding and received ceftriaxone 1g and 2 units FFP. Seen by GI
who recommended octreotide and pantoprazole drips, ceftriaxone,
q4hour HCT and plan for repeat scope in am. VS prior to
transfer: 107 94/53 on dopa 75mcg/kg/min 12 100% AC 500x18 PEEP
5 satting 100%. Access includes 20g PIV, 18g PIV, femoral CVL.
.
On the floor, he is intubaetd and sedated but opens eyes to
commands.
.
Review of systems: Unable to obtain
Past Medical History:
- EtOH cirrhosis, c/b esophageal varices, s/p banding [**2169-9-18**]
- HIV, on Atripla
- diabetes, on insulin
- seizures
- CAD s/p MI [**2155**]
- HTN?
- hypercholesterolemia?
- depression/anxiety?
Social History:
Disabled. Reportedly heavy EtOH use with ongoing daily use, no
tobacco or other drug use.
Family History:
Unable to obtain
Physical Exam:
On admission:
Vitals: T: BP: P: R: 18 O2:
General: Intubated, sedated, opens eyes to name and follows
commands.
HEENT: Sclera anicteric, MM with dried blood around ETT, no new
blood, oropharynx otherwise clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, faint 2/6 systolic
murmru LUSB. No rubs, gallops
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley draining dark yellow-[**Location (un) 2452**] urine
Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKin: No plamar erythema. Faint spiders anterior torso and
gynecomastia. No tremor of tongue or extremities
On discharge:
VS: Tm 98.4 Tc 97, 107/66 (103-137/65-79), 69 (65-80), 18, 95%RA
General: Pleasant male lying in bed in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no m/g/r
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds present, no rebound tenderness or guarding.
Ext: warm, well perfused, no clubbing, cyanosis, or edema
Neuro: Alert and oriented x3. Motor strength and sensory grossly
equal and intact bilaterally. No asterixis.
Pertinent Results:
On admission:
[**2169-9-27**] 10:19PM HCT-35.6*
[**2169-9-27**] 07:09PM TYPE-CENTRAL VE PO2-47* PCO2-44 PH-7.25*
TOTAL CO2-20* BASE XS--7
[**2169-9-27**] 07:09PM LACTATE-1.7
[**2169-9-27**] 06:38PM HCT-33.0*
[**2169-9-27**] 03:08PM PH-7.29* COMMENTS-GREEN TOP
[**2169-9-27**] 03:08PM freeCa-1.03*
[**2169-9-27**] 02:22PM GLUCOSE-189* UREA N-12 CREAT-0.5 SODIUM-141
POTASSIUM-4.2 CHLORIDE-117* TOTAL CO2-17* ANION GAP-11
[**2169-9-27**] 02:22PM CALCIUM-7.3* PHOSPHATE-2.9 MAGNESIUM-2.0
[**2169-9-27**] 02:22PM CALCIUM-7.3* PHOSPHATE-2.9 MAGNESIUM-2.0
[**2169-9-27**] 02:22PM PT-14.0* PTT-26.1 INR(PT)-1.2*
[**2169-9-27**] 11:04AM TYPE-CENTRAL VE PO2-43* PCO2-47* PH-7.21*
TOTAL CO2-20* BASE XS--9
[**2169-9-27**] 11:04AM LACTATE-1.5
[**2169-9-27**] 11:04AM freeCa-1.14
[**2169-9-27**] 10:30AM TYPE-ART RATES-/22 TIDAL VOL-500 O2-50
PO2-136* PCO2-37 PH-7.29* TOTAL CO2-19* BASE XS--7
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2169-9-27**] 10:30AM LACTATE-1.4
[**2169-9-27**] 10:30AM freeCa-1.14
[**2169-9-27**] 09:45AM HCT-28.8*
[**2169-9-27**] 05:56AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-50 PO2-82*
PCO2-41 PH-7.22* TOTAL CO2-18* BASE XS--10 INTUBATED-INTUBATED
[**2169-9-27**] 05:56AM LACTATE-1.5
[**2169-9-27**] 05:56AM freeCa-0.99*
[**2169-9-27**] 05:53AM GLUCOSE-230* UREA N-11 CREAT-0.5 SODIUM-137
POTASSIUM-4.4 CHLORIDE-116* TOTAL CO2-15* ANION GAP-10
[**2169-9-27**] 05:53AM CALCIUM-6.1* PHOSPHATE-2.4* MAGNESIUM-1.6
[**2169-9-27**] 05:53AM CORTISOL-25.7*
[**2169-9-27**] 05:53AM WBC-20.3* RBC-3.55* HGB-9.8* HCT-30.6* MCV-86
MCH-27.5 MCHC-31.9 RDW-18.8*
[**2169-9-27**] 05:53AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL TEARDROP-OCCASIONAL
[**2169-9-27**] 05:53AM PLT SMR-VERY LOW PLT COUNT-76*
[**2169-9-27**] 05:53AM PT-16.3* PTT-25.8 INR(PT)-1.4*
[**2169-9-27**] 03:21AM TYPE-ART RATES-/14 TIDAL VOL-500 PEEP-5
O2-100 PO2-181* PCO2-41 PH-7.18* TOTAL CO2-16* BASE XS--12
AADO2-491 REQ O2-83 INTUBATED-INTUBATED VENT-CONTROLLED
[**2169-9-27**] 03:00AM URINE HOURS-RANDOM
[**2169-9-27**] 03:00AM URINE GR HOLD-HOLD
[**2169-9-27**] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2169-9-27**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-9-27**] 02:04AM LACTATE-1.4
[**2169-9-27**] 01:50AM GLUCOSE-261* UREA N-9 CREAT-0.5 SODIUM-137
POTASSIUM-4.7 CHLORIDE-117* TOTAL CO2-13* ANION GAP-12
[**2169-9-27**] 01:50AM estGFR-Using this
[**2169-9-27**] 01:50AM ALT(SGPT)-17 AST(SGOT)-38 TOT BILI-1.9*
[**2169-9-27**] 01:50AM LIPASE-67*
[**2169-9-27**] 01:50AM ALBUMIN-2.7* CALCIUM-5.7* PHOSPHATE-2.3*
MAGNESIUM-1.4*
[**2169-9-27**] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2169-9-27**] 01:50AM WBC-18.2* RBC-3.81* HGB-10.3* HCT-32.6*
MCV-86 MCH-27.1 MCHC-31.7 RDW-18.7*
[**2169-9-27**] 01:50AM NEUTS-85.6* LYMPHS-8.7* MONOS-5.1 EOS-0.3
BASOS-0.2
[**2169-9-27**] 01:50AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-2+
[**2169-9-27**] 01:50AM PLT COUNT-150
[**2169-9-27**] 01:50AM PT-17.2* PTT-31.2 INR(PT)-1.5*
Other Relevant Labs:
[**2169-9-28**] 10:23AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2169-9-28**] 10:23AM BLOOD Smooth-NEGATIVE
[**2169-9-28**] 10:23AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2169-10-2**] 02:45AM BLOOD WBC-6.6 Lymph-17* Abs [**Last Name (un) **]-1122 CD3%-88
Abs CD3-991 CD4%-39 Abs CD4-440 CD8%-49 Abs CD8-555 CD4/CD8-0.8*
Micro:
[**2169-9-27**] Blood cx- [**1-23**] coag negative staph; [**3-23**] no growth
[**2169-9-27**] Urine cx- no growth
[**2169-9-29**] Blood cx- no growth
[**2169-10-1**] SPUTUM Source: Induced. RESPIRATORY CULTURE (Final
[**2169-10-5**]): SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. (pan sensitive)
[**2169-10-2**] HIV-1 Viral Load/Ultrasensitive (Final [**2169-10-3**]): HIV-1
RNA detected, less than 48 copies/mL.
[**2169-10-3**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2169-10-4**]):
Feces negative for C.difficile toxin A & B by EIA.
Studies:
[**9-27**] Duplex Doppler Abd U/S:
RIGHT UPPER QUADRANT LIVER/GALLBLADDER: The liver echotexture is
coarse.
This, and the inability of patient to hold his breath could
obscure a focal
lesion. The gallbladder is normal without evidence of stones.
There is no
intra- or extra-hepatic biliary ductal dilation. The common duct
measures 5
mm. The kidneys are not well seen. The pancreas and aorta are
obscured by
bowel gas. The spleen is enlarged, measuring 15.4 cm. There is a
small amountof ascites.
DOPPLER EXAMINATION: Doppler examination is limited as patient
was unable to hold his breath due to the intubated status. The
main, right anterior, right posterior, and left portal veins are
patent, with forward flow. The right, left, and main hepatic
arteries are patent with appropriate waveforms demonstrating
sharp systolic upstroke and preserved flow through diastole. The
right, middle, and left hepatic veins are patent with
appropriate direction of flow. Doppler evaluation of the IVC is
limited.
IMPRESSION:
1. Cirrhosis.
2. Splenomegaly.
3. Small amount of ascites.
4. Limited assessment of the pancreas, aorta and kidneys.
5. Normal Doppler examination of the liver.
CXR [**9-29**]:
Greater opacification in the left lower lobe is probably
worsened atelectasis. Moderate-to-severe atelectasis in the
right lower lung is stable or increased and small bilateral
pleural effusions have increased as well. Lung apices are clear.
Heart size is mildly enlarged, increased since the previous
study. ET tube in standard placement.
CXR [**10-8**] (s/p NGT placement): FINDINGS: As compared to the
previous radiograph, the lung volumes have increased, likely to
reflect an improved ventilation. Unchanged size of the cardiac
silhouette. Minimal remnant retrocardiac atelectasis. Normally
positioned right-sided PICC line. Unremarkable course of the
nasogastric tube, the tip of the tube is not visualized on the
image. No pleural effusions. No focal parenchymal opacity
suggesting pneumonia.
.
[**10-3**] CT Head- No evidence of acute intracranial abnormalities.
.
[**10-5**] EEG- This EEG showed some low voltage patterns alternating
with
widespread alpha frequencies. Overall, it suggested an
encephalopathy
with some medication effect. There were no areas of prominent
focal
slowing, but encephalopathies may obscure focal findings. There
were no epileptiform features.
On discharge:
[**2169-10-10**] 05:57AM BLOOD WBC-3.5* RBC-3.27* Hgb-9.3* Hct-27.6*
MCV-84 MCH-28.5 MCHC-33.8 RDW-18.3* Plt Ct-124*
[**2169-10-10**] 05:57AM BLOOD PT-15.1* INR(PT)-1.3*
[**2169-10-10**] 05:57AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-138
K-3.7 Cl-111* HCO3-22 AnGap-9
[**2169-10-10**] 05:57AM BLOOD ALT-21 AST-36 AlkPhos-137* TotBili-0.5
Brief Hospital Course:
56yo man with HIV, DM, h/o seizures, CAD, EtOH cirrhosis c/b
esophageal varices initially presenting to OSH with massive
hematemesis [**2-21**] variceal hemorrhage now s/p successful
endoscopic banding transferred to [**Hospital1 18**] for further management.
# UGIB/Variceal bleed: Per report, source of UGIB felt to be
variceal in nature from findings at endoscopy and hemostasis
achieved with no further episodes of bleeding since banding on
[**9-18**]. Passage of maroon stool (the reason for transfer) was felt
to most likely represent blood in trasnsit from UGIB rather than
separate source. GI was consulted and recommended octreotide and
PPI gtt; on [**9-28**] was transitioned to daily PPI, octreotide drip
d/c-ed on [**10-2**]. Repeat EGD was not performed as patient did not
have further episodes of variceal bleeding. Patient received 5
days of CTX for SBP PPX. During ICU course received 3 units of
pRBCs and 2 units FFP as there was some blood found in his ETT.
He was transferred out of the ICU and his home nadolol was
restarted and increased to 30 mg. He remained stable on the
floor, with stable hct and no further episodes of bleeding. If
the patient should rebleed in the future, it was felt that TIPS
would be the next step in management.
# Hypotension: Patient hypotensive on admission, likely
secondary to hypovolemia and GIB. Blood pressure improved on
arrival to ICU and dopamine was weaned. As hemodynamics
stabilized, patient became hypertensive and was restarted on his
home enalopril, HCTZ, and nadolol with good pressure control.
# ETOH abuse c/b cirrhosis: At high risk for EtOH withdrawal
given positive level at OSH, h/o seizures and reported daily
use. Pt received banana bag and was put on a CIWA scale.
Initially on fentanyl/versed for sedation while intubated,
though was changed to propofol drip on [**9-28**]. NGT placed on [**9-29**]
and tube feeds were started (the NGT was self d/c-ed on [**10-6**]).
Propofol shut off on [**9-30**] and pt received valium only per CIWA
protocol. CIWA was weaned. By the time of transfer to the floor
patient was [**Doctor Last Name **] zero on CIWA. Patient was started on
lactulose secondary to altered mental status (see below). Home
nadolol dose was increased as above. Social work was consulted
and worked with the patient to find an appropriate rehab for
alcohol abuse. He was instructed to follow up with his
outpatient gastroenterologist Dr. [**First Name (STitle) **] in [**Location (un) **], NH and
schedule an EGD to reassess his varices in the next 1-2 weeks.
# Hospital acquired pneumonia- Patient developed hospital
acquired pneumonia following extubation on [**10-1**]. Was treated
with broad spectrum antibiotics and then coverage narrowed down
to cefepime for 8 days to treat pan-sensitive pseudomonas. He
required a brief period of reintubation ([**Date range (1) 41932**]) secondary to
hypoxia and altered mental status (see below). On discharge,
patient was breathing comfortably on room air and lung exam had
cleared.
# Delirium- Patient was noted to have altered mental status,
with agitation requiring restraints. Was noted to have left gaze
deviation and neurology was consulted. Recommended CT head
(negative for acute process) and continuous EEG monitoring for
seizures (drowsiness/mild encephelopathy, negative for seizures
on [**10-3**] and encephelopathy w/ some medication effect on [**10-5**]).
Patient was continued on his home keppra (has history of
seizures). Delirium was attributed to prolonged ICU course,
medications, and possible hepatic encephelopathy. He was started
on lactulose, frequently reoriented, and symptoms gradually
improved. He was alert and oriented x3 at the time of discharge.
# Diabetes: On insulin at home. Was given glargine and humalog
sliding scale while in house.
# HIV: On HAART. HIV VL was checked and was undetectable. CD4
count 440. Patient was continued on his home atripla.
# Seizures: Was continued on home keppra. Was monitored on EEG
with no epileptiform activity.
# Depression/Anxiety: Sertraline and seroquel were held while
patient NPO, but restarted once he was taking POs.
Medications on Admission:
- Keppra 500mg PO BID
- Gabapentin 300mg PO BID
- Atripla
- Pravastatin 40mg PO daily
- Protonix 40mg PO daily
- Sertraline 150mg PO daily
- Seroquel 25mg PO BID
- HCTZ 25mg PO daily
- Nadolol 20mg PO daily
- Enalapril 20mg PO BID
- Novalog 70/30 10units daily
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*1000 ML(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
11. Efavirenz-Emtricitabin-Tenofov [**Telephone/Fax (3) 567**] mg Tablet Sig:
One (1) Tablet PO once a day.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ten (10) units Subcutaneous once a day.
13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare
Discharge Diagnosis:
Primary:
Alcoholic cirrhosis, complicated by esophageal varices
Alcohol abuse
Pneumonia
Delirium
Secondary:
HIV
Diabetes mellitus
Seizure disorder
HTN
Hypercholesterolemia
Depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3549**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted to the hospital because you were vomiting blood. You
underwent endoscopy and banding of esophageal varices (enlarged
blood vessels in your throat) at your local hospital in [**Location (un) **]
and were transferred here for further care. While you were here
at the [**Hospital1 18**] you were treated for a pneumonia and delirium.
It is important that you STOP drinking alcohol to prevent
further damage to your liver and your health. You must also have
a repeat upper endoscopy performed to evaluate your varices in
the next 1-2 weeks- you can schedule that in [**Location (un) **] or return
here for this procedure as we discussed. Please also follow up
with your gastroenterologist in [**Location (un) **].
We have made the following changes to your medications:
- please INCREASE your dose of nadolol to 30 mg daily
- please START taking lactulose
- please START taking sucralfate
You may continue to take your other medications as you were
previously.
We wish you a speedy recovery.
Followup Instructions:
Please schedule follow up with your outpatient
gastroenterologist Dr. [**First Name (STitle) **].
You will also need to have a repeat endoscopy performed to
evaluate the status of your esophageal varices.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2169-10-10**]
|
[
"041.7",
"276.0",
"041.19",
"571.2",
"456.20",
"V08",
"572.2",
"276.2",
"276.52",
"300.4",
"345.90",
"V58.67",
"349.82",
"997.31",
"518.81",
"507.0",
"291.81",
"250.00",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.72",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16125, 16180
|
10548, 14683
|
328, 336
|
16416, 16416
|
3534, 3534
|
17702, 18062
|
2093, 2111
|
14994, 16102
|
16201, 16395
|
14709, 14971
|
16567, 17425
|
2126, 2126
|
10186, 10525
|
17454, 17679
|
1730, 1748
|
277, 290
|
364, 1710
|
3548, 10172
|
16431, 16543
|
1770, 1970
|
1986, 2077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,012
| 155,952
|
9505
|
Discharge summary
|
report
|
Admission Date: [**2200-4-21**] Discharge Date:
Date of Birth: [**2129-11-1**] Sex: M
Service:
CHIEF COMPLAINT: Admitted to the outside hospital for chest
pain and congestive heart failure.
HISTORY OF PRESENT ILLNESS: A 70 year old male patient
admitted to [**First Name4 (NamePattern1) 32325**] [**Last Name (NamePattern1) **] on [**4-18**] with complaint of
chest pain and congestive heart failure.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post old anterior inferior myocardial
infarction noted on cardiac consultation in [**2182**], last known
ejection fraction of 20% with a negative stress test in
[**2198-7-17**], history of hypertension, diabetes mellitus,
hypercholesterolemia, congestive heart failure who presented
to the outside hospital primarily with cough and shortness of
breath. Workup at the outside hospital included a chest
x-ray which showed evidence of congestive heart failure,
electrocardiogram with left bundle branch block. The
patient's cardiac enzymes were cycled and the patient had
ruled out for myocardial infarction with three serial CKs
with negative MB fractions. The patient's maximum CK was 647
with an MB fraction of 6.2, the patient's troponins peaked at
0.96 which is high about two times the peak normal level at
the outside hospital. According to the patient the patient
didn't have any real symptoms of specific chest pressure. He
did have squisky left-sided, described by the patient on his
left side, not related to exercise. The symptoms were
unrelieved when he moves around in his bed. The patient also
described orthopnea and paroxysmal nocturnal dyspnea. The
patient took three sublingual [**Year (4 digits) 32326**] with relief of
symptoms. Symptoms have been occurring regularly, resolved
when he changes his body position but this time the pain
stayed and the patient took Nitroglycerin for the first time
in a couple of years. It is unclear whether he decided to
take [**Name (NI) **] at this time but the patient went to the
Emergency Room after calling his primary care physician and
the primary care physician felt that the patient might have a
case of pneumonia.
REVIEW OF SYSTEMS: The patient has persistent cough with
relatively yellow sputum.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post anterior inferior wall myocardial infarction (found on
cardiac consultation in [**2182**]) last echocardiogram in [**2198-7-17**] with an ejection fraction of 20% and a mildly dilated
left ventricle with associated hypokinesis of the anterior
and inferior distribution, last stress test in [**2198-7-17**]
which showed no evidence of electrocardiogram changes and no
new echocardiogram abnormalities. 2. Congestive heart
failure. 3. Hypertension. 4. Diabetes mellitus. 5.
Hyperlipidemia. 6. History of asymptomatic ventricular
ectopy.
MEDICATIONS ON ADMISSION: 1. Norvasc 5 mg q. day; 2. Lasix
40 mg q. day; 3. Zestril 40 mg q. day; Zocor 10 mg q. day;
5. Nitrodur 0.5 mg/hr patch; 6. Plavix 75 mg q. day; 7.
Lopressor 75 mg b.i.d.; 8. Humulin NPH 70 units q. AM; 9.
Regular insulin 18 units q. AM, 10. Aspirin 325 mg q. day;
11. Ceftriaxone intravenously for presumed pneumonia; 12.
Lovenox 100 mg b.i.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with wife, denies any
tobacco or alcohol use. The patient's cardiologist is Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital6 256**].
FAMILY HISTORY: Non-contributory.
LABORATORY DATA: Laboratory data on admission included a
sodium of sodium 141, potassium 4.7, chloride 103,
bicarbonate 33, BUN 48, creatinine 1.6, glucose 45. CK, here
was 562 with MB fraction of 7.6 and a troponin of 0.31.
White count 5.3, hematocrit 43.5, platelets 185, hemoglobin
A1c 6.7%, cholesterol 160 with LDL of 53, triglycerides 95
and HDL of 34.
PHYSICAL EXAMINATION: Temperature 98.6, pulse 65,
respirations 18, oxygen saturation 95% on 5 liters of nasal
cannula, blood pressure 136/60. Generally pleasant in mild
shortness of breath, persistent cough, in no apparent
distress. Normocephalic, atraumatic. Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements intact. Lungsounds clear. No evidence of
jugulovenous distension, no bruits, bibasilar rales,
expiratory wheezes, regular rate and rhythm, distant
heartsounds. No murmurs were appreciated. Abdomen was
distended, soft, nontender, normoactive bowel sounds.
Extremities without cyanosis, clubbing or edema, 2+ pulses
bilaterally, no evidence of blowing bruits bilaterally.
Neurological, cranial nerves intact, alert and oriented times
three, nonfocal examination.
RADIOLOGY: Electrocardiogram on admission showed a left
bundle branch block in normal sinus rhythm at 80
beats/minute, T wave inversions in leads 1, AVF.
HOSPITAL COURSE: This is a 70 year old male with a history
of coronary artery disease, congestive heart failure with
documented ejection fraction of 20%, hypotension, diabetes
mellitus presented to an outside hospital with a complaint of
dyspnea, ruled out for myocardial infarction, he did have a
borderline troponin and was transfer to the [**Hospital6 1760**] for cardiac catheterization.
It was thought that the patient's symptoms were much more
consistent with congestive heart failure rather than coronary
artery disease. The patient's BUN and creatinine have been
increasing in the setting of diabetes at the outside
hospital. The patient's BUN there was 45 with a creatinine
of 1.6. This was likely secondary to decreased renal
perfusion in the setting of worsening congestive heart
failure. The patient was started on a beta blocker for his
coronary artery disease. The patient's Lasix was initially
held with creatinine and the patient was slightly hydrated
for his cardiac catheterization. The patient underwent
cardiac catheterization on [**2200-4-22**]. Cardiac
catheterization showed an left ventricular ejection fraction
of 20%, left main coronary of 20%, left anterior descending
that was really diffusely diseased with 99 to 100% occlusion.
The left circumflex also had severe disease. The right
coronary artery was totally occluded, the left collateral had
diseased 99 to 100%. The Cardiothoracic Surgery consult was
obtained to evaluate this patient for possible coronary
artery bypass graft. However, given the severity of his
disease it was felt there was likely no takeoff that would be
optimal for appropriate coronary artery bypass graft.
However Cardiothoracic Surgery requested a right hemivalvular
study and if there was evidence of bilobar they would
consider a coronary artery bypass graft. The patient was
actively diuresed after the catheterization as the cardiac
catheterization showed evidence for significant congestive
heart failure with cardiac index 1.79, wedge pressure 32. It
was felt that the patient's congestive heart failure should
be optimized prior to a coronary artery bypass graft. The
patient's Lasix was started at 40 mg intravenously and the
Congestive Heart Failure Service was contact[**Name (NI) **] regarding
possible changes to his medications. The patient was
subsequently started on Digoxin 0.125 mg q. day due to
inotropia. Neutrocor was started and increased to a maximum
dose of 0.03 mg/kg/min. Lasix was slowly increased as the
patient was not adequately diuresing. The patient's
creatinine began to increase and the Lasix was increased to
160 mg intravenously b.i.d. along with the Neutrocor of 0.03
mg/kg/min. As the patient continued to not produce
significant output with the high doses of diuretics and the
patient's creatinine increased to 1.9 with BUN of 54, it was
felt that the patient should be transferred to the Coronary
Care Unit for Swan therapy to assist in his diuresis. Of
note, prior to transfer to the Coronary Care Unit the patient
was becoming more hypertensive with systolic blood pressure
in the high 80s and low 90s. In the Coronary Care Unit a
Swan-Ganz catheter was placed and the patient's initial
numbers showed a cardiac output of 7, wedge pressure of 19
and index greater than 3. Despite evidence that the patient
was not likely in gross overt failure, with the congestive
heart failure, having felt that the patient could be further
optimized. Therefore the patient was initiated on Melrinone.
With the addition of the Melrinone the patient's hypotension
increased and the patient became tachycardiac as well. Given
the lowering blood pressure and elevated PA pressures in the
setting of Melrinone. The vasopressor was initiated. In the
setting of the vasopressor the patient had demand elevated
ischemia which was likely a combination of his tachycardia
with the low blood pressure as well as vasopressor. The
patient had an episode of acute pulmonary edema, intubation
was averted at this time and the patient was treated with
Morphine and nitroglycerin but was still not responding to
Lasix. The Melrinone and vasopressor were subsequently
stopped and the patient was started on Dopamine which caused
an increase in his blood pressure and the patient began to
diurese effectively. However, the patient became
tachycardiac on Dopamine and was switched to Levofed. There
was concern that the patient was becoming more hypocarbic
with a gas of 7.34/57/121 and the question of sepsis was
introduced. The patient was empirically started on
Ceftriaxone, Vancomycin and Levofloxacin for antibiotic
coverage and received three days of these antibiotics. The
blood cultures remained negative, these antibiotics were
subsequently stopped. In the setting of his ischemia the
patient was effectively ruled in for a non-ST elevation
myocardial infarction. The patient had a repeat
echocardiogram which showed a decreased ejection fraction
function of 15% with 2+ mitral regurgitation. The patient
was eventually weaned off of the Levofed and immediately
diuresed effectively with high doses of Lasix intravenously.
The patient's creatinine began to decrease and decreased to
1.4, however, prior to transferring back to the floor, the
patient's creatinine began to increase again to 1.9 and his
doses were held and only prn doses were given as needed to
keep the patient negative. The patient was transferred to
the floor on [**4-30**] and remained stable on the floor. The
patient's Lasix was decreased and then held given the
elevated creatinine. The patient's of urea were
calculated and were consistent with a prerenal picture.
Given this the Lasix was held and the creatinine continued to
decrease. At the time of this dictation the patient's
creatinine is 1.6. The patient's afterload reduction was
reduction was started with a current Captopril dose of 25 mg
t.i.d. The patient's beta blocker was also increased.
Of note the patient had hematuria in the setting of a Foley
catheter placed in the unit. The patient's Foley catheter
was discontinued and the hematuria resolved.
It was felt that the patient is likely in end-stage heart
failure and will need to be tenuous in the setting of
balancing between his cardiac and renal function. It was
felt that the patient was actually as maximally diuresed as
possible in an effort to maximize his renal function. The
patient is currently stable and being screen or
rehabilitation and go to rehabilitation when a bed is
available. The patient's hematuria has resolved and the
patient's creatinine is decreasing back to baseline. The
patient will be discharged on 40 mg p.o. q. day of Lasix
along with his other medications to be further optimized
during this hospital stay.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient will be discharged to
rehabilitation to follow up with the Congestive Heart Failure
Clinic.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure with an ejection fraction of 15%
2. Coronary artery disease with inoperable three vessel
disease
3. Hypertension
4. Diabetes mellitus
5. Hyperlipidemia
Of note, after reviewing the films Cardiothoracic Surgery it
is felt the patient would not be a candidate for coronary
artery bypass graft in the future especially given the low
ejection fraction and likely low .
DISCHARGE MEDICATIONS:
1. Metoprolol 37.5 mg p.o. b.i.d.
2. Captopril 25 mg p.o. t.i.d.
3. Trazodone 25 mg p.o. q.h.s. prn insomnia
4. Prednisone 50 mg p.o. q. day (of note the patient had
episodes of while in the hospital and his Prednisone will
be tapered 5 mg q. 3 days)
5. Lactulose 30 cc p.o. b.i.d.
6. Senna 2 tablets p.o. b.i.d. prn
7. Imdur 30 mg p.o. q. day
8. Digoxin 0.125 mg p.o. q. day
9. NPH 70 units q AM
10. sliding scale
11. prn
12. Robitussin with codeine 5 to 10 cc p.o. q. 6 hours prn
13. 40 mg p.o. q. 24 hours
14. Lasix 40 mg p.o. q. day
15. Tylenol prn
16. Zocor 10 mg p.o. q. day
17. Atrovent inhalers q. 6 hours prn
18. Albuterol inhalers q. 6 hours prn
19. Colace 100 mg p.o. b.i.d.
20. Enteric coated Aspirin 325 mg p.o. q.d.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 2402**]
MEDQUIST36
D: [**2200-5-3**] 12:04
T: [**2200-5-3**] 16:07
JOB#: [**Job Number 32327**]
|
[
"410.71",
"584.9",
"599.7",
"250.40",
"274.0",
"276.2",
"458.9",
"593.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.23",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11676, 11809
|
3534, 3915
|
12257, 13256
|
11830, 12234
|
2902, 3310
|
4908, 11654
|
3938, 4890
|
2202, 2267
|
132, 211
|
240, 424
|
2290, 2875
|
3327, 3517
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,595
| 169,028
|
46695
|
Discharge summary
|
report
|
Admission Date: [**2141-7-11**] Discharge Date: [**2141-7-16**]
Date of Birth: [**2079-5-6**] Sex: F
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hip surgery
Major Surgical or Invasive Procedure:
Status post right total hip replacement revision [**2141-7-11**]
History of Present Illness:
62 yo Female with significant PMH of renal tx from FSGS, HTN,
CAD s/p MI, DM2, hyperlipidemia, who is s/p right revision of
total hip replacement on [**2141-7-11**]. [**Hospital Unit Name 153**] was called ~10:40 am as
pt with BP of 74/51 after fluid bolus ~400 cc. Pt was
complaining of lightheadedness and subjective dyspnea. Upon
arrival T: 100.3, HR: 90s; O2 90% on 4L and FS 167. BP increased
after initiation of second IV with NS bolus and came up to 130s
systolic after ~700 cc. Pt was transiently placed on a NRB,
though pleth of the O2 was not great. With warming the finger O2
saturation increased from mid 80s to mid-upper 90s and pt put on
FM with 6L. CXR showed scattered patchy alvelolar opacities b/l
greated in upper zones. ABG on 6L was 7.34/33/61/19.
Additionally, pt with ~3 episodes of coughing up hemoptysis,
which has since become clear sputum. It was decided to transfer
pt to [**Hospital Unit Name 153**] for increasing observation and nursing requirements
as well as for possible potential of increasing respiratory
distress.
.
Upon transfer pt is on 5L via facemask. She subjectively feels
better without lightheadedness. No CP/SOB. No N/V/F/C. Pt does
note that she felt like "I was getting a cold" for the days
prior to surgery and had been coughing with minimal productive
sputum, but no blood until this am. At bseline denies orthopnea,
weigh gain or LE edema. Overall she had been feeling well prior
to admission excpet with cold and mild cough symptoms prior to
admission. Of note in OR receieved 1.5LNS with 250cc blood loss
and 2.3L in PACU and 1.5L on floor, but no PRBC. She was started
on coumadin last night.
Past Medical History:
Renal Transplants x 2 ([**2095**], [**2136**]; last HD [**2128**]), Chronic
Dyspnea (since last transplant, [**2136**]; admitted 1 w/a for SOB and
DCed w/o Tx/Dx), LungCA(SCC)/Aspergilliosis s/p lobar
resections('[**38**]), Chronic UTIs, CAD s/p MI, Anemia, B/L Hip
Replacement x 2 ('[**27**]/'[**28**]), Back Pain (Unclear Etiology)
Social History:
Lives with her mother and step-father in [**Name (NI) 86**]. Recently moved
from [**Hospital3 **]. Her husband passed away this past [**Month (only) 116**]. Has one
daughter. Quit cigs in [**2138**] - has [**9-14**] p-y. Never more than
social EtOH. No illegal drugs.
Family History:
Dad - unknown. Mom (78) - heart murmur. Brother (58) - Healthy.
Brother (41, died) - MI/Cocaine. Daughter - Migraines. [**Name2 (NI) **] other
cardiac, renal, or pulm disease. No cancers.
Physical Exam:
[**Hospital Unit Name 153**] admission exam
PE:
T: 95.9/100.3; HR: 80; BP: 135/70; RR: 14; O2: 97% on 5L via
mask
Gen: AA female in NAD speaking in full sentences without
respiratory muscle usage.
Neck: JVP about 7cm
CV: I/VI systolic murmur, irreg, irreg, RRR S1/S2.
Lungs: Rales bilaterally [**12-29**] way up, no e/a changes no tactile
fremitus
Abd: +BS. Soft, NT, ND.
Ext: R hip dressing in place, tender to palpation. DP 2+ b/l. No
edema b/l.
Pertinent Results:
[**2141-7-11**] 10:15AM PT-13.5* PTT-29.6 INR(PT)-1.2
[**2141-7-11**] 10:15AM PLT COUNT-148*
[**2141-7-11**] 10:15AM WBC-9.3# RBC-3.93* HGB-10.1* HCT-33.0* MCV-84
MCH-25.6* MCHC-30.6* RDW-19.4*
[**2141-7-11**] 10:15AM GLUCOSE-145* UREA N-21* CREAT-1.5* SODIUM-140
POTASSIUM-3.6 CHLORIDE-112* TOTAL CO2-19* ANION GAP-13
CXR [**2141-7-14**]
IMPRESSION: Cardiomegaly.
Echo TTE [**2141-7-13**]
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is normal (LVEF 70%). No masses or thrombi are seen in
the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated.
There are focal calcifications in the aortic arch. 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
estimated pulmonary artery systolic pressure is normal. There is
a small
pericardial effusion. The effusion appears loculated around the
right atrial
free wall. There are no echocardiographic signs of tamponade. No
right atrial
diastolic collapse is seen.
Brief Hospital Course:
Impression/Plan at [**Hospital Unit Name 153**] admission: 62 yo female s/p LRRT on
immunosuppressives, PAF, DM2, hx of squamous cell lung ca s/p
RLL lobectomy in [**2138**] here after right hip revision with
increased SOB and bilateral infiltrates.
.
Respiratory Distress: Likely CHF exacerbation as pt likely
received fluids in the periop and operative period. Other
causes such as cardiogenic pulm edema, ARDS from infection
either aspiration related to intubation or atypical pneumonia
given immunosuppression or fat emboli and alveolar hemmorrhage
given hemoptysis were considered and ruled out with trial of
diuresis, cardiac enzymes, repeat echo and sputum cultures. Pt
was diuresed with lasix in the ICU and was transferred to the
floor not requiring further diuresis.
.
Hypotension - in the ICU transient episode of hypotension likely
secondary to overmedication with metoprolol and verapamil.
Quickly resolved with IVF, was not an issue during the rest of
the admission.
.
s/p hip revision: Worked with PT. She was given lovenox
prophylaxis and started on coumadin. Discharged with lovenox
until INR becomes therapeutic. Pt's hematocrit had dropped from
35.2 to 28.7 and repeat was 29.7. Ortho and medicine teams
evaluated patient, no signs of hematoma or bleeding. Incision
sight was clean. Pt was less symptomatic in the hip then
previously. Per Ortho resident low concern for bleeding and the
hct remained stable after this time.
.
CRI: stable at baseline creatinine s/p LRRT on
immunosuppressives, transplant team followed patient during the
hospitilization and checked the sirolimus levels. Renally
cleared meds dosed accordingly.
.
PAfib: stable continued verapamil, restarted coumadin goal INR
[**12-29**].
.
DM2: stable on glipizide and humalog sliding scale, appreciate
[**Last Name (un) **] assistance.
.
CAD: no hx of MI, but with EKG changes and hyperlipidemia, has
presumed CAD, so continued statin, Repeat Echo essentially
uncahnged from prior EF> 55% - mild demand ischemia likely
source of mild troponin leak.
.
Osteoperosis: stable cont alendronate.
Medications on Admission:
Mediactions on transfer:
Atorvastatin 40 qhs
Bactrim SS qday
Sirolimus 2 mg qday
Prednisone 5 mg qday
Allendronate 70 qFriday
Pantoprazole 40 mg qday
Folic acid 1 mg qday
Cefazolin 1 g q12 x 24 hr post-op
Verapamil 240 ER qday
glipizide 2.5 mg [**Hospital1 **]
humalog ss/lantus
Metoprolol 12.5 mg qday
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
7. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-27**]
Drops Ophthalmic PRN (as needed).
9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) 40 mg
Subcutaneous DAILY (Daily).
Disp:*10 40 mg* Refills:*2*
10. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: One (1) 3 units
Subcutaneous qAM. 3 units
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Status post right total hip replacement revision [**2141-7-11**]
CHF
A. Fib.
Discharge Condition:
stable
Discharge Instructions:
Please make and keep all follow up appointments.
Take all medication as prescribed.
If you experience shortness of breath that is not relieved with
rest please contact your PCP or [**Name9 (PRE) 5511**] the emergency room.
Followup Instructions:
Scheduled Appointments :
Provider [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2141-8-16**] 12:00
Provider [**Name9 (PRE) **] [**Doctor Last Name **], OD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2141-9-11**] 1:00
Provider PULMONARY BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2142-5-4**]
11:45
Please call Dr. [**First Name4 (NamePattern1) 5627**] [**Last Name (NamePattern1) **] to setup an appintment in [**11-27**] weeks
after discharge.
Also call [**Company 191**] anticogulation nurse([**Telephone/Fax (1) 250**]) on Monday if
you do not hear from them to setup an appintment to have your
INR checked.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2141-7-18**]
|
[
"996.4",
"733.00",
"250.00",
"427.31",
"458.29",
"428.0",
"V15.82",
"401.9",
"412",
"428.30",
"272.4",
"V42.0",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.53"
] |
icd9pcs
|
[
[
[]
]
] |
8785, 8823
|
4724, 6811
|
280, 347
|
8944, 8953
|
3355, 4701
|
9224, 10276
|
2683, 2872
|
7164, 8762
|
8844, 8923
|
6837, 7141
|
8977, 9201
|
2887, 3336
|
229, 242
|
375, 2023
|
2045, 2381
|
2397, 2667
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.